Malaysians living longer, but not much healthier

 

Before the pandemic, Malaysians’ overall health indicators have improved over the decades, but health gains of the population have been uneven. Undoubtedly, Malaysians are now living longer, meaning life expectancies have risen, but ‘healthy life expectancy’ has not risen as much.

According to Khazanah Research Institute’s (KRI) latest major report, ‘Social Inequalities and Health in Malaysia’, average life expectancy in 2020 before Covid-19 was 72.6 years for males and 77.6 for females. These are about 11 to 12 years longer than half a century earlier in 1970 when life expectancies were 61.6 and 65.6 years respectively.

The KRI report is the third and most novel of three in its ‘State of Households’ series reviewing progress in Malaysians’ wellbeing. The volumes focus on the three decades since Vision 2020 was announced after the period associated with the New Economic Policy’s Outline Perspective Plan for 1971-1990.

Living longer

Greater life expectancy is largely due to declining child and maternal mortality following post-colonial progress from the 1960s to the 1980s, implying modest progress due to other factors. Pre- and post-natal maternal deaths fell from 140.8 per 100,000 live births in 1970 to 23.5 in 2018.

The neonatal mortality rate, i.e., deaths of infants under 28 days per 1,000 live births, was 4.6 in 2018 compared to 21.4 in 1970. Similarly, infant mortality, i.e., deaths of infants under a year, and toddler mortality, i.e., of children under 5, were 7.2 and 8.8 per 1,000 live births respectively.

Additional life expectancy is unequal among Malaysians. Besides gender and ethnicity, there are also significant variations by location.

For instance, a male in Sarawak can expect to live an average of 74.6 years in 2020, whereas male life expectancy in Perlis is only 69.2, i.e., 5.4 years less. Whereas the average Kuala Lumpur female is expected to live to 79.4, her Terengganu counterpart can expect to live 4.3 years less.

International comparisons with other countries at similar income levels also suggest room for improvement. Although Malaysian life expectancy in 1990 was higher than in Mexico, Brazil, Thailand and Turkey, countries with comparable average incomes, they have all improved more since, at least before the pandemic.

Uneven progress

Health is not only determined by healthcare access, as progress is also due to other factors, including living and working conditions as well as behaviour. These can all be either health improving or worsening.

The KRI report emphasises socio-economic factors affecting Malaysians’ health outcomes, particularly income and work. It argues that health progress should ensure that people not only live longer but also in good health. As they age, more Malaysians have seen their health deteriorate, e.g., due to heart disease, back pain and mental illness.

The ‘healthy life expectancy’ measure considers living with illness and disability to estimate years one is in good health. Although a Malaysian in 2019 could expect to live to 75.0, 9.5 years are expected to be in poor health. The difference between life expectancy and ‘healthy life expectancy’ is greater in Malaysia than in Vietnam and Indonesia, both much poorer countries in the region.

Also, ‘healthy life expectancy’ progress over the last three decades has been modest, falling short of additional life expectancy. Almost three-quarters of this shortfall is due to non-communicable diseases, mainly food or diet and smoking-related.

Health gaps

The KRI report reviews health inequalities by gender, ethnicity, state, occupation and income, highlighting the inverse relationship of health to socioeconomic status. Unsurprisingly, poor health outcomes are more prevalent among lower-income households and vice versa, even for morbidities or ill health popularly associated with wealth.

The prevalence of diabetes mellitus, associated with high blood sugar levels, and hypercholesterolemia (high cholesterol) is highest among adults from bottom 20% (B20) households and lowest among top 20% (T20) households. Similarly, adults with hypertension (high blood pressure) were lowest (27.1%) among T20 households, and highest (38.3%) among B20 households in 2015.

The uneven prevalence of mental ill-health among adults and children has a similar bias: 33.6% of adults and 13.9% of children in B20 households have mental health problems, compared to 26.4% of adults, and 8.0% of children in T20 households.

Work and health

Incomes, typically from work, improve wellbeing by enabling health-promoting spending. But work can also adversely influence health by exposing workers to occupational hazards, including harmful, even toxic or carcinogenic substances, such as pesticides.

Stress due to excessive demands, or routine and repetitive work, or conditions over which workers have little say, may worsen mental health. Unsurprisingly, a large share of the working population, including family members doing unpaid care work, has work-related health problems.

Clearly, some workers are more vulnerable than others, with foreign labour and the informally employed generally more helpless. While work - especially in agriculture, industry and some services - may involve facing more occupational hazards, less income - for example, due to involuntary unemployment and underemployment – also has adverse consequences.

In 2019, unpaid (family) workers and homemakers had the highest incidence of high blood pressure (34.7%) compared to others, including government and semi-government employees at 29.4%, private sector employees at 18.8% and the self-employed at 30.7%.

About one in three private-sector employees, self-employed, unpaid workers and homemakers in 2015 had mental health problems. Meanwhile, about one in four government and semi-government employees were similarly afflicted.

Public health crucial

Health inequalities are shaped by many factors - including income, behaviour and environments - which public policies can influence. Yet, the KRI report finds that nominal near universal access of citizens to public health services in Malaysia has not ensured good ‘health for all’.

To improve health for all, and to reduce health disparities, policies must address the economic and social factors and processes underlying health indicators. While not its intent, the report makes a strong case for universal health coverage and better public health funding, emphasising disease prevention, instead of the current focus on curative services.

The report also recommends an ‘intersectoral approach’, mobilising ‘all of government’ for complementary nutrition, water, sanitation, labour, education, housing and occupational health policies. This should be part of providing social protection for all, including marginalised populations.

Thailand’s greater health progress than Malaysia in recent decades, and its better record thus far in coping with the Covid-19 contagion and recession can be attributed to its strengthened public health commitment despite greater political instability in recent decades. - Mkini

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JOMO KWAME SUNDARAM is Fellow, Academy of Science, Malaysia, and Emeritus Professor, University of Malaya. He was Founder-Chair, International Development Economics Associates (IDEAs), UN Assistant Secretary General for Economic Development (2005-2015) and received the 2007 Wassily Leontief Prize for Advancing the Frontiers of Economic Thought.

The views expressed here are those of the author/contributor and do not necessarily represent the views of MMKtT.