• This represent the lowest 40% income earners in Malaysia. This household earn up to around RM5,249 per month as of 2022 data. The B40 also is further divided into smaller bracket, with median incomes ranging roughly from RM1,929 to RM 4,387.

• This low-income families that qualifies for various government assitance program.

M40

• The middle-income group covers the next 40% of households, with monthly incomes between approximately RM5,250 and RM11, 819. Median incomes in this group range from about RM5,336 to RM9,695 depending on the subcategory.

• The M40 group is considered the middle class and is a key focus for policies aimed at economic growth and stability.

T20

• The top 20% of households that earn above RM11,819 monthly. This group includes the highest income earners in Malaysia, with median incomes around RM15, 867 and mean incomes even higher. The T20 group is often the target for wealth tax discussions and luxury tax policies.

Puan ST reluctant to receive her test may be due to these SES factors like no high income, insufficient for the clinical test, and her husband and she didn't realized the severity of her disease.

How it Affects Symptoms

🥗 Poor nutrition

May lead to fatigue, poor growth, and chronic diseases (e.g., diabetes, heart disease)

🧠 Stress

Chronic stress from financial instability may cause headaches, insomnia, anxiety, depression

🏠 Living conditions

Overcrowded or unsanitary housing can increase exposure to infections or pollutants

📚 Health literacy

Lack of health knowledge may delay recognition of symptoms or lead to misuse of medication

SES Level

High SES

Easier access to private hospitals, specialists, faster treatment, and preventive care

Middle SES

Moderate access—may rely on public clinics but can afford some private services

Low SES

Often face barriers such as:

🚫 Long wait times at public facilities

💸 Can't afford private care or transport

🏥 Live far from clinics/hospitals

📖 Limited health knowledge—may not seek care early

• Low SES

  • Higher rates of depression, anxiety, PTSD, and chronic stress

  • Limited access to therapy or psychiatric medication

  • More stigma around seeking mental health help
    

• High SES:

  • More access to preventive care and support

  • Stress still present (work pressure), but more resources to cope
    

2. Physical Health Symptoms

• Low SES:

  • Higher risk of chronic diseases like obesity, diabetes, hypertension

  • Limited access to nutritious food, clean environments, and healthcare

  • More likely to experience fatigue, pain, infections.
    

• High SES:

  • Healthier lifestyle due to resources, time, education

  • Less exposure to environmental hazards
    
    

3. Developmental and Cognitive Symptoms (especially in children)

• Low SES in childhood can cause:

- Delays in language, memory, and emotional regulation

- May increased behavioral issues

• High SES children:

More access to books, stimulating environments, and quality education

• Better Access to Healthcare Services

  • Individuals in higher SES brackets can afford private health insurance, out-of-pocket treatments, and preventive care.

  • This results in timely interventions, fewer complications, and better long-term health outcomes.

• Shorter Waiting Times

  • Private hospitals, which are more accessible to the wealthy, often offer appointment-based consultations, efficient service, and minimal delays.

  • Unlike government hospitals, where one might wait hours or even days for tests and treatment, private care is faster and more responsive.

• Advanced Medical Technology and Facilities

  • Higher SES groups benefit from facilities that have modern diagnostic tools, cutting-edge surgical equipment, and specialized professionals.

  • This improves both accuracy of diagnosis and success rate of treatments.

• Limited Financial Access

  • Many low-income individuals cannot afford private care and rely solely on government hospitals.

  • Even basic services can be delayed due to underfunded facilities and outdated equipment.

• Overcrowding in Public Hospitals

  • Government hospitals are often overwhelmed by the sheer number of patients.

  • Limited staff and resources lead to longer waiting times, increasing the risk of disease progression before treatment begins.

• Outdated Equipment and Infrastructure

  • Public hospitals in many areas continue to use old diagnostic machines, non-functional tools, or lack certain essential services.

  • This results in delayed test results, ineffective treatment, and poor patient experience.

• Time Constraints and Opportunity Costs

  • Many low-income workers cannot afford to take time off to wait in long lines at government hospitals.

  • The loss of daily wages or caregiving responsibilities forces them to either skip treatment or seek expensive private alternatives, often at great financial strain.

• Even with better facilities and medical technologies, there is a limit to how many patients can be admitted.

• Patients in the A&E department may wait for a long time to be admitted or even get to see a doctor

• This is also applicable to ICU units, especially during a pandemic

• Most hospitals are located in city centres, so those living in rural areas or other parts of the country may have difficulty visiting

• Even if they manage to travel to the hospital, there are extra expenses that can be a burden to the less fortunate

• May also face transportation challenges; minimal public buses/vans to travel to the city, leading to longer travel times without a car

• New ETAP rates under WBB:

  • Weekends/public holidays: RM275 (MO) and RM315 (specialists) per active call shift.

  • Non-WBB active calls: RM220 (MO) / RM250 (specialists).

  • Weekday on-call: RM200 / RM230 respectively.

• Weekend/public holiday WBB shifts are split into two groups:

  • Group 1: 7am–10pm (active call).

  • Group 2: 6pm–9am (active call eligible if over 15 hours).

• If the following day is a weekday, Group 2 does passive call (8pm–12am) and then works 12am–9am without extra pay.

• Replacements for emergency leave follow current system allowances.

• 33-hour shifts can qualify for active ETAP, but only passive ETAP if ending at 9am.

• In summary, doctors still working after 5pm are not compensated. This may lead to overworked staff and demoralisation of future doctors.

• May also lead to burnout and turnover due to the low pay

• Patients will also suffer, leading to a decrease in satisfaction levels, as understaffed hospitals may have an indefinite delay in surgeries and diffulty in receiving emergency care.

Expand free healthcare services in public hospitals and Klinik Kesihatan.

Ensure low / zero charges for outpatient treatment, maternity care, surgeries, and medications.

2. Deploying mobile clinics to rural and underserved areas to reach B40 communities.

Provide vaccinations, screenings, and basic checkups directly in their neighborhoods.

3. Expand insurance coverage under schemes like mySalam which offers financial support for critical illnesses and hospitalisation.

4. Improve Public Healthcare Facilities

Shorten waiting times since not everyone can spend their time in clinics waiting and increase staff in government hospitals and clinics where B40 families go for treatment.

5. Provide essential medications at minimal or no cost, especially for chronic conditions.

6. Provide free nutrition programs for B40 children and pregnant mothers by offering subsidies or food baskets to prevent malnutrition and anemia.

• Primary cause suggested by the scenario.

• Anaemia reduces the oxygen-carrying capacity of blood due to low haemoglobin.

• In pregnancy, the blood volume increases (hemodilution), which can worsen or unmask underlying anaemia.

• Common symptoms: fatigue, breathlessness on exertion, palpitations, pale skin.
  

2. Nutritional Deficiency

• Likely due to low income and inability to afford iron-rich or nutrient-dense foods.

• Deficiencies in iron, folate, vitamin B12, and protein can contribute to anaemia and fatigue.

• Her status as part of the B40 group makes this a significant risk factor.
  
  

• Even in healthy pregnancies, fatigue and breathlessness can occur

• Increased cardiac output

• Enlarged uterus pressing on the diaphragm

• Increased oxygen demand

• These changes are exacerbated by anaemia or poor nutrition.

  
  

4. Underlying Medical Conditions (Needs to be ruled out)

Although not stated, differential diagnoses could include:

• Cardiac issues (e.g., peripartum cardiomyopathy)

• Respiratory issues (e.g., asthma, infections)

• Thyroid dysfunction

• Chronic stress, poverty, and physical labor (as a cleaner) can contribute to fatigue, poor sleep, and low energy.

• Her reluctance to follow up may be linked to health literacy, financial concerns, or emotional burden.

• Iron & folate supplementation: Start oral supplements immediately, even without waiting for full anaemia profiling (especially in resource-limited settings).

• Dietary counselling within her means:

• Focus on affordable iron-rich foods like: Sardines, anchovies, liver, green leafy vegetables (e.g., bayam, sawi)....Legumes (e.g., lentils, dhal)....Fortified cereals, eggs….Pair iron-rich foods with Vitamin C sources (e.g., guava, oranges) to enhance absorption.

Diagnostic Follow-up:

• Subsidised testing via government clinics or NGOs.

Consider home visits or mobile clinics if access is a barrier.

Counselling for both Puan ST and her husband:

• Educate on the importance of anaemia treatment for both maternal and fetal outcomes.

• Emphasize free or subsidized options (if available) and long-term benefits.
  
  

  • Peer support groups:

• Link her to other pregnant women or community groups where experiences and low-cost tips can be shared.

  • Social work referral:

• Assess for possible inclusion in welfare aid, zakat, or food voucher programs (if in Malaysia or similar settings).

• Improve accessibility:

• Bring services closer to B40 communities (e.g., Klinik Desa, mobile clinics).

• Integrate anaemia screening into routine antenatal care, with same-day testing and treatment.
  

• Targeted health promotion:

  Create culturally appropriate, language-accessible materials about pregnancy nutrition and anaemia.

• Partnerships with NGOs:

  NGOs and community groups can help supply free food baskets, nutritional supplements, or transport vouchers.

• Task shifting:

  Empower nurses, midwives, and community health volunteers to follow up and provide basic education and supplements.