Overcrowding at government hospitals

The National Audit Department found in its most recent report that emergency and trauma departments (ETD) at certain Malaysian hospitals were “understaffed, overcrowded, underfunded and under equipped, with an additional footnote that waiting times were increased in some instances”.

The Ministry of Health rallied, and rightly so, to explain clearly that despite this, services were continuing unabated and being delivered without any sort of disruption and that the MOH would continue to shoulder the heavy responsibility of delivering health to the best of its capacity to all Malaysians.

We laud our colleagues in MOH who struggle daily with the ceaseless task of providing frontline care. As someone who worked alongside them in the trenches, I can’t help but commiserate with the report which also mentions issues such as staff fatigue and “burnout”.

At the same time, I can’t help but wonder: Can’t we possibly look at fixing this problem?

Well, before we find and implement any solution, we need to take a closer look at what’s really the problem.

Why are our ETDs crowded? The audit report, for example, highlighted that patient visits to ETDs are increasing between 2-3% annually.

Some of the reasons for Malaysians seeking treatment at ETD are as follows:

1. It’s convenient. MOH practises a “No wrong door policy” where patients are not turned away, so for many it’s just convenient to go to ETD.

I remember as an ED house-officer working in Hospital Kuala Lumpur on Saturday nights. A patient came at 2am with foot pain. “Just finished seeing midnight movielah Dr, so thought since I was awake might as well…..”.

The audit report also highlighted this fact as one of the problem’s contributors, namely the use of ETD for non-emergency purposes.

2. It’s open. ETD is open 24 hours 7 days a week. Many come including during odd hours because that’s the only time that they are able to obtain medical help. Daily wage-earners and small-business owners are really unable to access office-hour services, which pretty much means more than half of the MOH services are unavailable to be used by them.

So, they end up at ETD when they are able to. MOH really understands this, which is why they practise the “No wrong door policy”.

3. It’s almost free. The RM1 charge is a powerful “pull” factor to use ETD especially at night. Many patients who cannot afford care, as well as those who can, choose to visit ETDs compared to paying for equivalent services at private hospitals or all night-clinics which charge significantly higher.

The reason I use the comparison of night-time visits is simply because, in many cases MOH’s Klinik Kesihatan already operates on extended hours between 5-9pm; complemented by the Klinik Komuniti (formerly known as Klinik 1Malaysia) which works till 10pm in designated areas.

I already see people railing on this issue and using it is as a blunt instrument to bash MOH and the public healthcare system as a whole, saying things ranging from “Medical staff should work harder and do their jobs better in the public healthcare sector,” to “So many staff also they complain of being overworked all the time…”, to “Every time also, I see them sleeping”.

This is the reason MOH rallies behind the ETD staff and its entire institutional system as a whole. The audit report highlights shortages in staff and equipment, with some “leasing” strategies being touted as mechanisms to help fix the problem.

Other short-term strategies will include putting in more staff into frontline care, and of course this will end up costing a lot more to MOH’s budget.

Overcrowding at ETD is perennial, and not unique to Malaysia alone. In fact most countries which have almost free provision of healthcare services suffer from a similar fate.

As usual, calls also abound for more resources to be given to MOH to increase their resources to cope with this ever-increasing number of patients at ETD. One should not forget that it is also the gateway to admission at government hospitals.

More patients coming into ETD, irrespective of whether they are genuine emergency cases or not, mean more admissions to the hospitals, translating into higher costs for MOH overall.

How long can we keep increasing the healthcare budget to cope with this kind of influx of patients into the government hospital setting?

The NHS in the UK, the forefather of our system, itself has evolved many times in order to keep up with the changes in provision of healthcare to its people. But we still struggle with this despite having enough resources to deal with the problem.

Just across the proverbial road is our private sector including our extensive private GP network and private hospitals.

But is the public sector healthcare chicken ready to cross the road?

The views expressed are those of the author and do not necessarily reflect those of FMT.