How Can Talent Be Retained and Developed?
Dr Noor Hisham Abdullah
Ministry of Health (MOH)
I would like to begin by welcoming everyone to the International Investor: Health and Wellness Strategic Review 2016. The first debate in 2015 succeeded in bringing together important stakeholders to share best practices and general opportunities and challenges, in addition to how the ideas raised could be put into practice. The aim of this year’s meeting is to focus on a more clearly defined area, that of talent development and human capital in healthcare.
Talent is the most important asset in any organisation. Therefore, this discussion will concentrate on how the Malaysian healthcare sector grooms its talent and what steps are being taken to ensure that individual health workers are able to perform to the best of their ability on an ongoing basis.
Our debate will be framed in the context of the quality of care provided to patients and it is important to discuss a range of issues, from public and private sector convergence on training, to tracking performance data. However, I would like to begin with one of the major challenges facing Malaysia in terms of human capital: the retention of talent. How can stakeholders in the Malaysian healthcare industry address this brain drain and what are the priorities moving forward?
Dr Zaleha Abdullah Mahdy
UKM Medical Centre
A crucial part of retaining healthcare talent in Malaysia relates to good working conditions. This goes beyond attractive remuneration and includes the provision of a working environment conducive to career development. If these kinds of working conditions can be secured, the industry will go a long way towards becoming sustainable in the long term.
Dr Noor Hisham Abdullah
Healthcare training in Malaysia is generally provided in the public sector while the brain drain occurs towards the private sector. The critical aspect is therefore how the industry identifies the right balance between these two ecosystems so that talent is retained in the public sector and how, in conjunction with the private sector, skilled professionals can be encouraged to remain in Malaysia rather than developing their careers abroad.
As Dr Zaleha mentioned, working conditions and remuneration form a central part of this debate. Dr Azhari, what are the other priorities for stemming this brain drain?
Dr Mohd Azhari Yakub
National Heart Institute (IJN)
The priority is to stop the divergence between public and private healthcare in Malaysia. The example of IJN is useful in this regard because it sits between the two sectors. Given its particular status, the base structure of IJN is more flexible than, for example, that of the government, and so the institute has been able to put forth a financially sustainable model. It is critical that both the public and private sector follow this example.
With a sustainable financial model in place, emphasis can turn to human capital. For example, IJN spends approximately MYR4.5 million per year on staff training and development, which accounts for about 3 per cent of our human resources budget. The institute sponsors its own doctors, who agree to work with IJN for a set amount of time, and frequently sends them overseas for capacity building at its own expense.
Talent development is a top priority for IJN and so the institute is happy to collaborate with the government to address ongoing challenges. For example, we assist the government in the development of Masters students by approving approximately MYR4 million a year in postgraduate sponsorship. Under this scheme, a small number of postgraduates that specialise in cardiovascular or thoracic care may spend six months of their four-year university course at IJN. Despite the fact that we receive no direct return on our investment for the remaining three-and-a-half-year period, we are very happy to engage in such financing to address the shortage of specialists in Malaysia and to fulfil our goal to help create a more sustainable healthcare model.
In terms of ways to stem the brain drain to the private sector, one potential option is to implement a scheme similar to the government’s Human Resources Development Fund (HRDF). The HRDF is administered by Pembangunan Sumber Manusia Berhad (PSMB), an agency under the Ministry of Human Resources. As part of its wider efforts to help Malaysia become a high-income economy by means of human capital development, the HRDF encourages employers to retrain and upgrade the skills of their employees, apprentices and trainees in line with their business needs and the development strategy of the country. Significantly, the scheme enables employers to receive up to 100 per cent financial assistance to cover the training costs incurred, and employees can receive workplace training, expertise and certification.
A similar initiative applied to the healthcare sector, particularly in regard to specialist training, and into which, for example, contributions were tax deductible or based on tax incentives, would engender the sustainable and balanced ecosystem required in training and talent development in the country. It is important that one of the primary goals of any such fund is to incentivise private sector contribution. Towards that end, its co-management by the MOH and the Association of Private Hospitals of Malaysia (APHM) would help to validate the fund further.
Professor Dr Awang Bulgiba Awang Mahmud
University of Malaya (UM)
To improve convergence between the public and private healthcare sector, the UM created a limited private practice, the University of Malaya Specialist Centre (UMSC), in approximately 2002. The UMSC is a tertiary level medical centre and it provides a range of specialist services. One of its objectives is to prevent brain drain to the private sector by increasing remuneration and improving the overall working environment in the public sector.
Consequently, salaries in the UMSC are comparable to those in the private sector, particularly for the more independent, procedure-based specialties such as orthopaedics. However, more needs to be done to overcome the flight of specialists to private hospitals once they have completed their training in the public sector.
Dr Noor Hisham Abdullah
The main issues raised so far are remuneration and working environments conducive to career development. Accordingly, work is underway on the creation of private wings in the public sector, in institutions such as UMSC for example, in an attempt to improve both these factors.
For example, following the Country Health Plan: 10th Malaysia Plan 2011-2015, locum doctors have been allowed to practise in the private sector. Discussions are also underway to modify the existing framework to provide more flexibility for public doctors to work in the private sector for one or two days a week. There is also debate on enabling private sector doctors to return to the public sector in a similar capacity.
In addition, conversations are being held about doctor remuneration in the public and private sector and possible moves to make it less rigid, for example modifying the monthly payment system in which individuals work from 8:00am to 5:00pm to a sessional system in which private specialist doctors are able to treat public patients on a fee-per-session or fee-for-service basis.
All such efforts to improve doctor remuneration and working conditions are also geared towards improving patient choice and the accessibility of quality of care. Accordingly, under the MOH’s Full Paying Patient Services scheme, patients are able to select and pay for treatment from experienced specialists across a network of 32 public hospitals.
Consequently, convergence between the two sectors is becoming more common. Yee Mun, Prince Court has public sector doctors working in its facilities, so what is your experience in regard to convergence between the public and private sectors?
Chong Yee Mun
Prince Court Medical Centre
First, it is important to recognise the different models in play between the public and private sector, which are often the direct cause of many of the issues we have discussed. For example, in the private sector doctors essentially act as independent businesspersons, whereas those in the public sector are government employees.
In terms of talent development, the training fund mentioned by Dr Azhari has the potential to contribute a great deal. However, this discrepancy between how individuals, particularly doctors, operate in the public and private sectors is one of the biggest obstacles to the smooth management of any such fund. Accordingly, legislation is required to rectify the problem because the alternative is to request that doctors contribute a certain proportion of their income to a particular fund, which is, clearly, not ideal.
Public sector doctors from both the MOH and universities are allowed to see private patients in their practice in the public sector. From my experience, however, many still apply to practise in the private sector for one or two days a week for a number of reasons, including a lack of surgery time available for treating their private patients in the public sector.
Returning to your question, Director General, from my experience there are doctors from the public sector who conduct one weekly session, on Saturdays, in certain private hospitals. However, problems often arise in these situations in terms of management of patients and their follow-ups when the doctors are unavailable, as well as how practitioners can be contacted in the case of issues that require clarification. It is therefore crucial that, rather than simply expanding the system to allow public sector doctors to spend more time practising in the private sector, an in-depth approach that covers all the important areas is devised to adequately manage the needs of patients while managing all associated risks.
Dr Noor Hisham Abdullah
Overall, the aim of the government is to build bridges rather than walls between the public and private sector in an attempt to reduce the brain drain. Dr Heric, what is your perspective of the brain drain and how industry stakeholders can reverse the trend?
Dr Heric Corray
Queen Elizabeth Hospital
The internal brain drain from the public to the private sector is significant. However, it is crucial that stakeholders also begin to combat the external brain drain of human capital abroad, especially to Singapore, which is particularly active in headhunting professionals.
The reality is that government hospitals lack the resources to compete with the private sectors in Malaysia and Singapore. Therefore, it is important that stakeholders identify a range of new approaches. This includes the implementation of initiatives such as career development pathways that offer increased training opportunities and the chance to develop skills abroad for a certain period of time, prior to returning to work in Malaysia.
Many of the doctors who choose to leave Malaysia in search of professional opportunities in other countries are particularly interested in research. In order to keep this talent in-country, it is fundamental that the Malaysian healthcare sector, as a whole, affords these doctors the opportunity to conduct research at home. In turn, this necessitates the provision of research grants. In fact, a number of doctors who left their positions in the Malaysian private sector to conduct research abroad have communicated to me their regrets about leaving because their research has ended and there are no more opportunities available in this country.
A joint approach towards the enhancement of training and research opportunities for medical professionals, with a focus on the identification of a suitable means of fundraising to cover the associated costs, will help the Malaysian healthcare sector to combat the brain drain to other countries, including Singapore.
Ahmad Shahizam Mohd Shariff
The number of healthcare professionals moving abroad for employment reasons is relatively low compared to other professions. The concern for Malaysia, however, is that the external brain drain is occurring primarily during the formative stages of these individuals’ careers. This early stage brain drain consists of three levels and I will explain how it works using Singapore as an example.
The first level is the brain drain from Malaysia to Singapore at the point of entry to the local university system. It specifically relates to students yet to begin their Bachelor of Medicine Bachelor of Surgery (MBBS) degree. Many Malaysians who wish to study medicine struggle to secure places on MBBS courses at national universities and therefore turn to the ASEAN scholarships offered by the Singaporean Government, frequently applying to the National University of Singapore. Upon completion of the degree, many of these students receive a work contract from the Singaporean Ministry of Health, do their specialist training in the country’s hospitals and become a permanent part of the Singaporean system.
The second level is similar to the first and relates to the recruitment of Malaysian medical students recently graduated from Malaysian institutions. A number of international institutions target the best students and offer them numerous incentives to join their respective national healthcare systems, from work contracts all the way up to specialist training sponsorship.
The third level concerns graduates who have already undergone development in the Malaysian system but seek out junior doctor opportunities abroad. While this level is not as severe as the first two in terms of numbers lost, Malaysia is still losing out on qualified medical professionals.
The key point is that countries such as Singapore understand how to attract and retain medical talent by offering highly attractive incentives to medical students and graduates from all over the world, not just Malaysia. The difference in the Malaysian case is that the external brain drain is happening at a very early stage.
The Malaysian healthcare sector is facing a serious problem related to supply and demand and, specifically, the lack of supply, especially of experienced specialists. As a result, Pantai, together with local universities such as UM and the International Medical University (IMU), have been discussing moves to develop a manageable pipeline of specialists to increase this supply. If a natural flow of specialists between the public and private systems can be secured, the impact of the internal and external brain drain will be diminished.
Dr Nazirah Hasnan
University of Malaya Medical Centre (UMMC)
In order to retain talent at UMMC from the undergraduate to the postgraduate level, we run a Bright Sparks programme aimed at the best promising medical students at the Faculty of Medicine of UM (FOM, UM), in which scholarships are available to individuals after they have conducted their housemanship training at the centre. Once successful applicants complete their housemanship programme, they undertake their MO training based on key criteria areas identified by the hospital. Thus, the scholarship includes specialist training and goes one step further by covering subspecialty training as well.
Another step taken by UMMC to stem the brain drain at the undergraduate level is to identify the particularly talented housemen that are posted to the centre prior to them returning to the MOH for employment. By matching the most suitable housemen to the key criteria areas of the hospital, we offer them an employment contract as an MO and feed them into specialist training. This model aims to build up the centre’s own talent pool of specialists via collaborative approaches with exterior partners. By doing so, the centre is able to attract more talent on an ongoing basis, primarily because medical students are able to see that UMMC provides them with genuine development pathways.
Dr Noor Hisham Abdullah
Regarding the external brain drain to Singapore, that country is small and wealthy and its authorities are able to pick and choose the best talent from abroad. Consequently, the Singaporean Government does not need to invest extensively in medical education, unlike Malaysia.
I would like to gauge opinion on what participants think about the Malaysian private healthcare sector implementing a similar practice to Singapore and seeking a return on investment in terms of providing general and specialist training to national medical students and graduates.
Ahmad Shahizam Mohd Shariff
One important facet of this discussion is related to what Yee Mun said about private sector doctors acting as independent businesspersons. Pantai would relish the chance to directly employ its specialists, but no private consultant is incentivised to commit to just one employer under the existing system because it grants them extensive employment autonomy.
In response, Pantai is discussing training undergraduates and postgraduates under the premise that they become salaried doctors for the group for a certain period of time. These discussions have been taking place in conjunction with IMU, a private health sciences university based in Kuala Lumpur and which is a wholly owned subsidiary of our parent company, IHH Healthcare.
Accordingly, Pantai and IMU are formulating plans to construct a training hospital to train specialists. Although the facility will retain certain private sector elements, it cannot be considered as an independent tertiary level educational institution and will seek public-private partnerships to ensure success. For example, collaborative relations will be sought with public hospitals to increase the new institution’s training capacity and expertise.
Dr Noor Hisham Abdullah
That is an interesting development and lessons can be learned from the experience of Pantai and IHH Healthcare. Important lessons about training across different sectors can also be learned from IJN in terms of their development of cardiac surgeons and cardiologists. For example, trainee specialists at IJN are able to train in either the public sector, in IJN, or in the private sector. Dr Azhari, what are your thoughts on training in the private sector?
Dr Mohd Azhari Yakub
The private sector is based on a flat model because its overriding priority is profit. Thus, the system is dependent on the actions of its highest earners, which in this case are the independent specialists. To rectify this situation, it would be possible for the large group of private healthcare companies in Malaysia to collectively impose certain conditions on working practices. These changes could begin small, for example, ensuring that specialists work as part of a team rather than competing against one another in the same hospital, which is a prevalent issue. Changes could then increase in magnitude over time, gradually helping to shift private sector focus away from the bottom line of profit and towards core aspects such as clinical care results, transparency and auditing, as well as the normalisation of teaching and training to keep staff up-to-date on the latest developments.
The key to the success of this idea is enforcement. If big healthcare groups such as Pantai and KPJ Healthcare enforce these types of practices, they will become standardised and self-sustaining.
Therefore, realigning the focus of the private healthcare sector in Malaysia from its monetary and specialist-centrist approach to one that is more holistic and sustainable will have a tremendous impact on talent development. In turn, this will help to improve quality of care.
Dr Nazirah Hasnan
Given the expertise of IJN in this area, UMMC has sought collaboration opportunities with the institute in regard to specialist training. It is important that more of these kinds of partnerships emerge in which organisations from different sectors seek ways to facilitate the training and retention of medical talent in Malaysia.
For example, Ahmad mentioned efforts by Pantai and IMU to set up a new training institute in the private sphere. This represents an opportunity for the two parties involved to nurture the emerging talent in IMU and subsequently identify the best students capable of undertaking specialist training at the new institute. It is also vital that IMU, or any such private sector training entity, takes steps to pursue collaboration with public universities that offer specialist Masters programmes. The transfer of expertise and knowledge from an experienced institution to a new entity is an essential part of the provision of talent development initiatives.