Health is a central element in our lives. Everything that we are and do relies on us being healthy. Good health provides us quality in living, motivation to be better, and lower risks to biological hazards. In fact, health is so fundamental in civilisation and development that it is one of the three dimensions of the Human Development Index (HDI). The United Nations (UN) also emphasises the significance of health by setting the third Sustainable Development Goal (SDG) for Good Health and Well Being.
Unfortunately, in the past two years, our health has faced an unprecedented threat. The Malaysian public health system has been under distress due to the COVID-19 outbreak. Hospitals are running over their capacities, while the total number of COVID-related deaths has reached more than 16 thousand as of 31 August 2021. This pandemic is dreadful, and it is a fact no one can deny.
However, there is an age-old problem that has been hiding in plain sight amidst this health calamity. Not only has this problem contributed to our unreadiness in facing COVID-19, but it can also leave substantially more lasting damage to our society and generations to come than any virus would. Hence, it is past time we addressed the true “villain” in this whole crisis, which is health inequity.
Over the last decades, Malaysia’s health outcomes have experienced noticeable improvement, namely longer life expectancy as well as lower child and maternal mortality rates. Nonetheless, across the population, the gains in health are uneven between genders, ethnicities, and states. For instance, people living in Kuala Lumpur tend to have a longer life expectancy than those living in Terengganu or Perlis.
Looking deeper, we would see gaps in health outcomes between the rich and the poor.
As an example, the percentage of adults with hypertension was 38.3% in the bottom quintile and 27.1% in the top quintile. This pattern is also observed in mental health problems among adults, with 33.6% in the bottom quintile having some mental health illnesses, compared to 26.% in the top quintile.
These health inequities can be attributed to the unfair distribution of health-promoting opportunities. They can be closely related to social justice as there is discrimination and barriers to healthy lives among Malaysians. For this, we must first understand that health is beyond healthcare, meaning that health inequity is a complex issue comprising many factors besides unequal access to quality medical care. There are two types of factors that contribute to health inequity, which are direct determinants and structural determinants, as displayed in the diagram below.
The socioeconomic and political context generates a structure in which Malaysians are stratified by categories such as income, education, and so on. This context and the resulting social structure form the structural determinants. These structural determinants do not directly impact health outcomes, but they affect them through direct determinants. Health inequalities occur when the direct determinants are unfairly distributed due to the structural determinants (including other social inequalities in the country).
For instance, a low-income person (low wage issue) working in a hazardous factory (labour safety issue) and living in an unconducive environment (housing policy issue) may not have health insurance (health system determinant). This person may also experience high levels of stress (psychosocial determinant) and irregular eating habits (behaviour determinant). In short, the underlying social factors create differences in exposure to health-promoting circumstances, even with universal basic healthcare like in Malaysia.
The problem does not stop there. Health inequity worsens the existing context and social structure. As the grey arrows in the diagram above show, uneven health outcomes further strengthen social inequalities such as disparities in income, education, and so on. This situation creates a vicious cycle called the health poverty trap, which is a state of being trapped in low socioeconomic status due to ill health conditions and related health costs. This trap is what many development economists are working hard to eliminate and reduce across the globe.
Addressing the direct determinants may be straightforward to improve health, but the structural determinants are the ones we should target in order to combat health inequity. For this purpose, public policies play a critical role. Considering the interconnectivity of factors that determine health outcomes, policies must focus on social mechanisms which influence inequitable health distribution. There should be radical approaches to eliminate barriers to education, enhance social welfare protection, improve working conditions, and ensure safe housing. Going forward, our policymakers must emphasise the overall wellbeing of Malaysians and incorporate health considerations in all national policies.
This opinion piece is contributed by Bait Al Amanah and edited by Wiki Impact as part of a series to explore social mobility, equality and shared opportunity in Malaysia. This series is written against the backdrop of the Global Social Mobility Index which benchmarks 82 global economies and looks into five key dimensions including Health, Education (access, quality and equity, lifelong learning), Technology, Work (opportunities, wages, conditions) and Protection and Institutions (social protection and inclusive institutions).
The higher a country ranks in terms of social mobility, the greater the chance for the next generation to experience a better life than their parents. According to the World Economic Forum’s Global Social Mobility Report 2020, Malaysia ranked #43 out of 82 countries.
Explore Our Sources:
- United Nations Development Programme (UNDP). (2020). Human Development Index (HDI). Link.
- United Nations Department of Economic and Social Affairs. (2021). SGD Goal 3: Ensure healthy lives and promote well-being for all at all ages. Link.
- DG of Health. (2021). Kenyataan Akhbar KPK 31 Ogos 2021 – Situasi Semasa Jangkitan Penyakit Coronavirus 2019 (COVID-19) di Malaysia. Link.
- Khazanah Research Institute. (2020). Social Inequalities and Health in Malaysia. The State of Households 2020, Part III. Link.