An overview of Malaysia’s healthcare system. A miracle or a disaster?

An overview of Malaysia’s healthcare system. A miracle or a disaster?

Part III of III – The Professionals and a Conclusion
Having discussed patients’ attitudes and the balancing act between the public and private healthcare sector, I imagine the next obvious discussion lies in the attitude and professionalism of the healthcare workers themselves. Before I go on, I wish to share my experience to readers, as an insider to the system:

“A young man, was admitted into the Intensive Care Unit (ICU) for a fatal overdose of paraquat (a type of herbicide); an obvious suicide attempt. With the patient critically ill, the family waited nervously outside the ward. The Medical Officer (MO) briefed the freshly graduated House Officer (HO) of what the priorities are in regards of treating the patient, before she left him to deal with this tremendous but seemly impossible task of treating this patient. Shortly afterwards, the patient arrests, and the HO attempts to resuscitate him, and calls for help from the available medical staff in the ward. In that instance, the nurses and an attendant immediately came to support the HO. Meanwhile, the patient’s family, who realised the sudden urgency in the medical staff, sensed that something was going horribly wrong, tried to force their way into the ward. The nurses and attendant, restrained them from entering the ward, and told them that they were only getting in the way of the medical team. So the nervous family, were forced to wait outside, and their only comprehension of the scenario, was the little they could see through the tiny window that connects the ward to the outside.

In ICU, the HO is tiring from performing the cardiac massage whilst the other nurses who crowd the ICU are discouraging the HO in what they believe is a futile attempt. I was in utter disbelief when a nurse muttered these exact words,

“Cukup la doktor, dia sudah mati! (That’s enough doctor, he’s already dead).”

I understand that given the scenario, the survival of a patient who had consumed a fatal dose of paraquat is practically zilch. But nowhere along my medical training have I encountered calling a living man, dead, and staff discouraging the efforts of another staff to attempt to save him, regardless of the odds.

The HO ignoring these comments persevered but eventually exhausted, requests for a nurse to take over. She reluctantly takes over, but with minimal regard and effort for the technique required for the cardiac massage, she ultimately renders the procedure useless. The HO pushes her aside to continue with the cardiac massage, whilst the attendant (who is also trained for the procedure) comments, that he would feel obliged to help only if he were paid to do so. The HO, losing the battle of resuscitating the patient, recognises the need for an urgent inotropic drug administration asks the nurse to titre the required dose. But at that moment, the HO realises, all the nurses had left, save one who was a student nurse and inexperienced and even she had to call for the other more senior nurses to help prepare the required drug.

Finally, the patient dies. The HO walks over to the family to break the news. They cried in disbelief as they hear the difficult and shocking news, but they were well within earshot when the MO yells in background from across the ward, calling for the HO hurry up with his ‘time wasting’ and carry on to complete his wards rounds because she could not be bothered to wait any longer.”

This actual event took place in a district government hospital in Malaysia during my attachment as a pre-medical student. In my brief time there, there were uncountable accounts of unprofessional behaviour ranging across all levels of medical staff. Doctor-patient relationship goes no further than the extent of providing a drug to cure the disease. Nurses constantly complain of having to deal with both the patients’ and doctors’ attitudes, yet demonstrate little ability in completing their chores at an acceptable standard. These problems that I have highlighted are merely the tip of the iceberg of hugely unprofessional behaviour amongst medical staff in public healthcare service. Having experienced the public healthcare sector from varying perspectives, I have enough reason to believe that anyone would be discouraged from seeking healthcare services from the public healthcare services, if one could afford the more professional private healthcare service.

And if readers realised, I have yet to even discuss the competency of the medical staff in delivering a healthcare service that consumers require and demand. We have reason to believe that medical malpractice and negligence in government hospitals happens, which is indicated by the number of legal suits that have been filed, many of which reputedly have been settled out of courts. With the furore surrounding the de-recognization of Crimea Medical State University and other medical schools from Ukraine, the Malaysia Medical Association (MMA) stated that it places the highest importance in standards of doctors which are allowed to practice in Malaysia, a claim that is used to support their move. However, there have been numerous rebuttals from various groups demanding that Malaysia Medical Association (MMA) reveal and standardize the criteria which are used to ‘recognize’ medical degrees issued from all universities, yet it fell on deaf ears. The inconsistency that MMA portrays is worrying, with medical graduates pouring into the country from various institutions worldwide. How are we to know if they really are qualified to practice in Malaysia? The MMA solution to the question is a separate qualifying examination, which medical students from non-recognized universities need to pass. I personally wonder how many of our local graduates would actually pass these examinations.

The right for a healthcare service that meets the patients’ needs is a basic right that all citizens of Malaysia deserve. Anything short of that can only be perceived as an infringement of such a basic right. The earlier parts of my text discussed the growing trend of consumerism behaviour amongst healthcare users worldwide, but more prevalent in the developed country, a trend that is not currently widely observed in Malaysia, which could offer an explanation of the passivity of healthcare users in Malaysia with regards to the service that is being offered. This is a product of the paternalistic doctor-patient relationship, the elevation of the status of the doctor to somewhat mimicking a demigod: a doctor cannot do harm! Unfortunately, this is not true, and patients in Malaysia need to understand this, fast. We can preach about the unprofessional behaviour of the healthcare workers to limitless ends, but unless the patients adopt a new mentality, the arena of medical practice in Malaysia may never change.

Patients need to be more willing to assume a greater share of responsibility in their healthcare; be more willing to learn about the conditions which they suffer from and understand the implications of each treatment options. They need to discard their passive role and be more active with regards to the management of their own health, not merely absorbing the doctors paternalistic views, but instead challenging them to deliver the best of what the healthcare service has to offer. But this evolution will take time, and as for yet, it is impractical to introduce modern aspects of communication in medicine, such as informed consent and shared decision making, as patients are nowhere ready to take responsibility for their own health, and doctors likewise are nowhere ready to relinquish the authority and supremacy that they have been privileged to, all these years.

There are numerous areas in within the healthcare system that I have yet to discuss, such as healthcare delivery within the private sector, measuring patient satisfaction rates, and even expenses within the healthcare system. Also, I have not even approached the issue from the perspective of the medical staff, the limitations they face within the service, obstacles posed by guidelines, protocols and other red tape, inadequate facilities, poor opportunities for training, massive patient loads, horrendous working hours, and the list can go on. Other limitations in my text stemmed from the difficulty in accessing crucial statistics, such as exact figures of patients within each sector, breakdown of expenditure of the Ministry of Health, previous budget allocations, mortality rates, waiting times for patients in out-patients, waiting lists for medical/surgical procedures/investigations and others. Figures from the government allocations into the national budget and the 9MP, are in itself not useful unless we have figures from previous years to compare to and observe trends.

However, despite the numerous problems in the healthcare system that Malaysia faces, all is not lost. On the whole, as Ramesh and Holliday have said, Malaysia is truly a healthcare miracle, a miracle which has been made possible by the government who have created a system that is accessible by the multiple strata of the Malaysian society. For all the complaints, facts and statistics still prove that Malaysia possesses one of the leading healthcare systems in the Southeast Asia region, and a system that is the envy of many other developing countries. Furthermore, we can take some comfort in the recent efforts by the government with plans in place to show that things are definitely moving forward towards providing a better healthcare system for all. It may not be perfect, but it is definitely improving. However, the first step towards improvement lies in the ability to acknowledge the shortcomings within the system, such as some of the ones that I have discussed above. I self admittedly understand that huge chunks of my text have been critical of various parties, purely because I believe that there is much room for improvement.

As to the answer to the question that I put forward, ‘Is Malaysia’s healthcare system a miracle or a disaster?”…I believe that it is a miracle. It is an achievement that no one could have predicted with the numerous inadequacies and flaws at various levels. The existing system in far from being perfect, but it is undoubtedly a miracle that the healthcare system has succeeding in raising the overall standard of health (measured in terms of the variable mentioned above) of the mass population in Malaysia; a performance that deludes the circumstances under which the healthcare system operates on. However, as one who is within the medical profession, I too can appreciate and sympathize with the numerous problems that healthcare providers face: the lack of resources, support and protection. It is simply that, as patient, I would never give another the power to do harm, onto me.