COUNTRY REPORT POPULATION AND POVERTY IN MALAYSIA SECTION 1 : OVERVIEW OF POPULATION AND DEVELOPMENT SITUATION AND PROSPECTS. When Malaysia was formed in 1963, the population of the whole country was approximately nine million. The total population increased to more than 10.8 million in 1970 and 13.7 million in 1980. The rate of population growth had declined gradually from a high level of 3.0 per cent per annum in 1966 to 2.30 percent in 1980. With the high influx of immigrants during the period of 19801991, the average annual growth rate has risen to 2.64 per cent per annum giving the total population of Malaysia in 1991 to more than 18.5 million. The 2000 population census gives a population of 23.3 million, growing at an annual growth rate of 2.60 per cent per annum for the period 1991-2000 (Table 1). In terms of age structure, the present population of Malaysia can be described as “youthful”. Due to high fertility in the last two decades coupled with declining mortality, as many as 33 per cent of the current population are under the age of 15 years. The current median age of the population is less than 24 years. With regard to the aged population (65 years and older), there has been a clear trend towards ageing population. The proportion of aged population is currently at 4.0 per cent as compared to 3.7 per cent in 1991. The overall dependency ratio has decreased from 69.2 per cent in 1991 to 59.1 per cent in 2000 and expected to further decline to 57.8 per cent in 2020. The drop in the dependency ratio was due to the increase in the proportion of Malaysia Country Report for the Fifth Asian and Pacific Population Conference : Population and Poverty in Asia and the Pacific, 11-17 December 2002, United Nations Conference Centre, Bangkok, Thailand. 1 the working age population of 15-64 years as well as slower growth of the population below 15 years. In terms of spatial distribution, the proportion of the population living in urban areas has increased from 50.7 per cent in 1991 to 61.8 per cent in 2000, growing at an annual average rate of 4.8 per cent. This increase was due to rural-urban migration, spurred by expectations of jobs opportunities and a better quality of life, growth of new urban areas and extension of existing administrative boundaries. The decline in fertility and mortality levels in Malaysia has been consistent with the rapid economic growth that the country has been experiencing. While there has been general awareness of the need to integrate population factors within the broad framework of development, the vision of attaining an industrialised and developed nation status by the year 2020 would necessarily require closer understanding of the implications and consequences of future changes in population trends and dynamics. The population of Malaysia, which is 23.3 million in 2000, is expected to grow to about 33.4 million by the year 2020. The increase in population size for the next two decades is due to the in-built momentum of population growth arising mainly from maturing of young age groups of the last few decades into larger fecund age groups. The future age structure of the population will have considerable implications for social and economic development. In the next two decades, Malaysia will still have a moderately “young” population, with those within the age group 0-14 constituting 30.5 per cent of the total population. This implies that much of our development resources will still need to be devoted to cater for the needs of the younger age groups, particularly in terms of child care, education and other social services. While attending to the needs of the younger segment of the population, there is also concern for the steady increase of older persons, both numerically and in proportionate terms. Steps will have to 2 be undertaken to plan for the needs of the projected two million elderly by the year 2020. Malaysia stands unique today as one of the very few countries which has, within a relatively short period, succeeded not only in achieving growth but also in addressing more effectively the problems of poverty and economic imbalances. Alleviation of poverty has been in fact among the top priorities of development programmes since independence in 1957. The promulgation of the New Economic Policy in 1971 has the twin objectives of eradicating poverty and eliminating the identification of race with economic function. Its over-riding objective is to achieve national unity. Since then, poverty eradication has remained as an integral component and thrust of major policies of the nation, including the National Vision Policy, which is the successor to the New Economic Policy. Today, poverty is predominantly a rural phenomenon with absolute poverty diminishing. The number of poor households in Malaysia has been considerably reduced from about 619,400 in 1990 to about 274,200 in 1997. The incidence of poverty among Malaysians decreased from 17.1 per cent in 1990 to 7.5 per cent in 1999 (Table 2). Efforts to reduce poverty were hampered by the adverse effects of the Asian economic crisis in 1998. Both rural and urban households recorded reduction in poverty during the 19951999 period. The incidence of rural poverty decreased from 14.9 per cent in 1995 to 12.4 per cent in 1999 while urban poverty decreased from 3.6 per cent to 3.4 per cent. Households headed by the elderly and female-headed households experienced high incidence of poverty at 22.7 per cent and 16.9 per cent respectively. Under the current development plan, the thrust of poverty eradication will be to re-orientate poverty eradication programmes to reduce the incidence of poverty to 0.5 per cent by the year 2005. Poverty eradication programmes will be more target-specific by addressing pockets of poverty, particularly in 3 remote areas as well as among disadvantaged groups. Programmes will also be introduced to address the issue of urban poverty, particularly among those residing in the periphery of urban areas. Towards this end, programmes to provide social amenities, including housing, health and education, will continue as well as be upgraded to meet the needs and demands of these groups and improve their quality of life. SECTION 2: FERTILITY LEVELS AND TRENDS A significant decline in fertility has been evident since early 1960s and was further accelerated by the introduction of the National Family Planning Programme in 1967. From a high of 6.0 in the early 1960s, the total fertility rate has nearly halved to 3.3 in 1990 and 3.1 in 2000 (Table 3). The decline in overall fertility was partly due to the increase in age of marriage and the lowering of marital fertility, which was closely related to contraceptive usage. While 16 percent of women aged 15-19 years were married during the 1970 census, this had declined to 6 per cent in 1984 and further to 4.8 per cent during the 2000 census. The mean age at first marriage for women has risen from 23.5 years in 1980 to 25.1 years in 2000, thus delaying childbearing and subsequently lowering the rate of population growth. The decline in fertility may also be attributable to other indirect factors such as higher educational levels of the population especially females; increase in female labour force participation; the increasing pace of urbanisation; and the general improvement in the standard of living. Consequent to the decline in fertility and an increased preference to form nuclear households after marriage, there was a significant shift towards smaller family size. Average household size has dropped from 5.2 persons in 1980 to 4.9 persons in 1991 and further declined to 4.5 persons in 2000. Practice of contraception rose sharply between 1970 and 1994, reaching more than half of currently married couples. Reproductive health services including family planning have been upgraded since the International 4 Conference on Population and Development, 1994 and family planning services are easily available throughout the country with a wide range of contraceptive choices ranging from hormonal contraception and barrier methods to chemical methods and sterilisation. Abortion is not available upon demand but only on medical grounds. Family planning services in Malaysia are provided based on the policy of non-coercion for the promotion of maternal and child health. The National Vision Policy envisages Malaysia as a developed country by the year 2020. It will be highly industrialised, high technology society with an economy driven by knowledge, skills and diligence. In a society with such an economy, fertility is likely to be low. Experience shows that there are no wealthy countries with high fertility. Malaysia is unlikely to be an exception. In an urbanised, complex and competitive society with excellent employment opportunities for better-educated women, the desire for small family size will be more prevalent. The National Vision Policy stresses human resource development as well as the need for the creation of an economically resilient and fully competitive community. In this respect, it is the quality, rather than quantity of the population that matters. As such, interventions to influence fertility do not appear to be needed. Fertility has been declining over several decades and this decline can be expected to continue if Malaysia is successful in moving towards an industrialised society. An educated public can make its own choices about family formation and family size. Ready availability of reproductive health services such as counseling, contraceptive information and methods will be the strategy so that an informed choice can be made particularly by poverty and high risk groups who are generally slow in getting reproductive health information and disadvantaged by unplanned family size. The point to be made is that it is not necessary to intervene to “prop up” fertility. The key need for population programme is to plan and strategise for a population structure in the period between now and 2020 that is supportive of 5 the goals of the National Vision Policy. This requires an emphasis on quality, on human resource development and on allowing couples to plan their own family size. SECTION 3: MORTALITY AND MORBIDITY TRENDS AND POVERTY Achievements made in Malaysia’s medical and health services have been very successful in bringing about a significant decline in the infant, perinatal, neonatal and maternal mortality and also an increase in the life expectancy of the people. The success of these achievements has been mainly due to the bold health policies and innovative procedures taken by the government not only to resolve immediate health problems but also to institute long-term measures to achieve a standard of health that will enable Malaysians to enjoy a better quality of life. In line with the government’s objective to provide all Malaysians with a high standard of health and medical care, the development of health services has been given high priority. Emphasis has been on the development, modernisation, expansion and strengthening of rural health services system; the full integration of family planning into the primary health care services; and the promotion of psychosocial dimensions of health. This is to rectify the imbalance in distribution of health services between the urban and rural areas; to ensure accessibility; the eradication of high mortality and morbidity among sub populations; and to attain universal coverage for primary health care. Consequent upon the overall improvement in the health status of the population, mortality indicators have shown a significant decline (Table 4). The crude death rate has declined from 7.0 deaths per thousand population in 1970 to 4.6 in 2000. The infant mortality rate was 40.8 per thousand live births in 1970 and has plummeted to 7.9 in 2000. Similarly, maternal mortality rate has also declined from 1.48 deaths per thousand live births to 0.2 during the same period. In order to sustain the decline in avoidable deaths, a system to investigate maternal deaths among mothers who deliver at home and in government hospitals was implemented by the Ministry of Health. 6 The morbidity profile spanning three decades from the 1970s to the present indicates that Malaysia is undergoing an epidemiological transition in which diseases associated with urbanisation, economic affluence, sedentary occupations and a stressful lifestyle have taken precedence over the communicable diseases of yesteryears. In the 1970s and earlier, infectious diseases predominated but by the 1980s, heart diseases, cancers and injuries due to accidents (motor vehicle, industrial and occupational) were the leading causes of hospitalisations and deaths. At the same time, there has also been an increase in mental, social and health-related problems as evident from the growing number of drug addictions and HIV carriers. Health education programmes have been one of the most effective strategies in mortality reduction and ensuring a healthy lifestyle. These education programmes include efforts to eradicate alcohol and substance abuse, prevent sexually transmitted diseases and HIV/AIDS as well as instill the habit of regular exercise and the need for balanced diet. These programmes were implemented through the mass media, schools and through community groups. Specific intervention strategies have been implemented to reduce major causes of infant and child morbidity and mortality. Risk Approach Strategy and Safe Motherhood Initiatives help to reduce maternal mortality and morbidity among high risk and high parity mothers. Health programmes for the upliftment of the very poor and the rehabilitation of malnourished children were also implemented. The introduction of Confidential Enquiry Into Maternal Deaths System since 1991 has improved data collection/compilation procedures and enabled indepth investigations to be carried out to identify weaknesses and rectify them. 7 SECTION 4: MIGRATION, URBANISATION AND POVERTY The Malaysian population is highly mobile largely due to both the pull factors of economic opportunities in urban areas and the push factors of the traditional agricultural rural areas. These migrants are age and area selective, with those in the age group of 20-29 years having a greater tendency to move and settle in more urbanised dan developed areas to escape the poverty of the rural and under developed areas. Females have become more prominent in internal migration since 1970s, a trend related to the increasing level of education and growing employment opportunities for women. Over the long term, it is likely that a spatially more dispersed pattern of internal migration will emerge as development spreads more widely over the country and as de-urbanisation replaces urbanisation. The flows of internal migration will also be determined by the success and pace of particular states in restructuring their economies, as the present trend seems to indicate the preponderance of economic factors as reasons for migrating. Given this scenario, there may now be a need for some form of clear policy guidelines to provide for a general framework regarding future direction of population flow and distribution. Today already some parts of the country, particularly the more developed and urbanised states are facing a serious problem of meeting their labour requirements. Such a phenomenon implies the existence of spatial mismatching between sources of labour supply and demand. While this may suggest the need to further encourage rural-to-urban migration, care should be taken to ensure that this does not lead to the ultimate obsolescence and depletion of rural areas. Recent trends have clearly shown that such movements often involve the out-migration of the more dynamic and educated rural youths. Excessive urban-bound migration in the past has also resulted in imposing further strain on the ability of urban authorities to meet the basic needs of their fast growing population. Future patterns and trends of internal migration in 8 Malaysia will therefore require more careful monitoring as it will affect not only the total number of people in receiving and sending areas but also, in the case of out-migration, the viability of community life. High in-migration can pose unexpected needs for basic facilities such as housing and infrastructure. International migration has emerged as an important factor affecting population trends in Malaysia. Over the 1980 – 1991 period, international migration has altered population growth adding about 0.4 percentage points to the growth. During the boom period of 1991 – 1996, varying figures have been quoted ranging from 1.5 million to 2.5 million including both documented and undocumented migrants in Malaysia. However, with a slowdown in the overall growth of the economy arising from the regional financial crisis beginning in mid – 1997, a registration exercise of illegal foreign workers was conducted and a tightening of the policy on the employment of foreign workers was implemented. Besides a freeze in the recruitment of foreign workers, excess foreign workers and those who could not be redeployed, were repatriated. In 2000, the number of non-citizens in Malaysia is about 1.23 million. As mentioned earlier, the proportion of the population living in urban areas has increased from 50.7 per cent in 1991 to 61.8 per cent in 2000, growing at an annual average rate of 4.8 per cent. The urbanisation rate is expected to increase to 66.9 per cent by end of 2005. Apart from natural increase and rural-urban boundary changes, rural-urban migration has played a significant role in the growth of urban centers, especially those that are state or federal capitals. Changes in the administrative boundaries and expansion of existing town centers as well as opening of new big townships contributed to the higher share of population in urban areas. Despite the growth of several individual urban settlements, the urban system however, tends to be very strongly dominated by the Klang Valley where Kuala Lumpur is situated. 9 Urbanisation has brought considerable benefits, especially in stimulating modernisation and contributing to fulfillment of the development objectives of the country. Various changes have occurred with urbanisation, which include economic (example, labour mobility, income, savings and capital formation) and socio-demographic (for example changes in fertility, family size, quality of life, social stratification, and changing status of women in society). To illustrate these points, the incidence of poverty in the urban areas had drastically declined from 7.5 per cent in 1990 to 3.4 per cent in 1999.as compared against 12.4 per cent in the rural areas in 1999. The urban population also earned higher incomes, with the mean monthly income of the top 20 per cent increasing from RM6,474 in 1995 to RM7,580 in 1999. The bottom 40 per cent of the urban population enjoyed an increase in their mean monthly income, from RM942 in 1995 to RM1,155 in 1999. More than 98 per cent of the urban population currently enjoyed piped water supply and close to full coverage is expected by the year 2005. With increasing urbanisation, there is a need for more systematic planning, efficient administration and better delivery of services from local authorities. The emphasis in urban development was to ensure that urbanisation process was planned and implemented systematically to improve the quality of life and contribute towards economic growth. In this regard, the dispersal of urban development was undertaken as an important strategy to reduce pressures on major urban centers such as the relocation of the Federal Government Administrative Center from Kuala Lumpur to Putrajaya and the development of Cyberjaya. Measures were undertaken to improve planning and implementation of projects to address urban related issues such as flash floods, squatter settlements, traffic congestion, the hazards of vector-borne diseases as well as air and water pollution. A total of RM779 million was spent for urban flood mitigation programmes, while a total of 34,148 low cost houses were in various stages of implementation in Kuala Lumpur under the Integrated Housing Programme (Program Perumahan Rakyat Bersepadu). In addition, a 10 total of 17,630 housing units were identified for implementation in other major towns. To alleviate traffic congestion, particularly in the Klang Valley, various measures were undertaken such as the creation of bus lanes, park-and-ride facilities, feeder bus services and Light Rail Transit (LRT). The Healthy Cities Initiative (HCI), introduced in Kuching and Johor Bahru in 1994, was expanded to include more cities and towns. The HCI focused on communities in realising their potentials. By 2000, a total of 15 cities and towns participated in the HCI project. The development strategies will continue to emphasise the improvement of the quality of urban services. This is to ensure that the urban areas are more livable, with its citizens enjoying a higher quality of life. Migration from the rural sector to areas within and the outskirts of urban centers has created pockets of urban poverty. Appropriate measures will be instituted to alleviate the situation. This will include proper urban planning and the provision of adequate public amenities such as open spaces for children, kindergartens, and community halls, together with programmes aimed at raising civic consciousness. The urban areas will be developed through the efficient management of resources such as land, social infrastructure and human resources. In this regard, an urban policy will be introduced which will emphasise a total planning concept in order to attain balanced and sustainable development in all its multi-facets, that is, economically, socially, spiritually and environmentally. Under this policy, the urban areas will be evaluated in terms of size, roles, functions, population targets as well as human settlement planning and development. In addition, the spatial distribution and growth of existing and future urban areas will also be examined and improved. In medium and small-sized towns, the development of essential facilities such as housing, schools, community facilities and commercial premises will be given priority to create a livable and attractive business environment. 11 Efforts will be carried out to encourage greater community participation in managing, improving and resolving urban environmental issues together with the local authorities. In this regard local authorities will provide better human settlement facilities and improve the quality of life, in line with the Habitat Agenda and Local Agenda 21. The use of Information and Communications Technology (ICT), training of personnel, sharing of best practices and international networking will in the future enhance the effectiveness and efficiency of local authorities. To ensure that the local authorities are able to face new challenges and cope with the expansion of urban areas, the institutional capacity including the implementation of planning guidelines and enforcement, will be further improved and upgraded. In this regard, there is a need to review and streamline rules, regulations and procedures. In addition, the National Physical Plan will provide the necessary management tool for effective and efficient urban development. SECTION 5: POPULATION AGEING Since the 1960s, Malaysia has entered the demographic transition stage where rapid reduction in mortality is accompanied by a steady pace of fertility decline. Given prevailing demographic trends, it is projected that, by the year 2020, those aged 65 and above will constitute about 7 per cent of an estimated total population of 33.4 million that will put Malaysia into the ranks of countries having aged population. In terms of absolute numbers, the population of older persons will increase from about one million in 2000 to 2.3 million by the year 2020. This represents a more than two-fold increase within the span of 20 years, or an increase of 65,000 older persons per year. Even though Malaysia still lags behind in the ageing process when compared to the more advanced countries, the early sensitisation and consciousnessraising efforts of the government on the issue of ageing is reflective of its awareness of significant changes taking shape in the demographic process. 12 One of such changes is the clear trend towards declining family size. As care for the older persons has traditionally been within the family system, further decline would ultimately reduce the number of family members available for care of their aged dependents. Care of the elderly within the family system is fast becoming a problem owing to the fact that the extended family structure is slowly being undertaken by nuclear family. Such problems are compounded as more women participate in the labour market and with increasing mobility of young family members. Over the years the government has introduced various policies and programmes that aimed to improve the quality of life for older persons and to integrate them into the mainstream of development. The National Social Welfare Policy formulated in 1990 calls for the welfare of the aged to be safeguarded with the support of the family and the community. Institutional care is to be considered as a last resort. Towards this end, the government allowed tax deductions for the payment of medical expenses incurred by parents. The government approved the establishment of day-care centers to provide care for older persons during the day in the absence of family members. For older persons who are destitute and have no relative to care for them, the government has and will continue to establish homes and provide financial aid especially to the elderly living in poverty to ensure their wellbeing. Whilst the National Social Welfare Policy is very much welfare oriented, the National Policy for Older Persons formulated in 1995 put more emphasis on the developmental aspects of this group. The aim is to create a society of older persons who possess a high sense of self-worth and dignity, by optimizing their potential and ensuring that they enjoy every opportunity as well as care and protection as members of their family, society and nation. Currently a growing trend is emerging where retired professionals and government pensioners are being re-emplaced and their resources tapped in government and private sectors. 13 The Plan of Action for the Older Persons, which was introduced in 1998, recognised community-based programmes as one of the feasible approaches that would be able to meet current and future challenges pertaining to older persons. Additional support facilities would need to be provided so that reliance on family support would not put great stress on family members. Moves towards creating a caring society should take cognizance of the need to encourage three or four generation households or alternatively for elderly persons and their children to live close to each other. NGOs in Malaysia have also played a complementary role in helping the Government to meet the social needs of older persons in the country. The majority of NGOs for the aged target group provide institutional care and shelter for the older persons who are in need. SECTION 6: REPRODUCTIVE HEALTH INCLUDING FAMILY PLANNING Family Planning has been a national programme since the establishment of the then National Family Planning Board (NFPB) in 1966 and later with full integration into the Primary Health Care and Maternal and Child Health Services of the Ministry of Health (MOH) beginning from 1971. The programme is complemented by family planning clinics of the Federation of Family Planning Associations of Malaysia (FFPAM) and private clinics and hospitals in the urban areas. Through this tripartite collaboration, knowledge of family planning is almost universal and family planning services are widely accessible, affordable and acceptable to all, and are provided on the basis of health benefits to the mother, child and family. There is no coercion or discrimination and individual couples are free to choose the most suitable contraceptive method based on the timing, spacing and numbers of their children. Following the ICPD in 1994, Malaysia has undertaken several initiatives to ensure family planning services be provided under the broader package of reproductive health. A Central Coordinating Committee on Reproductive 14 Health, chaired by NPFDB, has been formed involving related government agencies, non-governmental organisations and the private sector to look into the policies, strategies and the optimal ways of integrating other reproductive health components such as prevention and treatment of HIV/AIDS, STDs, reproductive tract infection, infertility treatment, etc, into the primary health care system and into family planning programmes. In 2001, the Malaysian government made a decision that the NPFDB be given the mandate to plan and implement programmes related to population, family development and human reproduction. While recognising the importance of a comprehensive reproductive health services, effective implementation of such services depend very much upon the capacity of implementing agencies. Currently, core reproductive health services such as pre- and post-natal care, maternal care and HIV/AIDS are provided through primary health care services while service delivery of family planning services of NPFDB and FFPAM are being expanded to include other perspectives such as menopause, andropause, youth and adolescent sexual counseling, infertility, counseling for STDs and HIV/AIDS, screening for reproductive tract cancers and related services. In view of the need for greater understanding of the concept, scope and operationalising of reproductive health among service providers, and programme implementers, training updates have been intensified and a training package and standard operating procedures as well as model clinics are currently being developed. In Malaysia, service providers are committed to the needs of clients through quality, efficient and effective services. Couples have the right to decide on the number of children and timing of births. The availability of method-mix allows switching if and when the method initially selected is found to be not suitable. Malaysia recognises that interaction with clients require great efforts and skills so as to meet their demand and expectations of quality service. A clientcentered approach ensures client’s satisfaction whereby a high continuation 15 rate of users is expected to remain in the programme. High quality service is continually emphasised at all levels of programme management. As such, basic reproductive health services have become easily accessible, affordable and acceptable to almost 100 per cent of the target groups. Emphasis is now given on high risk and high parity women including those living in poverty. Malaysia has for several years substituted its target-oriented approach with quality service approach in the provision of reproductive health services especially in family planning services. This allows creativity among programme managers and service providers to expand their services and to enable them to perform their tasks without pre-set restrictions. This is in line with the client-centered approach currently being practised. It is based on the premise that satisfied clients become good motivators for the programme itself. SECTION 7: ADOLESCENT REPRODUCTIVE HEALTH Adolescent reproductive health has become an important national agenda in view of the increasing incidence of sexual activities among the young that has led to unwanted teenage pregnancies, abandoned babies, STDs and HIV/AIDS. As of March 2002, about 2 per cent of HIV carriers and 3.7 per cent of AIDS cases are from the age group 13-19 years. Findings from a National Study on Reproductive Health and Sexuality of Adolescents conducted by the National Population and Family Development Board in 1996 stressed the need for a pro-active strategy to tackle the emerging issues of adolescent reproductive health. This study forms the basis for multi-sectoral interventions, which include advocacy, education, counseling and training on adolescent development, motivation and creative capabilities among clients. The Cabinet adopted a decision that a Reproductive Health Service Package for Adolescent and Youth be formulated. In Malaysia, programmes for adolescent and unmarried persons require a socially acceptable approach. Currently, family planning services are provided 16 only to married couples. Although family life education, which includes topics on sexuality, is incorporated into the school curriculum, most adolescents are still ill-equipped to deal with their sexuality. Inadequate access to correct information, lack of referrals and counseling services, familial and religious norms are some of the problems faced by adolescents. Economic constraints as well as difficulties in reaching selective groups such as out of school youths and those in the workplace, constitute some of the problems faced by service providers in meeting the reproductive health needs of the adolescents. A Technical Committee on Adolescent Reproductive Health comprising relevant government agencies, schools, non-governmental organisations and interested parties has formulated strategic interventions on issues pertaining to adolescent reproductive health. At the same time, educational and training programmes are being conducted for adolescent, in collaboration with selected schools and NGOs, with the aim of instilling greater resilience, positive values and promoting healthy lifestyles. With the establishment of the Malaysian NGO Coordinating Committee for Reproductive Health (MNCCRH) in mid-1999, the NGOs programme complements the Government’s adolescent reproductive health programmes. One of the main aims of MNCCRH is to promote family life education in order to prepare young people for responsible parenthood and increase their access to appropriate information, education and services in addressing their reproductive health care needs. MNCCRH believes that involving young people in programme design, planning, implementation and evaluation of Sexual and Reproductive Health (SRH) programme will further empower them with appropriate knowledge and skills to enable them to practice healthy behaviours and responsible living. The Malaysian NGO National Seminar on Reproductive Health, 2000 and the National Youth Seminar on Youth-Friendly Sexual and Reproductive Health 2002 organised by MNCCRH will serve as a platform for the development of a National Plan of Action on Youth-Friendly SRH Programme. The programmes of MNCCRH will also serve as a benchmark towards developing an integrated programme on SRH for 17 adolescents with emphasis on partnership and collaboration between and within relevant government, non-government and corporate sectors. SECTION 8: DEMOGRAPHIC, ECONOMIC AND SOCIAL IMPACT OF HIV/AIDS The HIV/AIDS situation is recognised as a public health problem in Malaysia and one that is of a national concern especially with regard to cases of the spread of HIV/AIDS among young people and to newborns through mother-tochild transmission. Since the first case of AIDS was reported in December 1986, there has been a geometric increase in the number of HIV infection. Over the last seven years (1995 – 2001), the average number of new cases reported annually was 4,716. By March 2002, the cumulative number of HIV infections was 45,889 with 6,280 cases of AIDS. The HIV infection rate is highest among young adults of the age group 30 – 39 years while the proportion of women infected with HIV is also increasing. Based on the experiences of many countries, if the epidemic persists and goes unchecked, it will have vast impact on the demographic profile of the country such as population growth, distribution and structure, widowhood and increase in orphans among children and in a reduction of the reproductive years resulting in lower fertility. Experiences of many countries also demonstrate that HIV/AIDS epidemic exerts an upward influence on morbidity and mortality resulting in the decline of life expectancy. Economically there will be a reduction in the quality and quantity of labour; reduction in volume and use of savings, resulting in less investment, less productive employment, lower incomes, slower GNP growth and lower level of GNP. HIV/AIDS would also contribute to a rise in labour costs as productivity declines due to higher morbidity and increased absenteeism, and additional training costs incurred as labour turnover increases. There will be an increase in health and social expenditures of government and families. There will also be a decline in family income due to loss of productive family members resulting in an increase in the incidence of poverty. Given the above demographic, economic and social 18 impact of HIV/AIDS, Malaysia will, therefore, give due attention to the HIV/AIDS epidemic. In Malaysia, the HIV/AIDS prevention and control programme was established in 1987. The strategies and activities of the programme are guided by the following principles: Education is the key to HIV/AIDS prevention; Information, education and communication on HIV/AIDS should be made accessible and available to the public and those at risk; The community as a whole has the right to be protected from HIV/AIDS; Care and support to the infected and affected individuals should be provided in a professional manner and the highest possible level of confidentiality should be maintained by care providers; Those who are infected with HIV should be safeguarded against discrimination and stigmatisation within the community and in the work place; Each individual should take the responsibility to protect him/herself from being infected with HIV, and if infected, to prevent further transmission to others; The involvement of every sector of the society including those who are infected with HIV is essential to successfully meet the challenges of the HIV epidemic; The importance of continuous training and research in HIV/AIDS; and The need for national, regional and international collaboration on HIV/AIDS. The best option in addressing the present challenge is an effective health promotion strategy directed towards the high-risk groups and young people. The cultivation of non-risky behavior and the acquisition of skills that comes with it is a powerful weapon in the battle against the transmission of HIV. 19 A nationwide campaign on HIV/AIDS was launched in 1991 and while dissemination of information on HIV/AIDS is important, there is a need to provide gender sensitive education about sexuality, life skills and behaviour change among adolescents, young adults, men and women. Information and skill about healthy lifestyle, harm reduction practices and the ability to cope with the disease and its impact are given to those found positive. Free HIV testing and counseling are available in all government hospitals and some health clinics. A special community mobilisation programme for youth, PROSTAR, was established in 1996, conceived on the premise that it is ‘action by youth, through youth and for youth’, and aimed at enhancing “Staying Healthy Without AIDS” within the framework of our socio-cultural mores and religious values. To support this programme, the Government in 2001 has taken the leadership to train about 20,000 peer educators nationwide. Gender-based programmes targeting women and children, particularly the Prevention of Mother-to-Child Transmission of HIV Programme, has helped improved the chances of HIV positive mother to deliver healthy babies. This programme not only provides free HIV testing and counseling services, but also free anti-retroviral therapy to infected mothers and infants. In addition, awareness campaigns on “women and AIDS” are being carried out and efforts are being made to involve men with a view to focus on behavioural change. Although prevention is the mainstay of our response to the HIV epidemic, specific therapy is considered fundamental for an effective programme. The present regime is the Highly Active Anti-retroviral Therapy or HAART, given to cases that fulfill the medical eligibility criteria. The treatment for certain categories of patients are fully subsidised by the government, namely children less that 12 years old, persons who acquired infection through contaminated blood and blood products, health care workers infected through occupational 20 exposure and women detected positive through the antenatal screening programmes. In the fight against HIV/AIDS, the government works closely with NGOs. The Malaysia AIDS Council, an umbrella organisation of multiple NGOs has played an important role in advocacy, capacity building and coordinating activities addressing specific target groups. Community-based services are provided to outreach groups and people living with HIV/AIDS needing rehabilititative support, especially discharged inmates from rehabilitation centers and prisons. Provision of care and support to those infected and affected with HIV infection is very essential. To make the services available, the Government has integrated the management of HIV and STDs (using syndrome mix approach) at the primary care level. SECTION 9: GENDER EQUALITY AND DEVELOPMENT In Malaysia, efforts toward empowerment of women are integrated and incorporated into various five-year development plans. Through continuous efforts of the Government in providing an enabling environment, women continued to participate in and contribute towards the social and economic development of the country. The current Eighth Malaysia Plan (2001-2005) has continued to address women’s concerns and to enhance the role, position and status of women to ensure their participation as equal partners in national development. Under the current plan, women will be provided with the skills and knowledge to cope with the challenges of globalization and fulfill the needs of a knowledge-based economy. The Government’s commitment towards gender equality is manifested through the formulation of various policies such as the National Policy for Women, the Plan of Action for the Advancement of Women and through the enactment of legislation and amendments of various laws. In February 2001, 21 the Government established the Ministry of Women and Family Development to coordinate national programmes for women’s development and advancement. The most recent milestone was the amendment of Article 8(2) of the Federal Constitution in August 2001 to include the word “gender”, thus prohibiting laws or policies from discriminating against women. Following the adoption of a National Policy on Women in 1989, a National Plan of Action on Women has been formulated in 1997. Both are aimed at ensuring an equitable sharing of the acquisition of resources, information, opportunities and benefits of development for men and women, and in integrating women in all sectors of development in accordance with their capabilities and needs in order to enhance the quality of life, alleviation of poverty, ignorance and illiteracy. The progress of women’s advancement in Malaysia is evident in many sectors. Maternal mortality ratio is currently around 20 per 100,000 and women are expected to live up to 75 years as compared to 70 years among males. Primary education is almost universal with literacy rate of more than 85 percent among females aged 10 and above. The greater number of females pursuing higher education has enabled almost half of the women into the employment sector. Women today are more visible in business with the majority being self-employed in small-scale trades and services. Female Labour Force Participation Rate (FLFPR) has increased from 41.9 per cent in 1991 to 44.5 per cent in 2000. Recognising that increasing poverty among women is a world-wide phenomenon, various efforts were undertaken by the government and nongovernmental organisations to reduce the incidence of poverty among women, over and above the overall poverty redressal programmes of the country. The special programmes include the provision of micro-credit facilities to some 22,850 women to facilitate their involvement in small businesses. Loan and credit schemes operated by banks are not gender 22 biased and micro-credit facilities are available through Amanah Ikhtiar Malaysia aimed at helping to reduce poverty and increase self-reliance. Training programmes were also conducted to assist single mothers gain employment. In view of rising incidence of poverty among female-headed households, from 15.1 per cent in 1997 to 16.1 per cent in 1999, special efforts will be undertaken in favour of this group. Towards this end, research on the problems faced by women as head of households will be undertaken. Special emphasis will continue to be given to the empowerment of rural women. Various programmes specifically targeted to these women have been formulated and implemented, such as the establishment of women extension groups and the establishment of one-stop centres to assist rural femaleheaded households. Malaysian women have made significant progress in almost all spheres of development since the Bali Declaration, 1992 and the 1994 International Conference on Population and Development (ICPD) in Cairo. However, several obstacles and constraints to the further advancement towards gender equality and development continue to exist that may hinder the achievement of the goals set by ICPD and ICPD+5. These include discriminations based on perceptions, inadequacies in existing legislations as well as legal illiteracy among women. Efforts have been taken to amend legal provisions which are discriminatory or that are disadvantageous to women. Among the legislations emphasised are those related to marriage and divorce; child protection; domestic violence; guardianship of infants; and employment. Gender sensitisation programmes have been implemented to effect perceptual and attitudinal changes and the promotion of equitable family responsibilities through information dissemination, education and training activities. Realising the importance women to become more aware of their rights, the Ministry of Women and Family Development in collaboration with NGOs had implemented legal literacy campaigns for women. 23 Reproductive health has generally been seen as female concerns especially with regard to family planning practices. Male participation is still relatively low. However, efforts have been intensified since Bali and ICPD in promoting greater participation of males in reproductive health in particular and in household activities in general. A fatherhood educational module has been developed and implemented by the National Population and Family Development Board since 1997 in an effort to increase male participation in reproductive health responsibilities and the upbringing of children. To promote both awareness and commitment of government ministries and agencies, especially those responsible for policy and programme formulation, gender sensitising training programmes including issues on male responsibilities in the areas of reproductive health are continuously held. While access to education, employment and other services are generally free from gender biases, there still exist some disparities at the family and individual levels as well as certain geographic regions that have consequences on reproductive health. It is hoped that with more effective information dissemination, education and training, such disparities could be eliminated. SECTION 10: INFORMATION, EDUCATION AND COMMUNICATION (IEC), ADVOCACY AND ICT AS TOOLS FOR POPULATION DEVELOPMENT AND POVERTY REDUCTION The ability to create, distribute and exploit knowledge and information is often regarded as the single most important factor underlying economic growth and improvements in the quality of life. A knowledge-based economy presents the way forward to achieve sustainable rapid growth and remain globally competitive in the medium and long term. Recognising that information and communication technology (ICT) is an important enabling tool towards achieving this objective, the Government of Malaysia undertook various initiatives to facilitate the greater adoption and diffusion of ICT to improve capacities in every field of business, industry and life in general. 24 The Seventh Malaysia Plan period (1996 - 2000) saw a rapid growth in ICT utilisation. This was largely due to the increasing awareness of Malaysians on the importance of ICT in education, economic development and poverty eradication. The provision of special incentives such as the abolition of sales tax on computers and components, and the granting of accelerated capital allowance for expenses on computers and other ICT equipment also assisted in increasing the usage of ICT. The number of personal computers (PCs) installed rose dramatically from 610,000 in 1995 to 2.2 million in 2000. The number of PCs per 1,000 population also rose from 29.5 in 1995 to 95.7 in 2000. During this period, the usage of the Internet by households also increased. The number of Internet subscribers increased from 13,000 in 1995 to about 1.2 million in 2000, a phenomenal rate of growth of 145.2 per cent per annum. TMNet, Maxisnet and JARING are the Internet Service Providers (ISP) in the country. Despite the phenomenal growth, the penetration rates are still low at 9.0 per cent of the population for PCs and 7.0 per cent for the Internet. Several programmes and projects were implemented by the Government as part of the efforts to increase ICT usage among the population. The Gerakan Desa Wawasan was launched in 1996 to increase the awareness of the rural population to participate actively in bringing about change and development to their areas. Under this programme, the Village Development and Security Committees were given computer facilities not only to assist in the management and administration of the villages but as an initial step to introduce ICT at the village level. By the end of 2000, a total of 955 villages benefited from this programme. The Internet Desa programme was launched in March 2000 at two pilot locations, namely, Sg. Ayer Tawar, Selangor and Kanowit, Sarawak. The programme involved the provision of ICT infrastructure at post offices and the launching of web sites that provided information on government services, local events and activities as well as free electronic mail (e-mail) and Internet 25 facilities. Initial evaluation revealed that there were 55 to 70 users per week, many of whom were students. By the end of year 2000, a total of 12 such centers were implemented throughout the country. Another project that was implemented to promote ICT awareness and usage was the E-Bario project initiated by the Universiti Malaysia Sarawak (Unimas). Under this project, computers and Internet access were provided to schools to become community centers of learning. The Government of Malaysia has prepared a National IT Agenda to transform the nation into a knowledge-based society in line with Vision 2020. This agenda focused on human development and leveraging on the public-private sector partnership programmes. The framework was based on the balanced development of three key elements - namely people, infostructure and applications. During the Eighth Malaysia Plan (2001 - 2005), more concerted efforts will be undertaken to position Malaysia as a competitive knowledge-based economy, with ICT facilitating the development. In this regard, the ICT infrastructure will be expanded, particularly to rural areas to bridge the digital divide and enable all citizens to have equitable access to knowledge and information. Emphasis will be given to human resource development and network infrastructure to enable Malaysians to benefit fully from rapid technological developments. Social and equity objectives will remain a fundamental consideration with the added responsibility of ensuring that the knowledge-based economy does not widen disparities between various sections of the Malaysian society. Strategies will be designed to enable all Malaysians to gain from the opportunities created through the knowledge-based economy. Telecommunications infrastructure will be expanded throughout the country to achieve total connectivity. The focus will be to ensure widespread diffusion of ICT and access to rural areas and disadvantaged groups. Computers and Internet access will be made more affordable. The Government in partnership 26 with the private sector will introduce ICT literacy programmes to educate targeted population groups based on their needs and capability. They will also provide appropriate opportunities and financial assistance to the disadvantaged to be an active participant in the knowledge-based economy. In addition, efforts will be taken to create greater awareness on the importance of the knowledge-based economy, particularly among the poor and the lower income group as well as to ensure their equitable participation. Malaysia has made significant strides in increasing the information and knowledge content in all economic activities. In developing further the knowledge-based economy, Malaysia will leverage on the knowledge accumulated from the implementation of the Multimedia Super Corridor (MSC) since 1996. Efforts will be intensified in the provision of access, particularly of the rural population, to the necessary infrastructure and infostructure. This will enable all Malaysians to take advantage of advances in ICT to improve efficiency and productivity, thus contributing to the increased overall competitiveness of the economy. Additional measures will also be undertaken to enhance human resource development to provide adequate skilled and knowledge manpower to support the knowledge-based economy. SECTION 11: DATA, RESEARCH AND TRAINING Malaysia is fortunate in being relatively well endowed with data on population and vital social statistics. Presently, various agencies and institutions are actively involved in population related research in terms of data collection and analysis. The National Population and Family Development Board, in accordance with its enabling Act of 1966 (Revised 1998), is responsible for the promotion of research efforts on the inter-relationships between social, cultural, economic and demographic changes as well as studies relating to fertility and birth. Apart from the population censuses and the vital registration system, which furnish reliable data on births and deaths that are undertaken by the 27 Department of Statistics, several large-scale demographic studies have also been carried out by other agencies in the country. These surveys, which are conducted with the view to monitoring changes within the general population and family system, provide vital inputs for planning particularly for the preparation of the five-year development plans and their mid-term reviews. One such study, the Malaysia Population and Family Survey has been conducted every ten years since 1974 by the NPFDB. Our latest Population and Housing Census was conducted in year 2000 and the Fourth Malaysia Population and Family Survey will be conducted in year 2004. In addition, the NPFDB also undertakes biomedical research on reproductive health as well as the psychosocial aspect of families as the critical components of its population programme. One major project, which the NPFDB is presently embarking on, is the establishment of the national and sub-national population information system. This project, which involves the collection of both primary and secondary population related data linked to the central system, is aimed at complementing the census data required for planning at the state and local levels. It will be accessible to planners, programme managers and researchers through on-line and networking. While there has been marked improvement in the collection, analysis and dissemination of research data, many gaps remain with regard to the coverage of certain population related sectors. Gender specific information, which are needed to enhance and monitor the sensitivity of development policies and programmes are still insufficient. Measurement of migration, particularly at the sub-national levels, is also among the areas least covered. Information or data on the ageing situation is usually available through census data. As these are usually in the form of aggregated data, more micro information should be made available for planning purposes. Disaggregated data are available through sample surveys but their numbers and coverage are somewhat lacking. Specific demographic and socio-economic research is clearly needed to enable programmes to take into account the views of their 28 intended beneficiaries, especially women, the young, the aged, the disadvantaged and other less empowered groups, and to respond to the specific needs of those groups and communities. The changing orientation in planning is making it necessary for local level administrators and planners to be capable of using data and information to make informed policy decisions. A better integration of population factors in development planning will necessarily demand a better understanding of the inter-relationships between population and development and the skills in the usage of research findings. Towards this end, the NPFDB has developed training packages, viz, I) Population and Development Training Module; ii) Population, Environment and Development Training Module; and iii) Demographic Data Collection, Analysis and Presentation for Programme Planning Training Module. These training packages are currently being used to train national and local level administrators and planners of relevant sectoral agencies. SECTION 12: PARTNERSHIP AND RESOURCES The role of the civil society organisations in the formulation and implementation of population and poverty programmes has been recognised and supported in Malaysia. Civil society organisations and non-governmental organisations such as the Federation of Family Planning Associations of Malaysia, Malaysian NGO Coordinating Committee for Reproductive Health, Amanah Ikhtiar Malaysia, Malaysian AIDS Council to name a few, have been pivotal to the success of the reproductive health and poverty alleviation programmes in the country. As the organisations closest to the community and being in a better position to mobilise public opinion and attitudinal changes, especially on sensitive population issues such as HIV/AIDS, adolescent sexuality and reproductive health, the role of civil society organisations cannot be denied. Government support for these organisations has been increasing. Although civil society organisations involvement in policy formulation is somewhat limited, their role 29 in programme implementation is viewed as supplementing and complementing those already being implemented by government agencies. With no bureaucracy, they can tackle specific and emerging issues quickly. Since ICPD, a directory of NGOs involved in social development related programmes and activities has been produced and regularly updated to facilitate greater smart partnership. Recognizing the role played by civil society organisation, a yearly grant was given by the government to NGOs to enable them to play a more effective role in grassroots activities. Reflecting the nation’s commitment to reduce poverty to 0.5 per cent by 2005, a large allocation has been earmarked to implement programmes aimed at reducing poverty under the current development plan. Similarly, large allocations are being provided to accelerate low and medium cost housing programmes and improve community development while allocations for youth and women development have been increased. SECTION 13: OTHER MATTERS In the implementation of the ICPD-POA, Malaysia still maintained its position, stance and reservations on specific issues that were raised during the ICPD in 1994 and ICPD+5 in 1999 such as: - a. Our concept of the family is the traditional family formed out of a marriage/registered union between a man and a woman, and comprising children and extended family. We do not agree to families formed by other unions other than marriage/registered union nor union of the same sex. This concept differed from those of the western and developed countries that upheld the view that the family must be considered in all its forms reflecting the realities of today. b. Malaysia agreed that the broad package of reproductive health services including family planning; sexual health; prevention and 30 treatment of STD/HIV/AIDS; management of cancers and reproductive tract infections; and the humane management of complications of abortion be part of primary health care system. c. Adolescent reproductive health and sexuality has become an important agenda in the implementation of ICPD-POA. This is in view of the increasing incidence of sexual activities among the young, unwanted teenage pregnancies, abandoned babies and HIV/AIDS. Malaysia does not restrict the access of adolescents to reproductive health information and services. Malaysia stressed that designing programmes and strategies for adolescent and youth requires a cautious and sensitive approach acceptable to religious and cultural norms. Making contraceptive services available to adolescents is not agreeable. d. Reproductive rights recognised the basic rights of couples or individuals to decide freely on the number, spacing and timing of their children but in the Malaysian context, unmarried individuals or women who choose to be pregnant or bear a child are not condoned as it is against our religion, ethics, values and morality. Malaysia agreed that adolescents have the rights to reproductive health information, knowledge, counseling and education but not to contraceptive services. e. Malaysia does not agree to the provision of abortion as a means of family planning but agreed that attention be given to the prevention of unsafe abortions and its complications be recognized as a major public health problem and the humane management of complication of abortion be provided as part of the reproductive health package. f. Malaysia took a position that family reunification of immigrants could not be seen as a right but more as a principle and which is 31 subject to national sovereignty. Malaysia held its reservation on the requirement for countries to recognise the vital importance of family reunification and promote its integration into the national legislation in order to ensure the protection of the unity of families of documented migrants. In conclusion, Malaysia is committed in implementing both the Bali Declaration on Population and Sustainable Development and ICPD Programme of Action (ICPD-POA) and as such has initiated changes in policies; programmes; institutional and organisational framework among others to support the ICPD-POA. In the past, population was a game of numbers and many of our population programmes were linked mainly to demographic goals and targets. The ICPD has introduced a whole new paradigm for change from this concept to a more realistic and humane one, which has helped place population concerns at the heart of sustainable development. Towards this end, our existing population programmes have been revised along thematic areas of concern and priorities of the country in line with ICPD-POA that is reproductive health, adolescent reproductive health, family and women in the context of social equitability, poverty alleviation and environmentally sound development. National Population and Family Development Board, Ministry of Women and Family Development, MALAYSIA WH/Country Report/030902 32 Table 1 Population Size and Age Structure Malaysia, 1980 – 2020 1980 1991 2000 2020 Total Population (million) 13.7 18.5 23.3 33.4 Average Annual Growth Rate (%) 2.3 2.64 2.6 1.8 39.6 56.7 3.7 37.2 59.1 3.7 33.1 62.9 4.0 30.5 63.3 6.1 76.4 69.2 59.1 57.8 Age Structure (%) 0 – 14 15 – 64 65 & above Dependency Ratio (%) Source: Department of Statistics, Malaysia Eighth Malaysia Plan, 2001-2005 33 TABLE 2 INCIDENCE OF POVERTY AND NUMBER OF POOR HOUSEHOLDS, MALAYSIA, 1995, 1997 AND 1999 1995 Total Urban 1 Rural Total 1997 Urban Rural Total 1999 Urban 1 Rural Malaysian Citizens Incidence of Poverty (%) 8.7 3.6 14.9 6.1 2.1 10.9 7.5 3.4 12.4 Number of Poor Households (‘000) 365.6 83.8 281.8 274.2 52.4 221.8 351.1 86.8 264.3 Incidence of Hardcore Poverty (%) 0.9 3.6 1.4 0.4 2.5 1.4 0.5 2.4 Number of HardcorePoor Households Total Households (‘000) 88.4 20.1 68.3 62.4 10.6 51.8 64.1 13.5 50.6 (‘000) 4,212.3 2,315.8 1,896.5 4,488.1 2,449.8 2,038.3 4,681.5 2,548.0 2,133.5 (%) 9.3 4.1 15.6 6.8 2.4 11.8 8.1 3.8 13.2 Number of Poor Households (‘000) 418.3 99.3 319.0 332.4 64.9 267.5 409.3 102.7 306.6 Incidence of Hardcore Poverty (%) 0.9 3.5 1.4 0.5 2.4 1.4 0.6 2.4 Number of HardcorePoor Households Total Households (‘000) 94.0 21.8 72.2 67.5 12.2 55.3 71.1 15.6 55.5 (‘000) 4,497.7 2,449.7 2,048.0 4,924.0 2,660.1 2,263.9 5,047.0 5,725.9 2,321.1 2.1 2 Overall Incidence of Poverty 2.1 2 Notes : 1 Revised based on the latest household population data. 2 Estimated using half the poverty line income. 34 Table 3 Crude Birth Rate and Total Fertility Rate Malaysia, 1970 – 2000 1970 1980 1990 2000 Crude Birth Rate 32.4 30.6 27.9 24.4 Total Fertility Rate 4.9 3.9 3.3 3.1 Note: TFR for 1970 and 1980 refer to Peninsular Malaysia only Source: Department of Statistics Malaysia Table 4 Mortality Indicators, Malaysia 1970 – 2000 Year Crude Death Rate Perinatal Toddler Infant Maternal Mortality Mortality Mortality Mortality Rate Rate Rate Rate Life Expectancy Male Female 1970 7.0 36.9 4.2 40.8 1.48 63.5 68.2 1975 6.2 32.0 3.1 33.2 0.83 65.4 70.8 1980 5.5 26.7 2.0 24.9 0.63 68.0 72.0 1985 5.3 18.0 1.4 23.0 0.37 68.5 73.0 1990 4.9 13.9 0.9 12.0 0.20 69.0 74.0 1995 5.0 9.7 0.8 10.3 0.20 69.4 74.2 2000 4.6 6.5 0.1 7.9 0.20 69.9 74.9 Source: a. Eighth Malaysia Plan, 2001-2005 b. Department of Statistics, Malaysia 35