Introduction
When it comes to population health, historically, much effort has focused on delaying death—increasing longevity and reducing mortality. In fact, collecting vital statistics, such as births and deaths is a near-universal practice. This includes Malaysia, which has partial records of births and deaths rate from 1911. Similarly, the Department of Statistics has published estimates of Malaysian life expectancy spanning from 1966.
Indeed, for many decades life expectancy, often used as a key summary indicator of population health, has improved significantly in Malaysia. In 2020, on average, male and female newborns could expect to live to the ages of 72.6 and 77.6 years, respectively. If they were born 50 years earlier in 1970, their average life expectancies would only have been 61.6 years and 65.6 years respectively.
These achievements follow the declining death rates over the past decades. For example, the number of deaths among infants under 1-year-old (infant mortality) and children under 5 years old (under-five mortality) in 2019 were 6.4 and 7.7 per 1,000 live births, respectively, compared to 39.4 and 55.9 in 1970. In other words, Malaysia has reduced child mortality rates in the last five decades by more than 80%.
The reduction in mortality rates has happened across all age groups. These improvements are reflected in increased life expectancy among middle-aged and older-aged groups, not just among the younger-aged. Additionally, the report Social Inequalities and Health in Malaysia shows improving life expectancy in all states and ethnic groups, although some population segments have made much more progress while others have lagged behind.
Living longer, but not necessarily healthier
The evidence indicates that Malaysia has improved the longevity of its population. With life expectancy rising due to greater longevity and lower mortality, society should seek to ensure that the additional years gained are lived in good health. One metric that measures the health status of the population is “healthy life expectancy” (HALE). As the name implies, it estimates how long a population is expected to live in good health.
This indicator complements life expectancy, with the difference between the two (i.e. ‘life expectancy‘ minus HALE) being the time period lived in poor health. For example, if a population’s life expectancy at birth is 70 years, a HALE of 65 years suggests that the difference of 5 years or 7% of lifespan will be in ill health. One appeal of HALE as a summary measure of population health is that it is measured in years of life expectancy which are easily understood and intuitively meaningful to the average person.
The HALE metric serves as a useful broad population-based indicator of trends that enables governments to monitor changes in population health. As Malaysia does not calculate its own HALE metric, this paper refers to estimates by the Global Burden of Disease Collaborative Network 2020. The figure shows that while a Malaysian newborn in 2019 can expect to live to 75.0 years, 3.1 years more than in 1990, 9.5 years of those years will be in poor health. In fact, the number of years in poor health has increased from 9.1 years in 1990 to 9.5 years in 2019. If we consider years in poor health as a percentage of life expectancy, 12.7% of total lifespan in 2019 will be in poor health, the same percentage as in 1990.
As child mortality decreases and more of the population enters adulthood, they should be able to age with dignity and not be burdened by the consequences of poor health such as physical limitations and financial strains. Being in good health enables people to lead more fulfilling and meaningful lives. For example, grandparents being able to spend more time with family members and watch their grandchildren grow, individuals being able to pursue their hobbies and passions as they are more financially stable, and professionals being able to remain productive members of society even after retirement if they wish.
If Malaysia’s improvements in life expectancy are not accompanied by improvements in health outcomes, the population will not be able to fully benefit from living longer. Those suffering from chronic health complications requiring them to get support from family members and/or carers may need more support in terms of monetary, time and effort. Higher rate of morbidity in a population is typically associated with greater health care utilisation and expenditure, putting more strain on the healthcare system. Those with small savings or with no personal support may need to rely on care services provided by the government, further straining the government’s fiscal resources.
Way forward
Ensuring a life time of good health
Efforts to improve health outcomes should not only be directed at the elderly, but should also address every life stage, beginning with the pre-natal and early childhood phases, and be consistently monitored over life times. After all, good health from the earliest period in the womb and during the infant stage of childhood are associated with being able to grow up healthily to become healthy adults.
In absolute figures, the number of years in poor health increased for all the age groups, except those aged 80 years and above. In other words, while life expectancy has increased, morbidity levels have not decreased, resulting in more time in poor health.
More investments in preventative measures are needed
At a glance, it might seem inevitable that the elderly have poorer health, as ageing is typically accompanied by an increasing probability of disease and disability. However, World Health Organization study shows that the number of healthy life years 65-year-olds can expect to live varies among countries, giving examples of some Nordic countries achieving more healthy life years compared to some central and eastern European countries. This suggests that health for the elderly can be improved with appropriate policies and lifestyle behaviours.
Increasing healthy life expectancy comes with an implicit understanding that health policy planning should take a long-term, preventive approach. Malaysia’s health system has increasingly focused on curative care (e.g. treatment costs) compared to preventive measures (e.g. vaccination, health promotion campaigns, screening programmes). To put this in perspective, in 2018 Malaysia only spent 6.1% on preventive services, compared to 68.3% on curative care services. Studies have shown that investments in preventive measures are more cost-effective in the long-run due to cost-savings from reduced treatment needs. In addition, these interventions generally benefit the wider population, not just those who can afford medical care.
Improving health outcomes require a coordinated, intersectoral approach
While the benefits of increased investments in preventive efforts will likely be seen in the longer term, in the meantime, there should be a coordinated effort among ministries to improve health outcomes. Health outcomes are not just determined by access to healthcare, but also tied to social factors such as a person’s income, type of work, lifestyle choices and housing conditions. For instance, the pandemic has highlighted how poor housing conditions have been linked to worse health outcomes and more infectious disease spread. As many of these health determinants are from outside the healthcare system—and beyond the Ministry of Health’s purview—a “whole of government” approach is crucial for designing policies to improve health outcomes. In short, the design of national policies to improve well-being must also incorporate health considerations.
Conclusion
Malaysia has performed well in terms of metrics of longevity and mortality. However, to ensure that Malaysians not only live longer, but also in good health, we need to ensure that increased life expectancy is accompanied by significant health improvements. The importance of health was underscored in a report by Joseph Stiglitz, Amartya Sen and Jean-Paul Fitoussi, which noted that “health is perhaps the most fundamental component of capabilities as, without life, none of the other component matters.”
