Priority-setting to integrate sexual and reproductive health into universal health coverage: the case of Malaysia

Figures & data

Table 1. Key informants

Key informants	Number
NGO representatives and UN implementing agencies Sexual and reproductive health (SRH) organisation Women’s organisation LGBTQI organisation Health professional organisation UNHCR (United Nations High Commissioner for Refugees)	7
Academics with medical/MOH background or expertise in UHC and SRH	2
Current health policy-makers Family Health and Development Division (FHDD), MOH Obstetrics and Gynaecology Development Committee (JKPPOG), MOH Malaysian Health Technology Assessment Section (MaHTAS), MOH	3
Former health policy-makers	4
Health provider/medical practitioner	1
Religious leaders	2
Insurance provider	1

Figure 1. Analysis framework – what works, for whom, in what mechanisms, to what extent, in what contexts – to prioritising SRH services in UHC plans

Table 2. Outcomes: level of prioritisation of the three SRH tracer interventions

Health problem/issue	Maternal mortality	GBV	Deaths and complications due to unsafe abortion
	High MMR has been recognised as a significant population health issue in the 1960s – reduction in MMR is critical to improve overall population health	Recognised the physical and psychological harm suffered by victims of GBV Not being perceived as a population health problem	Maternal death due to unsafe abortion has not been acknowledged as a population health issue due to a lack of data and low MMR since 1990s
Health solution/ intervention	Pregnancy and safe delivery care	One Stop Crisis Centre (OSCC)	Safe abortion and post-abortion care
	Pregnancy and safe delivery care delivered through rural health services (RHS), supported by trained allied health personnel, have been seen as a cost-effective solution to reduce MMR from the 1960s to 1990s.	OSCC pilot – represented a feasible and successful model to respond to GBV through a multi-disciplinary, multi-sectoral and integrated approach using existing resources within the hospital, at no additional cost; has been perceived as a cost-effective solution. Special budget has been allocated to build the room/space for OSCCs but not the operational budget.	Safe abortion services – only recognised as a health solution, when pregnancy threatened the life, physical, and mental health of the mother No additional resources being allocated for abortion services in public hospitals – respective hospitals are expected to absorb the cost of the services within the O&G department
Level of prioritisation	High	Medium/partial	Low
	Pregnancy and safe delivery care are categorised as high priority services as MMR due to the risk of pregnancy and delivery has been perceived as a significant health problem and resources have been constantly allocated through Malaysia Plans and annual budget for such services	One Stop Crisis Centres: GBV has not been seen as a population health problem and only minimum budget is being allocated to ensure the space for OSCCs is available in the A&E department in all MOH’s hospitals.	Safe abortion and post-abortion care services: maternal deaths and complications due to unsafe abortion have not been seen as a population health problem, and there are no specific resources being allocated to support these services.
Coverage and financing scheme	Public healthcare system
	All Malaysian women, regardless of age and marital status (paid or subsidised by the Malaysian government through taxation system) - Young people and unmarried women may encounter challenges due to stigma and discrimination - Parental consent is required if the woman is <18 years old - Indigenous women and populations of East Malaysia have difficulties in access due to the lack of knowledge and geographical barriers Non-citizen (migrant workers) – foreigner rate Refugee with UNHCR card – 50% discount of the foreigner rate	All Malaysian (paid or subsidised by the Malaysian government through taxation system) - Unmarried women and young people will face barriers because of social taboos around premarital sexuality and pregnancy Non-citizen (migrant workers) – foreigner rate Refugee with UNHCR card – 50% discount of the foreigner rate LGBTQI, undocumented migrant workers and refugees encounter greater challenges in accessing such services due to stigma and discrimination, cost and legal barriers.	All Malaysian women (paid or subsidised by the Malaysian government through taxation system) – under the circumstances when the mother’s life, physical and mental health is threatened - Written consent should be from the women herself. However, for Muslim couples, consent from the husband is also necessary - Parental consent is required if the woman is <18 years old Non-citizen (migrant workers) – foreigner rate Refugee with UNHCR card – 50% discount of the foreigner rate
	Private healthcare system
	All Malaysians and Non-Malaysians can be covered – Mainly OOPE, cost is not being regulated and can be a barrier for lower socio-economic groups.	•	All Malaysians and non-Malaysians – Mainly OOPE, cost is not being regulated and can be a barrier for lower socio-economic groups.

Table 3. Context-mechanism-outcome configuration

SRH Tracers	Context	Strategies/ Measures	Mechanism Triggered	Outcome
a) Pregnancy, safe delivery and post-natal care	General context Sociocultural acceptance of pregnancy within marriage; legitimacy due to two lives at stake 1st phase (1960s–1990s) Outer context High MMR High levels of poverty 70% of the population resided in rural areas – - Rural population health needs and demands - Difficulties in access to care Local beliefs and customs on traditional medicines and home deliveries – valued the social and spiritual support received from traditional birth attendants (TBAs) during pregnancy and post-natal care Inner context Limited trained medical personnel, especially doctors	Strategy 1: Generate public demand/ social support through community participation and mobilisation – working with village development committees, NGO such FRHAM and National Family Planning Board (now known as National Population and Family Development Board) Strategy 3: Engage champion – trained midwives to work with TBAs	Strong demand and buy-in generated from the communities Increased political commitment since 1960s MOH ownership of the process	Increased the political will to invest and make pregnancy, childbirth and post-natal care as country’s health priorities. Budget and resources were committed and allocated in various country development plans to strengthen the health system to deliver these services. Significant reduction of MMR.
	2nd phase (1990s – present) Outer context Significant reduction of MMR in the 1990s – disease burden has shifted to non-communicable diseases Stagnant MMR since then until present Teenage pregnancy and stagnant adolescent fertility rate Inner context Stigma and discrimination from healthcare providers towards teenage pregnancies and unmarried women who access pregnancy and delivery care services	Strategy 2: Link it with international commitments – to achieve MDGs and SDGs Strategy 4: Reframe issues appealing to values & beliefs – Reframe the needs to provide pregnancy and delivery care for adolescents, young people and unmarried women under the umbrella of “Family Health”	Increased political will to provide continuing support for pregnancy and delivery care Created mutual understanding and buy-in on the need to provide pregnancy and delivery care for adolescents, young people and unmarried within healthcare providers and the community.	Pregnancy, childbirth and post-natal care have continued to be the country’s priorities with constant operational budget being allocated.
b) GBV and OSCC services	From pilot intervention to scale-up Outer context Perceived as a “private matter” that prevented others from intervening and prohibited victims from reporting GBV due to stigma, fear of retribution and socio-cultural beliefs. Burgeoning international movement on the rights of women and sexual and reproductive health in the early 1990s Domestic Violence Act passed under Penal Code in 1994	Strategy 2: Link it with international commitments – ICPD-PoA, Beijing Declaration and CEDAW Strategy 3: Engage champion – NGO working with health experts, engaging with champion from health sectors Strategy 4: Reframe issues appealing to values & beliefs – Reframe GBV as a health issue instead of rights issue	DVA enactment created legitimacy to engage health sector champion to generate buy-in of GBV solution (OSCC) Reframed the impact of GBV as a health issue to create mutual understanding and facilitate the buy-in The success of pilot OSCCs also increased the buy-in of MOH	OSCC has been partially prioritised as a feasible solution to address the health impact of GBV without additional operational budget support – mainly depended on the on the capacity of the hospitals as well as the volition of the decision-makers
c) Safe abortion services and post-abortion care	Development of Termination of Pregnancy (TOP) Guideline (2012) Outer context Perceived as a sensitivity issue – sociocultural norm deem abortion as taking a life as human life Legitimised and regulated by Penal Code Inner context Lack of data on maternal death due to unsafe abortion Lack of data on abortion services Health providers have vague interpretation of the legal context of abortion	Strategy 1: Generate public demand/ social support for the guideline: - including religious views and perspectives - introducing details on the eligibility and procedures for abortion, e.g. who can access, where and how abortion shall be conducted Strategy 4: Reframe issues appealing to values & beliefs – Reframe abortion services so as to address unsafe abortion and reduce MMR	Created the mutual understanding and buy-in at the top-management/policy making level	TOP guideline has been issued to all MOH’s hospitals. However, the services have not been prioritised. Services only available when there is a serious threat of medical complications. No specific budget being allocated for abortion services and the training for abortion services Healthcare providers may still not be comfortable to provide such services due to personal values or the lack of skills.