The East-West Healthcare Divide: Comparing Sabah, Sarawak and Peninsular Malaysia

In 1963, Sabah and Sarawak signed the Malaysian Agreement 1963 (MA63), which designated public health, sanitation and disease prevention as federal responsibilities. Inadvertently limited their administrative and legal autonomy over healthcare. Over six decades later, East Malaysia (Sabah, Sarawak and FT Labuan) continues to lag behind Peninsular Malaysia in healthcare accessibility, measured in terms of geographical availability, affordability and service quality. For instance, doctor-to-patient ratios in Sabah and Sarawak trail behind the national average of 1:406, at 1:775 and 1:682 respectively. Beyond interstate disparities, East Malaysia also reports extreme intraregional disparities. Urban capitals like Kota Kinabalu reflect healthy doctor-to-patient ratios of 1:268, while rural districts can exceed 1:1,000 or 1:2,000. Consequently, compared to Peninsular Malaysia, Sabah and Sarawak face higher infant, toddler and maternal mortality, alongside significant difficulty overcoming communicable and chronic non-communicable diseases. This article explores the reasons behind and solutions for the disparity.

Geography and rural access

Sabah and Sarawak are characterised for having challenging geography and size. Combined, they are about 1.5 times larger than Peninsular Malaysia. As a result, patients from East Malaysia travel an average round-trip distance of 261.5 km to reach specialized care, compared to 91.8 km in Peninsular Malaysia. In rural areas, diverse landscapes, such as swamplands around the coast, riverine plains and extensive mountain ranges and dense rainforest, further isolate Indigenous populations. Exclusion is exacerbated by poor road conditions and connectivity. For example, in Nabawan, whose roads are destroyed by frequent flooding, emergency aid must be delivered by helicopter. In other cases, the lack of, or unaffordability of, basic transport infrastructure, like road or rail, can be substituted by riverine methods, using livestock, or walking. However, the higher time and physical effort required makes patients less willing to make the trip (known as the distance decay effect). In Sarawak, which is almost 70% larger than Sabah, travelling to major specialist hospitals like in Miri from some regions may require passing through Brunei, excluding non-passport holders.

Medical staff also find it more difficult to provide adequate, consistent support, particularly in transporting and maintaining equipment. Subsequently, interventions such as Klinik Bergerak (moving clinics) who do screenings and checkups tend to be one-off. To combat this problem, state governments have introduced services like Flying Doctor Service (FDS), but it is limited to emergency cases.

As a whole, these conditions contribute to persistent clusters of structural disadvantage. In particular, mothers are less likely to seek necessary healthcare which reinforces gender inequalities.

Infrastructure and Technology

In Sabah, health facilities are concentrated along the west coast and major towns. Micro-level geospatial access embers of healthcare accessibility tiers in Sabah reveals substantial disparities between districts. Semporna (the most populated) is severely overloaded, while interior regions like Nabawan (which recorded a near-zero score on the Accessibility Deficit Index) faces significant accessibility gaps. 

Beyond geographical availability, infrastructure quality leaves much to be desired. Existing facilities struggle to accommodate large numbers of patients, offer limited appointment slots, and face prolonged referral procedures. Specialist services, expertise, essential medicines and up-to-date capabilities such as X-ray, laboratory and diagnostic equipment are concentrated in urban centres and major hospitals. As a result, in Sarawak, about 66% to 70% of Klinik Kesihatan are classified as daif (dilapidated). State leaders note that Sarawak needs RM310 million just to upgrade crumbling clinics and up to RM8.45 billion (with total infrastructure needs estimated near RM17 billion) for full redevelopment. Recently, federal delays have forced Sarawak to partially self-finance projects like cancer centers.

Limitations in ambulance and emergency transport led to the creation of the Flying Doctor Service. Originally designed as a stopgap measure, it has become a permanent necessity, reflecting the lack of resilience of rural populations in terms of healthcare. (At time of writing, it has been temporarily suspended pending safety reviews following the fatal Long Lellang helicopter crash.) 

In recent years, telemedicine and telehealth has been considered as a measure to address inequity. However, rural and sparsely populated regions still suffer from poor mobile network coverage and slow or non-existent internet connections, as the installation of cellular towers, fibre optic cables, and internet broadband facilities are costly and challenging. Digital literacy among rural populations is also significantly lower than in urban populations. Meanwhile, familiarity among healthcare providers is low, with medicolegal concerns cited as a major concern of healthcare providers. Hence, successful implementation will require continuous education, clear regulation and sustained technological support.

Healthcare workforce

Despite initiatives to increase capacity of healthcare infrastructure, the shortage and uneven distribution of healthcare workers remains one of the greatest factors constraining accessibility. Attracting healthcare workers to the interior of Sabah and Sarawak presents unique challenges. Historically, barely half of medical officer (MO) postings have reported for duty, mainly because of relocation costs and logistical difficulties. Previously, state governments have attempted to mitigate this by introducing relocation support and monthly incentives, but this is unlikely to be a sustainable solution.

Sabah and Sarawak face a critical retention issue, specifically for specialists, as most doctors leave after completing training. Even if specialists remain, most are concentrated in urban areas. In contrast, up to 45.6% of rural Klinik Kesihatan in Sarawak operate without a resident doctor, and are run exclusively by medical assistants and nurses. Patients from remote districts are therefore referred to major cities for complex procedures like oncology, cardiology, complex surgery and specialist diagnostics, which requires long-distance travel.

Financial and social burden

Out-of-Pocket (OOP) expenditures are direct payments made for medical services without reimbursement from insurance or government programs. These include travel, accommodation and food costs, childcare arrangements, copayments, coinsurance or services not subsidised by insurance. Transport costs are amplified amongst those requiring regular follow-ups, such as cancer patients, those with mental health disorders or those requiring dialysis. Additionally, patients and relatives lose wages taking time away from work. Thus, rural patients are disproportionately more likely to default on follow-up, leading to care being emergency-centred rather than holistic.

In Sabah, where 20% of the population lives below the poverty line, OOP expenses represent an outsized proportion of household income. Studies identify East Malaysian families as more likely to experience Catastrophic Health Expenditure (CHE), when a household spends more than 40% of its non-substinence income on healthcare. Households in Sarawak are especially vulnerable, with 15.6% experiencing CHE, and nearly 37.4% exceeding the 10% total household consumption threshold. They also have higher rates of Impoverishing Health Expenditure (IHE), which pushes households below the poverty line.

Importantly, although healthcare is subsidised for Malaysian citizens, Sabah and Sarawak have a significant undocumented and stateless population. These communities typically exhibit low immunization rates, poor education on reproductive health, low digital access and less nutritious food consumption, as well as barriers to legal status and limited insurance protection.

Solutions

Firstly, in response to significant vacancies in the healthcare workforce, Sarawak has called for the decentralization of regulatory powers under the Private Healthcare Facilities and Services Act 1998 to the state Health Department. Sarawak representatives have also proposed designing a specific state-level workforce pipeline specifically, where Sarawakian MOs will be trained in and posted to Sarawak. Throughout East Malaysia, federal training scholarships and cash incentives for state-based doctors have been introduced to facilitate specialist training and attract specialists. Overall, greater administrative control over financing, facility development and staff deployment back to state governments will enable them to better address local terrain and demographic needs.

Secondly, reducing patient financial burden is essential. In an effort to curb OOP expenses, under PeKa B40, patients undergoing specialized medical equipment or cancer treatments in Sabah, Sarawak and Labuan receive up to RM1000 to cover transit to major hospitals, twice the amount allocated for Peninsular Malaysia. The federal government has also pledged drone and other telecommunications technology to facilitate telemedicine and e-health interventions. Accelerating the implementation of digital health records could further improve continuity of care, especially for patients who must travel between rural clinics and urban hospitals.

To reduce hospital congestion, state governments are pushing forward with infrastructure upgrades and specialist service expansion. For instance, planned developments include upgrades to Hospital Queen Elizabeth II (Kota Kinabalu), Hospital Duchess Kent (Sandakan), as well as the construction of a new Sabah Blood Centre, Sabah Dental Specialist Centre (Kota Kinabalu) and an Institut Jantung Negara (IJN) hospital.

Conclusion

Sabah and Sarawak’s vastly different socioeconomic, geographical and structural realities mean that their healthcare needs cannot be treated through a uniform approach with Malaysia’s other eleven states. In addition, dermographic challenges, specifically the high undocumented population, must be taken into account. 

Ultimately, addressing the Sabah-Sarawak healthcare divide requires a combination of greater healthcare autonomy, stronger infrastructure, a sustained healthcare workforce and improved financial protection for patients. As a starting point, state governments should be granted greater autonomy so that they can tailor solutions to local needs. If Malaysia is to fully realize the MA63 promise, healthcare equity in East Malaysia should be treated not as a peripheral issue, but as an essential component to national development.