Did You Know
Did You Know
“You won a Nobel Prize? Good, now go study medicine!” said the Asian father with high expectations to his son.
Think that is a joke? Well, maybe only half a joke.
Partially because of this lionising of doctors, Malaysia now has an enviable problem to solve: the over-supply of doctors.
Given its complexity, we will examine this over-supply over three articles, starting with a new way to calculate and operationalise the optimal number of doctors for Malaysia.
The current government target is one doctor to 400 citizens. One doctor served 1,519 Malaysians in 1998 and 625 citizens in 2018, a tremendous progress.
Yet. we must ask, what if this target is actually inaccurate, misleading, or worse, dangerous?
Indeed, one can even argue that the correct target is zero physicians for a society that is healthy and self-caring, with resilient communities and acceptance of death.
I estimate that Malaysia now has more than 57,000 existing doctors.
The actual numbers are not publicly available, because the latest Malaysian Medical Council Annual Report dates back to 2016.
The lack of accurate and timely public statistics in Malaysia deserves a separate article, and we won’t analyse this issue today.
Between 2011-2016, the annual number of new doctors graduating rapidly grew from 3,710 to 6,238 new doctors per year.
That’s a compound annual growth rate (CAGR) of 10.3%, a very high number. We are graduating 1.7 times more doctors per capita than even the OECD (Organisation for Economic Co-operation and Development)!
Unfortunately, we can only accept a much smaller number of junior doctors into service annually.
This is because patient care and training quality depends on the ratio of House Officers to beds, specialists and hospitals.
It also depends on the number of Public Service Division (JPA) posts, number of contracts and financial budget allocations.
Using these rates, I projected two simple scenarios using ten-year horizons (2019-2028).
If we control the numbers, we may only add 6,238 new doctors annually.
If we allow the numbers to be uncontrolled with a CAGR of 10.3%, we may add up to 19,000 new doctors annually!
Both scenarios assume that everyone receives training spots without drop-outs, and all existing doctors continue practising.
Therefore, in 2028, an estimated 40 million Malaysians could be served by a cumulative total of between 126,000-193,000 doctors.
Both scenarios achieve the 1:400 target very early, in 2021 and 2020 respectively.
Those are a lot of doctors, but we are ignoring their quality, distribution and utilisation. Our system already appears unable to absorb so many new doctors so quickly. We are victims of our own success.
To be fair, this oversupply has good news for it.
One, democratising medical education improves social mobility and reduces inequality, i.e. if students from poorer families can be doctors, they will gain financial and social capital over a lifetime.
Two, the Health Ministry (MOH) can select “the cream of the crop”, who compete for limited contracts in the public service.
Three, Malaysia will have more trained doctors who can move into important and emerging medical fields like entrepreneurship, health economics or policy.
Four, an over-supply is a kind of “health system insurance” and may even stimulate competition on price and quality over the long term, which will benefit citizens.
Not a magic number
However, all of this assumes that the 1:400 target is accurate, useful and relevant.
A different answer could be “The 1:400 target could be misleading and unhelpful, more nuanced targets could be better and lower than we imagined, and we need many other factors to improve health outcomes”.
Indeed, the popular target of 1:400 is not backed by any recommendation from any reputable body. Despite an exhaustive trawl, I found no published literature, methodology or guideline supporting this number; it seems to be from thin air.
The closest “optimal number” I could find is the World Health Organization's (WHO’s) minimum index of 4.45 doctors, nurses and midwives per 1,000 population to achieve the Sustainable Development Goals (SDGs). Malaysia achieved this back in 2013, with an index of 4.59.
It’s telling that the 4.45 index combines three groups, not just doctors. Another unsatisfactory explanation for our 1:400 fixation is the developed country average of 1:294 (more doctors did not provide better health outcomes in these countries).
Frankly, it is unlikely for anyone to issue a “global recommendation for optimal number of doctors”.
One, it’s nearly impossible as countries have different needs and are not one-size-fits-all.
Two, worshipping one target overshadows other equally important targets.
Three, such a target over-emphasises the doctor’s role in a future of aged and community care where other health professionals increase in importance.
Four, we are falsely reassured that all problems will disappear once the target is met, without considering other factors like doctor quality.
Finally, poverty eradication is the single best predictor of better health, not more doctors.
Better targets are needed
It’s possible that the 1:400 target could have been arbitrarily selected as an ambitious target.
In this case, we must officially withdraw this target and calculate more sophisticated new targets.
We must also publicly communicate the new targets and the plan on how to achieve it gradually and organically.
We cannot be rigidly chained to an inaccurate or misleading target, without a plan on how to appropriately achieve it.
To create better targets, MOH can commission a 10-year planning document that must utilise modern planning models and existing WHO tools.
That 10-year planning document must consider three important elements of our future health system: structure (more primary and community care, fewer hospitals?), funding (what is the mix of taxation, insurance and out-of-pocket payments?) and multi-stakeholder collaboration (between ministries, agencies and government-linked corporations like Khazanah).
It cannot focus just on one narrow statistic of “doctor:population ratio”.
The report must also consider the distribution and utilisation of doctors, and suggest a “steady state target” and “stable rate of replacement and growth”.
The concept of a “steady state” will introduce predictability into the health system, because we cannot be in a constant state of change.
These steady state targets can be more surgical than the 1:400 blunt instrument, i.e. they can be one general practitioner (GP) for 200-250 citizens, one family physician for 300-350, and one orthopaedic surgeon for 600-700.
The stable rate of replacement will project the number of doctors retiring or changing careers.
The stable rate of growth will project the additional doctors needed as our population increases.
All targets could be stratified by urban-rural, or primary-secondary-tertiary hospitals.
It takes five years to train a doctor, which means that ultra-long-term planning horizons are crucial.
There must be a simultaneous communication plan to the public to moderate their expectations that “not everyone can be a doctor”.
This planning exercise should be done on a 10-year schedule, with five-yearly calibrations.
An ultra-long-term planning horizon not only provides a predictable rhythm for planners, it also allows citizens to make realistic life choices that balance their ambitions with public service needs.
All things being equal, the 1:400 target did help Malaysia in many ways and the over-supply is a good problem to have.
However, it’s time to withdraw this misleading target. Instead, we can create a more accurate and nuanced set of targets that consider many other elements, is updated on predictable rhythms, and is publicly communicated to manage society’s expectations.