The National Health and Morbidity Survey (NHMS 2019) recently released by the Health Ministry affirmed sobering statistics on the state of health among Malaysians. We are increasingly burdened with chronic non-communicable diseases (NCDs) and many of us are at risk of ill health, including infants and children. Health inequity will worsen, is worsening.
We need to urgently look at integrating the gender lens, the influence of socioeconomic determinants, and local-level data into population health planning and reform.
Whether it is diabetes, hypertension, asthma, mental health disorders or cancer, the impact of NCDs is felt differently by women and men. Both are at risk of NCDs, but gender has a strong bearing on exposure to risk factors, access to prevention and care, and even treatment by healthcare providers.
NCDs feature prominently among leading causes of death in women, including one in five deaths attributable to heart disease or stroke in 2018. Overall life expectancy for female Malaysians has increased slightly over the years. However, having a chronic disease means that fewer years are spent in good health.
Though only a snapshot of the Health and Morbidity Survey has been released, the available sex-disaggregated data is striking. One in two female adults are overweight or obese, and up to two-thirds carry excess weight in the abdominal region. Nearly 30% of females do not achieve target physical activity levels. Women also did not commonly engage in screening for breast and cervical cancer. Poor nutritional status in mothers are reflected in the rising rate of stunting in young children.
Behavioural risk factors are not simply a matter of making the “wrong” choices.
These factors are determined by our living and working conditions, the economy, legislation and policies, gender roles and cultural norms.
Low physical activity levels in females, for example, could derive from stereotyping sports as being masculine, safety concerns in public spaces, and the heavier burden of unpaid care and household chores.
Women generally earn less and may not have much influence in making household decisions to purchase fresh foods, control exposure to secondhand smoke, or practise other preventive health behaviours. Gender-based violence in households also disproportionately affects females, with implications for poor mental health.
On the other hand, trends of healthcare utilisation tend to be less in men due to lower rates of health-seeking behaviour, and rates of tobacco smoking and substance abuse are disproportionately higher.
NCD policies and programmes should be gender-responsive and address the needs of both men and women. This starts with schools and workplaces, boardrooms and government offices, and preventive and health services. Raising awareness of gender-specific issues, sensitising stakeholders, and conducting gender analyses when designing programsme are necessary.
Gender also intersects with socioeconomic inequalities. In Britain, women living in the most deprived areas face a decline in life expectancy not seen in other groups. Indeed, NCDs have been found to be of higher risk in lower socioeconomic groups.
The Health and Morbidity Survey found higher rates of depression in households at the lower end of income distribution (B40) compared with the T20 (higher income) group. It also revealed ethnic disparities: Indian Malaysians face both higher rates of overweight/obesity as well as anaemia among women.
Socioeconomic inequalities influence access to good health, starting at early life and development. We need to better understand how this happens in our setting as the distribution of risk factors can go both ways.
The vacuum of coordinated public policies and civil society initiatives means higher socioeconomic groups are not immune to risk factors. According to the survey, only 5% of the population consumed adequate amounts of fruits and vegetables, indicating that income levels are only part of the equation.
The key to “flattening” the alarming burden lies in a whole-of-society approach across the life course. We need local-level, granular data that is integrated with social and economic indicators. Members of Parliament, education district offices, and local governments should be familiar with and concerned about NCD risk factors and incidence statistics.
Cross-sectoral mechanisms should be adequately funded to have a sustained impact on living environments. Policies that miss the deep-rooted nature of the problem are those that ignore risk factors, needs, and barriers to prevention and care for specific groups in the community, both at the local and national levels.
All of us should ask ourselves if NCD prevention and control should be part of a new social contract. Economic development requires healthy citizens able to achieve their goals and aspirations. Seeing how we are becoming a high-income nation, health and wellbeing should not be accessible only to some but a public good for all.
Will the Health and Morbidity Survey be a living document for action? How useful its findings will be to the health and wellbeing of 32 million Malaysians, especially the more vulnerable, will ultimately depend on the next steps taken in the years to come.
Galen Centre for Health & Social Policy