“We Are All Hartal”: Malaysian Contract Doctors to Strike

Author Minxi Chua Illustrator Amita Sevellaraja

Dr. Mustapha Kamal A Aziz was at work at a private clinic in Kuala Lumpur on 23 June when he read the news: Malaysia’s health minister, Dr. Adham Baba, had announced on Facebook that the recruitment of medical officers into Malaysia’s public healthcare sector would go on “as usual”.

Within the current system, medical school graduates are recruited into government hospitals and clinics as contract doctors, and must complete a three-year medical internship, known as housemanship, plus two years of compulsory service with the Ministry of Health.

Once their five-year contracts are complete, they must then compete for a scant number of permanent posts to remain employed in the public sector. Out of the 23,077 contract doctors who have entered the workforce between December 2016 and May 2021, only 789, or 3.4%, have received permanent public sector posts. Adham cited constraints faced by the MOH that prevented the creation of more posts in government facilities, such as “rightsizing” policies from Malaysia’s Public Services Commission (SPA), a central government authority that oversees the country’s civil service. He also noted that contract doctors could seek jobs in the private sector or in hospitals run by other branches of government, such as the Ministry of Defence.

To most Malaysians, Adham’s statement may not have registered as anything more than a reiteration of the status quo. But for Mustapha Kamal, a general practitioner whose contract as an MOH medical officer at Sungai Buloh Hospital ended in April 2021, it was his government telling him and his colleagues that it could not secure their jobs.

“When you say as a government you cannot provide job stability to the citizens, that’s just morally and ethically wrong. As a government, you should be the one who is fighting for the people,” he tells New Naratif, calling Adham’s statement a “blow to contract doctors”.

“[The health minister] basically told us that there weren’t any more posts and was advising us to go to the private sector,” he recalls. “All this while, we have been serving the government because of the citizens of Malaysia. …We have been trying to give the best healthcare to those in need, especially those who can’t afford private healthcare.”

According to a 2013 report by the World Health Organization, 82% of Malaysians rely on the public healthcare system for inpatient care. Only 18% can access the private system, which is considerably more expensive and concentrated in urban areas. Addressing this discrepancy, the WHO notes: “[Malaysians] with higher purchasing power use private rather than public doctors and hospitals, which leaves the public sector with more poorer and sicker patients.”

Adham’s statement spurred Mustapha Kamal to post in a private Facebook group for contract doctors in Malaysia. The content of this post was later repurposed into a poll by Dr. Fauzi Rahim, a contract doctor and friend of Mustapha Kamal’s, in the same Facebook group. The poll asked group members: “Do you agree with the date 1 July 2021 for a one week nationwide strike? (Hari Hartal Doktor [Doctor’s Strike Day])”. Some 337 group members, of about 6,000, voted yes.

The next day, on 24 June, Fauzi tweeted a call to action: “After all the BS from [MOH] and Adham Baba, its time for a nationwide strike.”

So began Hartal Doktor Kontrak, a strike movement by Malaysia’s contract doctors that has since become a national phenomenon.

Resurrecting Hartal

A flyer initially posted to the United Contract Doctors Instagram page on 27 June defines “hartal” as “a word from Indian origin” that translates to “strike”, and locates its usage within a long history of labour movements in Malaysia: “We even had a Hartal Day on 20 [October] 1947, which was carried out by laborers during that period.”

The original Hartal Day in 1947 referenced in the flyer was launched by Putera–AMCJA, a multiracial coalition that opposed colonialism and sought to enact the People’s Constitution for an independent, democratic and racially equitable Malaya, an alternative to the British-backed Federation Constitution, the precursor to Malaysia’s present-day Federal Constitution. For a single day, the entirety of British Malaya stopped working, costing the colonial government an estimated £4 million (around US$220 million today, adjusted for inflation).

In the digital age, Hartal Doktor Kontrak organisers saw an opportunity to resurrect this historical term.

“We decided to use this word because it gives our movement uniqueness and diversity,” Mustapha Kamal tells New Naratif. “Instead of using the usual words, like ‘solidarity’, we used ‘hartal’ because it gives us a lot of attention. People will ask us: ‘What is hartal? Why hartal?’ That’s the kind of publicity that we wanted to bring to the movement.”

Unlike the original Hartal Day, which was led by political parties and labour unions, Hartal Doktor Kontrak has arisen more spontaneously, and its organisers have stressed that it is not a political movement.

“We have a small group that brainstorms, and we get help from our friends, who are all juggling work and the current COVID situation. From there, people jump up,” Fauzi says.

“The majority of doctors who are handling COVID, about 60 to 70%, are contract officers. It’s taken a pandemic to show that we [contract doctors] matter.”

United Contract Doctors was one example of someone “jumping up” (the account has since been deactivated). The Instagram page was set up by an anonymous member of the public, independently of Mustapha Kamal, Fauzi and their team of core organisers. The organisers say they do not know who is behind the page, but they stand by its statements and have reposted the same flyer on their own Twitter account and Instagram page.

In the days following Fauzi’s 24 June tweet, the Hartal Doktor Kontrak movement quickly picked up traction on social media. The hashtag #HartalDoktorKontrak was used 18.7 thousand times across platforms between 16 and 22 July, and trended on Twitter in Malaysia on 29 June.

Fauzi says he was surprised by the public support his initial tweet attracted. “Everyone is so frustrated with the government right now,” he says.

This decentralised approach to organising, which takes advantage of the anonymity and speed of social media, has placed Hartal Doktor Kontrak at the centre of national conversation about the public healthcare system, labour rights and the government’s ability to steer Malaysia through a devastating pandemic. The movement has attracted regular media coverage, and politicians from both sides of the aisle have called on the government to fix the broken contract system.

Mohamad Hasan, popularly known as Tok Mat, deputy president and election director of the United Malays National Organisation, shared a Facebook post on 27 June referring to the current contract system as “#modernslavery”, and commented that “the pandemic proves how much our medical system really needs radical improvement and renewal”.

The Malaysia Medical Association, which seeks to promote the rights of doctors in the country, released a statement on 29 June saying that the contract system has “led to discontentment, departures from the civil service and Malaysia, and an exhausted health workforce” and that the proposed strike “suggests that the government has failed to adequately protect [contract doctors’] welfare.”

“Since the contract system came about, we’ve always been told that there’s a surplus of doctors. Now, we’re scrambling for doctors. When did a surplus suddenly become a shortage?”

However, not all responses to the Hartal Doktor Kontrak movement have been supportive. The MMA’s Section Concerning House Officers, Medical Officers and Specialists (SCHOMOS) has condemned the strike, citing a need to prioritise patient care, especially in light of the ongoing pandemic. Health journalist Boo Su-Lyn published an opinion essay opposing the hartal movement, claiming it is “not punishing the government with the strike, but ordinary Malaysians”.

Even some contract doctors have expressed doubts about the planned strike. Aisha*, a contract doctor in Kuala Lumpur who is not part of the Hartal Doktor Kontrak organising team, learned about the strike on social media and says she has mixed feelings about it.

“We definitely need our voices heard, but I’m not sure if striking is the best way,” Aisha says. “My own ethics are that I would continue to do my duty and come to work.”

Malaysia has been under its third Movement Control Order since 1 June, a strict nationwide lockdown that limits travel and business operations within the country. Though MCO 3.0 was enforced to contain COVID-19, the number of new cases across the country have only exploded in this period, with a record-high 13,215 new cases recorded on 15 July, as opposed to the 7,105 cases recorded on 1 June—a 85% increase, despite 45 days of lockdown. Healthcare workers say that this spike in infections has pushed the country’s medical services to the brink, and have posted photos and videos on social media of COVID-19 patients sharing oxygen tanks and cardiopulmonary resuscitation being performed on hospital floors due to a lack of patient beds. As an alternative to the strike, SCHOMOS organised Code Black, a protest initiative that called for contract doctors to come into work wearing black between 1 and 12 July.

The Hartal Doktor Kontrak organisers tell New Naratif that they see the Code Black initiative as synergistic with their own. However, they remain firm in their decision to strike. The plan is for contract doctors to stage a “no-show” at work on the proposed strike date—originally set for 1 July, but later changed to 26 July—with a caveat exempting doctors posted in COVID-19 and ICU wards.

Dr. Deeban Ramasamy, a contract doctor on the Hartal Doktor Kontrak organising team, says: “We will try to minimise [those doctors], because obviously, patient care is of the utmost importance. But there will be a substantial movement to show our dissatisfaction.”

The 1982 Strike

Just as this is not the first hartal in Malaysian history, it is also not the country’s first nationwide doctors’ strike.

Dr. Michael Jeyakumar, a practicing doctor and chairperson of Parti Sosialis Malaysia, spoke to New Naratif about his role in the 1982 Malaysian doctors’ strike, which he organised as a founding member of SCHOMOS. The organisation had been dormant for five years prior to 1981—the year that Jeyakumar entered the workforce, beginning a decades-long career as a government doctor (he moved to private practice when he stood for election in 2008). The strike organisers demanded an increase in housemanship wages, as well as better working conditions and training opportunities for housemen.

Multiple hospitals across the country took part in the strike, though some doctors still treated patients in secret, Jeyakumar says. He considers the strike a success because the government ended up improving terms of service for housemen following the strike, most notably by increasing their starting civil service rank, guaranteeing an immediate promotion in rank following five years of service, and having their first two years in the workforce accepted as civil service. Civil service ranks in Malaysia are set by the SPA and determine fundamental aspects of a civil servant’s labour conditions, such as their pay scale, as well as access to paid leave and other benefits.

However, the 1982 doctors’ strike also riled the government. Jeyakumar says his hospital director at the time received a visit from the Special Branch, the Malaysian intelligence agency responsible for investigating subversive activities.

“There was a lot of pressure. It’s not difficult for them to clamp down,” he says.

Similar tensions between the government and its medical officers have arisen in the wake of the Hartal Doktor Kontrak movement. Under Malaysia’s 1998 Public Officers Regulations Act, MOH medical officers are prohibited from making public statements to the media that might be construed as critical of government policies, except in exceptional circumstances. Earlier this year, the MOH’s secretary general released a statement reminding medical officers of this gag order. The statement was then recirculated on 22 June, a few days before the Hartal Doktor Kontrak movement began. MOH officials have also reportedly threatened to deregister doctors who participate in the strike.

On his personal Twitter account, Fauzi has shared messages from fellow contract doctors who describe being harassed and surveilled by police and hospital authorities. According to the Hartal Doktor Kontrak organising team, which is made up of around 10 to 15 people, contract doctors have received phone calls from police about their participation in not only the strike, but also SCHOMOS’s Code Black protest; they have been questioned by supervisors for wearing black to work as per Code Black’s instructions and received warnings from hospital administration that those found supporting or even speaking to the Hartal Doktor Kontrak team would face disciplinary action. For a movement that is fighting for job stability for junior doctors, it is this prospect of no longer being able to work in healthcare that most worries Hartal Doktor Kontrak organisers.

“Worse case scenario—you get your contract terminated, and you’re out of a job,” says Deeban. “You will never be deemed hirable by [MOH] or any other government agency.”

A Decade of Decline

On 1 July 2021, the day Mustapha Kamal originally proposed as a strike date, Hartal Doktor Kontrak released a memorandum listing two demands: that the Malaysian government offer permanent appointments to all 23,077 existing contract medical officers; and that the government provide a detailed explanation of the selection criteria for permanent appointments. If these demands are not met by 26 July, the organisers say, contract doctors across the nation will go on strike.

The move has received some criticism. In her essay, journalist Boo Su-Lyn writes: “[D]emanding the instant creation of more than 22,000 jobs is unrealistic.”

The Hartal Doktor Kontrak organisers have clarified that they do not expect permanent posts immediately. Rather, they want the government to address “the crux of the problem”—the contract system itself.

The contract system for medical officers was originally announced by the MOH in December 2016. Previously, medical officers who completed housemanship training were guaranteed permanent posts in government healthcare facilities, as well as the civil service ranking of UD43. However, medical officers who have since entered the workforce are now employed on five-year contracts, with a service rank of UD41. They are paid RM664 (US$157) less per month and offered fewer benefits (such as childcare leave, educational leave, and leave for serious illnesses like cancer) than their permanent counterparts, despite sharing similar responsibilities in the workplace.

Most importantly, they are not afforded the same opportunities for education and job advancement as permanent medical officers, as they are not eligible for local postgraduate courses, which are one of the primary means by which Malaysian doctors can train to specialise. The other main pathway requires MOH medical officers to work in the public sector for at least seven years continuously—two years less than contract doctors are guaranteed. Without specialisation, contract doctors at the start of their careers cannot compete in or benefit from the private sector, as they enter a market already oversaturated with general practitioners. It is also virtually impossible for junior doctors to become specialists outside public hospitals, due to insufficient patient load and variety to facilitate training in private healthcare. The Hartal Doktor Kontrak organisers who are still in public service have cited this lack of opportunities for career progression as the main reason for their unwillingness to enter the private medical sector.

“If you go to any hospital or clinic, contract doctors are there doing the same job [as permanent doctors].”

Like many other young Malaysians in the workforce today, contract doctors in public healthcare exist in a state of employment limbo, where they must fulfill the responsibilities of a full-time job absent of job security. They must await one-off contract renewals every one or two years to remain employed , but are not guaranteed promotions or pay raises regardless of years served with their employers, unlike their permanent counterparts. For reference, a MOH specialist doctor, if promoted to the highest rank of UD53 in the civil service, can earn up to RM13,256 (US$3,131) per month—350% more than a contract doctor.

Ironically, the contract system was itself introduced as the temporary solution to a different dilemma. Starting in December 2016, medical school graduates were given five-year MOH contracts to fast-track their entry into the workforce—some had been waiting for work placements for up to a year until that point due to an overabundance of graduates and a shortage of placements. However, MOH has not given them any indication since then as to how, when or even if the contract system will end. This uncertainty is what the Hartal Doktor Kontrak organisers seek to remedy. While they do not have a timeline in mind for the implementation of an improved system, they stress that the government must publish a full and comprehensive selection criteria for permanent posts immediately.

“Given that the government has had five years, we’re gracious enough to give them three weeks,” Deeban says. “We’re not asking for permanent positions right now… We just want a proper long-term plan.”

Jeyakumar is also critical of the government’s failure to plan ahead, even before 2016.

“This mess that we’re facing now is because of 10 years of poor conceptualisation [and] poor execution,” he says. He believes MOH accredited too many private medical colleges too quickly, resulting in the glut of medical graduates that the contract system was invented to deal with. Other Malaysian doctors have echoed this opinion.

Jeyakumar also sees the rise of private medical education as tied to that of the private healthcare industry, which has led to the underfunding of Malaysian public healthcare, a dearth of specialists in public hospitals, and, consequently, their inability to train large numbers of incoming junior doctors. The 2013 WHO report states that Malaysia has “struggled… to integrate and regulate its rapidly growing private [medical] sector”, noting that there are 46% more private hospitals in the country than government hospitals—despite 77% of patient beds being located in the latter.

The end result is a public healthcare system with more patients than it can handle, yet without the budget to hire more doctors on a permanent basis to care for them, or to retain specialists with the expertise to both train new doctors and treat the millions of Malaysians with acute health conditions that cannot afford private healthcare.

“[The contract system] is a consequence of the weaknesses in governance,” Jeyakumar says. “But having said that, it’s not fair to let the young doctors bear the brunt of it.”

MOH did not respond to New Naratif’s request for comment about its apparently contradictory statements, its alleged threats against doctors voicing support for the strike, and its role in the deterioration of Malaysia’s public healthcare system.

MOH has made few public comments on the strike, though notes from private meetings between contract doctors and their supervisors, which have been shared online, paint the MOH as indifferent to the doctors’ plight. Malaysian Medical International, an organisation for Malaysian medical students, also criticised the ministry for its lack of transparency, as a full selection criteria for appointing contract doctors to permanent posts have never been released.

Last Resort

Malaysia has been in a state of emergency since January 2021, and parliament has not convened since. However, Prime Minister Muhyiddin Yassin announced recently that a parliamentary sitting will take place on 26 July—the same day as the proposed doctors’ strike. The announcement follows months of political turmoil and mounting dissent amongst Malaysians, who have taken to social media to express their anger through hashtags like #KerajaanGagal (#FailedGovernment) and #Lawan (#Fight).

Muhyiddin has also said that the Cabinet will review the proposal calling for all contract doctors to be given permanent posts, noting that the process could cost the government up to RM 2 billion (US$471 million).

The contract doctors that New Naratif spoke to say they see the strike as a last resort. As their five-year contracts near their end—Deeban’s contract will end this August; Fauzi’s and Aisha’s in October and July 2022, respectively—each of them describes feeling desperate and frustrated.

“When I started working, we were told that the contract system is just for a while,” Aisha says. “I think what’s really making people very wary is that there doesn’t seem to be any solution in sight. …There’s no light at the end of the tunnel.”

While she reiterates that she will not participate in the strike, she says she still supports the hartal movement: “I think the reason why they have to be so drastic is to get people to pay attention to the issue. …If you go to any hospital or clinic, contract doctors are there doing the same job [as permanent doctors]. …Obviously, there’s a need for us. I just wish they would realise that and stop messing us around.”

“We have been trying to give the best healthcare to those in need, especially those who can’t afford private healthcare.”

This sentiment is shared by Deeban, who works in a high-dependency COVID-19 ward and treats patients who are deteriorating from the disease.

“The majority of doctors who are handling COVID, about 60 to 70%, are contract officers,” he says. “It’s taken a pandemic to show that we [contract doctors] matter.”

As COVID-19 cases and death tolls rise and medical experts and workers fear a total collapse of the country’s healthcare system, the contradictions and failings of the contract system have become clear. The Hartal Doktor Kontrak organisers have also reported increased numbers of contract doctors quitting their posts with 24 hours’ notice, citing burn-out and disappointment with the government’s perceived lack of response to their movement.

“Since the contract system came about, we’ve always been told that there’s a surplus of doctors,” Deeban says. “Now, we’re scrambling for doctors. When did a surplus suddenly become a shortage?”

A Multiracial Malaysian Movement

In his 23 June statement, Health Minister Adham referenced a proposal by the Malaysian Public Health Physicians’ Association (PPPKAM), originally reported on by Utusan Malaysia, and the Malaysian Muslim Doctors Organisation that MOH prioritise contract doctors who are Bumiputera—Malay or indigenous—for permanent posts.

MOH has since clarified that it does not support the proposal, and PPPKAM denies having made the suggestion at all.

The Hartal Doktor Kontrak organisers say that they oppose any race-based solution to the contract system problem. Mustapha Kamal also emphasises the inclusive aims of the Hartal Doktor Kontrak movement.

“We treat our patients regardless of ideology, race or religion,” he says. “If you’re a doctor, whatever your ideology [or] the color of your skin is, what’s most important [to this movement] is that you want to see a reform in the healthcare system.”

Despite his departure from the public sector, Mustapha Kamal’s dedication to reforming Malaysian healthcare for all remains firm.

“This [contract system] issue is not just about us. It’s about the nation,” he says. “That’s why we’re going to keep fighting until the issue is resolved.”

Fauzi, referring to the strike organisers and the members of the public who have thrown their support behind the contract doctors, described their resolve with one simple phrase: “We are all hartal.”

*A pseudonym has been used at the person’s request due to their fear of reprisals by the Malaysian government.