KUALA LUMPUR, Oct 10 – While investments in family planning have the potential to generate substantial returns towards the country’s health, economic and social development, Malaysia allocates only a small portion (6.1 per cent) of its total health expenditure to family planning services and commodities, according to the UNFPA report Enhancing Human Capital Through Sexual and Reproductive Health Investment and Family Support Policies in Malaysia.
The country’s contraceptive prevalence rate, which is only measured through married women, was 52.2 per cent in 2014 among those aged 15 to 49, while the prevalence rate for modern methods was 34.3 per cent.
In comparison, the global prevalence rate was 62.6 per for any contraceptive method and 56.2 per cent for modern contraception during the same time.
Relying on data from the Fifth Malaysian Population and Family Survey from the same year, the UNFPA found that 12.5 per cent of surveyed married women aged 15 to 49 had an unmet need for contraception, while 27.0 per cent had an unmet need for modern contraception.
As a result, at least one in eight married women of reproductive age would like to stop or delay childbearing but are not using any method of contraception.
Furthermore, unmet need tends to correspond with socioeconomic status, notes the UNFPA report, which states that women with at least a post-secondary education are considerably least likely to report an unmet need compared to women with lower education (8.9 per cent versus 13.6 per cent).
While the UNFPA report acknowledges the strength of Malaysia’s national family planning programme, it also recommends that specific policies with quantitative, rights-based and service quality targets be implemented, while also addressing cultural factors that lead to low contraceptive uptake.
ROI For Family Planning In Malaysia
To realise the benefits of family planning globally, the UN’s Sustainable Development Goals set a target to increase “contraceptive demand satisfied by modern methods” to at least 75 per cent in all countries by 2030.
Given the fact that the modern contraceptive prevalence rate (mCPR) in Malaysia is significantly lower than the Organisation for Economic Co-operation and Development (OECD) average (Malaysia 34.3 per cent vs OECD 64.7 per cent), strategic improvements in family planning investments in Malaysia present a low-cost way to sustainably boost domestic human capital in the coming years, according to the UNFPA report.
The report provides an approximate estimate of the return of investment (ROI) for fully meeting women’s contraceptive needs in Malaysia in 2021 by comparing the commodity (contraceptives) and service delivery costs with the potential returns in terms of increased female labour force participation.
This method yields a conservative estimate of the potential ROI for family planning because it doesn’t take into account other positive impacts including enhancing educational outcomes, labour productivity and savings, and preventing negative health outcomes such as maternal and newborn deaths and STIs.
Three Scenarios For Meeting Women’s Contraceptive Needs
To estimate the potential benefits of fully meeting women’s contraceptive needs in Malaysia, the UNFPA compares three scenarios:
The UNFPA estimates that in 2021, the “all-needs-met” scenario can prevent 30 maternal deaths and increase the labour force by 0.27 per cent, which translates into economic benefits equal to 0.11 per cent of GDP.
The figures were derived by combining unit commodity pricing (UNFPA’s price list of contraceptives) and projected contraceptive consumption patterns from satisfying all women’s needs for contraception. The commodity costs for each method was calculated and multiplied by a factor of five to account for service delivery costs.
The additional estimated cost is equal to $195.6 million (including service delivery estimates), or 0.05 per cent of current GDP. A conservative estimate of the return for investment in family planning yields a return of investment (ROI) of 2:1 (0.11 per cent divided by 0.05 per cent) – i.e. each RM invested in family planning yields at least RM2.
If more generous family support policies were in place, the UNFPA estimates the “all-needs-met” scenario can increase the labour force by 0.4 per cent, which translates into economic benefits equal to 0.16 per cent of GDP.
An integrated portfolio of strategies including family planning investments and enhanced family support policies yield an ROI of 3.27:1 — i.e.each RM invested in such an integrated strategy yields at least RM3.
In the “current case” scenario, unintended pregnancies are due to either contraceptive method failure or unmet demand for family planning. In the “all-needs-met” scenario, unintended pregnancies are due only to method failure.
Supplementary Table 10 (above) summarises the demand for family planning satisfied with modern and traditional methods and the unmet demand in the two scenarios.
For unintended pregnancies due to method failure, the UNDP relied on a 2018 report on contraceptive use in the US by the Guttmacher Institute to determine the effectiveness rate of each contraceptive method.
Supplementary Table 11 (above) shows the effectiveness rates of each method and the percentage of users of each method out of all modern method users as documented in the Fifth Malaysian Population and Family Report.
For instance, while 13 per cent of the women relying on male condom become pregnant (male condom is effective in 87 per cent of the cases), only 0.8 per cent of the women using an intrauterine device (IUD) become pregnant (IUD is effective in 99.2 per cent of the cases).
As a result, the average effectiveness rate of the modern mix in Malaysia is 94.4 per cent (6.6 per cent of women using modern contraceptives get pregnant).
According to the Guttmacher report, withdrawal fails 20 per cent of the cases, while fertility awareness methods such as periodic abstinence, body temperature methods, and cervical mucus methods fail in 24 per cent of the cases.
As such, the effectiveness rate of traditional methods is assumed to be 0.78.
Given the modern and traditional prevalence contraceptive rates, the average effectiveness rate of the Malaysian method mix is around 90 per cent in the “current case” scenario, and increases to 94.4 per cent in the “all-needs-met scenario”, according to the UNFPA report.
The pregnancy rate for women with an unmet need for contraception is assumed to be 31 per cent. As such, the UNFPA estimates that if all need for contraception is satisfied, about 320,000 unintended pregnancies will be averted.
In developed regions, 59 per cent of unintended pregnancies on average end in induced abortion, compared to 55 per cent in developing regions. Given a stillbirth rate of 5.4 per 1,000 live births in 2019, an intervention aimed at satisfying all demand for family planning prevents about 190,000 abortions, 700 stillbirths and 128,000 live births.
If the Malaysian maternal mortality rate is 24 deaths per 100,000 live births, the policy would also prevent 30 maternal deaths.
Time Cost Of Child Care
On a global average, a child costs about 1.9 years of work, according to the UNFPA report. However, the length of time out of the workforce due to maternity depends on the type of job. In particular, if women are employed in the informal sector, the time cost is expected to be considerably lower.
In 2017, 9.4 per cent of employed women were working in the informal sector, which constitutes a non-negligible share. As an ad hoc assumption, the UNFPA assumes that for women working in the informal sector the time cost is about six months per child.
Given the number of unintended births averted and the size of the informal sector, 121,900 working-age women are positively affected by the policy in a year. Not all of them would participate in the labour force if they prevented the unintended birth.
If women leave the labour force forever after the first child (which seems to be suggested by the low proportion of older women in the labour force), the time cost per child depends on the level of parity.
In particular, the positive impacts of delaying the first child would be extremely high, while the benefits of limiting or spacing higher-order births would be negligible, unless adequate family support policies are implemented. Based on Department of Statistics Malaysia (DOSM) 2017 data, 34.3 per cent of births are first-order births.
As a conservative estimate, the UNFPA assumes that only these women would enter the labour force if the family planning policy that eliminates all unmet needs is implemented.
This corresponds to an additional 41,800 women participating in the labour force, which corresponds to a 0.27 per cent increase in labour force compared to the “current case” scenario (with 15.6 million people the in labour force).
In 2017 (the most recent estimate), the labour share of income was equal to 41.8 per cent. In other words, a 1 per cent increase in the labour force induces a 0.418 per cent increase in income (or GDP).
By meeting all needs for modern contraception, the UNDP estimates a 0.11 per cent increase in GDP. The benefits from investing in an “all-needs-met” scenario outweigh the costs (equal to 0.05 per cent of GDP), yielding a ROI of 2.2:1.
Family Support Policies In Malaysia
Two significant support policies of any human capital development policy are paid maternity leave and high-quality child care.
The UNFPA report cites the main challenges Malaysian families face as outlined by the National Population and Family Development Board (LPPKN), including the economic demands of bearing and rearing children, as well as the lack of social support for high-quality child care.
The Malaysian government has addressed these demands by formalising a maternity leave policy which guarantees women a minimum of 90 days of maternity leave in both the private and public sectors.
Additionally, key initiatives under Budget 2020 aim to increase female labour force participation through establishment of child care centres in the public sector (initiated since 2019), and the introduction of tax and work incentives for women returning to work, especially for the bottom 40 per cent (B40) household income group population.
Family Support Policies In High Income Countries
The UNFPA highlights some examples of family support policies and financing programmes in high-income countries that can be adapted to the Malaysian context in its report.
As of January 2020, 33 out of 36 Organisation for Economic Co-operation and Development (OECD) countries offered paid maternity leave for an average of 16 weeks with a wage replacement rate between 55 and 100 per cent.
In most OECD countries, these maternity leave programmes are financed through contributions from the government, employers, employees, taxes and health insurance, notes the report, which adds that no OECD country finances maternity benefits solely through employer contributions.
Various studies indicate that the short and long-term benefits of paid maternity leave are particularly amplified for disadvantaged groups, suggesting that successful family support policies will continue to target the B40 population.
In Norway, paid maternity leave conferred significant benefits on maternal health and behavioural outcomes as well as on education and wage outcomes for children, especially among low-income families.
Paid maternity leave reduced the incidence of preterm birth and low birthweight, particularly for unmarried and Black mothers in the US.
While the beneficial impacts of maternity leave have been more systematically examined in high-income countries, recent studies suggest that paid maternity leave policies are viable, cost-effective investments for lower-middle-income countries, especially in the context of socioeconomic wellbeing and sustainable development.
Low Uptake Of Parental Leave By Men In OECD Countries
According to the UNFPA report, evidence suggests that child education outcomes and female labour outcomes also benefit from close involvement of fathers. Fathers who take parental leave are more likely to bond with their children and share child care responsibilities with their partners.
However, while fathers are eligible to take paid parental leave in the majority of OECD countries, uptake by men tends to be low, often due to fear of career implications.
To encourage men to make use of parental leave, some countries offer bonus time for fathers, reserve portions of parental leave solely for fathers, or ensure that parental leave arrangements are flexible for both parents (e.g. shift sharing for parents who cannot stop work completely).
Increased uptake of parental leave by fathers could help dilute the negative impacts of maternity leave that have been observed in some contexts (e.g. hesitation to hire women of reproductive age, gender wage gaps and occupational segregation).
To facilitate continued long-term benefits beyond the period of maternity/parental leave, accessible, affordable and high-quality child care options and flexible work arrangements must be made widely available for more Malaysian families, the report recommends
As of 2017, the majority of child care providers in Malaysia were private, but public support for child care was provided for only up to 41,000 children from low-income households.
The UNFPA report cites a more recent qualitative study of low-income urban residents in Malaysia, which showed that mothers who wished to join the labour force were unable to do so due to the lack of dependable, affordable child care options.
Scandinavia The Gold Standard For Family Support Policies
Child care in Scandinavia is seen as both a parental responsibility and social right, with access to state-sponsored child care largely meeting demand. As a result, this region has often been looked to as the gold standard for family support policies.
Norwegian parents receive a child benefit allowance each month, which covers at least 50 per cent of childcare services for up to 10 hours per day. In Denmark, parents are only responsible for up to 30 per cent of total child care costs.
The UNFPA report notes that the Ministry of Women, Family and Community Development of Malaysia has made various initiatives related to child care centres such as child care fee subsidies for parents by income status, incentives for carers’ training (Kursus Asuhan PERMATA), grants for the establishment of childcare centres in the public sector and tax exemption to child care operators.
Similar programmes can be adapted and implemented elsewhere in Malaysia, in both the public and private sectors, the report recommends, adding that work incentives and child care subsidies might eventually also be extended to workers in the informal sector.
ROI For Family Support Policies In Malaysia
If appropriate family support policies were in place, more women can be expected to participate in the labour force by preventing unintended births through family planning interventions. In particular, there might also be substantial improvements in labour force participation among older women who already have children and are at their second or higher birth order.
Family planning interventions coupled with generous family support policies are effective ways to improve women’s work/family balance and can contribute to preventing the steep decline in labour force participation among adult women that is typical of the Malaysian labour market, according to the UNFPA report.
Based on the Fifth Malaysian Population and Family Survey, half of the women with children who are currently not working report a desire to work (see Supplementary Table 3 above).
As such, it can be expected that at least 50 per cent of working-age women with an averted unintended pregnancy would participate in the labour force if improved family support policies were in place, inducing a 0.4 per cent increase in the labour force compared to the “current case” scenario and a 0.16 per cent increase in GDP.
The benefits from investing in an “all-needs-met” scenario and from improved family support policies yield an ROI of 3.27:1.