When Health Minister, Datuk Seri Liow Tiong Lai announced that the 1Malaysia clinics will go on operating without doctors, it stirred up a bit of commotion among Malaysians online. For example, fellow blogger Niki Cheong in his article 1Malaysia Clinic has no doctors? commented:

If I still need to go to a hospital or polyclinic, why would I go to the 1Malaysia clinic in the first place? And who exactly are these health assistants and how much will they be able to help me if they are not doctors?

Are these health assistants qualified (they claim to have at least five years experience, but does this legally hold?) to even treat a patient? What about prescription of medication etc?

Knowing the logic behind this lack of doctors in clinics—me and my doctor sweetheart talk about this sort of thing often—I tried explaining the situation on Twitter. However, I feel an urge to give more information out, since some people take it as an opportunity to bash the government and the 1Malaysia concept.

Perhaps a disclaimer: I have no great love for the government and 1Malaysia, but I think it is ridiculous to ridicule (ha!) this 1Malaysia clinic concept without at least some background knowledge.

So, allow me to pass some information on the Malaysian public medical system—facts courtesy of Dr Puteri Zatil Aqmar—as roughly as I can in laymen terms.

Malaysian Public Healthcare System

In Malaysia, the public healthcare outlets belong in a hierarchy that goes like this:

(secondary care)
|                              |
(primary care)

Hospitals can be found in cities, with some big hospitals offering specialists in different fields. Klinik Kesihatan are usually situated in towns and in each district, while Klinik Desa are in rural areas and small kampungs.

In this hierarchy, the clinics will defer to the hospitals. Therefore, clinics will deal with simpler and less serious cases, while in hospitals, the cases you deal with become more specific and chronic. Patients who need to be warded, which is classed secondary care, will be handled by hospitals.

In a concept called triage, patients are sorted according to their priority. Therefore, one can make sure that those with minor injuries and illnesses do not need to crowd the emergency department (ED), and more room will be available for serious cases.

The same goes for the specialists in hospitals, it is a waste for them to spend their time on minor cases when their expertise can be used on bigger cases. Therefore, you only need to see doctors in Klinik Kesihatan for simple cases, and if need be, you will be referred to the hospitals.

Klinik Desa are usually situated in rural areas, to benefit those who are far away from other institutions. They are staffed by veteran nurses called Jururawat Desa (JD), and a doctor will make rounds to the Klinik Desa every few days. Therefore, Klinik Desa are run by the JDs, not doctors.

Nurses and Medical Assistants

In nursing school, two courses are usually offered: to be a nurse or medical assistant.

You should be familiar with nurses. Nurses are not only responsible for taking care of the patients, but most of the times they also do the legworks for doctors, such as taking blood samples etc. They help with the practical work so doctors can spend more time admitting and diagnosing patients (a doctor takes care of a whole ward by himself). Nurses are also predominantly female.

Medical assistants (MA) on the other hand are mostly male. Besides having the same knowledge as nurses, they are also capable of administrating first aid. Since they’re mostly men, MA also do the grunt work such as lifting and moving patients. MAs study 4-5 years in medicine, and they’re granted with licences to legally prescribe common drugs.

In Klinik Kesihatan, usually each room is staffed by MA, who will attend to the patients while the doctor rotates between them. The same concept of triage works here too: doctors will prioritise between patients, and MAs will take care of the rest, to treat as many patients as possible in a day.

Remember the Jururawat Desa? They are all veteran, senior nurses. So, I don’t need to stress how experienced they are in attending patients. Besides being full-versed in delivering babies, these nurses would also have taken extra nursing courses, and are nursing experts in certain fields. For example, if in a nurse’s village there are many children, the JD will probably take a paediatrics course to treat the children better.

Nurse licences do not allow them to prescribe, but a special arrangement by the Ministry of Health allows JD to prescribe common drugs, just like MAs. This special arrangement is important since there is a definite lack of doctors to operate and cover hundreds of Klinik Kesihatan in the country.

By this arrangement, the JDs will be able to triage (again) and treat common illnesses like fever, cold, cough etc. It is a symbol of trust to the JDs since they’re running a clinic by themselves, and the JDs know better to not betray that trust, since they will need to renew their licence very often.

Klinik 1Malaysia

Therefore, the concept of clinics without doctors is not so foreign at all. Klinik Desa have always been operating without one, and now Klinik 1Malaysia will too.

With respect to the hierarchy, I surmise Klinik 1Malaysia are on the same level as Klinik Desa. They are exactly the same, just situated mostly in urban areas. So the hierarchy should now look like this:

(secondary care)
|                               |                               |
(primary care)

So, to allay our fears: yes, nurses and MAs are capable of doing their job. In fact, all this while it has been them who were doing the medical work for us, right beside doctors.

Once again, it all comes down to the concept of triage. If one can understand the concept and its importance, then one will see that not all patients need to see doctors or hopsital straight away.

We still do not have enough doctors, and I believe nurses and MAs are doing a great job sharing the burden in order for Malaysians to get decent healthcare.

Klinik 1Malaysia might be a really shitty name, and the government share the failure of convincing cynical citizens already fed-up with the 1Malaysia schtick.

However, no one can say that this won’t benefit the people.

Just RM1 for treatments…come on!