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Correlation between education, income status, and quality of healthcare accessed.

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Correlation between education, income status, and quality of healthcare accessed.

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- Higher education tends to improve health literacy. People who are better educated understand medical advice more easily, know when to seek preventive care, and follow treatment regimens properly.

- Higher educational attainment often leads to better-paying jobs (or higher income status). With higher income, people can afford better healthcare (private clinics/hospitals), more frequent check-ups, medicines, healthier food, better living conditions, etc.

- Income also affects geographic accessibility: those with higher income can live nearer to good healthcare facilities, or afford transportation to reach them. Poorer/less-educated individuals often live in rural or under-served areas, where healthcare quality is poorer, fewer specialists are available and waiting times are longer.

- In 2024, ProtectHealth’s PeKa B40 scheme screened 301,650 individuals from the B40 group; about 70% had at least one NCD such as diabetes, hypertension, high cholesterol, or obesity. From the same group: ~25% had two or more NCDs. Also, 4.38% had three NCDs.

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Causes of anaemia (iron deficiency, folate deficiency, chronic disease, multiparity).

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Causes of anaemia (iron deficiency, folate deficiency, chronic disease, multiparity).

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1. Iron Deficiency Anaemia

Cause: Inadequate iron intake, chronic blood loss (e.g. menstruation, gastrointestinal bleeding), or increased demand (e.g. pregnancy, growth).

Mechanism: Iron is required for haemoglobin synthesis; deficiency leads to reduced haemoglobin production and smaller (microcytic), paler (hypochromic) red blood cells.

2. Folate Deficiency Anaemia

Cause: Poor dietary intake (common in malnutrition or alcoholism), malabsorption (e.g. coeliac disease), or increased requirement (e.g. pregnancy, haemolysis).

Mechanism: Folate is essential for DNA synthesis during red blood cell formation; deficiency leads to impaired cell division, resulting in large, immature (megaloblastic) red cells.

3. Anaemia of Chronic Disease (ACD)

Cause: Chronic infections, inflammation (e.g. rheumatoid arthritis), or malignancy.

Mechanism: Inflammatory cytokines cause reduced iron availability (via increased hepcidin), decreased erythropoietin production, and impaired bone marrow response — leading to normocytic or microcytic anaemia.

4. Anaemia due to Multiparity

Cause: Repeated pregnancies increase maternal iron and folate requirements, often exceeding dietary intake.

Mechanism: Frequent pregnancies deplete iron and folate stores faster than they can be replenished, leading to combined iron and folate deficiency anaemia.

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Impact of anaemia on pregnant women (fatigue, complications during labour, maternal morbidity).

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Impact of anaemia on pregnant women (fatigue, complications during labour, maternal morbidity).

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Anaemia in pregnant women reduces the oxygen-carrying capacity of the blood, leading to fatigue, weakness, and reduced physical capacity. During labour, anaemic mothers are at higher risk of complications such as preterm delivery, low birth weight, and postpartum haemorrhage due to poor oxygen supply and reduced resilience. Severe anaemia also increases maternal morbidity and mortality, as it can worsen infections, delay recovery, and contribute to heart failure during pregnancy or childbirth.

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Impact on children (low birth weight, preterm birth, impaired growth and development).

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Impact on children (low birth weight, preterm birth, impaired growth and development).

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Anaemia during pregnancy reduces the mother’s haemoglobin levels, limiting the oxygen supply to the placenta and fetus. This oxygen deficiency can result in intrauterine growth restriction (IUGR), causing low birth weight babies who are more vulnerable to infections and developmental delays. It also increases the likelihood of preterm birth, as the body may trigger early labour due to stress or poor placental function.

Furthermore, infants born to anaemic mothers often have lower iron stores, predisposing them to infant anaemia after birth. This can lead to impaired growth, delayed motor skills, and reduced cognitive development, affecting learning ability and overall health throughout childhood. In severe cases, chronic oxygen deprivation can even impact brain development, contributing to long-term neurological and behavioural issues.

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Common nutrient deficiencies in pregnancy (iron, folate, protein).

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Common nutrient deficiencies in pregnancy (iron, folate, protein).

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Subtask 2:Nutritional Deficiency and Affordable Food Choices

1. Common Nutrient Deficiencies During Pregnancy

Pregnancy significantly increases the body’s demand for nutrients to support both maternal health and fetal development. Nutritional deficiencies are one of the major causes of maternal anaemia and poor pregnancy outcomes, especially among low-income women (B40 group).(1)

a. Iron Deficiency
Iron deficiency is the most common nutritional deficiency in pregnant women. It occurs when iron intake is insufficient to meet the increased demand for haemoglobin synthesis. Iron-deficiency anaemia leads to fatigue, reduced immunity, and an increased risk of preterm birth and low birth weight.

b. Folate Deficiency
Folate (vitamin B9) is essential for DNA synthesis and neural tube formation in the developing fetus. Folate deficiency during early pregnancy increases the risk of neural tube defects such as spina bifida. In Malaysia, folic acid supplementation is routinely recommended for all pregnant women.

c. Protein Deficiency
Protein is required for the growth of fetal tissues, placenta, and maternal blood volume expansion. Insufficient protein intake can cause intrauterine growth restriction and low birth weight. Low-income families may struggle to afford high-quality protein sources such as red meat or fish.

d. Other Micronutrients
Deficiencies in calcium, vitamin D, and vitamin B12 are also common. These nutrients play vital roles in bone formation, energy metabolism, and red blood cell production.

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Low-cost alternatives for low-income families (e.g., anchovies, chicken liver, legumes, fortified rice).

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Low-cost alternatives for low-income families (e.g., anchovies, chicken liver, legumes, fortified rice).

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Nutrient

Low-cost food choice

benefit

iron

anchovies , chicken liver, spinach, legumes

Prevent anemia, support oxygen transport

Folate

Dark leafy greens (kangkung), fortified rice

Prevent neural tube defects, support cell division

Protein

Egg, tofu, tempeh

Support tissue repair and fetal growth

Calcium

Sardine, tofu, fortified milk powder

Strengthens bones and teeth

Vitamin C

Guava, papaya, orange

Enhance iron absorption and boost immunity

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Role of Menu Rahmah or government-subsidised meals in improving nutrition accessibility.

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Role of Menu Rahmah or government-subsidised meals in improving nutrition accessibility.

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The Menu Rahmah initiative, introduced by the Malaysian government, aims to provide affordable balanced meals priced at RM5 or less. This initiative encourages restaurants to offer nutritious options suitable for all income levels, especially targeting the B40 community. (2)

These meals typically include:

A carbohydrate source (rice or noodles)

A protein source (chicken, fish, or tofu)

Vegetables and fruits

This not only helps low-income individuals meet their daily nutrient needs but also raises public awareness about affordable healthy eating habits.

Other relevant government programs include:

PeKa B40: Provides free health screening and nutrition counselling.

Klinik Kesihatan (MOH clinics): Offer free or low-cost prenatal check-ups and supplements (iron and folic acid tablets).

Subsidised Food Programs: Some states provide fortified rice or milk for pregnant and lactating mothers.

References

1.https://pmc.ncbi.nlm.nih.gov/articles/PMC8988411/

2.https://hq.moh.gov.my/nutrition/wp-content/uploads/2024/08/01.Buku-MDGM-web_02.08.2024.pdf

3.https://www.kpdn.gov.my/en/faq/menu-rahmah-programme

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Nutritionist raising awareness of nutrient importance during pregnancy.

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Nutritionist raising awareness of nutrient importance during pregnancy.

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Raise the awareness of nutrition importance during pregnancy

For example, folic acid which is also known as Vit B9, is required for DNA replication. Thus, we need to explain to the public about the function of folic acid which is important for growth and development of the fetus.

Besides the folic acid, iron also plays an important role in the production of hemoglobin, which functions in the delivery of oxygen from the lungs to the tissues of the foetus.

In this case, the reason Puan ST is diagnosed with anaemia might be due to the lack of knowledge of the importance of those nutrients.

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Counselling on family planning to reduce maternal health risks.

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Counselling on family planning to reduce maternal health risks.

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Counselling Diet to Maternal Complication Prevention

Among the macronutrients, protein requires more attention during pregnancy especially when demand progressively increases to support protein synthesis, in order to maintain maternal tissues and fetal growth, especially during the third trimester. An excessively low intake of protein is associated with potentially negative effects in terms of weight and length at birth.

Let’s move on to the micronutrient part where Puan ST appears to be lacking. During pregnancy, iron requirement progressively increases until the third month, in parallel with the accumulation in fetal tissues. Leafy greens such as spinach and brussels sprouts are high iron-containing foods. Puan ST is suggested to add these dishes into her meal. In this case, Puan ST is facing financial issues, and she can't afford healthy food which is highly expensive. As a nutritionist, we are responsible for introducing the program Menu Rahmah to lighten her burden.

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Educating patients about balancing diet within financial constraints.

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Educating patients about balancing diet within financial constraints.

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In addition to fulfilling the responsibilities as a nutritionist to give advice and counselling, we can also teach them about smart shopping strategies.

For example, meal planning and list making methods is one of the effective cost-saving strategies. Puan ST is advice to check for sales and coupons before shopping. Besides that, nutritionists can plan meals for the week based on the essential nutrients that are needed by Puan ST. Thus, she can write out a shopping list and stick to it to avoid impulse buys.

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Financial and emotional support from husband.

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Financial and emotional support from husband.

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• The husband provides both financial and emotional support throughout Puan ST’s pregnancy.
• His encouragement positively influences her compliance with antenatal care and nutritional advice.
• Emotional reassurance from the husband helps reduce maternal stress, promoting better physical and mental wellbeing.
• Strong emotional support from the spouse is associated with improved pregnancy outcomes and maternal confidence.

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How the husband’s job affects income stability.

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How the husband’s job affects income stability.

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• The husband works as a construction labourer, a job that offers irregular and unstable income.
• His earnings depend on daily or contract-based work, leading to fluctuating monthly income.
• This instability affects the family’s ability to purchase nutritious food, pay for transportation to healthcare facilities, and afford follow-up medical tests.
• As a result, financial constraints increase health risks for both mother and baby.
• Encourage the husband to participate in skills training or income-generating programmes (e.g., TVET, community skill workshops) to improve job stability

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Factors like job opportunities, working hours, and construction labour wages influencing family SES.

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Factors like job opportunities, working hours, and construction labour wages influencing family SES.

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. Job Opportunities

Limited low-wage jobs (construction, manual labor)

Job insecurity (seasonal/temporary)

Few opportunities for career advancement

2. Working Hours

Long, irregular hours leave little time for healthcare or family

Physical strain impacts health

Lack of flexibility for medical appointments

3. Construction Labor Wages

Low pay, not enough for basic needs

Income instability due to seasonal work

No benefits (health insurance, paid leave)

4. Impact on SES

Traps family in poverty, limits healthcare & education access

Poor health outcomes due to financial strain

Intergenerational poverty cycle

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- Cost of investigations: As part of the B40 group, her household income is very limited. She perceives the diagnostic tests and possible treatments as expensive and unaffordable. Even if the government provides subsidies, the fear of hidden costs (transport, follow-up visits, or medication) makes her reluctant to proceed.

- Competing needs: Her income is mostly spent on daily essentials such as food, housing, and children’s school expenses. In this situation, healthcare costs are often seen as less urgent compared to immediate survival needs.

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Diagnostic centres may not be near her home, and public transport may be inconvenient or costly. This creates a physical barrier to accessing healthcare.

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Options for cheaper or government-subsidised healthcare.

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Options for cheaper or government-subsidised healthcare.

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Public healthcare facilities (Klinik Kesihatan, government hospitals) provide highly subsidised or free services.

Services include antenatal care, blood tests, iron and folic acid supplements.

Klinik Bergerak (mobile clinics) and community outreach improve access for remote or low-income areas.

NGOs and charitable clinics (e.g., Mercy Malaysia, Tzu Chi Free Clinic) offer free or low-cost treatments and medicines.

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Policies that can lower healthcare costs 

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Policies that can lower healthcare costs 

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PeKa B40: Free health screenings, medical device aid, cancer treatment incentives, and transport allowances for B40 group (age 40+).

MySalam: Free health insurance coverage for critical illnesses and hospitalisation for eligible B40 and M40 groups.

Klinik Kesihatan / Klinik Komuniti: Provide maternal and child health services at minimal or no cost.

Expansion of national health insurance schemes can further reduce out-of-pocket expenses.

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Bridging gaps between government and private facilities.

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Bridging gaps between government and private facilities.

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Encourage public–private partnerships (PPP) for shared use of diagnostic and specialist services at subsidised rates.

Helps reduce overcrowding in public hospitals and improves access for low-income patients.

Use of telemedicine and shared medical records can improve communication between sectors.

Policies to streamline referrals and coordinate resources enhance healthcare equity and efficiency.

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Definition of SES and how it relates to health.

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Definition of SES and how it relates to health.

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SES = composite of income, education, and occupation.

Strongly influences social determinants of health (housing, nutrition, healthcare access, environment).

Lower SES → poorer health outcomes (higher chronic disease burden, reduced healthcare access, lower life expectancy).

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Income ranges for B40, M40, and T20 groups in Malaysia.

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Income ranges for B40, M40, and T20 groups in Malaysia.

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Based on Household Income & Expenditure Survey (HIES 2019) thresholds:

B40: < RM4,850/month

M40: RM4,850 – RM10,959/month

T20: ≥ RM10,960/month

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Regional/state differences affecting income categorisation.

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Regional/state differences affecting income categorisation.

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Income groups are defined nationally, but actual household incomes vary by state.

Median monthly household income (HIES 2022):

Kuala Lumpur: ~RM10,234

Selangor: ~RM9,983

Penang: ~RM6,879

Sabah: ~RM4,713

Kelantan: ~RM4,402

Example: RM6k household → M40 in low-income state but closer to B40 in high-cost urban areas.

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Sub-categorisation within B40 (e.g., B10, B20).

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Sub-categorisation within B40 (e.g., B10, B20).

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B40 often broken into deciles for targeted policy:

B10 = bottom 10%

B20 = bottom 20%

B30 = bottom 30%

2019 decile estimates (example ranges):

B10 < ~RM2,500

B20 < ~RM3,169

B30 < ~RM3,969

HIES 2022 provides percentile distributions → more precise way to analyse income spread within B40.

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Impact of SES on opportunities for education and occupation.

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Impact of SES on opportunities for education and occupation.

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- SES (comprising income, education, occupation) determines what educational opportunities one has: ability to attend good schools, afford tuition, access tutoring, resources (books, internet, etc.).

- Those from low SES may drop out earlier (for economic reasons), may not have the same exposure to mentoring, extra-curriculars, or options to pursue tertiary education.

- Educational attainment in turn affects what kinds of jobs one is eligible for (skill level, qualification requirement). Low-SES people may end up in low-skill / informal / unstable jobs with low wages.

- From the 12th Malaysia Plan and other strategy papers: Malaysia aims to increase the percentage of B40 households with tertiary educational attainment from 9% in 2014 to 20% in 20

20.

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How improving income level (B40 → M40) can improve access to healthcare.

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How improving income level (B40 → M40) can improve access to healthcare.

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A. Government / Policy

- Expand health protection schemes like PeKa B40 (screening, subsidised services, medical equipment)

- MySalam scheme (one-time payouts for critical illness, hospitalisation) to reduce out-of-pocket risk for B40.

- Subsidies to reduce cost of living, cash aids (e.g. Sumbangan Tunai Rahmah) to increase disposable income for B40. These reduce financial barriers to accessing healthcare (costs, transport, time)

B. Education / Human Capital

- Improve access to quality education for low-income households (scholarships, tuition help, mentorship) so that more can attain tertiary or technical/vocational education.

- Expand and improve Technical & Vocational Education and Training (TVET) to match industry demand, enabling quicker entry into decent paying jobs.

C. Expand mobile clinics / outreach services in rural / under-served regions.

- Subsidised or free screening, preventive services for B40 (e.g. through PeKa B40).

- Contracting private clinics to provide basic services for B40/M40 under government schemes (e.g. Skim Perubatan MADANI).

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Should doctors treat patients differently based on income level?

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Should doctors treat patients differently based on income level?

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No, according to the fundamental principles of ethics, doctors should not treat patients differently based on income level.
A. Beneficence: The obligation of a physician to act for the benefit of the patient and promote their welfare. Doctors must recommend treatments that are in the patient’s best interest, without prejudice to their financial background.

B. Nonmaleficence: The obligation of a physician not to harm the patient. The practical application is to weigh the benefits against the burdens of all interventions and treatments, to choose the best course of action for the patient. Financial limitations should not justify substandard care, but rather motivate doctors to identify safe, cost-effective alternatives.

C. Autonomy: This principle upholds informed consent, truth-telling, and confidentiality. Each individual should have the power to make rational decisions and moral choices, and should be allowed for self-determination.

D. Justice: Fair, equitable and appropriate distribution of health-care resources determined by justified norms. Doctors should ensure that limited medical resources are used responsibly, while maintaining fairness among patients from different socioeconomic groups. Equity does not mean identical treatment, but rather the appropriate allocation of care based on clinical need, not income.

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Ethical considerations in prescribing drugs and planning treatment.

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Ethical considerations in prescribing drugs and planning treatment.

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A. Patient-centred care.
Treatment decisions should be tailored to the individual’s medical and personal context. Limited budgets and resource constraints often require physicians to balance fairness and clinical appropriateness. While clinical guidelines are based on population data, physicians must interpret them within each patient’s circumstances. The American Society of Clinical Oncology (ASCO) recommends assessing the Net Health Benefit (NHB) — weighing potential gains in survival and quality of life against financial and physical burdens — to align care with the patient’s evolving values and priorities.

B. Patient rights and preferences.
Respect for autonomy means patients must receive clear information about the benefits, risks, and costs of all available treatment options. This includes government-subsidised and private services, as well as branded and generic medications. By ensuring informed consent, patients can participate actively in decision-making and select care consistent with their beliefs and financial capacity

C. Equity in Prescribing
Prescribing should prioritise efficacy, safety, and affordability. Where possible, generic drugs should be offered to enhance accessibility without compromising quality. Doctors have an ethical responsibility to consider the patient’s financial situation when prescribing, while maintaining the same therapeutic standards and clinical outcomes expected for all patients.

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Comparison of government vs private hospitals: facilities, doctor availability, waiting times.

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Comparison of government vs private hospitals: facilities, doctor availability, waiting times.

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Comparative performance of public and private primary care service delivery in Malaysia. The data used is from the Malaysian International Quality and Costs of Primary Care (QUALICOPC) study conducted in 2015–2016.

We will be comparing in different categories:
Please move to the next page --->

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Life expectancy differences between income levels (T20 vs B40).

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Life expectancy differences between income levels (T20 vs B40).

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- T20 (top 20% of income earners) households are more likely to have longer lifespans than B40 (bottom 40% of income earners)

- better access to resources like nutritious food, quality healthcare, and safer living conditions that are facilitated by higher disposable income and social status.

- economic hardships that can lead to poor health outcomes and shorter life expectancies

Example: states with higher income (higher GDP per capita) have higher life expectancies. For example, Selangor has one of the highest in the country (~78.0 yrs) and poorer states like Terengganu, Kelantan, Perlis are lower (~72-73 yrs).

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Lifestyle influences: exercise, diet, mental health, occupational risks.

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Lifestyle influences: exercise, diet, mental health, occupational risks.

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Exercise:

- lower physical activity levels, mainly due to limited access to recreational spaces, long working hours, and unsafe environments.

- higher income have better access to exercise facilities, such as membership to the gymnasium.

- create opportunities for them to buy their own health equipment, which contributes to more PA.

- may spend more time in their workplace

- not have the time to increase PA

Diet:

- cheaper, energy-dense foods high in refined carbohydrates and saturated fats, and consume fewer fruits and vegetables

- increasing NCD risk

- more dietary diversity and higher intake of nutrient-rich foods, reducing chronic disease prevalence.

- lead to hypertension, obesity, and diabetes

- conditions that lower life expectancy, especially in low-income groups

Mental health:

- The NHMS 2019 reported that 42% of low-income adults experienced symptoms of depression or anxiety, compared with 22% among higher-income adults.

Occupational risks:

- more frequently employed in manual or high-risk sectors (construction, manufacturing, agriculture), exposing them to heat stress, dust, noise, and chemical hazards

- T20 employees are more often in office-based, lower-risk jobs.

- The Department of Occupational Safety and Health (DOSH) Annual Report 2023 reported the highest rate of workplace accidents in manufacturing and construction sectors—industries dominated by lower-income workers.

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Use of supplements vs natural food sources.

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Use of supplements vs natural food sources.

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- Enhancing purchasing power and allows the individual to meet the costs involved with dietary supplement use.

- Higher socioeconomic status might lead to increased use of dietary supplements.

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Raising awareness about healthcare through social and community channels.

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Raising awareness about healthcare through social and community channels.

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1. Social Media Campaigns

- The Ministry of Health (MOH) leverages #SihatMalaysia and #KitaJagaKita social media campaigns

- promote mental health, vaccination, and healthy lifestyle habits, particularly targeting youth and lower-income audiences.

2. Community-Based Initiatives (KOSPEN)

- The Komuniti Sihat Perkasa Negara (KOSPEN) program

- recruits volunteers from local communities

- promote healthy living through blood pressure checks, BMI monitoring, nutrition, education and smoking cessation.

3. Role of NGOs and Peer Outreach

- NGOs such as MERCY Malaysia and Women’s Aid Organisation (WAO)

- provide outreach on nutrition, reproductive health, and psychosocial support, especially for B40 and rural populations.

- bridging information gaps and encouraging preventive health behaviors.

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Both Puan ST and her husband work in jobs that don’t offer flexible hours or paid leave. If they take time off to attend medical appointments, they lose daily wages, which directly impacts their financial stability.

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Pregnant women often need someone to accompany them for reassurance. Since her husband works long hours, she may feel anxious about attending the clinic alone, further discouraging her.

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Many people avoid medical tests because they are afraid of receiving bad news. For Puan ST, being told she has a severe form of anaemia or another illness may cause worry about her health, pregnancy, and ability to care for her children. This fear can make her feel that it is “better not to know.”