Original Research
Health Systems & Patient Satisfaction
Satisfaction on Primary Health Care Services in Sarawak, Malaysia: Evidence from a Cross-Sectional Community Based Study
Key Findings
- A total of 1,236 respondents across three zones of Sarawak were surveyed, providing state-wide representation of community satisfaction with primary health care services.
- Ethnicity was a significant predictor of satisfaction: Bidayuh respondents were 17.4% less likely to be highly satisfied with antenatal care compared to other ethnic groups.
- Education level was inversely associated with satisfaction — respondents with primary and secondary education were less likely to be highly satisfied compared to those with tertiary education or no formal education.
- Respondents who incurred no out-of-pocket expenses were 1.935 times more likely to report high satisfaction with primary health care services.
Background and Context
Primary health care (PHC) services form the foundation of Malaysia’s healthcare delivery system, providing the first point of contact for the majority of the population seeking medical attention. In Sarawak — the largest state in Malaysia by land area, located on the island of Borneo — the delivery of PHC services faces unique challenges shaped by the state’s vast geographic expanse, diverse ethnic composition, and a population that includes substantial rural and remote communities.
Sarawak is home to more than 40 ethnic groups, including the Iban, Bidayuh, Melanau, Orang Ulu, Malay, and Chinese communities. This extraordinary cultural diversity, while enriching, introduces complexity into healthcare delivery. Different communities may have varying expectations of healthcare services, diverse health-seeking behaviours, and different levels of comfort with modern medical institutions. Understanding satisfaction levels across these diverse populations is essential for tailoring services to meet community needs effectively.
Patient satisfaction is recognised internationally as an important indicator of healthcare quality. Satisfied patients are more likely to comply with treatment recommendations, maintain continuity of care, and experience better health outcomes. Conversely, dissatisfaction can lead to delayed care-seeking, non-adherence to treatment, and poor health outcomes. In the context of maternal and child health services — which were a specific focus of this study — satisfaction with antenatal care influences attendance rates, which in turn affects maternal and neonatal outcomes.
Study Design and Methodology
The researchers conducted a cross-sectional community-based study across three zones of Sarawak, ensuring geographic representation of the state’s diverse communities. Women aged 18 years and above who had children aged 3 years and below were eligible for inclusion, irrespective of ethnic group. This criterion ensured that respondents had recent experience with maternal and child health services, enabling informed assessment of service quality.
Data was collected through face-to-face interviews using a validated Patient Satisfaction Questionnaire (PSQ-18), a standardised instrument widely used in healthcare satisfaction research. The questionnaire was adapted for the local context and administered by trained interviewers. A total of 1,236 completed responses were analysed using IBM SPSS version 22.0, with multinomial logistic regression employed to identify predictors of satisfaction levels.
The state-wide implementation of the study, with respondents drawn primarily from suburban and rural village communities, is a notable strength. Previous healthcare satisfaction studies in Malaysia have tended to focus on urban settings or single facilities, limiting their applicability to the broader population. This study’s community-based approach provides a more representative picture of satisfaction levels among the populations who most depend on public primary healthcare services.
Satisfaction Levels and Predictors
Overall, the study found that women were satisfied with the primary health care services provided through maternal and child health clinics in Sarawak. However, the multinomial logistic regression analysis revealed important disparities across population subgroups.
Ethnicity emerged as a significant predictor of satisfaction. Bidayuh respondents were 17.4% less likely to report high satisfaction with antenatal care compared to other groups. The Bidayuh are the second largest indigenous group in Sarawak, traditionally inhabiting highland areas in the western part of the state. The reasons for their lower satisfaction warrant further investigation but may relate to cultural expectations of healthcare interactions, language barriers in clinical settings, geographic barriers to accessing services, or perceptions that services are not sufficiently culturally responsive.
| Predictor | Finding | Statistical Significance |
|---|---|---|
| Bidayuh ethnicity | 17.4% less likely to be highly satisfied | p<0.05 |
| Secondary education level | 29.9% less likely to be highly satisfied | p<0.05 |
| Primary education level | 1.6% less likely to be highly satisfied | p<0.05 |
| No out-of-pocket expenses | 1.935 times more likely to be highly satisfied | p<0.05 |
Education level showed a complex relationship with satisfaction. Respondents with secondary and primary education were less likely to be highly satisfied compared to reference groups. This pattern may reflect a dynamic where some education raises expectations and awareness of service quality standards without necessarily improving the healthcare experience itself. The most highly educated may have access to private healthcare alternatives, while the least educated may have fewer comparative benchmarks against which to evaluate public services.
Perhaps the most policy-relevant finding was the strong association between out-of-pocket expenses and satisfaction. Respondents who did not incur any personal financial costs were nearly twice as likely to report high satisfaction. This finding underscores the importance of financial accessibility in healthcare. Even in a system where public healthcare is heavily subsidised, hidden costs — including transportation to facilities, medications not covered by public formularies, or indirect costs such as lost wages — can significantly impact satisfaction and, by extension, healthcare utilisation.
The Sarawak Healthcare Landscape
Understanding these findings requires appreciation of Sarawak’s healthcare infrastructure. The state’s primary healthcare network includes health clinics (klinik kesihatan), community clinics (klinik desa), and mobile health teams that serve remote communities. The Flying Doctor Service and riverine mobile teams provide healthcare access to communities that cannot be reached by road, while Village Health Volunteers have served as community health intermediaries since the 1960s.
Despite these extensive efforts, geographic barriers remain significant. Many rural and remote communities in Sarawak require hours of travel — by longboat, four-wheel drive vehicle, or small aircraft — to reach the nearest health facility. For pregnant women requiring regular antenatal check-ups, these distances represent a substantial barrier to consistent attendance. The satisfaction data from this study should be interpreted in light of these access challenges, recognising that respondents who participated in the study had successfully accessed services, while those most disadvantaged by geography may not have been captured.
Ethnic Diversity and Healthcare Delivery
The finding that ethnic variation significantly predicted satisfaction levels carries important implications for healthcare delivery in Sarawak’s multicultural context. Two-thirds of the study respondents were from the indigenous Dayak races of Sarawak, providing a perspective that is underrepresented in health research conducted in Peninsular Malaysia where Malay, Chinese, and Indian populations predominate.
The researchers recommended that health education and public health programme interventions should adopt community-oriented and culturally suited language-specific approaches rather than a one-size-fits-all model. This recommendation reflects a growing recognition in global health that effective healthcare must be culturally responsive — acknowledging and respecting the health beliefs, communication styles, and social structures of the communities it serves.
In practical terms, this might involve recruiting healthcare workers from local communities, providing health education materials in indigenous languages, incorporating cultural practices into the healthcare environment where clinically appropriate, and engaging community leaders as partners in health promotion activities.
Financial Accessibility and Universal Health Coverage
The strong relationship between out-of-pocket expenses and satisfaction connects this study to broader national and global conversations about universal health coverage (UHC). Malaysia has made significant progress toward UHC through its dual public-private healthcare system, where public facilities provide heavily subsidised care. However, the findings suggest that even within this system, financial barriers persist and affect user satisfaction.
Strategies to enhance financial protection might include subsidising transportation costs for rural communities accessing healthcare, expanding the range of medications and services available without charge at primary care level, and developing community-based health financing mechanisms. Each of these approaches could help ensure that the financial dimension of access does not undermine the quality of the healthcare experience.
Public Health Implications
This state-wide study provides evidence that while overall satisfaction with primary healthcare services in Sarawak is positive, significant disparities exist across ethnic groups, education levels, and financial burden categories. These findings support the adoption of culturally tailored, language-specific health interventions rather than uniform approaches. The strong association between financial accessibility and satisfaction reinforces the importance of minimising out-of-pocket costs in public healthcare delivery. Policymakers should consider these findings when designing maternal health programmes for Sarawak’s ethnically diverse population, with particular attention to communities showing lower satisfaction levels.
Study Limitations
The study focused on women with children aged 3 years and below, meaning the satisfaction data primarily reflects experiences with maternal and child health services rather than the full spectrum of primary healthcare. The cross-sectional design limits causal inference. While the study achieved good state-wide representation, the most geographically isolated communities may still be underrepresented. The PSQ-18, while validated, was originally developed in a Western context and may not fully capture cultural dimensions of satisfaction relevant to Sarawak’s indigenous communities. The study relied on recall of healthcare experiences, which may be subject to bias. Future research should incorporate qualitative methods to explore the cultural factors underlying ethnic differences in satisfaction.
How to Cite This Article
Rahman MM, Ngadan DP, Arif MT. Satisfaction on primary health care services in Sarawak, Malaysia: evidence from a cross-sectional community based study. Malaysian Journal of Public Health Medicine. 2016;16(3).
This article is published under the Creative Commons Attribution-NonCommercial 4.0 (CC BY-NC 4.0) licence. Content may be shared and adapted for non-commercial purposes with proper attribution to the Malaysian Journal of Public Health Medicine.