Medical Education in Malaysia : A reflection

Everyone wants to be doctor

Every year we hear about many students applying for medical schools and scholarships through various means. The government, being the major provider of medical education through public medical schools and overseas scholarships, is usually put at fault when high achieving students fail in their application into state-funded medical education for various reasons. These high achieving students often lament that their peers with lower academic credentials are given advantage over them due to the affirmative action policies of the government.

While no government in the world can guarantee public medical education for every aspiring student, a pro-affirmative policy will definitely reduce the chances of non-beneficiaries obtaining a place in a state-funded program. One therefore has to increase one’s chances of scoring a place through an arbitrary selection process, based on rough guidelines such as the following:

a) Do outstandingly well not only to qualify for public medical school, but superiorly, at the top of the class and region;

b) Exhibit strong leadership qualities and special skills through involvement in co-curricular activities at state and national levels;

c) Possess flawless communication skills in Malay and English in a collegial setting;

d) Be able to articulate opinions on various socioeconomic and political issues, besides showing appreciation of local culture and norms;

e) Have access to some well-known political parties and figures to support one’s application.

Thus, for the average student who does not benefit from affirmative action, it is very challenging to gain a place in state-funded programs. However, they have a reason to rejoice with the recent liberalization of private education in Malaysia in the last decade. Many aspiring students who failed a place in the public sector may be able to pursue medical education and career inside and outside the country. It is a popular career choice for many Malaysians of all ethnicities, as a medical career does not only promise social mobility but also a stable income and social prestige. With greater affluence and increasing accessibility for private medical education through various twinning and private programs, the demand has increased dramatically.

More medical schools are opened not only by private institutions, but by state-owned institutions as well. The overwhelming popularity of medical education has been exemplified by the opening of various colleges, including ones which are dubious. State governments lobby for the opening of medical school campuses, medical schools are used as political and economic tools to reward different regional communities, like the recently Terengganu state university. Newer urban communities aspire to have the prestige of a medical school like the Cyberjaya, Iskandar Developmental Region and Kuala Lumpur Education City. To meet the fierce demand for medical education insufficiently provided by domestic providers, state scholarships seek not only to fund medical education for students from traditional providers like the UK, Australia, New Zealand, India and Egypt, but also lesser known and somewhat questionable ones like Indonesian, Ukrainian, Russian, Czech and Polish institutions.

Sustainability

I am no economist. But I have a deep nagging fear that the Malaysian health system may not be able to absorb a steady stream of fresh medical graduates into the workforce. Health workers are not mass-produced workers for the system, but they are more of apprentices who require ongoing training and supervision from their seniors. Would they therefore gain adequate and appropriate post-graduate medical education?

Beside, with a health budget of RM8.7 billion (from 2006 figures), 6.33% of the national budget, health spending per capita is a meagre RM327. I wonder whether the government would be able to consistently increase its spending on healthcare to employ more doctors annually, not considering those who are already underpaid and overworked. With an increasing influx of graduates, would we be able to pay our doctors reasonably comparative to other developing countries, and would we be able to provide adequate ongoing training and supervision? The thought of the Phillipines, where doctors have to go overseas as nurses haunt my dreams.

With the proliferation of private healthcare providers due to a poorly coordinated dual health system, leeching off public medical consultants and medical officers, are we seeing junior doctors bloating our underinvested public health institutions, providing less than optimal care to our populace?

The justification for excessive and unsustainable training of medical students is the shortage of medical staff, repeated often by government officials and ministers of health. Tun Dr Mahathir’s ambitious Vision 2020 with a doctor-populace ration of 1:500 has perhaps driven the craze for the mass-production of medical graduates to achieve a so-called “developed nation status”. But to aspire for such unrealistic figure within a short time without proportionate increase in GDP per capita healthcare spending comparative to other OECD, is perhaps an exercise of self-delusion. Without an economy resilient and strong enough to support an extensive health system, a hyperinflated model of healthcare would mean few things; underpaid, overworked and undertrained staff.

Cheap measures to prevent these underpaid and overworked staff namely by bonding them with an almost-lifetime bond of 10 years (for basic training) and another 8 years (for postgraduate training) may work in the short term to prevent them from escaping the system that treats them with equal dignity with a factory machine. But until and unless there are systemic reforms in the public healthcare funding, recruitment and delivery of service, we are deluding ourselves of a “developed status healthcare” boasting only of our holy ratio of 1:500, but unable to deliver a system that effectively engages with the health of the nation. We will only be able to boast of thousands of health slaves providing for the people, but we may not be able to deliver a system that is well-funded, well-equipped, well-trained, well-coordinated and well-delivered to the people. Our noble intentions of serving the people would bear no fruit, as we may lose public confidence in the long run due to suboptimal services.

Thus, a brave systemic reform in Malaysia is sorely needed.