Introduction

Many countries frequently use strikes as a legitimate deadlock-breaking mechanism when labour negotiations between affected parties fail during collective action. Each strike is motivated by a distinct combination of local conditions, employee concerns, and most importantly, the relationship between employers and trade unions. The international health community is becoming increasingly concerned about healthcare worker (HCW) strikes due to the effect on healthcare service delivery [1]. HCW strikes are frequently the results of failed employer-employee negotiations on fair wages and working conditions, policy issues, a lack of infrastructure, and concerns about personal safety in the workplace, particularly in developed countries such as the United Kingdom (UK), the United States (US), Israel, and Norway [2]. In 2012, the British Medical Association (BMA), which represents two-thirds of UK medical practitioners, organised a non-urgent care boycott in response to government pension reform in which doctors would need to work longer hours but receive fewer retirement benefits [3]. Aside from that, Irish doctors staged a protest over disagreements over long working hours, which violated EU employment law and could endanger patients [4]. During the COVID-19 pandemic, there were also HCW strikes in Hong Kong, and the US in response to various issues with outbreak management [5]. Strikes like these by healthcare workers can sometimes lead to detrimental impact on the service delivery and patient care.

A strike is almost unheard of in Malaysia, especially in the healthcare setting. The last two strikes by doctors in the country, both precipitated by wage-related issues, dated more than 40 years back in 1977 and 1982 [6]. Since the days of independence, medical officers have always been given permanent appointments. However, beginning in 2016, the Malaysian government enforced the contract appointment policy for house officers due to a lack of permanent medical officer positions available. This followed the directive of the Public Service Department (JPA) to halt the formation of new posts in all governmental agencies in accordance with the Malaysian Government Policy on human resource optimisation [7]. The five-year contract allows medical graduates to fulfill their mandatory service requirements (three years as house officers and two years as medical officers). However, between December 2016 and May 2021, only 3.4% out of the 23,077 contract medical officers were given permanent appointments in the Ministry of Health (MOH) following the completion of their five-year tenure [8].

On 23^rd June 2021, a group known as the Hartal Doktor Kontrak (HDK) was formed to fight for the rights of contract doctors. It consisted mainly of junior contract doctors who shared the same plight. The HDK movement used social media to rally support for the plight of contract doctors across the country, as well as to voice their demands in terms of policy change to the government. and they eventually called for Malaysian doctors to go on a strike, i.e. “Hartal” (a mass protest which brought all commercial activity to a standstill for a limited period). The protest, which was expected to culminate in a massive labour strike, took place on 26^th July 2021. The massive dissemination of the event across both traditional and social media drew widespread attention from the medical fraternity, the general public, and stakeholders. It was no longer confined to an internal MOH issue but had become a national public concern. Various healthcare groups and associations, as well as individual medical personnel have expressed their viewpoints on many platforms, most notably on social media. As a result, our study aimed to explore the perception of the medical fraternity and stakeholders towards the HDK strike in order to better understand the underlying issues of contract appointment policy to provide practical recommendations for solving the issue.

Methods

This was a qualitative content analysis of Facebook (FB) posts focused on the issue of the HDK strike from 1^st June 2021 until 28^th February 2022. In this content analysis, we purposively sampled FB pages of three main groups, namely government stakeholders (SH), healthcare interest groups (HIG) such as medical association/ network/ platforms, and lastly prominent medical key opinion personnel (MP). All these FB pages were set as ‘PUBLIC’ and thus the posts were visible to all FB users at the time of study. For the group of MP, senior healthcare personnel, i.e. specialists or experts in their respective fields who frequently write and share their opinions related to health systems on their public FB pages with substantial amount of FB followers were selected.

The content of the relevant FB posts formed the data for this study. The keywords "contract doctor", "hartal", “HDK” and "strike" were used in the search. As this content analysis focused on written texts, only primary FB posts in the forms of sentences and paragraphs that were written by the owners of the FB pages were included. Other forms of posts such as photos, reels, video clips, links, webpage link, polls, infographic posters that required different analysis methods were not included for the purpose of this study. FB posts shared by the owners from other sources were also excluded.

In total, 182 posts were extracted from the official FB pages of three selected SH: i. MOH Malaysia, ii. Minister of Health, and iii. Director-General of Health; four selected HIG: i. Section Concerning House Officers, Medical Officers, and Specialists of Malaysian Medical Association (SCHOMOS MMA), ii. CodeBlue, iii. Health Empowerment and Reform Team (HEART), iv. Malaysian Primary Care Network (MPCN); as well as seven prominent MP in the country with FB followers ranging from 10,000 to 638,000.

We performed a thematic analysis of all the transcripts from the related FB posts based on the six-step framework described by Braun and Clarke [9]. All relevant posts that covered all aspects of the study aim were identified and extracted. After completing data collection, one researcher performed data cross-checks and data cleaning. Duplications were identified and eliminated. After all the researchers familiarised themselves with the data and agreed on the preliminary coding approach, the inductive process of content analysis was performed. The transcript data were inductively coded until saturation was achieved. Open coding was conducted by two researchers at the initial stage to form a codebook. The final codebook consisted of codes agreed upon by all the researchers. Meetings were held regularly to discuss the abstraction process in formulating categories and themes that contributed to answering the research questions. Discrepancies were resolved through a series of discussions among all the investigators. NVivo 12 was used for data management and analysis.

We acknowledge that the experiences and opinions of the researchers may have influenced data analysis and caused unintentional bias. However, all researchers had a strong background in medical research and had also received training in qualitative research, including content analysis courses. They also had common experience conducting prior research regarding contract house officers, so they shared a common perspective and understanding of the issue of interest. Furthermore, any bias was explicitly examined throughout the generation of codes and themes.

This study was registered under the National Medical Research Register (NMRR) of Malaysia (NMRR ID-22-00850-MTS). The Medical Research and Ethics Committee (MREC) of the Ministry of Health Malaysia exempted ethical approval for this study as it does not involve human subjects. Based on similar studies in the literature [10], the justification for accessing and analysing data from FB was that users’ data exists in the online public domain and can thus be accessed by anyone. In other words, the data in this study were all retrieved from a public space as shared by the respective owners of public FB pages who understood that they should not have a “reasonable expectation of privacy” with regard to their posts.

Results

The three main themes and sub-themes derived from this qualitative thematic analysis are presented in Table 1, including (1) triggering factors of the strike, (2) reactions toward the strike, and (3) outcomes of the strike.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Summary of identified themes and sub-themes.

https://doi.org/10.1371/journal.pone.0292213.t001

Discussion

A strike is identified as a collective action that generally involves a temporary interruption of work to voice certain demands for the economic benefit of the strikers [12]. Sylvester and Chima [1] mentioned that strikes are strategies used by an employee or group of employees as leverage for the employer to meet their demands. Among HCWs, the determinants of strikes can be diverse. In the past, HCW strikes mostly stemmed from dissatisfaction over salaries, working hours, and other administrative factors [13]. While it is necessary to understand the underlying factors that provoke the call for strike by the organiser (i.e. employee/ staff), it is also important to explore the perceptions towards the strike among the medical fraternity and stakeholders (i.e. government/ employer/ influential personnel) with an active and participatory role in making a decision or providing a solution.

This study highlighted the three themes that emerged from the wide range of perceptions towards the HDK strike among SH, HIG, and influential MP, namely the perceived triggering factors, responses toward the strike, and lastly, the perceived impact of the strike. The inequitable treatment between contract officers and their permanent counterparts in the MOH sparked off the dissatisfaction that gradually brewed into prolonged frustration, especially when the solutions offered were viewed as reactive and short-term in nature. The situation took a turn for the worse when these officers bore the tremendous burden as the front liners in the COVID-19 pandemic and more than half of them experienced burnout [11]. Nevertheless, they felt unappreciated and demotivated as no viable solution was offered by the government about their contract employment status. Their job security and career pathway were also unclear. All these interrelated factors prompted some of the contract doctors to call for the HDK strike. In a way, the strike became the last resort here as a deadlock-breaking mechanism as they felt that the negotiations had reached an impasse during collective bargaining [2, 14]. Similar strikes happened in the UK before to fight for better pay for junior doctors as well as in Hong Kong, and the US during the COVID-19 pandemic due to mismanagement that adversely affected HCWs [5].

Contrary to other professions, HCW strikes often attract extra public attention due to the underlying ethical dilemma [15]. Boycotting the work of delivering care and potentially compromising the safety of needy patients are viewed as violating the Hippocratic Oath, the primary moral consideration in medical practice [2]. Based on the FB posts of stakeholders, the HDK strike was condemned because it was against the code of ethics with a potentially adverse impact on health services. Likewise, strikes are prohibited by almost all medical councils in the world. For instance, the Delhi Medical Council in India stated that "Doctors should never resort to strike action" [16]. On a similar note, doctors in the UK are required by the General Medical Council (GMC) UK to make sure that the industrial action or strike does not endanger patients. The American College of Physicians (ACP) also opposes any sort of work stoppage, even when it is aimed at prompting healthcare system reforms to address infrastructure issues, poor policy, or poor governance [17]. In comparison, even though the American Medical Association (AMA) allows some methods of collective bargaining, the code of ethics explicitly forbids doctors from using strikes as a means of negotiation [18]. According to a retrospective analysis of recent doctor strikes in the UK [3, 19], New Zealand [20], and Kenya [21], the main effects of doctor or HCW strikes are disruptions in the delivery of healthcare services to the general public, such as decreased elective admissions, increased outpatient cancellations, fewer admissions, and fewer accident and emergency attendances but there was no significant rise in patient mortality during HCW strikes [17, 19, 21, 22]. Nevertheless, these studies were conducted in the pre-COVID era.

In the case of the HDK strike, the contract doctors saw the strike as the last resort for their plights to be given serious attention by the authority in power. In general, our findings revealed that almost all HIGs and prominent MPs supported the strike in solidarity with the contract doctors. In other countries, HCWs’ support toward strike action was divisive and frequently fragmented [13]. For example, it was widely supported in Israel [23] and Croatia [24] while frowned upon in Nigeria [25]. However, it was a critical period to call for a strike among front liners, especially when the country was facing an unprecedented crisis due to the COVID-19 pandemic and the healthcare system had been stretched to the maximum. Any disruption of service delivery that compromises patient care could risk the ire of the public and backfire on them, possibly diminishing the public support for their cause. Considering this, the strike was planned as a brief walk-out after a proper handover of their tasks at work. There was no long period of work boycott or protest march on the streets. As commented by the medical fraternity, there were no disruptions to the health service. Judging from the subsequent responses, the peaceful protest worked out to the benefit of all who were involved.

In a way, the strike also acted as a catalyst for expedited actions. The underlying issues were not solved by reactive measures like short-term contract extensions and wage readjustments. Even worse, it might jeopardise the health system’s robustness [26]. Despite different views, all parties mutually agreed to cooperate in brainstorming and implementing the most appropriate mechanisms to solve the crisis faced by these contract doctors. Following the strike, a special task force led by the MOH and Malaysian Medical Association (MMA) was set up in September 2021 to formulate viable long-term solutions for all the issues of contract appointment policy. Some suggestions that were put forth included the possibility of amending the Pensions Act 1980 and utilising the Employees Provident Fund (EPF) scheme to offer permanent jobs for contract officers. This was similar to what happened in Kenya when the Musyimi Task Force, composed of six government officials and six union members, was formed in 2011–2012 to address concerns about the health sector, particularly poor working conditions and low wages [27]. In addition, the newly appointed Minister of Health held a town hall session with representatives of contract doctors and several medical associations in the presence of other stakeholders such as JPA and the Ministry of Finance to obtain multi-faceted input on this issue. Russo et al. [28] found that when other ministries (such as the Finance or Public Administration Ministries) or higher levels of decision-makers (such as the Prime Minister or President) were involved in the process, resolutions were more frequently reached as compared to actions taken by a single ministerial department. In this case, issues pointed out were acknowledged by the stakeholders and some of the recommendations were implemented as a system-wide effort to address the plights of these doctors. To begin with, their work contract was extended by up to four years to allow for specialisation. Additional permanent posts were also created. Benefits such as paid study leave, specialisation scholarships, flight warrants, and other leaves were extended to contract doctors as well. These were widely shared on the FB of SH, HIG, and MP alike and garnered positive reception from all the involved parties, giving temporary relief to the contract doctors.

Nevertheless, from a wider perspective, the HDK movement highlighted the importance of long-term solutions to be put in place as the contractual employment policy may have larger repercussions not just for the future of medical practitioners, but also for the healthcare system and population health. A similar sentiment was echoed in another study from Kenya [29]. Many of the HIG and MP warned that the existing brain drain among the medical profession will worsen with a massive exodus of contract doctors if they sense a bleak future with a lack of job security and career progression. As illustrated by the WHO building blocks of a healthcare system [30], the health workforce, together with the other building blocks represents the vital inputs to ensure equitable access, coverage, quality, and safe healthcare for the people. Thus, it is not surprising that our findings showed that HIG and MP were mostly in support of the HDK strike. A continuous supply of trained healthcare workforce in the system relies on the provision of a better working environment and guaranteed job security. In Malaysia, the recruitment of public servants is centralised under JPA. MOH, as the major public healthcare provider and one of the biggest ministries in the Malaysian government, was debilitated by the freeze of the creation of new posts in the public service in 2015. The serious understaffing issues in MOH hospitals were also reported by the Department of Audit in 2018. However, without additional funding from the Ministry of Finance (MOF) and JPA, MOH is unable to unilaterally recruit more HCWs. As a result, this has led to calls from certain groups to establish a separate pathway and agency responsible for the recruitment of HCWs under the direct jurisdiction of MOH. Nevertheless, this might not materialise soon considering the prevailing economic and political circumstances. In other words, health human resources play a vital role in the delivery and output of healthcare services. Thus, apart from taking immediate actions to tackle any ongoing human resource issues, long-term meticulous planning is crucial to ensure the sustainability and seamlessness of patient care. The HDK strike during the pandemic is a clear imperative to improve healthcare human resource management and to develop proactive policies and risk-management plans that can strengthen the systems’ ability to withstand crises while continuing to function [26].

There are some limitations to our study. Firstly, we were unable to portray all frame elements completely because our samples were limited to selected FB groups and pages. The FB pages included in this study were purposively sampled to identify the representative voices of the largest and most influential healthcare groups and individuals in Malaysia. In addition, we did not explore the perceptions of affected contract doctors as it was not within the scope of our study objective. Furthermore, because of the nature of the study design, the level of subjective interpretation can affect the reliability and validity of the results, resulting in potential cognitive bias.

Conclusion

A strike by HCWs in Malaysia poses various unprecedented challenges, particularly during the pandemic. It emphasises the need for proactive measures to be put in place as reactive responses would only provide short-term reprieve. Although the MOH has taken some steps regarding contract doctors, more comprehensive long-term actions by all the stakeholders involved are necessary to address the root causes of the contract employment issues. Left unaddressed, recurring HCW strikes may cripple healthcare services and compromise the health and well-being of the people. The government’s roles and responsibilities in a devolved health system should be clearly defined to prevent similar strike incidents in the future. Mechanisms for dispute resolution should be established by anticipating and pre-empting changes in the health system that may result in conflict between parties. Both sides must remain rational and fair, whereby the demands made by HCWs should be reasonable and the government must respond in a suitable manner, especially in a complex setting like the healthcare system. Furthermore, social media has been shown to influence every step of the strike action process in this case, thus the role and utilisation of the media in covering similar issues should not be overlooked.

Acknowledgments

The authors would like to thank the Director General of Health Malaysia for the permission to publish this paper.