1. I Went
Many years ago, I did my housemanship in Kuching, Sarawak.
It was a very different medical world.
I was young. The work was hard. The hours were long. And because there were fewer doctors, young doctors were often given considerable responsibility.
I learnt enormously.
There were procedures and clinical situations I encountered there that, in a larger centre, I might only have encountered much later or during postgraduate training.
Around that period, I also volunteered with the Flying Doctor Service.
That was medicine stripped down to its essentials.
There was the patient.
There was the doctor.
There was what you carried with you.
And there was the knowledge that the nearest hospital might be a very long way away.
But what I remember equally clearly were the people.
The people of Sarawak were friendly, humble and welcoming. I never felt that I was an outsider or that I was treated differently because I had come from Peninsular Malaysia.
Looking back, I do not remember those years as a sacrifice.
I remember them as an opportunity.
But it would be very easy — and very wrong — for someone of my generation to say:
I went. Why can't today's doctors?
Medicine has changed.
Families have changed.
Career pathways have changed.
Expectations have changed.
And the choices available to young doctors have changed.
2. A Different Generation, A Different Decision
There is another important distinction.
My experience in Sarawak began with housemanship.
The present controversy concerns medical officers who have completed housemanship and are being offered permanent postings.
They may be several years older.
They may be married.
They may have children.
Their spouse may have a career.
Their parents may be ageing or unwell.
They may already be preparing for postgraduate examinations or trying to enter specialist training.
And Sabah and Sarawak are not simply a drive down the highway from Kuala Lumpur.
There is a sea in between.
A doctor considering such a posting may reasonably ask:
How long will I be there?
How often can I return home?
What happens to my training?
Will this help my career — or interrupt it?
These are not necessarily signs of a less committed generation.
They are reasonable questions.
3. Sabah and Sarawak Are Not the Problem
We also need to be careful with language.
A posting to Kuching is not the same as a posting deep in the interior of Sarawak.
Kota Kinabalu is not the same as an isolated rural facility several hours away from a major hospital.
The real issue is not simply Sabah or Sarawak.
It is remoteness.
Accessibility.
Staffing.
Accommodation.
Transport.
Water and electricity.
Internet connectivity.
Professional support.
And the distance from the next level of care.
Malaysia already recognises this difference.
For eligible Ministry of Health personnel serving at designated interior clinics, the Bayaran Insentif Mengikut Lokasi dan Tahap Kesusahan (BIMLTK) is graded according to hardship:[5]
Pedalaman 1 — RM500 per month
Pedalaman 2 — RM1,000 per month
Pedalaman 3 — RM1,500 per month
That is sensible.
A doctor working in a major city should not automatically be treated the same as one working in a genuinely difficult-to-access facility.
But money is only part of the story.
4. What Malaysia Already Provides
It would also be unfair to write as though nothing is being done.
There are hardship and regional incentives, relocation and travel-related provisions, and accommodation arrangements subject to the applicable rules and availability.[5][6]
There are postgraduate training and sponsorship pathways.[12]
There is telemedicine.
There are mobile health services.
And there are doctors, nurses, medical assistants and other healthcare workers already serving in difficult locations every day.
The question is therefore not:
Why hasn't anyone done anything?
The better question is:
Is the present package strong enough, simple enough and attractive enough for the workforce we are trying to recruit today?
There are also some details worth reviewing.
Under current public-service rules, eligible personnel receiving BIMLTK are not eligible for certain other benefits, including the general interior incentive and Tambang Ziarah Wilayah.[5]
There may be sound administrative reasons for this.
But from the doctor's side, the question is simpler:
Should someone serving in one of the most difficult locations have to choose, in effect, between hardship compensation and assistance related to returning home?
Perhaps the whole package needs to be looked at from the perspective of the person actually receiving it.
5. The Doctors Have Already Spoken
The Malaysian Medical Association has called for stronger incentives for doctors serving in Sabah and Sarawak.
Its proposals include reviewing regional incentives, improving housing and transport support, providing relocation assistance before the move, giving greater certainty about the duration of postings and creating clearer pathways for doctors who eventually wish to transfer.[7]
Importantly, MMA has also proposed that service in underserved areas should contribute meaningfully towards postgraduate training, specialist pathways, promotion and future placements.[13]
MMA Sabah has raised similar concerns about accommodation, transport, reliable utilities, internet connectivity and career development.[8]
Sarawak Deputy Premier Dr Sim Kui Hian has made an important point of his own:
The answer is not just about money.[9]
I agree.
Because we can keep increasing an allowance and still fail to answer the doctor's bigger question:
What happens to my life and my career if I go?
MMA president Dr Sivanaesan Letchumanan put the patient consequence very simply:
“An empty post does not treat a patient.”[16]
That sentence deserves another question.
What does an empty post cost the patient?
But perhaps Sabah and Sarawak are not the whole story.
Malaysia has a wider problem retaining doctors in public healthcare. Figures disclosed by the Health Minister in a written Dewan Negara reply show that 6,212 medical officers resigned from the Ministry of Health between 2021 and 2025 — 4,380 contract MOs and 1,832 permanent MOs.[3]
There is another worrying signal. While contract-MO resignations have fallen from their earlier peak, resignations among permanent MOs rose every year over that five-year period, from 238 in 2021 to 498 in 2025.[3]
But we still cannot say what percentage of these resignations was directly caused by postings to Sabah or Sarawak. The available national data do not provide that causal breakdown.
What we can say is that geography and family matter. In a 2025 CodeBlue poll of 938 contract and permanent medical officers across Malaysia, 62% said they would rather resign than serve away from their home state. Among those who explained why location mattered, 86% wanted to serve where their family lived.[4]
That survey needs to be interpreted cautiously. It was an online poll and CodeBlue itself acknowledged the possibility of self-selection bias. But another finding is particularly relevant: only 6% said they would absolutely reject Sabah, Sarawak, rural or interior placements regardless of what was offered. The leading factors that could persuade doctors to go were higher pay or incentives and a fixed period of service with a clearer route back.[4]
That suggests something important.
Sabah and Sarawak may therefore not be creating the retention problem so much as magnifying it.
Take an already stretched young doctor, move that doctor farther from family, add relocation costs, uncertain accommodation, poorer connectivity and concerns about postgraduate training, and the decision becomes considerably harder.
Perhaps the doctor who never arrived is telling us something about the doctors who are leaving everywhere else as well.
6. Don't Just Add Another Allowance
Imagine we offer a doctor another RM500.
Would that solve the problem?
Perhaps for some.
But what if the quarters are poor?
What if the internet is unreliable?
What if the spouse cannot find work?
What if the doctor cannot get home regularly?
What if there is no clear supervision?
What if postgraduate training seems further away rather than closer?
What if nobody can say how long the posting will last?
Then another allowance becomes compensation for a problem rather than a solution to it.
What we need is not simply another allowance.
We need an offer.
A package that says:
Come here.
Do meaningful medicine.
We will support you.
We will help your family.
We will keep you connected.
We will train you.
And the years you spend here will count.
7. Don't Forget the Family
We sometimes talk about doctors as though they travel alone.
Many do not.
If the family remains in Peninsular Malaysia, the doctor needs reasonable opportunities to return home.
That means travel support.
It means sufficient leave.
And sometimes it means allowing leave to be organised sensibly enough that going home is actually practical.
If the family moves with the doctor, the questions change.
Where will they live?
Where will the children go to school?
What childcare is available?
Can the spouse find employment?
Nobody can promise every spouse a job.
But relocation assistance, information about local employment, schooling and childcare, and help navigating an unfamiliar community would make a difference.
Where both spouses work within government or healthcare, coordinated postings should at least be explored where feasible.
And there should be somebody to call.
Not another website.
Not another form.
A person.
A relocation or posting coordinator who can help solve practical problems.
Because we are not merely moving an employee.
Sometimes we are asking an entire family to build a life somewhere new.
8. Make Rural Service Part of the Career
This may be the most important part.
Young doctors are understandably worried about postgraduate training.
So turn that fear into an opportunity.
If a young doctor gives some of the most formative years of a medical career to an underserved community, surely those years should count for something.
Not a free pass into specialist training.
Standards must remain standards.
But experience should count.
Service should count.
And what that doctor learnt while working far from a tertiary hospital should certainly count.
The principle is hardly radical. MMA itself has proposed that service in underserved areas should count towards postgraduate training, specialist pathways and career progression.[13]
The question is whether we can turn that principle into a sufficiently clear and attractive career proposition.
Serve here and we will invest in you.
That is a very different message from:
Report here because you have been posted here.
Don't make rural service a detour from a medical career.
Make it one of the roads towards a better one.
9. Bring Training to the Doctor
There is another assumption worth challenging.
Why must postgraduate learning always require the doctor to travel to the teaching centre?
Some things obviously require physical presence.
A surgeon cannot learn an operation entirely on a laptop.
But much of postgraduate education can now travel.
Grand rounds.
Case discussions.
Journal clubs.
Radiology sessions.
ECG teaching.
Exam preparation.
Postgraduate lectures.
Specialist case conferences.
Clinical mentoring.
These can be delivered remotely from tertiary hospitals and universities.
But they should not become just another collection of webinars.
The learning should be structured.
Protected time should be provided.
Competencies should be documented.
Where appropriate, recognised educational activities should contribute to CPD, portfolios or postgraduate requirements.
The doctor should have a mentor.
And there should still be periodic rotations through tertiary centres for the skills and exposure that cannot be delivered remotely.
The model is not complicated:
Rural clinical experience + structured remote education + specialist mentoring + documented competencies + periodic tertiary rotations.
If we want young doctors to give some of the best years of their early careers to underserved communities, perhaps we should make those years some of the best years of their training.
10. From Flying Doctors to Connected Doctors
When I volunteered with the Flying Doctor Service, we overcame distance by moving the doctor.
We flew the doctor to the patient.
Today we can increasingly move expertise as well.
And this is not merely an idea on paper.
Telemedicine has a long history in Malaysia. Ministry of Health guidance records its introduction in 1997 to allow medical officers in rural facilities, particularly in Sabah and Sarawak, to consult hospital specialists.[10]
In July 2026, the government reported teleconsultation services at 34 Klinik Kesihatan in Sabah and 48 in Sarawak.[11]
So telemedicine exists.
The next question is whether it is sufficiently reliable, sufficiently widespread and sufficiently integrated into everyday clinical care.
A digital clinic is not necessarily the same as having the right specialist available when a difficult patient is sitting in front of you.
That should be the next step.
Patient teleconsultation should evolve into professional tele-support as well.
Imagine the young doctor in a remote clinic who can reliably discuss a difficult ECG with a physician, a complicated pregnancy with an obstetrician, an uncertain X-ray with a radiologist or a sick child with a paediatrician.
Not theoretically.
Actually.
Telemedicine cannot intubate the patient.
It cannot perform the emergency Caesarean section.
It cannot resuscitate major trauma.
And it must never become an excuse for understaffing.
But it can reduce professional isolation and bring another level of expertise to the bedside.
The model becomes:
Doctor on the ground + specialist expertise online + functioning referral and evacuation system.
And if that is the model, reliable high-speed internet is no longer a lifestyle perk.
It is clinical infrastructure.
Where feasible, that connectivity should extend beyond the clinic to staff accommodation as well, because education, mentoring and professional communication do not stop when the clinic closes.
Remote should describe the location. It should not describe the doctor's connection to the rest of medicine.
11. Ask Before They Leave
There is one more thing we are very good at asking:
Did the doctor report?
Perhaps we should also ask six months later:
How are you doing?
How is the family?
Are you learning?
Are you coping?
And one question we probably do not ask often enough:
What would make you stay?
There should be structured follow-up throughout a difficult posting, particularly during the early months.
Not another bureaucratic appraisal.
A genuine conversation.
Professionally:
Is the workload manageable?
Is supervision adequate?
Is the doctor getting the clinical exposure promised?
Educationally:
Is the teaching actually happening?
Is there protected study time?
Is the doctor progressing towards career goals?
Socially:
Is the accommodation acceptable?
Does the doctor feel isolated?
Has the family settled?
And separately — importantly separately — how is the doctor coping mentally and emotionally?
A confidential wellbeing conversation should not simply become another performance assessment.
If the accommodation is poor, fix it.
If supervision is lacking, find a mentor.
If the training programme is not happening, correct it.
If the workload has become unsafe, investigate it.
If family separation is becoming unsustainable, see what can be done.
This is not bureaucracy.
It is an early-warning system for retention.
Ask “What would make you stay?” before the transfer application arrives.
12. What Does an Empty Post Cost?
Then there is the accountant's question.
How much is all this going to cost?
Fair question.
A flight costs money.
Accommodation costs money.
Broadband costs money.
Relocation assistance costs money.
Training costs money.
An additional allowance costs money.
They are easy numbers to put into an Excel sheet.
But where is the other column?
What did it cost when the post remained empty?
What did the additional overtime cost?
What did temporary coverage cost?
What did the extra referrals cost?
The ambulance transfer?
The boat?
The aeromedical evacuation?
What did it cost when another doctor became exhausted and left?
What did it cost the patient who travelled hundreds of kilometres?
The family member who accompanied that patient?
The lost day's wages?
The delayed diagnosis?
A vacant post may look like a saving because nobody is drawing the salary.
In healthcare, the bill often appears somewhere else.
And there is an important economic distinction.
If the medical post and normal salary already exist, the policy cost is not necessarily the doctor's entire salary.
The additional cost is the package required to make that difficult post workable:
the hardship incentive,
the travel,
the housing,
the relocation,
the connectivity,
the education,
the mentoring,
and the family support.
That should be compared with the cost of repeatedly failing to fill the post.
How much are we already paying because the doctor isn't there?
13. What Could Better Access Prevent?
The harder question is not money.
It is health.
How much morbidity might better access to medical care prevent?
Could earlier diagnosis prevent complications?
Could better follow-up keep somebody out of hospital?
Could a patient with hypertension avoid a stroke?
Could a person with diabetes avoid renal failure or an amputation?
Could deterioration in a child be recognised earlier?
Could a high-risk pregnancy be referred before it becomes an emergency?
We should be careful here.
It would be scientifically irresponsible to claim that one additional rural doctor will save a particular number of lives.
Healthcare does not work that way.
Doctors work within teams, facilities, referral systems and communities.
But we do know that access to effective ambulatory care matters.
A 2026 Malaysian study examining chronic ambulatory care sensitive conditions identified 203,608 potentially preventable hospital episodes in Ministry of Health hospitals in 2022 — 8.6% of the inpatient episodes analysed.[15]
These included conditions such as diabetes, hypertension, chronic kidney disease, heart failure, ischaemic heart disease, asthma, COPD and epilepsy.
That does not mean vacant rural doctor posts caused those admissions.
It means something more defensible:
Good outpatient and ambulatory care has measurable downstream consequences.
And the disease burden is certainly there.
The National Health and Morbidity Survey 2023 found diabetes in 15.6% of Malaysian adults and hypertension in 29.2%.[14]
Importantly, 5.9% of adults had diabetes without knowing it, while 11.9% had hypertension without knowing it.
These are diseases that benefit from detection, continuity and follow-up.
So perhaps the chain we should be studying is:
Vacancy → reduced clinical capacity → poorer access and continuity → delayed detection or treatment → deterioration → emergency referral or hospitalisation → complications, disability and, in some cases, premature death.
Not every patient will follow that chain.
But enough might for us to measure it.
14. The Rural MO Offer
If I were designing the offer to a young doctor today, it might look something like this.
1. Pay for genuine hardship
Grade incentives according to actual remoteness, accessibility and working conditions — not merely the state in which the facility happens to be located.
2. Make it possible to go home
Provide practical travel assistance and enough flexibility in leave for doctors separated from their families.
3. Help the family relocate
Assist with moving, accommodation, schooling and childcare information, spouse employment support and community integration.
4. Provide decent infrastructure
Safe accommodation. Reliable water. Electricity. Transport. Communications.
These are not luxuries.
5. Guarantee connectivity
Reliable high-speed internet at the facility and, where feasible, staff accommodation.
Where terrestrial broadband cannot deliver it, explore alternatives.
6. Bring training to the doctor
Structured remote education, protected learning time, specialist tele-mentoring and a digital training portfolio.
7. Keep the doctor connected to tertiary medicine
Provide periodic rotations through larger centres.
8. Make rural service count
Give meaningful recognition to difficult service within competitive postgraduate, scholarship and career pathways — without lowering professional standards.
9. Provide certainty
Tell the doctor what the expected period of service is and what happens afterwards.
10. Ask how the doctor is doing
Monitor professional development, education, social adjustment, family circumstances and wellbeing.
And keep asking:
What would make you stay?
15. Serve — Learn — Train — Return
Perhaps the entire model could be simplified into four words.
SERVE
Spend a defined period in an underserved facility with proper financial, accommodation, relocation, family and travel support.
LEARN
Gain the kind of hands-on clinical experience that remote medicine can provide, supported by specialist advice, structured education, mentoring and periodic tertiary exposure.
TRAIN
Allow that service and experience to receive appropriate recognition within competitive postgraduate and specialist-training pathways.
Standards do not change.
Opportunity does.
RETURN
After specialist training, create meaningful reasons and opportunities for some of those doctors to return to Sabah, Sarawak or other underserved communities.
Perhaps one day they become the specialists mentoring the next young doctor on the screen.
But there is a fifth word — and it belongs at every stage.
LISTEN
Ask the doctors.
Ask their families.
Measure the patient outcomes.
Fix what is not working.
Then measure again.
Serve. Learn. Train. Return. And throughout it all — listen.
16. Don't Just Count Posts. Count Outcomes.
Traditionally, workforce planning can become a sequence of numbers:
Vacant post.
Post advertised.
Doctor appointed.
Doctor reports.
Success.
But was it?
Did the doctor stay?
Did the workload improve?
Did the doctor become more competent?
Did postgraduate training progress?
Did the family cope?
Would the doctor recommend the posting to another young doctor?
And most importantly:
Did patients do better?
We could measure waiting times.
Continuity of care.
Screening.
Blood-pressure and diabetes control.
Emergency transfers.
Potentially preventable admissions.
Maternal and neonatal outcomes.
Staff turnover.
Patient travel.
And, where the numbers are large enough and the methodology sound, morbidity and mortality.
Then compare facilities before and after chronically vacant positions are filled.
That would give us three scorecards.
The doctor.
The family.
The patient.
And perhaps a fourth:
The taxpayer.
What did it cost to fill the position properly?
What did it cost when the position remained empty?
Don't just count posts.
Count outcomes.
17. The Doctor Who Stayed
When I think back to my own time in Sarawak, I remember the long hours and the responsibility.
But I also remember how much I learnt.
I remember the Flying Doctor Service.
I remember the patients.
And I remember the warmth of the people.
I was fortunate.
But today's young doctor lives in a different world.
So telling them “we did it in our time” achieves very little.
Instead, perhaps we should build a system that makes them say:
This will be difficult.
But I will learn.
My family will be supported.
I will not be professionally isolated.
My career will continue to move forward.
And the work I do here matters.
Compulsion may get the doctor to report.
Incentives may get the doctor there.
Opportunity, support and belonging may make the doctor stay.
And ultimately, that is not merely a workforce outcome.
It is a patient outcome.
MMA was right about one thing:
“An empty post does not treat a patient.”
But perhaps we should take the question one step further.
What happened because the doctor was there?
Was the diabetes diagnosed earlier?
Was the hypertension treated?
Was the pregnancy complication recognised?
Was the emergency managed in time?
Was a hospital admission avoided?
Was a life saved?
Some of those questions will be difficult to answer.
We should still ask them.
Because the success of a rural medical posting should not ultimately be measured by whether a doctor signed the reporting form.
It should be measured by whether the doctor stayed.
Whether the doctor developed.
Whether the family coped.
And whether the community was healthier because that doctor was there.
The doctor arrived.
The real achievement is when the doctor stayed.