8.1 Introduction

This chapter explores how the Malaysian health workforce evolved over a 60-year period. It analyses the dynamic interactions between various forces in the health system and explores how broader societal elements such as education levels and economic growth; evolving epidemiological, demographic and behavioural patterns; and macroeconomic policies contributed to the dynamic interactions and influenced the subsequent outcomes for the health system.

This chapter does not attempt to provide a detailed profile of the Malaysian health workforce, as such information is available on the websites of the Malaysian Ministry of Health (MoH) (Ministry of Health Malaysia, 2016b) and the World Health Organization (WHO) (World Health Organization, 2014).

8.2 Post-independence: The Early Phase (1960s and 1970s) – Focus on Improving Access

During the years immediately after independence, the Malaysian population was largely rural and had relatively low literacy and high rates of maternal and infant mortality, vaccine-preventable diseases, malaria, tuberculosis, water- and soil-borne disease and malnutrition (see Chapter 3). The economy was doing well, with a steadily increasing gross domestic product (GDP). Guided by strong political considerations, the government implemented policies for rapid integrated rural development, focusing on infrastructure, education and healthcare (see Chapter 3). A nationwide rural health service developed rapidly (see Chapter 4), together with vertical disease control programmes for malaria, tuberculosis, filariasis, yaws and various food-, water- and soil-borne diseases (Chapter 6). Community mobilisation was a key feature of the development process. Table 8.1 summarises key drivers shaping the development of the workforce at this time.

The rapidly expanding rural health programmes needed large numbers of healthcare workers close to rural communities. The interventions they needed to deliver were not too technically complex. The MoH concentrated on rapidly producing large numbers of allied health personnel (mainly nurses of different categories) to populate the rural health services. At this juncture, the government did not attempt to rapidly increase the number of doctors (Table 8.2). Several considerations underpinned this policy. First, entry competence for basic training was lower for allied health personnel than for doctors, so allied health candidates were more readily available, given the literacy levels at that time. Additionally, allied health personnel were more affordable. The challenge was to ensure the production of sufficient numbers of health personnel with the skills and competence to provide safe and effective care. To address this, training institutions for allied health personnel were placed under the control of the MoH rather than in universities under the Ministry of Education (MoE). At that time, the sentiment was that universities were too distant from the front-line of healthcare delivery and would focus on academic measures of excellence rather than the practical skills needed at the front-line. Box 8.1 summarises the critical features of the training programmes. Training institutions were confined to the public sector, enabling the MoH to co-ordinate production with subsequent employment and deployment in the rapidly expanding public sector services. Another feature was that domestic funding, and not foreign aid, supported the training programmes. Foreign assistance was mainly of a technical nature (Box 8.1).

Training programmes expanded rapidly for allied health personnel, namely midwives and health nurses (for MCH and nutrition), public health overseers and health inspectors (for environmental sanitation), and medical assistants and pharmacy assistants (for treating common illnesses) (Table 8.2).

In contrast, during this phase of development, the production of doctors, dentists and pharmacists was limited. For example, during the 20-year period 1955–1975, the number of nurses and assistant nurses/midwives increased at a much faster rate than that of doctors (Table 8.3).

Courses that provided the basic qualification for doctors were available only in three local universities, and the number of places was severely limited. No post-graduate training was available, and there was a limited number of scholarships for specialist training in foreign countries (mostly in the UK). During these earlier years, expatriate staff on short-term contracts filled key vacancies in medical officer and specialist positions until local staff became available and replaced them.

As a result of the rapid recruitment and training of nurses and midwives, the number of people per nurse/midwife declined about four-fold from 2,488 in 1964 to 570 in 1980 (see Chapter 3: Supplementary Table 3.L). The number of people per doctor also declined by about half from 7,145 in 1960 to 3,563 in 1980 (see Chapter 3: Supplementary Table 3.K).

Several governance mechanisms controlled the quality of health personnel (World Health Organization, 2014). First, legislation mandated that qualified personnel in core categories such as doctors, dentists, pharmacists, nurses and midwives had to be licensed to practice and were placed on registers. This served to control unqualified, illegal practitioners. Second, as the public sector was by far the largest employer of health personnel, their employment conditions were governed by civil service rules and regulations that also defined their financial and non-financial benefits such as medical care, travel subsidies, highly subsidised housing, employment security and pension benefits. Thus the public sector was able to control the composition and quality of the health workforce.

The health system outcomes relevant for assessing this early phase of development include availability of and access to health staff, utilisation of services, and selected mortality and morbidity indicators closely associated with the performance of the health workforce. Data for nurses/midwives suggests that increased availability was associated with utilisation and health status (Table 8.4) (trend data for other categories were not available).

8.3 The Second Phase of Development (1980s–1990s)

Several overarching features influenced development during the 1980s and 1990s. Rapidly rising female literacy and rural-to-urban migration contributed to the evolving morbidity and mortality patterns (see Chapter 3). Communicable diseases (CDs) declined, while non-communicable diseases (NCDs) became more common (see Chapter 6). As long-established vertical disease control programmes (malaria, tuberculosis, leprosy) merged with primary care (Chapter 4), their staff were absorbed and, where necessary, re-trained to provide a broader range of services. Larger hospitals that offered treatment facilities were overcrowded while smaller district hospitals were underutilised, catering mainly for normal childbirth and ambulatory care for less complex conditions (Public Health Institute, 1983). The bypassing of clinics and district hospitals by patients in favour of larger or more sophisticated facilities for inpatient and ambulatory care was a significant pattern in health care utilisation at this time (Chapter 5). This phenomenon illustrated the growing demand for higher levels of clinical and technical services that came with rising socio-economic and educational status in the population. Table 8.5 summarises the interactions that influenced the evolution of the health workforce at this time.

Staff with higher levels of competence were needed. Several new categories of personnel were recruited. For example, public health engineers were recruited to complement health inspectors (Chapter 7) and pharmacists to complement pharmacy assistants (Chapter 10).

Categories of staff such as nurses, medical assistants and health inspectors attending training programmes in the public sector received living allowances and accommodation during their training period. The health personnel training programmes profile of 1975 provides an insight into the evolutionary process of the workforce. The training of nurses and assistant nurses was at a peak; midwives were being converted into community nurses, health inspector training was upgraded and pharmacist training had just begun (Table 8.6).

Meanwhile, growing prosperity encouraged the growth of private sector healthcare. This was associated with the continuing challenge of the brain drain of doctors, particularly those who were more experienced and specialist, from the public sector to the private sector (Ministry of Health Malaysia, 2016b). Although the production of doctors increased during the 1980s and 1990s, a sizeable proportion moved from the public to the private sector after the mandatory period of public sector service. Thus the ratio of public-to-private sector doctors remained about 50:50 (Figure 8.1). According to an analysis by Reference Hameed MusafarHameed Musafar (2014), the major contributory factors of this brain drain were the slowing of wage growth in the public sector combined with the rapid increase of private hospitals and beds, where doctors had better remuneration and working conditions.

Figure 8.1 Malaysian doctors in the public and private sectors, 1955–2013.

Sources: Calculations by the author derived from data from the Ministry of Health Malaysia (1971; 1974; 1982; 1983; 1984; 1986; 1995a; 2000; 2010) and the Government of the Federation of Malaya (n.d.).

The shift of doctors from the public to the private sector also created regional disparities. The West Coast states of Peninsular Malaysia experienced much faster socio-economic development than the East Coast states and the states of Sarawak and Sabah¹ (see Chapter 3), thus private sector healthcare was concentrated in the West Coast states, where patients could pay for these services (Figure 8.2). Consequently, the health sector faced the dual challenge of addressing brain drain to the private sector and inequitable access to healthcare between the regions.

Figure 8.2 Regional disparities in availability of doctors, 1970–2010.

Sources: Calculations by the author derived from data from the Ministry of Health Malaysia (1971; 1974; 1982; 1983; 1984; 1986; 1995a; 2000; 2010) and the Government of the Federation of Malaya (n.d.).

Several policy responses targeting health sector development emerged to address these challenges. One was the national drive to balance the inequitable development that had seen the West Coast states progress much faster than the other states (Prime Minister’s Department, n.d.b). Faster development of the less-developed states was expected to facilitate the growth of the private sector, including the private healthcare sector. Another policy was to improve managerial skills in the public sector for better efficiency (obtaining more and better outputs for the inputs) (Prime Minister’s Department, n.d.a). Better in-house personnel management was expected to address some of the frustrations of the higher-level categories in the public hospitals. A third approach was to leverage the scarce resources of skilled clinical specialists in the public sector by upgrading the competencies of healthcare workers and encouraging the adoption of a team approach by clinical specialists working together with other categories of healthcare workers. Internal MoH policies on staff placement continually struggled to increase numbers in the less-developed states. These policies resulted in changes in the health workforce profile.

Clinical competencies were upgraded through curricula changes. Some allied health professional categories were upgraded to acquire broader competencies and better remuneration, while others were phased out (Box 8.3). Simultaneously, nursing training was broadened and opened to private sector training institutes. These strategies resulted in a rapid increase in the nursing workforce. As a result, the number of people per nursing personnel was reduced from 1,879 in 1970 to 481 in 1990 (Table 8.7).

The local production of physiotherapists, occupational therapists and radiographers also increased rapidly (Table 8.2). Improved school enrolment and positive discrimination measures enabled rural students to acquire secondary education and resulted in larger numbers of better-qualified candidates for these courses. To improve managerial efficiency, doctors who occupied managerial positions at district and state levels received specialist post-graduate training in public health, while those with managerial positions in hospitals attended purpose-designed in-service management courses (Box 8.3). The establishment of new medical schools accelerated the production of doctors (Table 8.3); specialist training for doctors and for nurses was enhanced.

Various measures were introduced to redress the geographic imbalance in distribution (e.g. special allowances and housing, access to specialist training) and also to stem the brain drain to the private sector (e.g. compulsory public sector service for specified periods). However, as illustrated in Figure 8.1, the proportion of doctors in the public and private sectors did not change until the end of this period. The flow to the private sector was merely contained and not reversed. Also, although the availability of doctors improved steadily, the gap between the West and the East Coast states of Peninsular Malaysia narrowed only after 1995, while the gap with East Malaysia remains challenging even today (Figure 8.2).

Systemic factors driving individual and collective choices have contributed to the persistence of the gap. Doctors in East Malaysia face more difficulties in accessing facilities such as education for children and entertainment, as well as distance from extended families (Ministry of Health Malaysia, 2016b). Additionally, both public and private hospitals are in places with higher population density for economies of scale; with doctors and medical staff of other higher categories concentrated in hospitals, the pursuit of efficient resource use inadvertently contributes to inequalities. Finally, private hospitals are concentrated in more prosperous regions, where the community has the ability to pay for services. These factors jointly create conditions for the inequitable distribution of human resources, and especially of doctors.

The challenges of regional inequalities notwithstanding, overall access to healthcare has increased, with a significant proportion of this increase resulting from private sector expansion (Table 8.8), and utilisation has increased along with access (Figure 8.3).

Figure 8.3 Utilisation of outpatient services in Malaysia.

Source: Reproduced from Health Policy Research Associates et al. (2013).

8.4 The Third (Most Recent) Phase of Development (2000s through to 2017)

After the turn of the century, macroeconomic policies focused on achieving ‘developed country status’ by 2020, which included eradicating poverty and redressing imbalances, building a knowledge-based society and strengthening human resource development with higher levels of knowledge, technical and thinking skills (Economic Planning Unit, n.d.). Globalisation and information communication technology increased, as did urbanisation (62% in 2000) (Department of Statistics, 2001). Lifestyles changed, particularly in relation to food and exercise habits (Reference LimLim, 2016; Koh et al., 2015), and migration increased (an estimated 0.23% of the population) (Department of Statistics Malaysia, 2019), with a sizeable proportion of undocumented migrants. All these forces impacted on the health status of the community (see Chapter 3). While the prevalence of NCDs was rising rapidly, some CDs re-surfaced (tuberculosis and dengue) while new threats emerged (HIV/AIDS, severe acute respiratory syndrome (SARS)) (see Chapter 6). Meanwhile, public expectations of health services also increased, influenced not only by rising economic and education levels but also by readily accessible information through electronic connectivity (see Chapter 3).

Medical technology in clinical, imaging and laboratory sciences developed rapidly, bringing with it demands for more varied and higher levels of competencies in the health workforce. These demands on the health services were mirrored by demands from the health workforce for better recognition, higher levels of education and better wage scales. Table 8.9 illustrates how different socio-economic changes at that time influenced the evolution of the health workforce.

A confluence of pressures from socio-economic forces, population behaviour, technological advances, and demands from health service delivery and the health workforce resulted in changes in three related but distinct developments in human resources for health, namely:

1. 1. Basic (pre-employment) education programmes for health and allied health professionals increased their entry requirements and became more focused on achieving defined exit competencies, replacing the earlier implicit and often vague academic standards. A wide range of education programmes for health personnel that hitherto had been under the purview of the MoH were transferred to universities and colleges under the purview of the MoE so that they could have diploma- or degree-level qualifications that commanded higher remuneration packages.

2. 2. A wider range of categories of health personnel, particularly allied health personnel, was produced and employed. By 2014, there were 31 categories of allied health professionals employed by the MoH (Ministry of Health Malaysia, 2016b). They required relevant governance mechanisms (qualification standards, practice regulations, remuneration packages, career pathways) (World Health Organization, 2014).

3. 3. Demand for specialists increased, bringing with it challenges in ensuring standards of quality, appropriate remuneration, distribution and access. This in turn gave rise to the need for managing standards for quality (specialist registers, accreditation, credentialing and continuing education) and remuneration packages (World Health Organization, 2014).

Dichotomies between the health and education sectors and between the public and private sectors in education and health were major structural challenges that affected all the above three aspects of development, which in turn constrained health service delivery. The education sector produced health personnel, while the health sector utilised them. There was a dichotomy in the vision and motivations of education and health between the public and private sectors. In both education and health, the public sector focused on societal expectations within tightly controlled budgets and the private sector on commercially viable and competitive enterprises. Box 8.4 summarises the Malaysian experience.

8.5 Workforce Performance

The performance of the health workforce is intimately related to its equitable distribution and utilisation, client satisfaction and quality of healthcare. This sub-section provides information on selected indicators of the performance of the workforce.

8.5.1 Equitable Distribution

Specialist doctors are the most expensive category of healthcare worker and the category for which equitable distribution is the most difficult to achieve. The distribution of selected illustrative key specialist doctors in 2013 was, as expected, highest in the West Coast states of Peninsular Malaysia, but there was a much smaller difference between the Peninsular East Coast states and East Malaysia (Figure 8.4).

Figure 8.4 Distribution of selected specialist doctors in Malaysia, 2013.

Source: Ministry of Health Malaysia, 2016b.

8.5.3 Satisfaction

Human resources play a large role in determining client satisfaction with healthcare services. The community perception module of the 2015 National Health and Morbidity Survey obtained user satisfaction scores on several aspects of services in clinics and hospitals in the public and private sectors. In terms of provider behaviour, more than 70% of users of clinics and hospitals recorded satisfaction levels of ‘good’ or ‘excellent’ in terms of ‘ability to give diagnosis and treatment’, ‘give clear explanations’ and ‘courtesy and helpfulness’. There was little difference between the satisfaction levels reported by users of public and private facilities (Figures 8.5 and 8.6). However, among the other aspects of care, the main source of dissatisfaction regarding public sector clinics and hospitals was waiting time, whereas that for the private sector was treatment charges (Figures 8.5 and 8.6).

Figure 8.5 Reported satisfaction with public and private clinics, 2015.

Source: Institute for Health Systems Research, n.d.

Figure 8.6 Reported satisfaction with public and private hospitals, 2015.

Source: Institute for Health Systems Research, n.d.

8.6 Conclusion

In the Malaysian experience, the evolution of the health workforce was determined by the demands of the evolving service delivery system and the capacity of educational institutions, both local and foreign, to produce health workers. As noted in earlier chapters, the evolution of service delivery patterns was influenced by evolving socio-economic status, demographic profile and morbidity and mortality in a community. In parallel, educational status and evolving socio-economic status influenced the evolution of educational institutions. This interaction between demand and supply was moderated by financing and governance measures that evolved over time in recognition of the competing pressures from the larger ecosystem on the demand for and supply of health workers.

Governance and financing mechanisms flexibly shaped the health workforce in response to demands from the health services as they evolved in response to population and health demands.

Legislation required registration and annual licensing for practice key professions, resulting in:

• control of unqualified practitioners, and

• standards for practice defined by recognised qualifications and sources of qualification.

Education standards for curriculum and quality were enforced during:

• the earlier phases – through licences and recognition only of institutions only in the public sector (mainly the MoH), and

• the later phases – through a regulatory authority (the MQA).

Financing of students for training has mostly been from the government for study at local public and private institutions and foreign institutions. This largely facilitated the government’s management of the composition, numbers and quality of the health workforce.

Employment: Being the major employer, the public sector can set standards regarding wage structure and benefits packages. However, in the case of specialist doctors, where demand exceeds supply, pressures from the private sector created the necessity for the public sector to upgrade its benefits package.

Foreign inputs have been used strategically to develop and support local resources:

• Monetary aid has been negligible.

• Technical input is used strategically to design curricula, train trainers and set standards.

• Expatriate staff have been very few, mainly for working in rural areas during the earlier years and to provide specialist skills while awaiting the development of local expertise.

The composition of the workforce contributed to the development of an affordable health system.

• Nurses were the backbone of the rapidly developing rural health service that responded effectively to conditions of high maternal and infant mortality (Reference Pathmanathan, Liljestrand, Martins, Rajapaksa, Lissner and de SilvaPathmanathan et al., 2003) and remain the dominant category in the health workforce. They far outnumber doctors.

• ‘Task shifting’, although not acknowledged formally, has been practised throughout all phases of development in accordance with specific service needs. Anecdotal evidence suggests that it was associated with focused on-the job training (e.g. procedures in and anaesthesia by medical assistants, emergency obstetrics by nurse-midwives in hard-to-reach locations, and renal dialysis by nurses).

• Education programmes aim to build competence, particularly among nurses and doctors specialising in public health, to manage health programmes and respond to health behaviour that is influenced by the patient’s cultural and personal beliefs.

Alignment of educational curricula with the competencies required in the health sector has been achieved through effective institutional mechanisms. However, the reliance on the public sector to provide almost all facilities for acquiring clinical skills is a major impediment.

The higher categories of healthcare workers undergo relatively long and expensive training. The time lag between entry to an education programme and entry into the workforce could range from 4 years for courses of shorter duration to as long as 10–12 years for doctors. The health sector is unable to predict and prepare for large changes in the quantity or quality of entrants into the workforce, because institutional mechanisms are weak in terms of:

• providing timely information on the numbers and types of graduates the health sector can expect in forthcoming decades, and

• joint strategic planning between the two sectors to adjust production to the capacity for utilisation.

The result is an imbalance between production and absorption capacity and between production and health sector requirements. When the health sector had control over both production and utilisation, the two could be managed through relatively simpler governance mechanisms. With the evolution of systems, much more sophisticated and time-sensitive mechanisms are needed to generate information and co-ordinate policies and policy implementation tools.

The outcomes of this interaction between the supply and demand of healthcare workers impacts on the access, quality, satisfaction and safety of healthcare, which in turn impacts on the morbidity and mortality in the community.

8.7. Key Messages from Malaysia’s Experience