HEALTH professionals are in the news this month not for Covid-19 reasons, but for their employment contracts.
Between July 1 and July 12, the Malaysian Medical Association (MMA) encouraged Malaysians to change their social media profiles into monochrome and wear black to work, as part of the Code Black and Black Monday initiative.
Separately, on July 1, a group of junior doctors on the contract system (calling themselves Hartal) issued a three-week ultimatum to the government to offer permanent positions to all contract doctors and publish clear selection criteria for permanent posts.
Failing which, they “will take drastic action by going on leave beginning July 26 until our demands are fulfilled” (which is essentially a strike).
Code Black, Black Monday and Hartal are intended to call for fairer terms of service for contract doctors. However, these movements are broader than just doctors, because pharmacists, nurses, dentists and other healthcare professionals (HCPs) are also employed on a contract basis by the Health Ministry (MOH).
In this article, we shall attempt to dissect the motivation behind these movements, consider the ethical issues at play, and propose solutions to end the stalemate of the contract system.
Unfairness since 2016
The source of this dissatisfaction among junior doctors and other HCPs stem from the introduction of the contract system in December 2016. Prior to that, doctors and other HCPs were employed on a permanent basis till retirement.
The contract system was introduced to reduce the size of the civil service and introduce competitiveness in hiring.
While the contract system is a reasonable human resource (HR) policy, the system currently hinders the career progression of contract doctors. These doctors are only provided contracts for a total of five years, which is inadequate to complete their specialist training that may take five to 10 years.
Additionally, contract doctors cannot enrol in the Masters’ programmes in local universities, as it is limited to doctors with permanent posts.
With about 23,000 contract doctors unable to train to be specialists, this will affect Malaysia’s future supply of specialists.
On top of that, contract doctors do not receive certain types of annual leave that their permanent counterparts do, such as unpaid leave, childcare leave, and hazard leave (which is provided to doctors working in departments exposed to higher risk such as radiology and psychiatry).
Contract doctors and other contract HCPs are also not eligible for government housing loans or even flight tickets to/from Sabah, Sarawak and the peninsula.
During this pandemic, we have seen how contract doctors and HCPs have sacrificed selflessly. They sought reassurance and durable solutions for their employment situation from the government, but have not receive satisfactory responses. This led the doctors to take matters into their own hands, through the Code Black, Black Monday and Hartal initiatives.
On July 14, the police released a press statement confirming that it has opened investigations on an individual calling for public participation in Code Black. This confirmed the content of the MMA statement on July 13 and prompted a statement from the Malaysian Health Coalition on July 18 asking for fair treatment for HCPs.
We’ll examine ethics in two aspects: freedom of expression and protection from intimidation, and the ethics of a strike by essential workers during a pandemic.
Firstly, every Malaysian has a right to freedom of expression and association, as enshrined in Article 10 of the Federal Constitution. While we understand that several civil service rules and regulations restrict this right to free expression, changing social media profiles into monochrome and/or wearing black are not against civil service rules.
Police investigations on health professionals are an unusual step.
There is no demonstrable harm to public safety, and the police are essentially investigating their fellow civil servants.
Therefore, the state apparatus should not be utilised to target doctors who are raising their concerns through a peaceful act of solidarity.
The second complex ethical dilemma is about an essential worker strike during a pandemic. We start by saying that this is a labour dispute between employer and employee, and less a matter of medical ethics.
In the past, doctors and HCPs worldwide have gone on strikes, with studies showing no clear evidence of increased risk to patients during such events. These precedents suggest that strikes that involve minimal disruption of healthcare services may be allowed to take place.
However, Malaysia is currently furiously fighting a pandemic, with resources stretched thin across the nation.
Which brings us to the question: Is a strike an acceptable form of action during a pandemic?
The answer is yes and no.
No, because doctors and HCPs have a moral and legal duty to deliver care for their patients, especially during a pandemic.
But “Yes, a doctors’ strike is an acceptable form of action during a pandemic” if the strike is designed to minimise disruption of clinical care and has clearly defined objectives.
To be clear, there is never a perfect time for a strike. Besides, HCPs are also citizens with legal rights for free expression and fair employment practices.
And after 18 months of selfless sacrifice during Covid-19, HCPs are at a breaking point physically, emotionally and psychologically, and this is their cry for help from the government.
If nothing else, the spectre of a strike has raised public attention to the issues of the contract system, pressuring the government to resolve the situation.
It is possible that the government will make some concessions to avert the strike. But without durable solutions, the spectre of a strike will only be postponed.
Seeking a way out
Whether one supports a strike or not, the concerns raised by our doctors remain pertinent and swift action is required to resolve these issues. We propose three simultaneous solutions.
First, the government must provide adequate contract lengths to junior doctors to receive the proper training to qualify as specialists.
Data from Malaysia’s National Specialist Register shows the average specialist to population ratio is 4:10,000, which is severely behind that of the Organisation for Economic Cooperation and Development’s average of 14:10,000.
More specialists means better accessibility to specialist care for the rakyat, and longer contracts can support the specialist training pathway.
At the same time, longer contracts must be accompanied by fairer contracts. This means that all contract professionals should receive the same benefits as those on permanent posts (including annual leave and workplace benefits).
Contract doctors may not need a government pension, but must receive equal benefits in their Employee Provident Fund contributions.
At the same time, there should be more permanent posts for health professionals in the MOH, simply because we need them to serve a larger, older and sicker population of Malaysia.
More permanent posts will meet our increasing healthcare needs while helping to retain doctors in the public sector (instead of losing them to the private sector or to Singapore or Australia).
The right mix of permanent posts and longer contract posts is open to discussion, and can be decided by professional technocrats (not politicians).
Second, health professionals should be provided proper channels for their concerns to be heard, especially regarding their welfare and rights.
Such channels should be safe spaces where they can raise their concerns to relevant parties with no fear of repercussions. Issues raised must be responded to in a timely manner, with efficient and equitable solutions provided.
Furthermore, contract health professionals must be well-represented during discussions of policies that affect them.
Third, in the long-term we will need a durable HR solution between the Public Service Commission, Public Service Department and MOH.
An independent health commission could be an elegant solution. Its function would be to examine staffing needs for the public healthcare system, and subsequently manage the distribution of healthcare workers nationwide.
With the tenure of many contract doctors ending in Dec 2021, it is only natural that anxiety is mounting.
Transparent communication about the long-term future of contract HCPs will soothe anxieties among our essential workers. A compassionate government will provide short-term solutions to boost morale and increase equality, while implementing the difficult-but-necessary structural reforms for our health HR practices.
Dr Sean Thum is a trainee in psychiatry and advisor to Malaysian Medics International. Dr Khor Swee Kheng is a physician specialising in health policies and global health. The views expressed here are entirely their own. For more information, email firstname.lastname@example.org