By Dr Larry Nyanti, a physician and senior lecturer

Recent weeks have seen an outpouring of grievances and demands relating to the plight of doctors, in both media outlets and private messaging groups. These have led to murmurs of industrial action, or simple known as “strikes”.

Our Prime Minister, Ministry of Health, Public Service Department, Director-General of Health, state directors, and hospital directors are all facing proverbial fingers pointed at them.

To put it coyly: ‘it’s getting hot in here’. In this article, I intend to present research-based data on the factors leading to strikes, the conduct of strikes, effects of strikes on patient mortality; before finally suggesting points to consider prior to planning a hypothetical strike.

Malaysia is not alone in all of this; in the UK, a ballot for NHS consultants (yes, not just the junior doctors) organized by the British Medical Association is underway to decide whether strike action should proceed.

It is no question that medical doctors working in the public sector of developing countries like ours often operate in resource-limited environments. Thus, the moral dilemma lies between protecting patients or using strikes as a means to gain better facilities and remuneration.

Much has been written on the ethics of industrial action, but one researcher sums it up best: strikes may be justified if their outcomes are sustained improvements in health care facilities that eventually serve the majority.

In this article I will explore the factors and outcomes of previous strikes, before suggesting points to consider in the context of our local situation; all the while attempting to be as objective and unbiased as possible.

Factors for Industrial Action

To begin, we should understand the reasons doctors want to initiate industrial action. Aside for a comprehensive CodeBlue-published list of 12 demands, there is an absence of other local published data (hint to Malaysian academics and data-lovers). Hence, let’s look overseas for more answers.

In the UK, continual unhappiness with pay and unfair pension tax rules are the driving factors for doctors’ industrial action. In Kenya, poor perception of leadership, exodus of health care workers, government failure to agree to improve remuneration, staffing, facilities and research funding while simultaneously abolished patient fees, leading to overcrowding and overutilization of public health care resources, are factors cited for doctors’ strikes.

Thus, it is not alien nor illogical for Malaysian public sector doctors to demand better wages, facilities, and administrative transparency.

The Lessons from Past Strikes

And yet, industrial action must not be rash or taken on a whim. We must learn from the lessons of the past; and so, let’s go on a tour of past strikes.

In 2016, Kenyan public sector doctors initiated a 100-day strike. Now, take note that two-thirds of Kenya’s health system is managed by public services. How did they manage?

Military doctors and consultants had to be deployed to replace those on strike. Non-emergency surgeries were postponed. Clinical officers (which I assume are the equivalent to our medical assistants) manned the emergency departments and consulted consultants as needed. The nurses, who initially went on strike as well, returned to work after a few days after a successful deal with the government.

In the 2016 UK junior doctor strike (48 hours at a time, monthly for four months), senior doctors and locum were called in to cover the clinical duties. Personally, I can confirm through a friend that this was the case. Also, the British Medical Association lent its support throughout the entirety of the pre-strike and strike process (no need to cite this, they were releasing statements and were everywhere in the news).

Do strikes lead to proportionally higher patient deaths? No. In the UK, there was no detectable change in mortality. The same conclusion was found in post-strike analysis in Kenya and in other countries.

The exception? A 20-day strike in South Africa in which one hospital left running had to cater to 5.5 million people in one province. Before naysayers point out the gaping holes in my point, I’ll admit that current data does not cover the effects of strikes on morbidity and quality of care.

Reflection Points

What does this all mean for Malaysian doctors planning for industrial action (hypothetically)? Here are the suggested points to reflect on.

1. The role of representative bodies

The MMA has been vocal, but to some, has oft opted for the path of least resistance (if one remembers Hartal). If, hypothetically, a strike was to be planned, it should follow the UK model of firstly establishing that its doctors indeed do agree for a strike.

This may be done by ballot. The ballot should be anonymous, conducted without fear of repercussion, but also regulated in a way to prevent double-voting. Industrial action, without representative body support and a unanimous voice, will lead to nothing.

Just look back and reflect on the various stories that abound of gatherings by hospital directors to address a list of anonymous complaints which often end in no one speaking up. Perhaps in our nature, we are timid and mild; not willing to offend. Thus, a representative body could contribute to overall confidence to spur action.

2. The role of consultants and senior administrative doctors

Is it possible that the higher-ups do not see the same picture as junior doctors? This is merely intuition.

Let’s imagine: the higher a doctor progresses in the public system, the larger their rewards, the higher the stakes. Thus, the more muted they become. In reality, it is difficult to pressure consultants with a bleak future of dwindling specialty trainees or “not enough manpower”.

After all, they came from a time of deep resource constraints and they know that specialty spots are limited, and will always be filled up, somehow. After all, one is never indispensable in the public system. There are a few exceptions to the rule, but as it stands; it’s imaginable to think, “I’ve worked so hard and so long to get here, why jeopardise it?”

Consider also the realities of adulting and growing old; one settles down, has kids, tries to stay in one place, and cares for their elderly parents. They start to take on administrative responsibilities and are hit hard with the constraints of the system.

Many feel obliged, even tied-down by their duty to the public. Many have to answer to higher-ups in state departments to satisfy KPIs.

All these, while trying their best to pursue their own career interests and passions. Dealing with their inner frustrations while putting up a brave front for the department, or hospital, is a daily battle. Is it no wonder that many consultants can only offer a sympathetic look when faced with conversations about strikes or resignations?

Industrial action only succeeds with the backing of administrative support – otherwise, one would expect a hospital or state director to release a letter banning strikes or threatening repercussions.

Thus, it is logical that doctors (hypothetically) aiming for industrial action engage consultants and senior administrative doctors to at least agree to work during the proposed strike hours, and for administrative doctors to (hypothetically) make concrete plans to ensure clinical services are kept to a minimal acceptable level of functioning.

This may require extra help from the nurses and medical assistants. This was an essential factor in the UK strike, and will protect patients.

In the unlikely situation that consultants join the strike, there arises the need to hire military consultants (as was done in Kenya), private sector consultants (as was done in the UK) and even doctors from academic institutions to aid the effort.

3. The role of the public and media

Hypothetically, members of the public should be duly informed about the strike dates and times, urged to seek private health care if they can afford to, and avoid overutilising public services, throughout the strike.

The media should be duly engaged, given press statements from relevant representative bodies, and interviews can be conducted prior to the strike. Based on previous studies, researchers found that emergency department visits dropped drastically during strikes, which may have contributed to reduced mortality numbers.

4. The role of private hospitals and university hospitals

While there isn’t much data on this, one may theorise that pre-strike engagement with private and academic institutions may allow for reduced burden on public hospital services during strike action.

Perhaps emergency departments of private or academic hospitals can offer reduced rates on triaging and initial assessment, as an example.

5. The role of legal practitioners

It is imperative that the legalities of industrial action are consulted, prior to a hypothetical strike. We all know why. Legal practitioners may consider pro-bono services to those who face legal repercussions after a said strike.

6. Sustained and continual engagement with policymakers and stakeholders

At the end of the day, an impending strike may move the hands of those in power, lead to agreements that satisfy all parties – thus averting the strike from happening. In an ideal world, everything I’ve written above need not happen, if the government can sit down and reach a win-win agreement with public sector doctors.

Even if the strike were to proceed, continual engagement with the relevant ministries and stakeholders is essential.

In conclusion, research shows that industrial action is theoretically justified if it results in better patient outcomes, and the conduct of a strike is feasible with enough support and does not seem to increase patient mortality.

However, before considering any industrial action, doctors must continually engage policymakers and health care stakeholders, reach a voice of unison amongst the medical fraternity, lay down steps to avoid harm to patients, fully appreciate the legal implications of such action, and seek protection for medical practitioners involved to avoid unnecessary and unlawful repercussions.