Occupational Therapy (OT) is a unique health care service that enables people of all ages who have limitations in their sensory-physical, cognitive, or psychological functioning. OT uses assessment and interventions to remediate, maintain, or improve participation in meaningful activities (or occupations), of individuals (or groups and communities) to attain health and quality of life [11]. Occupational Therapy’s goal is to enable clients with a range of physical or psychosocial dysfunctions, to improve their participation in their daily activities and reengagement in their occupational roles. The individual is approached as a whole person (not a diagnosis), within their environment and its effect on their occupational performance to optimise participations in occupations for the promotion of health [12] [13]. As a newer health science discipline in Malaysia, Occupational Therapy services started at the Neuro-Psychiatric Institute in Hospital Kuala Lumpur in 1972. Yet, in 2021 the profession remains critically underdeveloped and stagnated [14], despite its evidence-based interventions [15] [16] [17] [18]. Surely after 50 years of Occupational Therapy in Malaysia—it should have developed and be well situated to govern itself through its national council and international federation, and not by an external political medical rehabilitation discipline. Such an outdated, middle-men alliance does not serve health science, the health economy nor global health, as Occupational Therapists collaborate directly with case relevant health/social specialists or primary physicians/ surgeons. This approach is timely and cuts down unnecessary costs and time with case-relevant specialists, social welfare institutions and special education teachers [19] and others. Autonomy allows any profession to be self-governing, self-regulating, and self-directed, empowering its members to respond to societal needs [20].

Figure 1 outlines the scope of services as clearly being beyond mere rehabilitative, into social preventive care and health promotion, along with the profession’s fundamental emphasis on “occupation”—i.e., the range of functional tasks and activities to be performed throughout life, meaningfully, purposefully and independently by the individual [21], across many practice areas [11] [12]. In addition, a set of established core values guide Occupational Therapy’s practice [22] [23]. These values include: Altruism (a concern for the welfare of others which requires them to be committed and caring), Equality (clients have human rights, which calls for an aptitude of impartiality and inclusion of clients in their own care), Freedom (choice and self-direction towards autonomy), Justice (legal rights of clients), Dignity (valuing the inherent worth of individuals), Truth (therapists being accountable to facts and reality), and Prudence (reflecting judiciousness, discretion, vigilance, moderation). These values act as the guiding governance for the education and development of Occupational Therapy professionals and therapists’ interaction with clients and other health providers professionally [24]. These values are aligned with the concept of occupational justice. However, in developing countries values and ethical incorporation are becoming a real challenge due to medical hegemony obstructing newer health professions from achieving professional autonomy, and controlling for self-serving and self-preserving a medical rehabilitation discipline that has become irrelevant in a highly reorganised targeted care. It’s peculiar that these “medical consultants” in

Asia are dictating to therapy professionals, and taking over domains of therapy such as cognitive training, driving simulation, transcranial magnetic stimulation amongst many others, claiming for these long-established therapy areas, by changing terminologies such as clinical “medical rehabilitation” protocols and redirecting referral systems to go through the group, acting as the political gatekeeper, to reinforced a redundant cost-ineffective middleman role.

History has repeats itself [25] [26] [27] [28] but in even more damaging ways to the new health professions’ domains in Asia [3] [4]. Where autonomy is not based on guiding values like altruism or high ethical standards, the medical/ health disciplines will merely become self-seeking, self-preserving and violating regulations for the promotion of self-centred agendas, rather than for societal needs [20]. It is also a destructive force and a hindrance to newer science-based disciplines, causing occupational stress to the members of the newer professions and hampering affordable health care.

Like all health professions, Occupational Therapy has a responsibility to contribute, addressing the social determinants of health and towards reducing health inequalities [21]. Holst [29] recommended that a strategy to attain global health is by pursuing the enforcement of the universal rights to health, and contribute together to overcoming global or in this instance medical hegemony which is no longer a model that can best serve society today. Global health is a view of health as a rights-based universal good, along with its social inequalities, power asymmetry, and resource disparity. Greater resilience for epidemiological preparedness (e.g. of cross-border disease threats) warrants holistic global health with a focus on social-political, not just economic determinants of health,—with the basis of which must include a need to overcome global hegemony [29].

However, in Asian countries, Occupational Therapy’s standing is critically low in the ratio of therapist: patients [3] [4], and it also has few members with a university based education. Such a social situation puts the profession of Occupational Therapy in a weak position to contribute to global health, and is compounded by a domineering group of young rehabilitation doctors who are exerting unethical governance on newer health professions. In addition, a low literacy of the OT profession by the education/medical/health sectors, low awareness among policy makers, lack of leadership representation within the profession, and absence of governmental will power to address the stagnation and professional (dys)-autonomy [3] [30] has debilitating impacts on the potential for Occupational Therapy to contribute to affordable health care and health for all, and also in OT research priorities for a global health agenda. Medical hegemony is often controlling, and it tends to neglect the requirements of a comprehensive transdisciplinary and interdisciplinary understanding of health policy [29].

This article aims to understand and reconstruct the underlying root issues affecting health professionals’ stagnation and to promote literacy on Occupational Therapy. Reconstructing the social phenomenon based on analytical reflections and postulations of forces hindering its growth can offer insights into barriers including country specific systemic institutional barriers.

The occupational reconstruction theory [31] and the global health view underline the development of this paper. Firstly, the philosophy and knowledge based of the domains of Occupational Therapy supports the active action taken to improve problematic situations through hope, networking and cooperative engagement. Occupation (“doing something”) is a mediator of the relationships between persons (therapists) with their living environment (e.g., therapists in a state of occupational deprivation), and between the self in society (e.g., a focus of OT in Malaysia and the rest of the world). As global health becomes increasingly visible, relevant, and prominent (with infectious diseases such as Covid19), it has driven research priorities and academic programmes, and become a key area of philanthropic action [29]. This shapes the healthcare from solely economically driven and where elite hegemonic medical mastery dictates in a master-slave model rather than a professional collaborative culture. Utilising the occupational reconstruction theory [31] [32] can help researchers understand collective issues and actions to ameliorate hegemony problems and to explore means for socially transformative action; in lieu of the worldwide movement towards global health (or health for all) within a country and across borders.

The Occupational Therapy profession in Malaysia is reliving the social problems of being oppressed under a debilitating medical hegemony system [25] [34]. Medical hegemony/governance has eroded the job autonomy of the newer health professionals, causing a source of occupational imbalance that eroded the job autonomy of newer health professionals [34], and where basic rights and freedom for professional judgment in practice were occupationally deprived [24] [25] [26]. The International Labour Organisation has cautioned that 40 percent of the world’s population have no health insurance nor are able to access national health services resulting in debilitating consequences—where 100 million people fall into poverty due to health expenses [37]. It is beyond reproach to utilise the current shrinking health care budget to self-preserve and self-serve an empire-building of high salaried rehabilitation consultants to take over domains that are evidently therapy professionals’ long-established scope of practice such as transcranial magnetic stimulations, return to work interventions, cognitive rehabilitation, driving, among many others. Where therapy protocols are unethically changed into non-evidence-based medical protocol for these areas that are fundamentally non-medical, and evidently therapy domains. They should evidently remain the province of therapists not doctors. The use of rehabilitation doctors to address the lack and low number of therapists has serious ramifications for their code of ethics and will continue to aggravate the peculiar phenomenon occurring currently in Malaysia.

With the occupational reconstruction theory to do something about something’, the panel of experts reflected and postulated through voluntary and intrinsic motivation for change affecting the undesirable situation in Malaysia, and to highlight the occupational injustices in the profession [32]. These preliminary concept/themes of justice should be further explored in future research to enact the situations affecting occupational therapy and gather evidences of injustices so that something can be done to rectify the unfair social phenomenon in Malaysia. It will be sometime before Malaysia can gather enough manpower and follow the developed world with an established council which accredits the profession’s curriculum, oversees examinations and competence to practice [38] [39]. Indeed, without the barriers of medical hegemony, OT in Malaysia can improve its human resource capacity, a critical component in attaining affordable comprehensive health goals in developing countries [40]. Medical hegemony can be re-constructed as the problem social situation that allows occupational alienation, marginalisation, apartheid, deprivation, and imbalances with negative outcomes for the profession and its members which result in the continuation of aggravated dissatisfactions, low morale conflict, limited participation, and poor health for its therapists, which calls for more studies.

Occupational justice is the right to inclusive occupational participation which benefits the profession and the clients receiving care, and appears to be violated by the current situation under governance of other discipline exerting their authority on newer health professions in Malaysia [24] [26]. However, as outlined above it will be sometime before Malaysia can gather enough manpower and follow the developed world with an established council which accredits the profession’s curriculum, oversees examinations and competence to practice. OT in Malaysia must be afforded the budget and priority to improve its human resource capacity with university-based programmes organised independently from unrelated medical discipline. This critical workforce component to attaining affordable comprehensive health goals in developing countries [40] must be extended into subspecialisations to ensure their services are delivered in a cost effective and efficient manner to the public without a redundant middle man regime which in this case is in the form of rehabilitation doctors. The myth and misconception that therapy professionals belong under the leadership of a rehabilitation doctors must be corrected immediately, and one way is education to promote the literacy level of health providers in relation to healthcare system globally. Malaysia needs to start moving towards the global international standard for all its neglected and oppressed health disciplines, and increase their workforce to ensure sufficient leadership in the field to help with literacy disseminations and contribute to health care.

Hocking [41] described “occupational justice” as a powerful idea that bridges the differences between people’s well-being and the harmful social conditions that limit them from being themselves or restrict what they can do. Thus, an emphasis on treating people/professions with respect and ensuring an equitable distribution of societal resources (Hocking, 2017) should be upheld, particularly for the newer professions. Yet, the Occupational Therapy profession in Malaysia without recognised professional leadership faces an inequitable distribution of resources such as zero to low training budgets for OT programmes in universities, zero professional representations, zero planning for its growth, and violated autonomy in daily clinical practice, suggesting serious occupational deprivation and violation. This entrenched medical dominance in Asia by Asian rehabilitation doctors, reflects a reminiscence of events in developed countries in the 1960s [27] [28] —with its associated occupational deprivation, occupational imbalance, occupational alienation, occupational marginalisation, and occupational apartheid (discussed below).

In the reconstruction of an occupational perspective on Occupational Therapy—an autonomous profession trapped in the medical hegemony healthcare system in Asia, the concept of injustice was critically reflected and found to have debilitating impact on the profession’s scope and values. Figure 1 is a reconstruction of this social phenomenon experienced by the profession in Malaysia. The diagram has two axes—the theme of occupational injustice and occupational justice as a continuum across a vertical axis, and a medical hegemony vs an inclusive system continuum as it horizontal axis. Occupational justice is a continuum dependent on the context and environment, where injustices are predictably higher in less developed countries due to low awareness and less social progress. The category (and its extent) of deprivation, imbalance, marginalisation, alienation, and apartheid, stemming from occupational injustice (within the context of medical hegemony) is viewed as leading to a severe debilitating impact on the newer health profession. Occupational reconstructions were shaped continuously over time with key experts who decided together “to do something about something” collectively, for social transformation as a solution to counter occupational injustices [44]. The OT profession is a strong advocate for justice, with values that ensure the occupational rights of individuals. Yet, it is ironic that its own occupational rights in Malaysia have been severely violated—inconsistent with the position articulated by the World Federation of Occupational Therapists on the “centrality of occupation” (or focus) on health, well-being, and human rights [42] [45]. The Malaysia health system has failed to invest in the educational upgrading of Occupational Therapists, and has continued to disregard a known contributor to healthcare in an autocratic medical model where even a young medical discipline has the full power to continuously violate the autonomy of health professions that have existed even longer than them. Such boundary encroachments have been reported by many other health disciplines including physiotherapy, nursing and pharmacy [9] [27] [46].

More planning and better budgets should be in place to address the current workforce level which is critically low, with the lowest ratio per 10,000 populations at 0.20 in 2010 as shown in Table 1 which is based on census from the ministry of health [47]. The number of Occupational Therapists serving Malaysia’s 33 million population at a mere 1893 in 2021 (Table 2). Table 3 provides an

Source: Estimations based on WFOT (2020) Human Resources Project.

estimation of the number of therapists in a sample of countries, with United Kingdom, Australia, Sweden, Japan and USA leading with the highest number of therapists per population [48] [49] [50] [51] [52].

Currently, the entire country of 33 million population has a mere 17 trained/ qualified educator workforces in the field of Occupational Therapy. There is an urgent need to address the oppressive medical hegemony and initiate opportunities to improve the autonomy of the Occupational Therapy workforce across its clinical work, education and research.

Medical hegemony, the dominance exerted by a medical group with characteristic active suppression of other professions and with emerging elitism, has positioning itself beyond reproach, and was identified as the key source of several categories of occupational injustices in the profession; and does not serve the individual patients, the science nor the healthcare system. More dialogue about occupational justice for Occupational Therapy, and clinical practice guides from around the globe is needed to help articulated this numerically small and “invisible” profession with increasing evidence-based contributions [35] to society. Research is also particularly needed in countries suffering from the barricades erected by medical hegemony, to problem solve towards a position of mastery for the profession. Based on the occupational justice framework, policy makers need to step in and advocate principles of occupational justice to educate against medical hegemony. Some broad strategies that may help are:

1) Societal accountability—i.e., ensuring all disciplines are able to perform their duties without injustices in their daily occupations;

2) Institutional changes with fair and just participation policies that allows inclusive employment, job autonomy, and interdisciplinary;

3) Promotion of justice with conditions for inclusive engagement and fair participation.

University-based education for Occupational Therapy must be initiated to address the current low level of education prevalent in the Occupational Therapy profession in Malaysia. The first doctorate Occupational Therapy lecturer working in a premier university has nevertheless been controlled by rehabilitation doctors with the apparent power to control Occupational Therapy education, clinical work and research. The World Federation of Occupational Therapists needs to initiate a position statement against non-therapy clinicians/academician as key supervisors for its members—to protect the theoretical underpinning of the profession.