Navigating health inequities and human rights violations: a narrative review on refugees and asylum seekers in Malaysia

Introduction

Asylum-seekers and refugees (ASRs) are individuals who have fled their home countries due to persecution, conflict, or severe human rights violations. While asylum-seekers are awaiting a decision on their application for protection, refugees are legally recognized under international law, such as the 1951 Refugee Convention. The 1951 Convention Relating to the Status of Refugees and its 1967 Protocol are key international legal instruments that aim to provide protection and define the rights of refugees. The 1951 Convention states that “refugees should have the basic rights including the right not to be expelled, except under certain conditions, to work, education, housing, public relief and assistance, access the courts, and the right to freedom of movement within the host country” (1,2). Despite hosting approximately 191,830 ASRs (3), Malaysia is not a state party to the Convention or its 1967 Protocol (4). Consequently, there are no legislative or administrative structures to formally recognise and protect the needs of ASRs in the country (5).

In Malaysia, while ASRs registered with the United Nations High Commissioner for Refugees (UNHCR) are allowed to remain in the country, they are not protected under any national legislation (6), resulting in restricted access to employment, formal education, and free healthcare (7). Unlike in some host countries where ASRs reside in designated refugee camps, those in Malaysia live in urban settings (8), exposing them to various social and health risks. Given their limited resources, many ASRs often live in subpar living conditions including overcrowding (9), inadequate sanitation (7,9,10), and food insecurity (11), all of which contribute to poor health outcomes. Healthcare access is particularly challenging, with 26.7% of ASRs with chronic conditions reportedly unable to seek treatment (12). Access to antenatal care has also been documented as a significant challenge (12). Barriers to healthcare include limited health literacy, lack of awareness of healthcare rights, language and cultural differences, absence of legal status, and financial constraints (13).

A study by Chuah et al. [2018] documented the high medical costs, legal uncertainties, and social stigma as key healthcare challenges that ASRs faced (13). Research also identified significant health concerns including chronic diseases and mental health issues, which are exacerbated by limited access to healthcare services (9). Comparative analyses have also explored how different Southeast Asian countries such as Indonesia, Malaysia, Myanmar, and Thailand, address health system challenges related to forced migration, providing a regional perspective on policy responses (14). However, there is a notable gap in the literature concerning the ethical implications of these healthcare barriers within Malaysia’s specific context. While previous research has primarily focused on identifying and describing the obstacles to healthcare access, there is a lack of in-depth analysis on how these barriers contravene ethical principles and human rights standards (15). Existing studies often do not provide concrete policy recommendations tailored to the Malaysian healthcare system that address these ethical concerns.

Furthermore, much of the literature examining Malaysia’s ASRs healthcare challenges was published at least four to six years ago, before significant global events such as the coronavirus disease 2019 (COVID-19) pandemic, which further exposed and exacerbated inequalities in healthcare access for marginalized populations. This paper provides a more contemporary analysis by incorporating recent developments, including policy changes, pandemic related impacts, and ongoing humanitarian efforts, offering updated perspective on evolving healthcare of ASRs in Malaysia. This article aims to fill this gap by critically examining the ethical dimensions of healthcare access for ASRs in Malaysia through a pseudo case study of a Rohingya refugee. While this case is not based on a specific individual, it reflects commonly reported challenges faced by the Rohingya community in accessing healthcare due to legal, financial and social barriers. By examining the intersection of health inequities and human rights violations, this paper critically evaluates how legal, economic, and social barriers hinder equitable access to healthcare for this vulnerable population and assess Malaysia’s healthcare policies, in relation to international human rights standards. We present this article in accordance with the Narrative Review reporting checklist (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-108/rc).

Methods

Study design

This study is a narrative review, which synthesizes existing literature to examine health inequities and human rights challenges faced by ASRs in Malaysia, particularly regarding healthcare access barriers. A narrative review approach was chosen instead of a systematic review due to its flexibility in integrating diverse sources of evidence, including policy documents, legal frameworks, and comparative country analyses (16). Narrative reviews are particularly useful in health policy research, as they allow for the interpretation of complex social, legal, and ethical issues beyond what a purely empirical systematic review can capture. This study also includes a pseudo case study to illustrate key systemic challenges faced by ASRs, offering a conceptual lens for discussing Malaysia’s refugee healthcare policies in relation to international human rights standards.

Literature selection and sources

A structured literature search was conducted in September 2024 using PubMed, Scopus, Google Scholar, and official reports from organizations such as UNHCR, World Health Organization (WHO), and IOM. Keywords used for the search included: “asylum seekers”, “refugee” “healthcare access”, “Malaysia”; “refugee health barriers”, “migrant health policies”, “health inequities”, “human rights”. The detailed research strategy is outlined in Table 1.

Selection criteria included peer-reviewed articles, policy documents, and reports from 2010 to 2024 that focus on healthcare access challenges among ASRs. This includes studies that discuss the legal and policy frameworks affecting ASRs’ health rights and compare healthcare provisions for ASRs in other countries. Whereas studies that are not specific to refugees, or focused solely on general migrant workers and those pre-2010 were excluded to ensure the analysis was relevant and current.

Development of the pseudo case study

To contextualize the findings, a pseudo case study was constructed, based on commonly reported healthcare barriers experienced by Rohingya refugees in Malaysia. The case study was not derived from interviews or primary data collection, but instead synthesized from news reports from UNHCR, Médecins Sans Frontières (MSF), and peer-reviewed literature detailing ASRs’ real-life struggles in accessing healthcare (17). The case scenario of Abdullah, a 36-year-old Rohingya refugee, illustrates key systemic barriers, including financial constraints due to high foreigner healthcare fees, fear of arrest and deportation leading to delayed treatment, and limited access to public healthcare despite UNHCR agreements. This approach allows for an ethical analysis of Malaysia’s ASRs healthcare policies in relation to international human rights standards.

Comparative framework

To situate Malaysia’s challenges within a broader global perspective, the study also compares Malaysia’s ASRs healthcare policies with those of Thailand, Germany, Indonesia, and Canada. Key factors analyzed includes the legal recognition of ASRs and healthcare entitlements, financial barriers (e.g., subsidy availability, insurance schemes), and social determinants of health, such as employment restrictions and xenophobia. This comparative element strengthens the analysis by identifying alternative policy approaches that could be adapted to the Malaysian context.

Overview of the case

In 2020, Abdullah, a 36-year-old Rohingya refugee in Kuala Lumpur, lost his job due to the COVID-19 lockdown. When he developed COVID-19 symptoms, he avoided seeking medical help, fearing arrest due to his refugee status. When his condition worsened, he went to a public hospital, but despite the Memorandum of Agreement between UNHCR and Ministry of Health Malaysia, he was charged full foreigner fees, which his family couldn’t afford. Delayed treatment and financial hardship led to severe health complications and extended hospitalization.

Here are the key ethical questions that arise:

• Is it fair that Abdullah be charged the full foreigner fee against the UNHCR agreement?
• Is it fair that Abdullah be denied healthcare treatment due to arrest given his refugee status?

Case details

In 2020, during the COVID-19 pandemic, a 36-year-old Rohingya man, Abdullah (pseudonym), was living in the outskirts of Kuala Lumpur with his wife and two children. As a refugee, he is not allowed to work by law, however, to make ends meet, he had been working as a labourer. But when the Movement Control Order was imposed to contain the pandemic, he lost his job and his family’s situation became dire. When he began experiencing symptoms of COVID-19, including a high fever and severe coughing, Abdullah avoided seeking medical help due to fear of arrest. Like many refugees, Abdullah was wary of public hospitals, where his refugee status which is often associated with undocumented migrants may lead to detention by immigration authorities.

As his condition worsened, Abdullah sought help from a local clinic run by MSF, one of the few healthcare providers offering assistance to refugees and asylum seekers. The clinic prescribed basic medication, but his condition deteriorated further. Eventually, Abdullah was forced to visit a public hospital. However, despite UNHCR agreements allowing refugees a discounted rate, the hospital charged the full foreigner fee, which his family could not afford. The delay in seeking treatment and financial barriers ultimately contributed to the worsening of his health, resulting in extended hospitalization and severe complications.

Results and discussion

The findings reveal that ASRs in Malaysia face systemic barriers to healthcare, primarily driven by financial constraints, legal uncertainties, and social stigma. The pseudo case study further illustrates how these obstacles contribute to delayed treatment, worsening health outcomes, and ethical concerns in healthcare provision.

Legal and ethical analysis

The case above highlights the challenges ASRs encounter in accessing healthcare, stemming from the effects of restrictive legal, health, and social protection policies on their well-being. The United Nations fundamental principle is to promote and protect human rights. While Malaysia is a member of the United Nations, it did not ratify the 1951 Convention and its 1967 Protocol. This affects the development of legal and administrative frameworks for the protection of ASRs due to political and legal challenges. Hence, refugees in Malaysia face human rights and health rights violations as they have no right to work, attend formal school or access affordable medical care. While registration with UNHCR provides an official refugee status, and refugees do receive some measure of protection and support such as access to healthcare, and education, however, UNHCR support alone is not adequate. The lack of legal protection has a cascading effect including impacting refugees to seek any jobs that they can find and usually these are 4D jobs ‘difficult, dangerous, dirty, demeaning’ that locals do not want. These kinds of jobs predispose them to social stigma, and health risks. Refugees are stigmatised, often being equivalent to undocumented migrants. All the above has implications that when refugees seek healthcare services; they may be denied service due to the misconception of their illegal status, and the high healthcare cost for foreigners.

Malaysia has an extremely affordable public healthcare system whereby a general outpatient consultation costs as little as RM 1 (USD 0.30) while specialist-level medical care costs RM 5 (USD 1.50), however, this is only for Malaysian citizens. For ASRs, through the Memorandum of Agreement between UNHCR and Ministry of Health Malaysia, they are accorded a 50% discount rate of foreigners’ fee at public healthcare facilities (8). However, affordability remains an issue (18). In 2011, a mandatory healthcare financing system for foreign workers known as the Hospitalisation and Surgical Scheme for Foreign Workers was launched. This insurance scheme provides an annual healthcare coverage of RM 20,000, with an annual premium of RM 120. However, due to the amendment made to the 1951 Medical Fees Act whereby the medical fee for foreigners was increased to a 100% (19), the scheme is unlikely to provide adequate financial risk protection, and again, healthcare access remains a barrier for ASRs. Efforts had been made by UNHCR to reduce healthcare access barriers for secondary and tertiary medical care by collaborating with a private insurance company to introduce a health insurance programme namely the Refugee Medical Insurance (20). However, there was a low uptake among ASRs and the programme was later discontinued. The reason for the inability to afford healthcare is attributed to the difficulty in seeking employment for independent financial sustenance. Hence, ASRs usually engage in informal employment (21) with low wages or have no fixed income (22).

The COVID-19 pandemic exacerbated the human rights violation faced by ASRs in Malaysia. A study conducted by the International Organisation of Migration on the implications of COVID-19 on health and protection risks among 420 Rohingya refugees and other migrant communities in Malaysia found that 67% of the respondents had either lost their jobs or had their spouses/family members experiencing such job loss due to the pandemic (23). The frequent crackdowns and mass arrests of migrants during the movement control order led employers to terminate their positions out of fear of fines from authorities for employing migrants or refugees. The lack of awareness of the clear legal status for ASRs further compounds the healthcare access issue. Currently, there is a lack of distinction between ASRs and undocumented workers, and most of the time they are all deemed as ‘illegal immigrants’ (24). Hence, ASRs often fear being arrested, or sent for detention, or deportation (25). This is a barrier for them to seek healthcare especially when undocumented migrants who are present in healthcare facilities will need to be notified to the immigration authorities based on the Ministry of Health’s (MOH) Circular 10/2001 (26). This issue was also exemplified during the national vaccine roll-out scheme in the COVID-19 pandemic where some ASRs avoided getting vaccinated due to fears of immigration arrests and anti-foreigner sentiment (15).

During the COVID-19 pandemic, ASRs were also faced with xenophobia and discrimination because they are often blamed for the spread of the virus. Barriers in language and culture, and their inability to pay for treatment further challenge their healthcare access. Some were discriminated against when getting treated at health facilities such as having their names called last when receiving treatment. These experiences caused ASRs to access healthcare only when it is absolutely necessary (27). Human rights activist have called for the withdrawal of the 2001 MOH circular, which was felt to encourage xenophobic attitudes among civil servants (28).

The case of Abdullah highlighted several ethical concerns, particularly the principles of autonomy, non-maleficence, and justice (29), in the context of refugee healthcare access in Malaysia. Autonomy refers to an individual’s right to make decisions regarding their own life and well-being. In Abdullah’s case, his autonomy in choosing healthcare treatment was severely limited due to his limited financial capability. Given that he has lost his job, and with a family to support, seeking healthcare treatment was not a priority. The fear of arrest also restricted him from seeking help at public healthcare even in the time of emergencies.

The principle of non-maleficence, which calls for avoiding harm, was also challenged in Abdullah’s scenario. The existence of the employment law which prohibits ASRs to work legally forced Abdullah into a labouring job that usually provides meagre salary, and coupled with the full foreigner fee increase in the Medical Fees Act place financial strain, further limiting his access to care. Furthermore, when Abdullah delayed seeking treatment due to fear of being arrested, this also conflicted with the ethical principle of nonmaleficence among healthcare providers.

Finally, justice in healthcare implies equitable access to resources and fair treatment regardless of one’s background, but this was challenged in the context of ASRs access to healthcare in Malaysia. Due to the lack of recognition of the status of ASRs, there is an inequitable access to resources and fair treatment; Malaysian citizens benefit from highly affordable healthcare, while refugees face higher costs, even with the UNHCR discount, making it difficult for ASR such as Abdullah to access treatment.

Human rights violations

In Malaysia, the lack of formal legal protections for ASRs including Rohingya creates significant barriers to accessing essential services, such as healthcare. Malaysia is not a signatory to the 1951 Convention Relating to the Status of Refugees or its 1967 Protocol, which are key international legal instruments protecting refugees. These instruments require host countries to afford refugees certain fundamental rights, such as the right to work, access to education, healthcare, and freedom from arbitrary detention. Malaysia’s non-ratification leaves ASRs (including registered refugees like Abdullah) without the legal framework to ensure these rights (30).

The right to health is one of the most pressing human rights issues for ASRs in Malaysia. This right is recognized under the Universal Declaration of Human Rights, specifically in Article 25, which affirms the right to an adequate standard of living, including medical care. Additionally, Article 12 of the International Covenant on Economic, Social and Cultural Rights underscores the right to the highest attainable standard of physical and mental health. Abdullah’s case highlights how financial and legal barriers obstruct access to healthcare. Despite agreements between UNHCR and Malaysia’s Ministry of Health that entitle refugees to a 50% reduction in healthcare costs, many refugees still cannot afford these fees, and some, like Abdullah, are charged full foreigner rates, which are prohibitively high. This situation illustrates a clear breach of both the right to health and the right to life, as outlined in Article 6 of the International Covenant on Civil and Political Rights (ICCPR), to which Malaysia is a party (13,31).

Further violations arise in the treatment of ASRs in Malaysia, where arbitrary detention remains a common threat, violating the ICCPR’s Article 9, which protects individuals from arbitrary detention. During the COVID-19 pandemic, Malaysia conducted large-scale raids and detentions targeting migrants, many of whom were refugees, under the pretext of pandemic containment. Such practices subject refugees to indefinite detention, often in overcrowded, inhumane conditions, without legal recourse. The International Convention on the Elimination of All Forms of Racial Discrimination mandates equal access to healthcare and services regardless of race or nationality, yet systemic exclusion in Malaysia means that refugees, especially the Rohingya, face discrimination and stigmatization in both public perception and policy (31,32). Table 2 below summarizes key international instruments and their relevance to refugee healthcare, illustrating the global standards applicable to Malaysia’s treatment of ASRs.

Impact on public health

The denial of healthcare to ASRs in Malaysia poses broader public health risks. The exclusion of these populations from comprehensive healthcare access creates a public health vulnerability, as individuals who are excluded from preventive care and treatment for communicable diseases increase the likelihood of disease outbreaks. This situation became particularly concerning during the COVID-19 pandemic when undocumented and marginalized groups, including the Rohingya, were left out of early healthcare efforts. Living in overcrowded and unsanitary conditions, these communities had limited access to testing and treatment, contributing to the virus’ spread within both the refugee community and the general population. This situation underscores the interconnection between individual and public health and illustrates how exclusionary practices can undermine community health resilience (30,40).

Mental health is another critical aspect affected by restrictive policies. Many ASRs arrive in Malaysia fleeing persecution and conflict, carrying deep trauma. However, due to the financial and legal obstacles they face, mental health services remain inaccessible, leaving conditions such as depression, anxiety, and post-traumatic stress disorder unaddressed. In Abdullah’s case, the fear of arrest and inability to access healthcare in a timely manner likely intensified his and his family’s stress, highlighting the ripple effects of limited healthcare access on mental well-being. Without mental health support, these issues often lead to deteriorating social cohesion and individual suffering, as individuals struggle to cope with the trauma and insecurity of displacement without appropriate resources (41).

The treatment of ASRs also has societal implications beyond immediate health outcomes. Excluding these groups from basic services fosters xenophobia and social resentment, which can disrupt social cohesion. For example, during the pandemic, xenophobic sentiments against the Rohingya intensified, with some public figures openly blaming refugees for Malaysia’s economic and social challenges. This social hostility not only affects refugees’ sense of safety and belonging but also perpetuates a cycle of exclusion and vulnerability, making it even more challenging to integrate public health measures effectively across the population. Addressing these issues calls for policies that recognize the interdependent nature of health and human rights, ensuring that all individuals, including ASRs, can access healthcare without fear or discrimination (30,32). The case of Abdullah and similar instances emphasize the urgent need for Malaysia to re-evaluate its policies toward ASRs. Ensuring healthcare access for all, regardless of status, aligns with international human rights obligations and strengthens Malaysia’s public health infrastructure.

ASRs challenges and barriers in healthcare access in Malaysia and other countries

Many challenges to healthcare access among ASRs are common across both developing and developed countries, including Malaysia, Germany, Canada, New Zealand, Sweden, the Netherlands. These challenges include delays in accessing healthcare, language and cultural barriers, mental health concerns, and fear of deportations or arrest. However, the severity of these issues is more pronounced in developing countries such as Malaysia, Indonesia, and Thailand, where there is no legal framework for ASRs (14).

In Southeast Asia, access to healthcare for refugees largely depends on each country’s legal framework and available resources (14). The Philippines, as a signatory to international refugee conventions, offers relatively better healthcare access, whereas non-signatories like Malaysia, Thailand, and Indonesia rely heavily on UNHCR and non-governmental organisations’ support, with limited access to comprehensive care (14). While policies vary across the region, common barriers such as legal restrictions, high healthcare costs, and inadequate mental health services—negatively impact refugees’ health outcomes and quality of life.

Bureaucratic delays in asylum application also limit early access to healthcare. In some developed countries such as Germany and Sweden, asylum seekers can receive basic and emergency healthcare while their applications are being processed (42,43). However, in many other countries, including Malaysia, ASRs are only entitled to public healthcare after being granted refugee status. Healthcare financing for ASRs differ significantly between developed and developing nations. In countries such as Germany, Canada, and Sweden, ASRs’ healthcare cost are covered in government funding. In contrast, developing countries such as Malaysia and Indonesia provide no healthcare subsidy for ASRs, leaving them to rely on out-of-pocket payments or external aids. The lack of financial support exacerbates health disparities and limits access to essential services.

Language barriers present a significant challenge for ASRs in seeking quality healthcare. Limited proficiency in the host country’s language can hinder communication with health care providers, making it difficult to schedule appointments, describing medical symptoms or history, understand medical instructions, and translate for others. For example, Syrian refugees in Germany, have reported difficulties navigating the healthcare systems due to language constraints (44). The lack of culturally appropriate healthcare, including gender-sensitive healthcare providers, and interpreters, remains a significant barrier in both Malaysia and other countries (45).

As alluded above, many ASRs fled their home countries due to persecution, conflict, or severe human rights violations, leaving them at high risk for post-traumatic stress disorder, anxiety, or depression. In the Netherlands, ASRs have access to state funded healthcare, including mental health services (46). Similarly, Germany and Sweden have specialised refugee mental health programmes (43). However, in Malaysia, Indonesia, and Thailand, mental health services for ASRs are extremely limited, with non-governmental organizations filling critical gap in care. The absence of structured mental health support further exacerbates the psychological distress faced by ASRs.

In countries that are signatory to the 1950 Refugee Convention, ASRs are granted a certain right and protected from deportation even while waiting an official refugee status determination. However, those whose applications are rejected often live in fear of deportation. In Malaysia, undocumented ASRs are particularly vulnerable, as they risk being reported to immigration authorities when seeking medical care. This fear deters many from accessing necessary healthcare services, worsening their healthcare conditions and increasing public health risks.

Policy recommendations and solutions

At the policy level, the ratification of the 1951 Refugee Convention and its 1967 Protocol would create a foundation for inclusive laws and policies recognizing the rights of ASRs. This would enable them to seek formal employment with better job securities, access education, and make independent healthcare decisions—thereby addressing key ethical concerns related to autonomy, and justice. However, given Malaysia’s current stance on immigration and its economic constraints, full ratification may not be politically viable in the near future. A more practical step could involve targeted policy reforms, such as granting ASRs temporary legal status for employment in sectors facing labour shortages, thereby allowing them to contribute to the economy while securing their own healthcare needs.

The 2001 Ministry of Health Circular (MOH Circular 10/2001) should be amended to ensure that ASRs can access healthcare without fear of being arrested or deported. This reform would uphold the ethical principle of non-maleficence by removing a policy that inadvertently harms refugees’ health. However, a common counter argument is the financial burden on Malaysia’s public healthcare system. To address this, the government could explore tiered healthcare subsidies, where ASRs with verifiable income contribute to their healthcare costs, while most vulnerable continues to receive support from humanitarian organizations and subsidies from international agencies.

A key challenge expanding ASRs’ access to healthcare is financing. Currently, Malaysia offers subsidized treatment rate at 50% for ASRs but this remains unaffordable for many. A potential solution is the introduction of scaled healthcare assistance based on income levels, where ASRs with work permits contribute a portion of their healthcare costs, thereby reducing dependency on state funding. In addition, local public-private partnership could also be established with corporate sponsors, humanitarian organizations, and international agencies to fund health initiatives targeted at ASRs. Local health authorities could collaborate with non-governmental organisations to set up mobile health clinics in areas with high refugee populations, ensuring access to healthcare without requiring them to enter public hospitals, where stigma may deter them from seeking treatment. Community-based healthcare models have been successfully implemented in Thailand and Indonesia, where international partnership supplement local healthcare services.

A crucial step in reduce dependence on government aid is by allowing ASRs to work legally. However, the lack of distinction between ASRs and undocumented workers poses a challenge, as refugees are sometimes misclassified as ‘illegal immigrants, hindering their ability to seek healthcare and employment. Recognizing this issue, the Malaysian government has been exploring policies to grant work permits for ASRs in 3D jobs (dangerous, dirty, difficult labour sectors) (47). However, limiting ASRs to only these jobs risks reinforcing economic marginalization. A more effective approach would be expanding work eligibility to other sectors facing labour shortages—such as agriculture, constructions, and caregiving which could help ASRs become self-sufficient while contributing to Malaysia’s economy. Countries like Canada and Germany have implemented structured work programs for ASRs, integrating them into labour market while ensuring compliance with national laws. Malaysia could adopt a similar framework tailored to its economic needs. There are also efforts to establish a national refugee data collection system to supplement the existing UNCHR registry, ensuring better oversight and legal status verification for ASRs. A centralized refugee would allow authorities to differentiate ASRs from undocumented migrants, improving identification processes and reducing administrative challenges. One potential solution is the introduction of biometric identification cards or digital verification systems for registered ASRs, which have been successfully used in Turkey and Germany to ensure legal protection and access to services without misclassification.

Discriminatory attitudes towards ASRs often stem from concerns that they compete with locals for jobs, resources, and social services. Addressing this issue requires more than just training healthcare providers; broader public awareness campaigns are essential for shifting societal perceptions. While training can help reduce bias among healthcare professionals, meaningful change occurs when the public understands ASRs inclusion in the workforce and healthcare system benefit society rather than burdens it. Raising public health awareness about ASRs related issues, with an emphasis on humanitarian and ethical aspects of refugee care, can foster a more supportive social environment and help reduce stigma and xenophobia.

The issue of ASRs’ rights and immigration policies has always been contentious in Malaysia. Authorities often cite high unemployed rates among locals and concerns over taxpayer-funded healthcare for non-citizens as reasons for limiting social, employment and healthcare rights for ASRs and undocumented migrants. However, excluding ASRs from healthcare access does not eliminate healthcare costs—it only delays treatment, leading to high healthcare expenditures for emergency care and greater public health risks. The COVID-19 pandemic is a good example that illustrated the necessity of inclusive public health policies, as excluding vulnerable populations from healthcare access worsens disease control efforts. Malaysia’s temporary policy of free COVID-19 testing and treatment for ASRs demonstrated how public health must transcend legal status to ensure national well-being. If full healthcare entitlement could not be provided, then ASRs should at least be granted legal employment so they can generate income to meet their own healthcare needs (41).

While this study provides an in-depth ethical and policy analysis of healthcare challenges faced by ASRs in Malaysia, it has certain limitations. Although, the pseudo case study of Abdullah is based on commonly reported challenges, it is a constructed scenario rather than empirical data derived from direct interviews. As such, while the case study reflects commonly reported challenges, it may not capture the full diversity of ASR experiences in Malaysia. To strengthen the findings, future research should incorporate primary data collection, including interviews with multiple ASRs, healthcare providers, and policymakers to validate and expand on the issues identified.

This study primarily focuses on Malaysia’s healthcare policies, which may limit broader comparative insights into refugee healthcare across different socio-political contexts. A regional comparative study involving multiple ASRs communities across Southeast Asia could provide a more comprehensive understanding of systemic healthcare challenges and best practices. Expanding the dataset to include quantitative health outcomes, financial burden assessments, and policy effectiveness analyses would further enhance the evidence base for healthcare reform. Despite these limitations, this study contributes a timely ethical and policy perspective, offering a foundation for future empirical research and advocating for evidence-based policy changes to improve ASR healthcare access in Malaysia.

Conclusions

The case study of Abdullah and many like him highlight the critical intersection of health inequities and human rights challenges faced by ASRs in Malaysia and other countries worldwide. Without legal protection under international conventions, ASRs remain highly vulnerable to systemic barriers, financial strain, and social stigma, which limit their access to essential healthcare services. This limited access not only infringes upon their fundamental rights, such as the right to health, but also poses broader public health risks, affecting societal cohesion and overall community well-being.

Malaysia’s current policies reveal the need to align domestic healthcare frameworks with international human rights standards. While ratifying the 1951 Refugee Convention and its 1967 Protocol would provide a strong foundation for reform, immediate and pragmatic policy measures can also be taken. Key steps include:

• Establishing a national refugee data collection system to ensure clear differentiation between ASRs and undocumented migrants, allowing better oversight and reducing administrative barriers to healthcare access.
• Expanding legal work opportunities beyond 3D jobs (dangerous, dirty, and difficult labour sectors) to enable ASRs to become financially self-sufficient and contribute to their healthcare costs, reducing dependence on government aid.
• Introducing tiered healthcare subsidies that allow ASRs with verifiable income to contribute to their healthcare expenses while ensuring the most vulnerable continue to receive necessary support.
• Strengthening public-private partnerships by collaborating with corporate sponsors, non-governmental organizations, and international agencies to fund healthcare initiatives targeted at ASRs.
• Launching nationwide public awareness campaigns to address misconceptions and xenophobia by emphasizing ASRs’ contributions to society and the benefits of inclusive healthcare policies.

Implementing these reforms require balancing national interests with humanitarian responsibilities. Potential challenges such as public resistance, financial constraints, and political opposition, can be addressed through incremental policy-changes, multi-sectoral collaboration, and data-driven advocacy. Lesson from countries like Germany, Canada, and Thailand—which have successfully integrated ASRs into their labour markets and healthcare systems—can inform Malaysia’s approach.

Ultimately, addressing the health and human rights needs of ASRs is not only a matter of ethical and legal responsibility but also a strategic public health measure that benefits the nation as a whole. Implementing inclusive healthcare policies for ASRs will lead to a healthier, more resilient society, while reinforcing Malaysia’s commitment to universal human rights and sustainable public health planning.

Discussion questions

• How do Malaysia’s current healthcare policies for asylum seekers and refugees compare to those in other Southeast Asian countries, and what lessons can be drawn to improve accessibility and affordability?
• What are the ethical implications of denying or restricting healthcare access to asylum seekers and refugees in Malaysia, particularly in relation to the principles of justice, non-maleficence, and autonomy?
• Considering the financial, legal, and social barriers faced by asylum seekers and refugees, what are the most feasible policy reforms that Malaysia could implement to address these challenges while balancing national interests?

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mellissa Withers) for the series “Case Studies in Global Health Leadership and Management” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-108/rc

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-108/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-108/coif). The series “Case Studies in Global Health Leadership and Management” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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