Malaysia
Shila Kumur; Health action International Asia Pacific (HAI-AP)
Evelyn Hong; Third World Network (TWN)
1. Introduction and Background
On record Malaysia has attained health standards comparable to those in the developed world. This was
achieved through universal access to health care services financed with public funds. In terms of the MDGs it is
said to be on track to achieve them at aggregate level by 2015.
1.1. Selected health indicators
Indicator
Under five years child mortality
Infant mortality
Primary Immunization Coverage
Maternal Mortality
HIV/AIDS, Malaria, Tuberculosis
Trend
Declined from 16.8 deaths per 1000 live births to 8.1 from 1990 to 2008.
Declined from 13.1 deaths per 1000 live births to 6.4 from 1990 to 2008.
>90% of target population covered.
In 2008, immunization for measles, mumps and rubella >94%.
Declined from 140 per 100 000 in 1970 to 44 per 100 000 live births in
1991, and further to 28.1 in 2000 and 27.3 in 2008.
HIV/AIDScase volume peaked in 2002 before declining in 2009. 20% of
new cases were in women.
Malaria declined from 11 000 cases to 7 010 between 2002 and 2009. Of
these a major proportion was in East Malaysia where the fastest rate of
deforestation is occurring. The region also has a large migrant
population. In 2008 about 38% of total reported cases in Malaysia were
amongst migrants.
In West Malaysia, Orang Asli– an interior district -- registered high rates of
incidence.
TB: Trend is increasing: 10 873 cases in 1990
18 102 cases in 2009
Multi drug resistant TB increased from 41 cases to 56 cases from 2007 to
2008; TB-HIV co-infections increased with 1644 cases reported in 2009.
TB incidence in Orang Asli (indigenous peoples) is 3x higher than in the
general population, majority in children <14yrs.
1.2. Status of Equity
Population, Gender and Ethnic Distributions
Malaysia has a land area of 330,803 square kilometres. The population density stood at 86 persons per square
kilometre in 2010 compared with 71 persons in 2000. The population of 2010 is 28.3 million, with an annual
growth rate of 2.0 % for the period 2000-2010.
The highest population densities are found in Federal Territory of Kuala Lumpur followed by, Penang and
Putrajaya (6,891, 1,490 and 1,478 per square km respectively) for the year 2010. The states of Sabah, Sarawak
and Pahang had the lowest population densities (less than 100 per square km) for the year 2010.
Men outnumbered women with a sex ratio of 106. A similar pattern was observed in the year 2000 (104). The
ratio of males to females was relatively high for Pahang (113), Johor (112), Negeri Sembilan, Sabah, Selangor
and Labuan 107 each and 106 in Sarawak; however men outnumbered by women in Federal Territory of
Putrajaya (89), and Perlis (97).
Malaysia is a multiracial country consisting predominantly of Bumiputras (67.4%) followed by Chinese (24.6%),
Indians (7.3 %) and other ethnic groups (0.7%). Among the Malaysian citizens, the Malays were the
predominant ethnic group in Peninsular Malaysia which constituted 63.1%. The Ibans constituted 30.3% of the
total citizens in Sarawak while Kadazan/Dusun made up 24.5 % in Sabah. Approximately 8.2% of 2010
projected population are non-citizens.
1.3. Governance for Health
Malaysia’s approach to developing the nation is via a five-year plan. In adopting Vision 2020 Malaysia aims to
achieve fully developed nation status by the year 2020. To do this it has adopted a four pillar framework to
drive change: the six National Key Result Areas outlined in the Government Transformation Programme; the
12 National Key Economic Areas of the Economic Transformation Programme; the strategic economic reforms
in the New Economic Model; and the Tenth Malaysia Plan.
The Economic Planning Unit (EPU) has identified 5 National Mission Thrusts to ensure that the nation’s
economic development is on the right trajectory to realize Vision 2020. The 4th National Mission Thrust is the
improvement of the standard and sustainability of quality of life. The deliberations by the Mission Cluster
Group for Key Result Area 2 (Ensure access to quality healthcare & promote healthy lifestyle) have attempted
to reach a consensus on the more pressing gaps and identified key result areas and outcomes, and formulate
strategies towards developing a plan towards the expected outcome (to ensure provision of and increase
accessibility to quality health care and public recreational and sports facilities to support active healthy
lifestyle) and for overcoming the obstacles.
The contribution of the health sector is primarily through provision of services that will lead to improved
health outcomes and ultimately better health status of the nation. Tenth Malaysia Plan (10MP) stresses on
quality healthcare and a healthy community and spells out a strategy that is geared towards the establishment
of a comprehensive healthcare system and public recreational and sports infrastructure to support active
lifestyles. The Ministry of Health (MOH), as the lead agency for health has been assigned to provide a more
efficient and effective health system that ensures universal access to quality healthcare. In line with this, the
MOH has developed a conceptual framework to restructure the health system. The restructuring proposal
involves aspects of health services delivery, financing, enabling structures and its governance.
2. Progress on MDGs
2.1. Relevance of the MDGs: Critique based on country’s performance
It can be seen that the achievements of the MDGs targets do not tell the whole story of the state of health in
Malaysia. The MDG approach to health:
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Does not explain the structural causes of health problems afflicting the population. Free market driven
development policies, unequal trade agreements, promotion of tobacco, smoking, dangerous drugs, infant
formula, junk food, dirty and dangerous industries etc creates poverty, marginalisation, violence, gender
disparities, diseases and death.
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Emphasis on narrow targets does not address the structural solutions required for change. It is not people
oriented. It is results oriented and relies on technical solutions e.g. school attendance, more DOTs, more
immunisation, more drugs for malaria, HIV/AIDS; eradicating half of poverty (US$1 day). Solutions are not
community driven but in the hands of external players and the corporate sector. Efficiency is the key and
equity issues get lost.
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The MDGs success becomes the important criteria for successful development policies (Malaysia is
confident it will be a developed and high income nation by 2020). It absolves the government from its
responsibilities to implement universal healthcare for its citizens (cut backs on health is already
happening). MDG targets do not promote health. Health as an instrument of change is left behind.
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Gender dimensions are not addressed in the MDGs. There is a lack of emphasis in the relationship
between women’s equality and empowerment and the seven MDGs and its implications for women. For
e.g. the increasing incidence of female poverty and female headed poor households in Malaysia shows
that poverty is a ‘highly gendered phenomenon’ and cannot be captured merely by income or eradicated
by targets.
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Discriminatory policies that work against women, their subordination and exploitation will have a bearing
on the achievement of the MDG targets and goals. Education levels, literacy, employment, women in the
national parliament etc. do not sufficiently indicate empowerment, and equality. Access to health services
and credit, a living wage, equality before the law are crucial factors that determine empowerment and
gender equality.
2.2. Progress achieved
Eradicate Extreme Poverty & Hunger
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Malaysia has surpassed the target of halving the proportion of people whose income is less than US$1 a
day, both in the rural and urban areas.
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However at subnational levels, poverty still exists. In 2009, some 228 000 households remain poor, a rise
from 210,000 households in 2007. This poverty rate amounted to more than 1.5 million people. Female
headed households remain the poorest.
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Income inequality persists: the income gap has widened from RM4,150(USD 1,366.67) in 1989 to RM8,000
(USD2,634.54) in 2009. The Ginicoefficient lose from 0.471 in 2007 to 0.473 in 2009. Income inequality in
Malaysia is one of the widest in the region. The bottom 40% of households had mean monthly income of
RM1,440 (USD 474.22) in 2009.
Child Hunger
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In a 2006 MOH survey, the prevalence of moderate under nutrition was 7% for children under 1 year of
age; 20% for children aged 1-3 and 16% for children aged 4-6. This was linked to income levels, with the
lowest income bracket having an incidence of 21%.
Gender Equality and Empower Women
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Although there are improvements at the national level, Malaysia has slipped in rankings relative to other
countries globally. Its ranking in the global Gender Gap index fell from 72 in 2006 to 92 in 2007 and 98 in
2010. It has slided in UNDP’s Human Development Index from 61 in 2005 to 66 in 2009; Gender-related
Development Index (50 to 88) and Gender Empowerment Measure (51 to 68).
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One important indicator of empowerment is gender based violence (not addressed by MDGs).In Malaysia
violence against women and rape are on the increase. Reported rape cases in 2009 translate into a rate of
12.8 per 100,000 population, putting Malaysia in or near the top quartile globally.
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Around three quarters of reported cases involve children. The incidence of sexual violence (which include
rape, incest and outrage of modesty) is 21.8% per 100,000 population. When domestic violence is
included, women are at greater risk of gender based violence than the population is to ‘assaults’ leading
to serious bodily injury. This is a serious public health and development issue.
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The low rate of prosecution is a reflection that perpetrators of violence against women can commit crimes
with virtual impunity, rendering them ‘acceptable’. Sexual harassment in the workplace continues to be
widespread although national data is unavailable.
2.3. Lessons learned
Despite the glowing targets achieved in the MDGs, these successes masks the market driven development
strategies that are posing the greatest threat to development, health, human rights, and environmental
sustainability. This may eventually undo all the impressive targets achieved so far. Some of these policies
include:
Health Privatisation& Medical Tourism
Malaysia is facing a serious challenge in how to finance rising demand for health services as the health system
becomes more expensive. The past and projected total expenditure for health shows escalation driven by
advancements in medicine and health technology. MOH expenditure both in real and nominal terms has
increased steadily though as a percentage of total government spending it has remained steady. Healthcare
expenditure has increased since independence.
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Public spending in 2007 accounts for 2.1% of GDP8 . Initially public spending was higher in public than in
the private sector. Since 2004, this ratio has reversed. In 2007, public spending was 13.5 billion and private
spending 16.7billion. The rise in private spending is associated with the rapid growth of the private health
insurance industry during the same period. Currently Malaysia spends 2.5% of GDP, which is way below
WHO’s 5%.
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However, at the same time recent studies have shown that out of pocket payment has increased from
32% in 2001 to 40% (RM10.05 billion) in 2006. The 2006 National Health Accounts report indicates a high
out-of-pocket (OOP) expenditure i.e. 40% of total health expenditure; 73% of private health expenditure
in 2006. A high OOP expenditure is reflective of a lower income country. Malaysia is in the upper middle
income country group.
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However, despite universal coverage, the World Health Survey Report (2002) shows that 4% of Malaysian
households were exposed to catastrophic spending and 2% were impoverished. Furthermore, the
household expenditure survey (2004) indicates that the lowest deciles (poorest) spends higher OOP than
8th deciles in terms of proportion to income. Hence, there is a need to ensure fairness in financing and
continuing protection of the disadvantaged and vulnerable through a more comprehensive safety net.
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The irony is that the government is a major shareholder in the private health sector. The largest private
hospital chain KPJ is government owned; Malaysia’s investment vehicle Khazanah is owner of the largest
hospital Parkway.
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Taxpayers are also financing health through social security funds paid by workers and employers (e.g.
SOCSO and EPF) not public taxes. Low income wage earners through SOCSO are contributing a large
subsidy to the State.
Export led Growth
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Toxic industries have affected the environment and health of communities. This growth model has led to
massive deforestation, the expansion of oil palm plantations, construction of dams and tourism projects
among others.
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In the process, communities especially the aboriginal peoples have been displaced from their lands,
livelihoods destroyed and led to increasing poverty and deprivation.
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In East Malaysia, deforestation and dam construction have displaced and marginalise thousands of natives
flooding out their lands. These people make up a majority of the poor in the country and children from
these communities suffer from high rates of undernourishment and stunting.
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Among the Orang Asli (aboriginal communities) where data is incomplete, the life expectancy at birth in
the 1980s was about 35 years compared to the average life expectancy at birth for West Malaysians i.e.
68-72 years. Malnutrition and stunting, worm infection and diarrhoeal diseases are common problems
among children. Alcoholism is now a serious problem in the community.
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The Indians, who in recent years were displaced from the rubber estates when these were sold and
developed, comprise one of the most deprived communities in West Malaysia suffering
undernourishment, high crime rates, homelessness, unemployment, and various other social and
economic problems.
Trade agreements
Malaysia is on its way to join the Trans-Pacific Partnership Free Trade Agreement (TPFTA) in which the US is a
member. This will have a major impact on the Malaysian government’s policies.
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The TPFTA will make medicines more expensive as the US will demand that TPFTA countries including
Malaysia give stronger intellectual property protection than the WTO requires.
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The US wants Malaysia’s tariff on US farm products to be reduced to zero so that it can export more farm
products to Malaysia. This will have far reaching impacts on Malaysian farmers. E.g. Malaysia has a 40%
tariff on rice to protect Malaysian rice farmers and reach the goal of 90% self sufficiency in rice. If this
tariff were reduced to zero, American rice which is subsidised so that it can be sold at 25% below the cost
of production will flood Malaysia; Malaysian farmers will leave their lands and the nation will be
vulnerable to international food supplies.
Nuclear Power
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Malaysia’ is planning to build two nuclear power plants in the wake of the Fukushima earthquake and
tsunami which has led to the biggest nuclear disaster to date.
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More than RM 50 million have been spent on feasibility studies and according to leaked reports the
potential sites have been identified.
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The nuclear power plants are estimated to cost RM 21.3 billion.
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This is Malaysia’s answer to solve climate change and reduce its carbon footprint. Instead of investing in
renewable energies like many developed countries are doing, it is embarking on a project that will have
serious health and environmental impacts and which will harm and put the future generations in debt.
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This is the result of aggressive lobbying by the nuclear industry and the encouragement of the
International Atomic Energy Agency. Nuclear power is now a bad word in the West, so these corporations
are trying to foist their toxic technologies on developing countries. South East Asia, Indonesia, Vietnam,
Thailand are showing keen interest in investing in this technology.
3. Future perspectives
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The MDGs do not provide the framework for the structural analysis of problems and issues confronting
developing countries.
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The unequal relations between the developed and the developing countries;
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The challenges posed by the financial crises, climate change and rising food prices especially to the
developing countries; and
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The role of the World Bank-IMF, WTO and trade and investment treaties and their impact on national
sovereignty and development policies in developing nations.
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All these have direct implications for health and development. E.G. UNCTAD has said that the on going
economic crisis means that it will be virtually impossible for the MDGs goals to be reached by 2015.
Economic inequality has now emerged as the central concern in the wake of the global crisis. The per
capita income gap between the richest and the poorest countries is now widening.
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Recent climate change events across Asia e.g. floods in Pakistan, Thailand, Vietnam, increasing loss of
Himalayan glaciers have affected millions of people and resulted in tragic loss of life and livelihoods;
incurring massive social, economic and environmental costs. More frequent andsevere climate related
disasters will increase the numbers of environmental refugees. The indirect effects include the increase in
the prevalence and distribution of vector borne diseases e.g. malaria and dengue fever; and vulnerability
to water, food borne diseases (cholera and dysentery);and climate change will decrease the quantity and
quality of drinking water.
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Investment treaties signed between governments allow private companies and investors to sue countries
for billions of dollars. Some of the most recent cases include cases taken by a tobacco giant against
Australia and Uruguay for making regulations on cigarette packages to control smoking. The companies
claimed that their future investments and profits had been affected by government new health measures.
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Prolonged wars,armed conflicts and humanitarian crises impact on health and development.
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The Palestinian crisis, the Syrian crisis, the war in Iraq, Afghanistan, Pakistan, Yemen, Somalia and now
Mali are a reflection of the global power relations that exists today. US drones have killed tens of
thousands (mainly civilians) in Yemen, Afghanistan and Pakistan violating international law. Hundreds of
thousands have been made homeless and become refugees. US support for Israel guarantees that the
latter continues to behave with impunity towards Palestinians.
In the past decades, civil society had played a key role in highlighting the role of MNCs and their impact on
health. Successful international campaigns were launched. They include:
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The baby food campaign
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Action for Rational Drugs in Asia
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Junk food campaign
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Anti tobacco campaign
Currently, Malaysiahas a wide spectrum of civil society groups focused on issues such as HIV/AIDS(AART++,
Malaysian AIDS Council, Community AIDS Service, AIDS Action Research Group), consumer rights and
environmental concerns (CAP/SAM), hazardous environmental technologies ( Lynas), pesticides action
(PANAP), womens rights and concerns (WAO, AWAM, EMPOWER, Sisters-In-Islam, WCC), infant and baby
foods (IBFAN-CDC, WABA), migrant issues (Tenaganita), etc. As enablers to empower individuals and
communities to take control over their health at individual and policy levels, they often act as monitors as well
as co-providers of essential services complementary to the government.
4. Urgent business
Policies, rules and conditionalities of international trade, finance, aid and intellectual property rights and
interventionist policies from international institutions, controlled by developed nations have been a source of
economic, social and political destabilisation for many developing countries. These have all threatened
development and health.
A true global partnership for health and development would need to:
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Adopt a new health and development agenda i.e. a new ‘MDG’ which should include structural analyses of
the problems and challenges to development and health and provide structural solutions;
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Expand the targets and indicators in the new MDGs;
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Increase public investments in health
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Promote the Peoples Health Charter
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Reform the world’s trade and financial system
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Reform the IMF-World Bank to allow developing countries a fairer and effective role in its policies.
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A R & D Treaty to promote R&D on diseases prevalent in developing countries including non
communicable diseases. Currently funding for research is focused on areas which will bring profits to the
drug industry. Diseases which have a great impact on public health in developing countries is largely
ignored e.g. TB, malaria & Chagas disease. Neither can poor people benefit from treatments for noncommunicable diseases e.g. cancer & cardiovascular diseases as the high prices of patented medicines
make them unaffordable.
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The world is nearing the end of the antibiotic era. Serious steps need to be taken worldwide to curb/ban
the indiscriminate use of antibiotics in agriculture, animal husbandry and medicine.