Covid-19 has further worsened inequalities in healthcare

A boy born in Perlis, Terengganu or Kelantan this year has an average life expectancy of 69 years, compared to the 74 years of his compatriots in Sarawak and Kuala Lumpur. — Photos: Filepic

Universal Health Coverage (UHC) Day was commemorated on Dec 12 (2020).

It was slightly over a year ago when the United Nations on Sept 23, 2019, made a political declaration to “reaffirm that health is a precondition for, and an outcome and indicator of, the social, economic and environmental dimensions of sustainable development and the implementation of the 2030 Agenda for Sustainable Development, and strongly recommit to achieve universal health coverage by 2030, with a view to scaling up the global effort to build a healthier world for all”.

The international organisation also reaffirmed “the right of every human being, without distinction of any kind, to the enjoyment of the highest attainable standard of physical and mental health”.

Health equity, which has been defined as fairness and justice, exists only when people have an equal opportunity to be healthy.

As such, health inequity is the unfair and avoidable difference in health status seen within and between countries.

There is health inequity globally whether in high, middle or low-income countries, although more so in low-income countries.

This is reflected in the health indicators within and between countries.

Widening the gap

Pulau Berhala residents in Sabah getting tested for the SARS-CoV-2 virus. The state has 57.7% of the country’s deaths from Covid-19. — BernamaPulau Berhala residents in Sabah getting tested for the SARS-CoV-2 virus. The state has 57.7% of the country’s deaths from Covid-19. — Bernama

The association between income and health is well recognised.

Income permits purchase of the necessities of life, avoidance of harmful exposure, promotion of psychological well-being, participation in the activities of daily living, and access to health and healthcare resources.

Vulnerable populations in ordinary times already face barriers to healthcare that predisposes them to worse health outcomes.

The disadvantaged are affected disproportionately whenever there is a public health crisis.

The Covid-19 pandemic is laying bare the longstanding inequities in healthcare globally, with consequential excess illness and death in underserved populations.

Covid-19 imposes an additional burden on the vulnerable populations.

Economic insecurity, over-representation in low wage or daily jobs, living conditions and pre-existing concurrent illnesses are among the factors that have an adverse influence on Covid-19 and non-Covid-19 illness and death.

There are reports of disparate case positivity rates, outcomes and death rates within high-income countries.

The poorest areas have the highest incidence and death rates, as well as financial hardship.

For example, in the United Kingdom, of the 10 local areas with the highest death rates, half of them are from the poorest 30% of local authorities.

Similarly, the Covid-19 crisis is far worse in the poorer boroughs of the Bronx and Queens than in more affluent Manhattan in New York City, United States.

In Malaysia

Female-headed households in low-cost flats, like this one led by a 62-year-old grandmother, are extremely vulnerable to the socioeconomic effects of the Covid-19 pandemic.Female-headed households in low-cost flats, like this one led by a 62-year-old grandmother, are extremely vulnerable to the socioeconomic effects of the Covid-19 pandemic.

The three local examples below provide much food for thought.

The Khazanah Research Institute report The State of Households 2020 Part III found that there was significant variation in life expectancy between genders, ethnicities and states.

A male newborn’s life expectancy in Sarawak or Kuala Lumpur in 2020 is 74 years, compared to 69 years in Perlis, Terengganu or Kelantan, i.e. a gap of five years.

Similarly, a female newborn’s life expectancy in Kuala Lumpur is 79 years, compared to 75 years in Terengganu or Perlis, i.e. a gap of four years.

It also found that poor health outcomes were more prevalent in lower-income groups.

The frequency of diabetes, high blood pressure and high cholesterol were highest among adults in the bottom 20% of household income and lowest in the top 20%.

For example, the percentage of adults with high blood pressure was 38.3% in the bottom 20% of household income, and 27.1% in the top 20%.

A recent United Nations Population Fund (UNFPA) and United Nations Children’s Fund (Unicef) study looked at the socioeconomic impact of Covid-19 on 500 families with children in Kuala Lumpur’s low-cost flats.

They found that low-income families were more likely to be unemployed, have reduced working hours and experience greater challenges in accessing healthcare and home-based learning.

Their report states: “Covid-19 had also further exacerbated food insecurity among low-income households and forced many low-income families to adopt less healthy diets, thereby threatening to further exacerbate Malaysia’s worsening child malnutrition crisis.”

The study also found that low-income female-headed households were exceptionally vulnerable, “with higher rates of unemployment at 32%, compared to the total heads of households.

“Female-headed households also registered lower rates of access to social protection, with 57% having no access, compared to 52% of total heads of households.

“These low rates of access to employment-based social protection suggest a bold rethink of Malaysia’s social protection system will be necessary to prevent Covid-19 exacerbating pre-existing poverty, inequality and social exclusion challenges.”

The Covid-19 wave in Sabah has been unfolding since October (2020).

Although its population of 3.91 million comprises 12% of Malaysia’s 32.7 million total, it has a disproportionate share of the total number of positive cases and fatalities.

According to Health Ministry data, as of Dec 12 (2020), it had 32,495 positive cases, which was 39.5% of Malaysia’s total of 82,246.

There were 237 Covid-19 deaths, which was 57.7% of Malaysia’s total of 411.

Sabah’s case fatality ratio (number of deaths divided by number of positive cases x 100) was 0.73%, compared to 0.16% and 0.26% in Selangor and Kuala Lumpur respectively.

This means that the chances of dying for a Covid-19 patient in Sabah was 4.56 and 2.81 times more than in Selangor and Kuala Lumpur respectively.

Although the previous Sabah Chief Minister requested for Covid-19 testing laboratories in Tawau on April 16 (2020), the laboratory there was only functional on Dec 2 (2020), when the number of positive cases had peaked in October and November.

Going forward

Malaysia is committed to achieving the Sustainable Development Goals (SDG) by 2030.

UHC is central to SDG3, which is to ensure healthy lives and promote well-being for all at all ages.

Malaysia states that it has UHC. The examples above remind everyone that it is time to address the gaps between the narrative and reality.

The health inequities exposed by Covid-19 makes a strong case for the establishment of a Royal Commission on healthcare to inquire into and report on the existing and future needs for safe and quality healthcare services and the resources to provide such services, as well as to recommend the necessary measures to ensure that all Malaysians stay healthy and continue to have access to UHC, and that no one is left behind.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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