Health Impacts of Gender Discrimination
by Dr. Subatra Jayaraj
Women in Malaysia continue to have their individual and community health impacted by gender discrimination, violence, and coercion. The United Nations Committee on the Elimination of Discrimination against Women affirms that access to healthcare, including for reproductive health, is a basic right under the Convention on the Elimination of Discrimination of All Forms of Discrimination against Women (CEDAW).
Through the Women’s Tribunal that took place on 27 and 28 November 2021, we heard from several women who testified regarding circumstances that have prevented them from achieving the right to the highest attainable standards of health.
(A) Key Points from Witness Testimonies
At least six witnesses described how their individual health, and the health of the community, have been negatively affected.
Witness Agnes Padan’s testimony provides a compelling example on how the right to health — specifically the right to maternal healthcare — continues to be elusive for the Lun Bawang population of Sarawak.
Maternal health includes postpartum health up to six weeks after delivery. This is a period in which postpartum complications without early detection and appropriate medical intervention may lead to death. In a violation of her right to health, Agnes Padan’s mother, the late Kam Agong became a statistic that contributed to the high maternal mortality rates that are prevalent in rural and indigenous communities in Malaysia.
Access to contraception has been shown to be a key factor in preventing maternal mortality globally.
Kam Agong conceived eight children. It needs to be questioned if she was given the opportunity to access her reproductive right to decide if she wished to have children, and how many and when; and her right to information and access to the complete range of contraception if she chose to do so.
Kam Agong’s experience also highlights the various social determinants of health that prevent rural and indigenous communities from achieving their right to health, such as access to logistics and transportation, and access to education and livelihood. Discrimination against the Lun Bawang community can be seen as healthcare that has not been equitably provided in the Lawas region of northern Sarawak.
Subsequently, Witness Mebpung Akup’s testimony highlights how her statelessness prevents her from accessing healthcare services. She faces discrimination on the basis of her non-citizenship, despite having been born in her current place of residence, which is located in Malaysia. Non-citizens are required to pay a much higher rate than Malaysian patients for public health services.
The testimony of witness Latha (pseudonym) highlights that health promotion for sex workers is hindered by the apparatus of the State. This is further exacerbated by the fact that sex work is criminalised in Malaysia.
Sex workers form one of the communities that is most vulnerable to human immunodeficiency virus (HIV) infections and other sexually transmissible diseases. Sex workers face the tremendous stigma and discrimination attached to their profession, which deny them safe and quality access to preventative healthcare.
Siti Nur (pseudonym) gave testimony that brought to the forefront the discrimination faced by women with disabilities as well as the mental health burden that is caused by sexism and harassment at work, where cases may be drawn out for a long period of time, and psychological sequelae persistent.
Women with chronic illnesses have the added burden of negotiating multiple and repeated barriers to healthcare access, affecting their mental health and financial stability.
The testimony of Glorene Das, Executive Director of Tenaganita, on behalf of the late Adelina Lisao highlighted how women migrant workers are vulnerable to neglect, physical and emotional abuse, and forced labour, at the hands of employers, without adequate protection of the law. Abuse and exploitation leading to poor health are compounded by the inability of women migrant workers to access healthcare services due to their work permit or documentation status, restriction of movement, and financial barriers.
Witness Tharani Kutty’s experience highlights how women and gender-diverse individuals in the healthcare workforce continue to be subjected to dangerous and unhealthy working conditions without proper occupational safety and hazard coverage. Her right to a safe working environment is restricted along with her rights to freedom of speech and expression, assembly, and association.
(B) Overview of Health Impacts of Gender Discrimination in Malaysia
These witness testimonies provide us with an overview of how discrimination, violence, and coercion against women negatively impacts health. I would like to highlight a few themes that need urgent action to improve healthcare inequities that are still faced by women in Malaysia.
(1) Higher Maternal Mortality Ratio in Vulnerable and Socially Disadvantaged Groups
Despite Malaysia having successfully reduced its maternal mortality ratio (MMR), the distribution of maternal deaths remains increased in vulnerable and socially disadvantaged groups that have inequitable healthcare.
In 2019, the MMR in Malaysia was at 21.1 maternal deaths per one hundred thousand live births. Malaysia has successfully reduced maternal mortality through several efforts which, in the broad sense, include: (a) the overall socio-economic development of the country; (b) strengthened health services; and (c) specific efforts and initiatives for the reduction of maternal mortality, one of which is the audit of maternal deaths by confidential enquiry into maternal deaths.
However, maternal mortality rates are increased in vulnerable and socially-disadvantaged groups that have inequitable healthcare and poor social determinants of health. Statistics on health are sometimes disaggregated by the following categories: Bumiputera, Chinese, Indian, and ‘Other’. This can mask the realities of the health of indigenous women — especially in the states of Sabah and Sarawak — who are categorised generally as Bumiputera, along with ethnic Malays.
(2) Unable to Exercise Right to Reproductive Choice, and Lack of Access to Reproductive Health Services
Many women in Malaysia are unable to exercise their reproductive right to choose, and face difficulty accessing high-quality reproductive health services, which can be seen by the following:
(a) The use of contraception has remained stagnant at 52% since 1984.
(b) The use of modern methods of contraception is lower, at 34%.
(c) The law allows for abortion to protect the physical and mental health of the mother, but abortion is stigmatised and costly. Furthermore, government hospitals often do not provide the service
The Contraceptive Prevalence Rate (CPR) is low in rural areas of Malaysia, while the unmet need for family planning is often higher than in Kuala Lumpur. The CPR in rural areas of Sarawak was at only 42.9% in 2014, which was lower than Malaysia’s overall CPR of 51.9% in 2014. This can be partly explained by the difficulty involved in reaching outlets that sell contraceptives, including condoms, in rural areas, as well as the lack of medical commodities and skilled healthcare providers in rural clinics.
Access is made even harder for unmarried women, who may not be comfortable purchasing contraceptives in public due to the stigma and legal consequences associated with doing so. For women migrant workers who become pregnant, their contracts have clauses that result in immediate revocation of their work permits. Women with disabilities are also not heard, nor planned for, in the provision of sexual and reproductive health services. Data on barriers to access for these communities is severely lacking and needs to be actively sought so that equitable services may be provided.
(3) Poor Social Determinants of Health Hinder Women’s Access to Healthcare
Poor social determinants of health worsen logistical challenges, hindering or preventing access to healthcare for women.
In addition to transportation issues, a general lack of finances and time deters women from seeking help before a medical condition reaches a critical stage. Although there are bridging services such as the Flying Doctors in Sarawak, these services face budget constraints. Additionally, with the opening of logging roads, helicopter services have been reduced.
There is therefore a critical need for a comprehensive and accessible healthcare system to be developed in rural areas, which would not only increase facilities in, and access to, clinics but would also enable effective healthcare outreach to dispersed rural communities. In 2010, it was reported that out of Malaysia’s 55 tertiary care centres specialising in the treatment of cancer, 28 are public hospitals while 27 are private. Most of these centres are located on the west coast of Peninsular Malaysia, mainly in urban areas.
According to the Country Health Plan 2011–2015, the doctor to patient ratio in Sabah and Sarawak is at a concerning 1:1357 and 1:957, respectively, while states in Peninsular Malaysia like Kelantan and Kedah fare slightly better at 1:917 and 1:837, respectively. The 12th Malaysia Plan (2021-2025) has not adequately addressed the issues of rural health infrastructure and human resources in the public health workforce. It remains to be seen if the Lawas hospital upgrade will resume, with accountability.
(4) Requirement of Formal National Identity Documentation is a Systemic Barrier to Healthcare
For many women from diverse backgrounds, the requirement of formal national identity documentation is a systemic barrier to accessing healthcare.
The intersectionality of statelessness and gender discrimination worsens the impact on healthcare for women without formal identity documents approved by the State. These barriers to healthcare access are faced by populations who are considered non-citizens, such as stateless individuals, women migrant workers who may be documented or undocumented, refugees and asylum-seekers, rural and indigenous women, and those with gender-diverse identities.
The structural violence of the system that regulates identity documents increases the vulnerability of these communities with regard to health, to the further detriment of their livelihood, personal security, access to education, and welfare services. The collective impact of these violations not only affect the witnesses themselves, but also have repercussions for a wider group such as Lun Bawang women and girls of reproductive age, and their extended families as well as their community in Lawas.
In its Concluding Observations to Malaysia in 2018, the CEDAW Committee expressed its concern with a “Government directive that requires public hospitals to refer undocumented asylum-seekers and migrants to the Immigration Department when they seek medical attention”. The directive deters women from accessing healthcare services due to fear of arrest and detention. This issue continues to be contentious during the COVID-19 pandemic, with the Ministry of Home Affairs and the Ministry of Health giving directly contradictory statements on the arrest of undocumented residents involved in vaccination programmes.
(5) More Severe Impacts of Gender Discrimination on Health Due to COVID-19 Pandemic
The violations and discriminations surrounding the right to health have worsened during the COVID-19 pandemic, and healthcare continues to be inaccessible for many women in Malaysia. Domestic violence hotlines have recorded a significant increase in calls and requests for assistance since the lockdown orders were imposed in March 2020. COVID-19-related movement restrictions in Malaysia disrupted livelihoods, exacerbated socio-economic and gender inequalities, and added accessibility barriers to sexual and reproductive health and rights (SRHR), and mental health services.
Early efforts prioritised the treatment and containment of COVID-19, with hospitals and community clinics limiting or halting routine SRHR services. Nonetheless, maternal mortality is predicted to increase due to COVID-19-related deaths within the antenatal and postpartum period.
Women are the primary caregivers in families, and they face additional burdens of domestic and unpaid care work during school closures. They also constitute a large proportion of essential service providers in the response to COVID-19 (i.e. doctors, nurses, caregivers, hospital cleaners, teachers, and domestic helpers). SRHR services are essential and should operate during health emergencies, and women need support in these roles. Mental healthcare support continues to not be accessible nor available for many women in Malaysia.
(C) Recommendations to Eliminate Discrimination against Women in Health
In keeping its CEDAW commitments, the Government of Malaysia needs to take all appropriate measures to eliminate discrimination against women in the field of healthcare to ensure, on a basis of equality of men and women, access to healthcare services. The following are some recommendations to achieve this objective:
(1) Remove All Barriers to Healthcare Access, Especially for Sexual and Reproductive Health, and Mental Health Services
The Government has a responsibility to:
(a) ensure women have access to, and receive, appropriate healthcare services in connection with pregnancy, confinement, and the postnatal period, granting free services where necessary, especially in areas that are difficult to reach, with low accessibility and poor social determinants of health;
(b) provide access to healthcare on a non-discriminatory basis, and ensure that women, regardless of nationality or income, can access public healthcare — in particular, contraception, childbirth and reproductive healthcare, and mental health services;
(c) make antenatal and maternity care affordable for pregnant women (including non-citizens such as refugees and stateless persons), and offer postnatal care and family planning counselling as part of sexual and reproductive health services; and
(d) address inequities for women with disabilities in accessing health services, including physical and non-physical limitations to such access.
(2) Institutionalise Non-Discrimination Policies and Data-Driven Guidelines in Healthcare
The Government has a responsibility to:
(a) clearly define and collect distinct data and analyses for indigenous populations, to better understand the state of health of indigenous women from both Peninsular and East Malaysia;
(b) collect disaggregated data on health, and tailor health programmes to the specific needs of vulnerable populations from both the public and private sectors;
(c) take measures to improve the affordability of healthcare services for non-citizens, including by fully exempting asylum-seeking and refugee women from the payment of deposits and higher fees than Malaysian nationals for the same healthcare services, including for sexual and reproductive health;
(d) immediately repeal the directive requiring public hospitals to refer undocumented asylum-seekers and migrant workers to the Immigration Department; and
(e) decriminalise sex work and associated practices, such as carrying condoms, that are used as a basis to detain and harass sex workers.
(3) Commit to Gender-Responsive Budgeting in Healthcare
The Government has a responsibility to:
(a) invest in and strengthen routine and preventive care for women and gender-diverse communities, including antenatal and postnatal care, contraception, reproductive healthcare, and mental health services;
(b) invest in long-term, durable policies to strengthen health systems, governance, and expansion of healthcare services, including infrastructure and human resources in rural and remote areas;
(c) follow through with budgetary commitments on healthcare, especially human resources and infrastructure in rural areas and East Malaysian states; and equitably distribute resources, considering the impact of COVID-19; and
(d) ensure oversight and accountability in healthcare funding commitments — including for human resources and infrastructure projects that have been delayed or managed improperly — to eliminate corruption, wastage, fraud, leakages, and abuse of power.
The witness testimonies have shown how discriminatory policies and practices continue to negatively affect the health of women in Malaysia. The repercussions not only impact the individual witnesses, but further influence the health of their families and communities.
The Government of Malaysia needs to take urgent steps to eliminate all forms of gender-based discrimination in order to achieve the highest standards of health that every individual deserves. The COVID-19 pandemic has demonstrated that health inequities rapidly affect the health of our entire population.
Eliminating discrimination, violence, and coercion in women’s health is an urgent and immediate concern for all.
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