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National Policy Dialogue on SRH in Malaysia

August 26, 2015

The Policy Dialogue on Universal Access to Sexual and Reproductive Health Post-2015 Development Agenda was organized by the Federation of Reproductive Health Associations, Malaysia (FRHAM) on 6 June 2015, at Empire Hotel Subang, Selangor. The project was supported by the Asian-Pacific Resource & Research Center for Women (ARROW) and the European Union (EU). A total of 41 representatives from international and regional organisations, government agencies, universities and non-governmental organizations participated in the policy dialogue.

The Policy Dialogue was officially opened by Yang Berbahagia Dato’ Hajah Mariam Mas bt Yacob, the Chairperson of the National Population and Family Development Board (NPFDB), who reviewed some of the global and country achievements of the Millennium Development Goals (MDGs). Despite Malaysia having done well at the national level in achieving the MDG 2015, Yang Berbahagia Dato’ emphasised that there was a need for specific interventions to address and eliminate the inequalities among the most-at-risk populations (MARPs). In order to address these gaps in the Post-2015 Development Agenda, a number of practical next steps would be needed and these include: “ensuring universal health-care coverage, access and affordability”; “ending preventable maternal, new-born and child deaths as well as malnutrition”; “ensuring the availability of essential medicines”; “realizing women’s reproductive health and rights”; and “realizing the vision of a future free of AIDS and tuberculosis”. In view of that, Yang Berbahagia Dato’ urged all the sexual and reproductive health experts, policy-makers, government agencies, civil society organizations, advocates, and other key stakeholders to use the policy dialogue as a platform to discuss and formulate recommendations towards the Post-2015 development agenda. The opening remarks was followed by a launch of the “Malaysian Profile on Universal Access to Sexual and Reproductive Health” by the Chairperson of the NPFDB.

Session 1: Current Situation of SRH in Malaysia

The first session entitled “Current Situation of Sexual and Reproductive Health in Malaysia” chaired by YBhg Dato’ Dr. Kamruzaman Ali, President of FRHAM was designed to review the current success and challenges and formulate recommendations. The session started with Ms Lim Hwei Mian, Head, Programme Services, FRHAM presenting an overview and summary on the “Malaysian Profile on Universal Access to Sexual and Reproductive Health”. Her presentation focused on the current situation of contraceptive usage, maternal health, adolescent and young people’s sexual and reproductive health as well as HIV and AIDS in Malaysia.

With regard to contraception, the decline of total fertility rate, stagnated contraceptive prevalence rate in Malaysia and unmet needs of family planning were highlighted and it was suggested that the stalling of contraceptive usage may be attributed to the following factors:

1) The shift in national programme thrust from family planning to family development
2) Structural barriers such as non-functioning of State Reproductive Health Committees as well as lack of “coordinated planning and evaluation of implementing agencies at the State level to address barriers and improve performance”
3) Social cultural and personal barriers that hinder individuals from using contraception, and
4) Induce abortion

On the other hand, despite Maternal Mortality Ratio’s significant decline since 1991, Malaysia has yet to achieve the MDG 5a target, which is 11 per 100,000 live births. It was pointed out that Malaysian women made up 75% of maternal deaths and the three main direct causes of maternal deaths were haemorrhage, hypertension and obstetric embolism. In Malaysia, while the adolescent birth rates had declined from 28 to 13 per 1,000 women aged 15-19 years old, however, the maternal mortality ratio (MMR), teenage pregnancies and live births among adolescent girls aged 15 – 19 years old had increased significantly and is now a major concern. In recent years, there has been an increased number of girls below 18 years old getting married to adult or older men. This is a worrying trend and may result in increasing teenage pregnancies (wanted or unwanted) and MMR among young girls. Although the sexual and reproductive health information and services for adolescents and young people are available at the healthcare facilities of Ministry of Health (MOH) Malaysia, and MOH also has been taking initiatives in advocating and making the services more accessible, awareness among adolescents of the services and the quality of the services are still lacking. With regards to the HIV and AIDS situation in Malaysia, it was highlighted that the HIV epidemic is a concentrated epidemic, particularly among most at risk populations (MARPs) but the number HIV cases among women are increasing.

In order to strengthen the SRH services in Malaysia, it was proposed for Malaysia to:

1. Strengthen provision of comprehensive SRH information (e.g., promote usage of modern contraceptives, promote broad range of method-mix contraceptives, addressing the side-effects and discontinued usage of contraceptives, and availability of termination of pregnancy services) and services (e.g, counseling for contraception, and HIV and AIDS prevention, treatment, care and support) at the government, non-government and private health facilities to all, especially the marginalised, the poor, the migrant workers and the refugees.
2. Strengthen capacity and skills of health care service providers in terms of their awareness on the laws and policies pertaining to SRH, especially on delivering quality service to all without discrimination and stigma regardless of age, marital status, citizenship, sexual orientation and gender identities.
3. Promote the available SRH services for young people, including contraceptives and termination of pregnancy, at all levels of government health facilities in the urban and rural areas.
4. Ensure confidentiality of all young people who seek sexual and reproductive health services, especially at government health facilities
5. Mainstreaming sexual and reproductive health services, including HIV and AIDS as part of outpatient care.
6. Strengthen management and follow-up of sexually transmitted infections (STIs) to reduce transmission of HIV.
7. Strengthen initiatives on universal access to voluntary HIV counseling and testing, especially for individuals involved in high risk behaviours.
8. Upscale antiretroviral treatment to more PLHIV, especially for the most-at-risk-populations.

The second presenter for the first session, Assoc. Prof. Dr. Mary Huang Soo Lee, Vice President of FRHAM provided an overview on several gaps on SRH in Malaysia, which included the following:

1. Growing number of child marriages and teenage pregnancies and their consequences on adolescent health, education, poverty and domestic violence
2. The lack of attention given to men’s SRH as well as their involvement in SRH
3. Limited HIV and SRH linkages despite the fact that they share the same root causes (such as unsafe sex, gender inequality, poverty, stigma, and sensitivity associated with sexuality), target groups, behaviours, messages and delivery of the services
4. SRH of the ageing population
5. Linking SRH with non-communicable diseases (NCDs)
6. Research gaps such as
a. abortion,
b. the need for contraception and contraceptive use among indigenous populations, young people, refugees, migrant workers, sex workers and PLHIV

Questions and comments for Session 1:

A number of perspectives emerged in the general discussion:

1. Linking SRH with human rights
SRH health framework needs to apply the principles of human rights in order for people to exercise their reproductive rights and access affordable, accessible and quality SRH services.

2. Multi-sectoral approach in addressing the gaps of SRH
The ministries and government agencies (other than MOH, NPFDB and Ministry of Women, Family and Community Development) such as Ministry of Finance, Ministry of Education, Ministry of Information, Communication and Culture, and Ministry of Youth and Sports need to be engaged and involved in the discussion of SRH issues and work together to address the gaps in SRH.

3. Proactive approach in delivering SRH information and services
Stakeholders and relevant agencies need to take a proactive approach to provide SRH information and services to all at every opportunity. It was also suggested that we engage the Ministry of Information, Communication and Culture in giving out information on SRH, especially to the communities in the rural area.

4. Strengthening SRH programmes and services through budget advocacy and allocation
Civil society organizations need to play a more active role in strengthening the effectiveness of resource use through advocacy, participation in national budget allocation process and enabling greater accountability of national programmes to the needs of communities, including universal coverage and equitable access to SRH.

5. Advocate and connect the country actions to international development agendas for SRH
It is important to advocate the SRH needs and issues by using the latest international documents, for example, CEDAW and Beyond 2014 ICPD review.

6. Educational workshop on preventing violence against women for children as an entry point for SRH
It was suggested to use the educational workshops on preventing violence against women for children (initiated by Ministry of Women, Family and Community Development) as entry points to convey messages on gender equity and equality, respect, sexuality and SRH to them.

7. Strengthening SRHR and HIV linkages
The needs of SRHR of most at risk populations such as contraceptive usage and safe abortion services for drug users and sex workers, and hormone usage by the transgender and the risk of breast cancer from excessive usage. HIV prevention programmes should be linked with SRH, especially for most at risk populations. In order to strengthen the linkages between HIV and SRHR, it is important to reduce stigma and discrimination towards people living with HIV and the most at risk populations. In addition, it is also important for the relevant agencies to have clear policy and guidelines on SRH and HIV linkages including guidelines on HIV counselling and testing as a reference for the service providers.

Session 2: Discussion on “Post-2015 Development Agenda: SRH Issues in Malaysia”

The second session was chaired by YBhg Datuk Dr.Raj Karim, Vice-President of FRHAM. YBhg To’ Puan Dr. Safurah binti Jaafar, Director of Family Health Development Division, MOH, presented the MOH’s perspective on the topic. She started with the definition and working framework of SRHR. The following SRH issues were highlighted as the priority areas for MOH:

• Sex disaggregated data
• Equity and access to healthcare services
• MMR and family planning
• Abortion and access to SRH services
• Violence against women
• HIV/AIDS- discrimination
• Mandatory testing for HIV
• Female circumcision
• Differing levels of access to healthcare for vulnerable women
• Non-citizens spouse
• Refugee women
• Indigenous women
• Privatization of healthcare services and health insurance
• Health of the aged

YBhg To’ Puan Dr. Safurah concluded her session by presenting MOH’s commitments on Post-2015 development agenda, which included the following:

• To extend life expectancy for all by achieving universal health coverage.
• No one must be left behind.
• Commit to accelerating the progress made to date in reducing infant, child and maternal mortality by ending all preventable deaths of infants, children and expectant mothers by 2030.
• Ensure universal access to SRH care services, including for FP, information and education.
• Accelerate equally the pace of progress made in fighting malaria, HIV/AIDS, tuberculosis and other communicable diseases and epidemics.
• Devote greater effort to tackling non-communicable diseases.
• To end preventable deaths of newborns and children under 5 years of age, in line with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births by 2030.

The second presentation was presented by Dr. Hamizah Mohd Hassan on the NPFDB’s perspectives. Dr. Hamizah gave an overview on NPFDB’s policies, programmes, research studies and services on SRH including adolescents SRH such as PEKERTI programmes. She also shared the preliminary findings of the 2014 Malaysian Population and Family Survey (MPFS):

• The CPR for any method and modern method in Peninsular Malaysia has increased slightly, from 51.9 in 2004 to 55.4 in 2014 and 34.4 to 35.7, respectively.
• The CPR for Sabah and Sarawak for any method has also increased from 53 in 2004 to 61.4 in 2014, while the CPR for modern method has increased from 42.3 to 45.4.
• The unmet need for contraception has declined slightly, from 24.5% in 2004 to 22.7% in 2014. Factors influencing unmet needs in Malaysia included socio-economic factors, education level (primary education or no education) and age (40 years and above).
• The reasons for not using contraceptive include wanting more children (21.9%), fear of side effects (22.7%), medical and health reasons (4.2%), husband’s objection (2.5%) and others (44.3%).
• Oral contraceptive pills (15.8%) remained as the most popular modern method, followed by female sterilization (7.5%), injection (5.9%), condom (5.4%) and IUD (2.5%).
• Withdrawal (10.3%) was found as the most common traditional method, followed by rhythm (4.8%) and abstinence (1.0%).
• In regards with adolescents SRH awareness, it was found that:
o 44% were aware of family planning methods available
o 3.1% admitted to ever having premarital sex
o 47.5% admitted to masturbating
o 35.8% were exposed to pornography

As for the Post 2015 Development Agenda, NPFDB would focus on the following:

• Increase accessibility of SRH services to the community, especially to the high risk groups.
• Increase collaboration between government sectors, private sectors and NGO in expansion of adolescent psychosexual programs.
• Provision of SRH services for the ageing population.
• Continue to monitor and evaluate the research studies

Dr. John Teo was the last speaker. He shared on “Tales from the Field” from the NGO’s perspectives. He started his presentation by sharing some global and country statistics and cases studies relating to unintended pregnancies. In order to address the issue of unintended pregnancies, he recommended the following:

1. Implement age-appropriate comprehensive SRH education (which includes facts about pregnancy risks, contraceptive knowledge and access) in schools and universities nationwide.
2. Intensify efforts to dispel myths and misinformation about contraception and highlighting the benefits of contraceptive usage with regard to women’s health through media, internet, public health campaigns and forums at schools, universities and workplaces.
3. Inclusion of contraceptive skills and knowledge in existing medical curriculum and continuing professional development (CPD) Programmes for all healthcare professionals, especially those who work in primary healthcare.
4. Strengthen stakeholders’ (MOH, NPFDB and FRHAM) commitment and effort in increasing contraceptive uptake and prevalence as well as reducing the unmet need of contraceptive.
5. Ensure that contraceptives are easily available and accessible (as accessible as the fast food outlets).
6. Expanding the range of contraceptive choices, in particular promoting long acting reversible contraceptives such as Implant and IUCD.

At the end of the session, Dr. Teo urged the audience to rethink the issue of unintended pregnancies in its broader perspective, as an outcome of poverty, gender inequality, discrimination, lack of access to services rather than an individual girl or woman’s problem due to her own behaviour or fault. He concluded his presentation by saying that “We Need to Deliver a Malaysia Where Every Pregnancy is Wanted, Every Childbirth is Safe and Every Malaysian Young Person`s and Woman`s Potential Fulfilled”.

Questions and comments for Session 2:

1. Reframing sexuality education
There is no specific subject called “sex education” in the school curriculum because of the sensitivity attached to the word “sex”. However, sex education has been introduced by the Ministry of Education as Pendidikan Kesihatan, Reproduktif dan Sosial (PKRS or Reproductive, Social and Health Education) since 2011.

It was suggested that sex education should go beyond abstinence and be more comprehensive. It should include life skills to enable adolescents and young people to make informed decisions about their sexuality and health and increase responsible behaviours.

On the other hand, some issues faced by teachers in teaching sexuality education are such as the lack of capacity and skills, feeling uncomfortable and embarrass. Objection from parents should also be addressed. Nonetheless, parents need to be taught that sex education is not about the sex act itself.

2. Working with adolescents to address their SRH needs
It is important for the service providers to work with the adolescents and young people to understand their healthcare and SRH needs through the young people’s perspective.

3. Socio-cultural approach in addressing SRH
The issues on SRH need to be understood from broader perspective such as human rights, poverty, socio-cultural practices and gender relations. It is important to address the SRH issues from the socio-cultural approach and not just the biomedical approach.

4. Health budget for Malaysians
It was noted that the health budget allocation for Malaysians remained at 3-4% of GDP, which was slightly lower than WHO’s recommendation (5% of GDP). As such there is a need to advocate for a higher budget allocation for the health sector.

5. SRH programmes and research studies of NPFDB
The SRH programmes and services of NPFDB for adolescent such Kafe@Teen are publicised through social media such as Kafe@Teen’s Facebook and outreach programmes lead by teen educators. In addition, NPFDB provides SRH information and training for students in the boarding schools, high risk youth, and lecturers from Teachers Training College, teachers, wardens and parents through the PEKERTI programme. Issues such as gender equality, HIV, LGBT have been addressed in the module CAKNA Diri for PEKERTI programme.

NPFDB also explained that their data on premarital sex was collected from their survey which is cross-sectional data collected through qualitative and quantitative methods. The respondents for quantitative study included adolescents or young people who are school drop-outs.

6. Increasing trend of sexual violence and abuse among domestic workers
According to Tenaganita, the increasing incidence of sexual violence and abuse of domestic workers is of concern. There is a need to address their SRHR needs as most of them may not be able to access to SRH information and the public healthcare services.

7. Training on contraceptive skills and knowledge for all healthcare professionals
Currently, Sabah Family Planning Association is collaborating with MOH and Obstetrical and Gynaecological Society of Malaysia (OGSM) to organise one-day basic FP course for healthcare providers. In addition, NPFDB also organised basic FP courses three times a year. However, more publicity is needed as most healthcare providers, especially those from private hospitals may not be aware of the courses.

It was suggested that the training programmes or courses on contraception for medical personnel be accredited for the benefit of participants. Alternatively, medical schools must make sure that contraception and FP be incorporated into existing medical curriculum and continuing professional development (CPD) Programmes for all healthcare professionals in Malaysia be conducted.

In addition, greater emphasis should be given to long-acting reversible contraception methods such as implants and IUCDs to increase the uptake of these methods as it is more effective in preventing unintended pregnancies.

8. Provision of SRH services for vulnerable groups or most at risk populations such as people in the prisons and rehabilitation centres
Ministry of Health would be extending healthcare services for the prisoners by assigning a doctor to be based in each prison.

At the end of the session, YBhg Datuk Dr.Raj Karim summarised the presentations and concluded the discussion by making the following points:

1. From time to time all the stakeholders should gather to discuss and share information, experiences, issues and programmes related to SRH. It was suggested the FRHAM organises a post-dialogue amongst a smaller group as a follow-up to the forum and Post-2015 Development Agenda.
2. More effort is needed to achieve some of the Post-2015 development goals, such as maternal health and MMR. It was proposed that review on the indirect causes of maternal death be carried out in order to have a more targeted approach to reduce MMR.
3. Greater focus, non-bias and non-judgemental approach is needed when providing SRH services to young people who currently make up about 30% of the total population.
4. Linkages between SRH and HIV need to be intensified. SRH needs to be incorporated into the new National Strategic Plan on HIV. Malaysian AIDS Council (MAC) would also introduce SRH programme and services for drug users, sex workers and young people through the needle exchange and sex worker programmes in order to address the rising trend of sexual transmission of HIV.
5. It was also reminded that SRH should be assessed or analysed not only from a biomedical standpoint but also from a broader perspective which include socio-cultural factor, rights and gender. It is important to ensure universal access to SRH care services for all, where quality services must be available, accessible, acceptable, affordable, gender sensitive and free from stigma and discrimination as well as address the needs of the marginalized populations.