Rural Health
by Nadia Malyanah
Based on witness testimonies by Agnes Padan and Mebpung Akup
1. Background
1.1 Rural women in Malaysia, — particularly in Sarawak where at least 45 per cent of the population live in rural settings — continue to be denied the right to health. The stories of the challenges they encounter, as seen in the testimonies of two Women’s Tribunal witnesses, Agnes Padan and Mebpung Akup, are not isolated cases in a nation with decades of chronic underinvestment in public healthcare services.[1] In fact, this is what caused many states, including Sarawak, to be very badly affected by the COVID-19 pandemic.
1.2 Sarawak has a wealth of natural resources but is amongst the poorest states in the country. According to a report by the UN Special Rapporteur on Poverty in 2020, around 15.5 per cent of households here live below the poverty line on a monthly income of less than RM2,000 (DOSM, 2017: 54-57).
1.3 In terms of healthcare, there is a large discrepancy in the doctor to population ratio for Sarawak, which is 1:892 compared to the 1:150 ratio in Klang Valley. Within Sarawak itself, there is a further gap as the Kuching division has a doctor-population ratio of 1:604 whereas the smaller divisions of Kapit and Mukah have a ratio of 1:1721 and 1:2038 respectively.
1.4 The distance of major hospitals and clinics from longhouses, settlements and villages adds on to the complexities and expense of obtaining medical treatment. Some villages are dependent on mobile clinics and the Flying Doctors Services, which may only visit a village every one to three months. However, these services cannot medically evacuate patients in the event of emergencies and patients use dangerous timber roads to travel, which can take five to six hours. Doctors also provide services through a mobile boat clinic ‘Klinik Bot Bergerak’ for certain areas, but this is highly dependent on weather conditions (Kanmani, 2020).[2]
1.5 Access to maternal health in Sarawak is far more challenging than in Peninsular Malaysia due to the lack of adequate maternal healthcare facilities close to home and the lack of trained obstetrics and specialists. Nearly half (46 per cent) of rural clinics in Sarawak are not staffed by doctors and have very limited diagnostics and therapeutics. Some are only able to provide paracetamol (Vinodh, 2019). Over 70 per cent do not have laboratory services, while 88 per cent do not have x-ray services (Kanmani, 2020).
1.6 For those seeking oncology services, specialised healthcare is insufficient and inaccessible, particularly for those living in rural areas. There is only one cancer treatment facility for radiotherapy at Sarawak General Hospital (SGH) in the State capital of Kuching, staffed by five oncologists. This is far below the recommended number of 24 oncologists for the State (the recommended ratio of oncologists to the Malaysian population is 10 to 1 million persons) (“MOH mulls building new cancer centre in Samarahan”, 2021). Patients regularly have to travel by road, air and riverboat hundreds of miles from one end of Sarawak to the other to access cancer treatment at SGH in Kuching, racking up thousands of ringgit in travel expenses alone.
1.7 Further, a recent report revealed that only 73 per cent of people living in East Malaysia had timely access to emergency and essential surgical services (Hoh et al., 2021). The situation is even worse for those who are stateless, or undocumented, like Mebpung, who are deprived of any access to these services.
2. Findings
2.1 Issues of concern
2.1.1 Women living in rural Sarawak face severe socio-economic deprivation, stuck in a cycle of multi-dimensional poverty. As a result, they are often unable to afford a balanced diet and may suffer from dietary deficiencies that result in anaemia and other antenatal or postnatal complications.
2.1.2 Agnes Padan testified about how pregnant rural women and mothers are often unable to access routine antenatal and postnatal services in their local village health clinic. The journey to bigger towns and cities for routine check-ups often costs hundreds of ringgit. Additionally, these women may also be caring for several other young children making them unable to take time to travel for these check-ups.
2.1.3 Agnes's mother, Kam Agong, died from not having timely access to emergency and essential surgical services when she had her eighth child at the age of 44. There was no trained midwife or resident doctor in her village, nor was she able to get a blood test routinely done as part of antenatal screening. It is also not known if Kam Agong was counselled about her choices and options for contraception, or if she was empowered to choose and plan her pregnancies.
2.1.4 Nearly 20 years after her death, there is still no trained obstetrics and gynaecology specialist at the nearest public facility, Lawas Hospital, and high-risk pregnancies and patients requiring caesarean section are referred to Miri General Hospital or Likas Women and Children’s Hospital. During the COVID-19 pandemic and restricted movement orders, maternal healthcare access at Lawas deteriorated further as transfers to Sabah across the State border were very challenging, as were transfers to Miri across the Brunei-Miri border.
2.1.5 Additional barriers to maternal healthcare access include a lack of indigenous women’s participation in the professional healthcare workforce. In Sarawak, a significant proportion are doctors and nurses from Peninsular Malaysia who may not speak the local language or be familiar with local customs.
2.1.6 Mepbung’s challenges in terms of accessing healthcare services stem back to a larger systemic failure by the State to recognise the citizenship rights of indigenous children born in Sarawak. Due to conditions at the time of her birth — her father, a Sarawak Border Scout was away at work during the Konfrontasi, and it was not possible for her mother to walk for days to officially register Mebpung’s birth at Lawas — she does not have a Malaysian identity card. As such, she is unable to access diagnostic work and care for suspected breast cancer. She is also unable to get any social welfare or healthcare support through programmes such as MySalam and Peka B40.
2.2 Rights violated/standards not adhered to/failure of duty bearers (State)
2.2.1 The 1946 Constitution of the World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. The right to health is the right to the enjoyment of the highest attainable standard of physical and mental health and is a fundamental human right (OHCHR and WHO, 2008). It encompasses a range of interrelated rights including the right to safe drinking water and adequate sanitation, adequate nutrition and housing, a healthy environment and gender equality.
2.2.2 The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) affirms that access to healthcare, including reproductive health is a basic right. Article 12 of the Convention specifically addresses the right to health by stating that:
1. States Parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services, including those related to family planning.
2. Notwithstanding the provisions above, States Parties shall ensure to women appropriate services in connection with pregnancy, confinement, and the post-natal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation.
2.2.3 Based on the witness testimonies of Agnes and Mebpung, it is apparent that the Malaysian Government has failed to uphold such internationally recognised standards where their right to health is concerned.
2.2.4 As a duty bearer, the Government has also grossly failed the people of Lawas, who have been waiting more than 25 years for a new hospital facility after being promised one in 1996 under the Seventh Malaysia Plan. This project has been identified as one of the worst ‘sick hospital’ projects in the history of Malaysia, with three collapsed hospital tenders each worth a hundred million ringgit.[3]
2.2.5 At the same time, Mebpung’s case has highlighted the plight of indigenous women and children from Sarawak and Sabah who are more likely to face citizenship issues compared to people living in Peninsular Malaysia due to the lack of adequate infrastructure (roads and transportation to town) and centralised registration services that require time and money to access. With citizenship applications often remaining unresolved for years and sometimes decades, the right of those like Mebpung to access healthcare services is further compromised by the Government.
2.3 Victim impact
2.3.1 As noted above, pregnancy for women in rural Sarawak is especially risky since they are deprived of adequately equipped clinics and emergency healthcare facilities within safe reach of their villages. Not only was Kam Agong's death potentially avoidable had the Government addressed the systemic failures of healthcare services in the State and ensured that these met national and global standards, but the fact that other pregnant women continue to be put at risk two decades on, due to the continued lack of proper infrastructure and adequate healthcare services in rural community settings, is extremely troubling.
2.3.2 Mepbung’s citizenship issues have resulted in her being unable to access diagnostics and healthcare services in a timely manner. This may have devastating consequences if her breast lump turns out to be cancerous. It is also difficult for her to access non-governmental organisation (NGO)/non-citizen support networks that assist non-citizens in accessing healthcare services, due to a lack of awareness, digital connectivity, and her remote location.
2.3.3 The issue of statelessness is dealt with in detail under the Citizenship Findings and Recommendations paper. However, it is worth noting here that while the exact number of stateless indigenous people in Sarawak is unknown, many women and children living in rural villages are believed to be affected, given the excessive bureaucracy and their inability to afford the high cost of repeated travel to Sarawak’s towns and cities. Importantly, citizenship issues often are intergenerational and since access to healthcare, education and social services in Malaysia is heavily dependent on proof of citizenship, those affected become trapped in a cycle of poverty and poor health.
3. Recommendations
Short Term (within one year)
3.1 Conduct an urgent service evaluation and stakeholder analysis of the current state of maternal healthcare provision in rural settings in Sarawak and Sabah to identify local needs, gaps and enable effective implementation of service improvement and development.
3.2 Repeal immediately the directive for public hospitals and clinics to refer undocumented persons to the Immigration Department.
3.3 Conduct an open and transparent parliamentary enquiry into the delayed construction of Hospital Lawas from 1996 and expenses incurred through previous failed tenders.
3.4 Ensure that all pregnant women and mothers in Sarawak and Sabah have access to adequate, safe and accessible antenatal and postnatal care with appropriate diagnostics and therapeutics at government healthcare clinics locally, regardless of citizenship status.
3.5 Ensure healthcare access for all on a non-discriminatory basis, including non-citizens and refugees, and provide clear information on NGO services, referral pathways and clinics that provide support and treatment for non-citizens and refugees.
3.6 Ensure all women have adequate access to family planning services to allow women and families to time and space desired pregnancies for the health and safety of the mother and overall well-being of the family.
Medium Term (within two to three years)
3.7 Ensure robust data collection and analysis of healthcare outcomes for women in Sabah and Sarawak, stratified according to ethnicity, district and socio-economic status, to improve public health service planning and equitable access to treatment.
3.8 Implement frequent and accessible education and awareness programmes on various aspects of rural women’s health, including family planning, sexual and reproductive health, and hygiene.
3.9 Build local health capacity by training more healthcare professionals including specialty doctors, nurses and midwives from indigenous communities in Sarawak and Sabah, to fulfil the needs of the rural communities in these states.
Endnotes
[1] In 2021, Malaysia spent 3.8 per cent of its Gross Domestic Product (GDP) on healthcare, an amount inadequate to meet the level of healthcare needs nationwide. This was far less than the global average of 9.86 per cent (2018). See World Health Organization Global Health Expenditure database, available at https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS.
[2] Only 143 clinics are accessible by tar roads, 21 by logging roads, 19 by river, and the rest dependent on a combination of river, air, plantation, and logging roads. Only 170 out of 215 (79 per cent) clinics have 24-hour electricity supply, and only 128 out of 215 (60 per cent) have treated water supply (Kanmani, 2020).
[3] Recently, a total of RM175 million was allocated for a third time to build a new 74-bed hospital, slated for completion by August 2023.
References
Department of Statistics Malaysia (DOSM) (2017). Household Income and Basic Amenities Survey Report 2016.
Hoh SM, Wahab MYA, Hisham AN, Guest GD, and Watters DAK. (2021). “Mapping timely access to emergency and essential surgical services: The Malaysian experience”. ANZ Journal of Surgery. 1 June 2021. Available at https://doi.org/10.1111/ans.16986.
Kanmani Batumalai (2020). “57 years later, do Sarawak, Sabah enjoy equal health care to Peninsula?”. Code Blue. 16 September 2020. Available at https://codeblue.galencentre.org/2020/09/16/57-years-later-do-sarawak-sabah-enjoy-equal-health-care-to-peninsula/.
“MOH mulls building new cancer centre in Samarahan”. Code Blue. 17 November 2021. Available at https://codeblue.galencentre.org/2021/11/17/moh-mulls-building-new-cancer-centre-in-samarahan/.
Office of the High Commissioner for Human Rights (OHCHR) and World Health Organization (WHO) (2008). The Right to Health. Fact Sheet No. 31. Geneva: OHCHR. Available at https://www.ohchr.org/documents/publications/factsheet31.pdf.
Report of the Special Rapporteur on Extreme Poverty and Human Rights (2020). Visit to Malaysia. A/HRC/44/40/Add.1. Available at https://www.srpoverty.org/wp-content/uploads/2020/07/malaysia-final-report.pdf.
Vinodh Pillai (2019). “No health care in rural Sarawak 29 of 30 Days”. Code Blue. 30 December 2019. Available at https://codeblue.galencentre.org/2019/12/30/no-health-care-in-rural-sarawak-29-of-30-days/.