Code Number: mj03001

As Malaysia enters the new millennium and the objective of attaining a developed nation status by the year 2020, there is a similar expectation that the healthcare of the nation will also be at par or even better than the developed nations. Will this be an eventuality or will this be only a dream? If the present statistics were anything to go by, we are still behind and will likely to remain behind if we were to persist with the present rate. The present doctor to population ratio is about 1:1500 and this needs to be brought down to 1:600 by the year 2020. Considering that the present 6 local public Medical Schools produce about 600 new medical graduates a year, this output is hardly sufficient to meet the numbers required. After 45 years of independence, why are we still short of medical doctors and what can be done to try overcoming this problem?

One of the main problems is the limited number of medical training places available in this country due to a limited number of institutions offering medical courses. It is expensive to set up a Medical School and even more expensive to run it. In all the 6 local Universities, the Medical Faculty is the most expensive and this is a well-known fact throughout the world. It costs at least RM 40,000 to train 1 medical student a year in this country and in a public university; this is almost entirely subsidized by the government. The sort of money involved is not affordable by the government as we are still a developing nation with GNP per capita income of about USD 4,000 per person. Hence the number of Medical Schools that the government can afford to set up has been limited, resulting in limited number of medical places available thus far. Given the current economic climate, it is difficult to see the Government opening up new medical schools to meet the demand for medical places.

As to the teachers required to train medical students, this is also in acute shortage. Even if the Government were to build more Medical Schools to ensure the adequate number of places be made available for medical students to meet the requirement of the nation, there are not enough medical lecturers to staff all the Medical Schools. One reason is that there are not enough medical doctors around; hence the pool of available people that can be trained to be medical lecturers is small. There is almost a continuous tussle between the Universities and the Ministry of Health for the doctors to be released to the Universities to fill up the trainee lecturer posts. The Ministry of Health understandably wants to retain their medical officers to ensure adequate staffing of their hospital and health centers. This has invariably led to a catch-22 situation whereby the lack of medical lecturers results in the inability of the Medical Schools to produce enough doctors which in turn leads to difficulty in getting enough medical lecturers to staff the Medical Schools and the cycle continues.

The establishment of new medical schools also creates a strain on the existing Medical Schools, as the new Schools invariably require staff from the established Medical Schools to start off. This only worsens the existing staffing problem of the established Medical Schools whilst at the same time, not solving the staffing problem of the new Medical Schools - a typical case where the cake is too small for everybody to share and left everyone still hungry in the end.

The other reason as to why there aren't enough medical lecturers is that the remuneration given to medical lecturers is not attractive enough. Compared to what they can get in private medical practice, the remuneration as medical lecturers is only at least half of that in private. It is of little wonder why many lecturers only continue up to the time of their contract and then quit to go into private practice. Some don't even bother to finish off their contract and would readily pay off the penalty imposed. In comparison to the Ministry of Health specialists, more is expected of a medical lecturer. While the Ministry of Health specialists are only required to treat patients, their colleagues in Medical Schools are not only expected to treat patients but also to teach, undertake research and publish papers and their promotion is largely based on the researches they do and the papers they publish. Promotion in the Ministry of Health is largely based on seniority and hence they do not need to perform anything extra other than day-to-day management of patients whilst the Medical School lecturers are required to perform more than this. Thus a career as medical lecturer is seen to be unattractive unless one is interested in research and in writing papers or books. As far as remuneration is concerned, there isn't much difference between a medical lecturer and a specialist in the Ministry of Health. Hence, there is no monetary incentive for medical officers to choose a career in academia.

The other problem, which the country is facing, is the maldistribution of doctors. Doctors tend to be concentrated in large cities and towns so much so that in Klang Valley for example, the doctor to population ratio has already met the Vision 2020 target of 1 doctor: 600 population while in the interior of Sabah and Sarawak it is still around 1 doctor: 5,000 population. This implies that the urban areas are well serviced as far as health is concerned but the rural areas are poorly serviced. While it is difficult to alter the doctors' preferences, the Medical Schools can play a role in influencing the choice of work place of the young doctors by putting rural medicine in a positive perspective and instilling passion to serve the rural community.

The solution to the problem of shortage of doctors is to increase the output of new doctors. This of course means that the number of Medical Schools needs to be increased. With the government unwilling to put in more money, the alternative is to get the private sector to set up Medical Schools and we have already seen it happening. The major worry in having the private sector doing this is the affordability to the masses and the standards. There is a need for a method of financing students who are otherwise eligible but cannot afford the costs. As medicine is by far the most popular choice among students, there is also a worry that students with lower grades but can afford to pay the fees would be accepted into the course. Hence there is a need to ensure quality of the students and programmes and conformance to a standard. The National Accreditation Board and the Malaysian Medical Council will play a major role in the enforcement to ensure the output of quality medical graduates by these private institutions.

As to the shortage of medical lecturers, the strategy is to attract doctors into the academic line and to reduce the brain drain to the private sector. Medical lecturers should be better remunerated so that there is a clear advantage for medical doctors to join the medical schools. If there is a clear advantage, then there will be keen competition to join Medical Schools thus ensuring a better pool of medical lecturers. With the corporatisation of the Universities, it is hoped that the lecturers will be better remunerated hence making it more attractive for doctors to join Medical Schools and for medical lecturers to remain in Medical Schools and not opt to the private sector. Whether this is the case is yet to be seen as though the Universities are now corporatised, this is only for the governance. The new salary scheme for medical lecturers has yet to be implemented due to the current economic slowdown and the austerity drive by the government. Whatever the case maybe, with the corporatisation of the Universities, the medical lecturers will be allowed to do limited private practice thus enabling them to earn additional income. This could entice medical lecturers to remain in the Medical Schools as they can continue to be in an academic environment while at the same time enjoy the benefits of private practice.

With the corporatisation of the Universities, it is also hoped that it will be easier for Universities to appoint private medical specialists as part-time staff in disciplines, which do not have adequate staff. This is because as a corporatised body, there should be less bureaucracy and red tapes. The expertise available in the private sector can be tapped and made used of to overcome the shortage of experienced medical teachers. Many of the private medical specialists were once senior academic staff before opting for private practice. Hence their experience will not go to waste by giving them a chance to serve the Medical Schools again in a part-time capacity.

Another solution to overcome the shortage of medical lecturers is through the wider application of IT in the teaching of medicine. Through the propagation of student-centred teaching, students should be provided with easily accessible resources to reduce their dependency on their teachers as the major source of knowledge. With proper guidance, students will be able to acquire the required knowledge on their own with the use of IT and didactic learning can be much reduced. A lecturer can then cover many more students more effectively than what he or she can do in the traditional way. Computer aided learning also is more fun to the students and many students prefer this type of learning than attending lectures.

In conclusion, the health care system and the medical schools in this country are still grappling with manpower shortages. However, with the current steps being taken, it is hoped that this problem can be overcome. Apart from the resources that need to be put in, a little innovation in how we do things can help speed up the process of attaining self-fulfillment in the health manpower needs of our country.

Copyright 2003 - Malaysian Journal of Medical Sciences