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Analysis of dental services distribution in Malaysia: a geographic information

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 International Dental Journal
SCIENTIFIC RESEARCH REPORT
doi: 10.1111/idj.12454

Analysis of dental services distribution in Malaysia: a

geographic information systems – based approach
Nor Faezah Md Bohari1, Estie Kruger2, Jacob John3 and Marc Tennant2
1
Sungai Buloh Campus, Universiti Teknologi MARA, Selangor, Malaysia; 2International Research Collaborative, Oral Health and Equity,
Department of Anatomy, Physiology and Human Biology, The University of Western Australia, Nedlands, WA, Australia; 3University Malaya,
Kuala Lumpur, Malaysia.

Objective: The aim of this study was to analyse, in detail, the distribution of primary dental clinics in relation to the
Malaysian population and relative population wealth, to test the hypothesis that an uneven distribution of dental services
exists in Malaysia. Method: This 2016 study located every dental practice in Malaysia (private and public) and mapped
these practices against population, using Geographic Information Systems (GIS) tools. Population clusters within 5, 10
and 20 km of a dental clinic were identified, and clinic-to-population ratios were ascertained. Population data were
obtained from the Population and Housing Census of Malaysia 2010. Population relative wealth was obtained from the
2014 Report on Household Income and Basic Amenities Survey for Malaysia. The physical address for each dental prac-
tice in Malaysia was gathered from the Official Portal of Ministry of Health Malaysia. All data for analysis were
extracted from the integrated database in Quantum GIS (QGIS) into Microsoft Excel. Result: The population of Malay-
sia (24.9 million) was distributed across 127 districts, with 119 (94%) having at least one dental clinic. Sixty-four dis-
tricts had fewer than 10 dental clinics, and 11.3% of Malaysians did not reside in the catchment of 20 km from any
dental clinic. The total dental clinic-to-population ratio was 1:9,000: for public dental clinics it was 1:38,000 and for
private clinics it was 1:13,000. Conclusion: Dental services were distributed relative to high population density, were
unevenly distributed across Malaysia and the majority of people with the highest inaccessibility to a dental service
resided in Malaysian Borneo.

Key words: Malaysia, dentist, GIS, distribution, access

This public health system is universal3–5, whereby

INTRODUCTION
Malaysia is situated in the centre of South-East Asia,
is located immediately north of the equator and con-
sists of two geographical regions – the peninsular
Malaysia and the Malaysian Borneo (Sabah and Sara-
wak) – divided by the South China Sea. The total land
area of Malaysia is 330,803 km2 and had a popula-
tion of 28.3 million in 20101. The population density
is 94 persons per km2, and 75.5% of the population
resides in urban areas. Malaysia comprises 13 states
and three federal territories. The three most populated
states are Selangor (5.46 million), Johor (3.35 million)
and Sabah (3.21 million)1.
A dual health-care system coexists in Malaysia2.
The government provides health services through pub-
lic hospitals and health clinics throughout the country.
© 2018 FDI World Dental Federation
everyone can access public health services, including
dental services, at a heavily subsidised rate2. Private
health-care providers, through fee-for-service, comple-
ment the government health services. They mainly
focus on curative care in single-practitioner or group
practices2,5. These private health-care services are
business-oriented and driven by market demands.
Geographic Information Systems (GIS) methods are
widely used in health services research to investigate
health issues through integration and analysis of phys-
ical, social and cultural environments6–9. A number of
studies have used GIS in spatial analysis to examine
accessibility to health services and multiple factors
that could affect access to health-care facilities, such
as socio-economic status, transport and distance7–12.
GIS methods have previously been used not only to
1
Md Bohari et al.

provide a clearer understanding of spatial patterns Population statistics

and relationships between service access and disad-
vantages but also to obtain insight into health
inequalities10–16.
Access to health services is a core element of any
health system around the world and is defined as the
ability of a population to utilise health services when
needed6. It involves a complex relationship between
the service provider (the health practitioner) and the
consumer (the patient). Geographical accessibility
refers to the ease with which residents of a given area
can reach services and facilities, and the common
approaches for defining geographical accessibility are
based on distance or travel time to a resource7,8.
Thus, optimal delivery of dental health services also
requires taking into consideration two dimensions of
health care, namely availability and accessibility,
which together are referred to as spatial accessibility6.
The term availability refers to the locations of dental
clinics, and the term accessibility refers to the distance
or the travelling time between the patient’s location
and the location of the dental clinic6.
The aim of this study was to analyse, in detail, the
distribution of public and private dental clinics in
relation to the Malaysian population and relative pop-
ulation wealth, to test the hypothesis that an uneven
distribution of dental services exists in Malaysia.
METHODS AND MATERIALS
All data were collected between 1 April 2016 and 31
July 2016 from open access sources of de-identified
data; therefore, no ethics approval was required.
Dental clinic locations
The address of each dental practice was obtained
(March 2016) from the official portal of Ministry of
Health Malaysia, through the websites www.moh.
gov.my and medicalprac.moh.gov.my. Hospital-based,
specialist clinics, school dental services, mobile dental
clinics and duplicate addresses were identified and
excluded from this study. Only primary care dental
clinics were included for analysis. (Hospital-based and
specialist clinics in Malaysia are strictly tertiary and
patients need referrals from primary care clinics to
access care. School clinics only provide services to
schoolchildren.) Randomly selected samples of 1%–
2% of all geocoded practices were tested against per-
sonal knowledge and then web searched to test the
integrity of the data. Following this, the addresses
were converted to longitude and latitude, using Goo-
gle Maps (www.google.com/maps), and all addresses
were resolved to a minimal accuracy of street level,
with 90% being at the level of the building.
All population data were obtained from the most recent
Population and Housing Census of Malaysia (2010)
Department of Statistics, for population numbers of each
district1. Administrative Districts were chosen as the
geographical region, as this is the only available data
source in file format that matched the population data
files, and these files were obtained from DIVA-GIS, a
free computer program from the Internet for mapping
and geographical data analysis. In this study, 127 (79%)
of 160 districts and 24,952,453 (88%) of 28,334,135 of
the Malaysian population were analysed. All 13 states in
Malaysia were analysed in this study. The major capital
city [Federal Territory (F.T.) Kuala Lumpur] and F.T.
Putrajaya were included in the state of Selangor, and
F.T. Labuan was included in Sabah, in order to match
the population numbers with the map boundaries that
were used for analyses. Thirty-three districts (which rep-
resent 12% of the Malaysian population) were excluded
from this study because of population data not being
available. Population relative wealth was obtained from
the 2014 Report on Household Income and Basic
Amenities Survey for Malaysia17. This information was
available at the state level.
Geographic integration
Geographic mapping was conducted on Quantum
Geographic Information Systems (QGIS version 2.14,
QGIS Development Team, GNU General Public
License, Essen, Germany), with the World Geodetic
System 1984 (WGS 84) standard of coordinate refer-
encing. All geographical data and linked population
data were imported and analysed using Microsoft
Excel (version 14.0; Microsoft, Redmond, WA, USA).
Statistical analyses
All data for analysis were extracted from the inte-
grated database in QGIS into Microsoft Excel.
Descriptive statistical analyses (including number of
dental practices within each district) and calculation
of practice-to-population ratios were completed using
Microsoft Excel 2011 version 14.0.
RESULTS
The population of Malaysia analysed in this study
(24.9 million) was distributed across 127 districts at
the time of the census. The districts were presented
with different geographical areas and population sizes
ranging from 1 to 57 districts per state, with an aver-
age of 196,476 people per district. Twenty-seven per-
cent (6.8 million) of the Malaysian population resides
in Selangor1. A total of 652 public dental clinics and

2 © 2018 FDI World Dental Federation


Figure 1. Distribution of public (dark-blue triangles) and private (red
dots) dental clinics in Peninsular Malaysia.
1,875 private dental clinics are distributed across 127
districts (Figures 1 and 2). In total, 2,527 clinics –
652 (26%) public and 1,875 (74%) private – were
included in this study. The national dental clinic-to-
population (CtP) ratio was 1:9,000. The state of
Selangor had the lowest CtP ratio (1:6,000), despite
being the most populated state. The Malaysian
Borneo (Sabah and Sarawak) had the highest CtP
ratios – 1:21,000 and 1:15,000, respectively. The pub-
lic dental clinic-to-population (PuCtP) ratio was high-
est in Sabah (1:89,000), with the average PuCtP ratio
in Malaysia being 1:38,000. Sabah was also the state
with the highest poverty incidence17. Selangor had the
Figure 2. Distribution of public (dark-blue triangles) and private (red dots) dental clinics in Malaysian Borneo.
© 2018 FDI World Dental Federation
Malaysian dental services distribution
lowest private dental clinic-to-population (PrCtP)
ratio – 1:7,000 – with the average PrCtP ratio for
Malaysia being 1:13,000 (Table 1).
Selangor boasted the highest number of dental clin-
ics (971), almost half (47.5%) of which were private
dental clinics. Sabah, although having the second-lar-
gest population (2.9 million), had only 132 dental
clinics, and 5.3% of the country’s private and 4.9%
of the country’s public dental clinics. Public dental
clinics were more evenly distributed throughout the
country, with the percentage ranging from 1.2% to
13.8%, and Johor had the highest number of public
dental clinics (Figure 3).
One-hundred and nineteen (94%) of 127 districts
had at least one dental clinic. Of these districts, 64
(54%) had fewer than 10 dental clinics and eight had
more than 50 dental clinics. In Sarawak, 16 districts
had fewer than 10 dental clinics. Johor, Negeri Sembi-
lan, Perak, Pulau Pinang and Selangor had more than
50 clinics. Selangor had the highest number of dis-
tricts with 50 or more dental clinics in each (Table 2).
In Malaysia, 41.2%, 61.1% and 88.7% of all peo-
ple live within 5, 10 and 20 km, respectively of a den-
tal clinic (Figure 4). Similar findings were found in
that for every radius (5, 10 and 20 km), the majority
of the total population that resided outside the 5-, 10-
and 20-km catchment areas from a dental clinic were
from the Malaysian Borneo (Sabah and Sarawak)
population.
DISCUSSION
Geographical accessibility is only one of the dimen-
sions of accessibility to health services according to
Penchansky18, and other dimensions include
3
Md Bohari et al.

Table 1 Dental clinic/population ratios and mean household income of different states in Malaysia
State DC (n) Population CtP ratio* PuCtP ratio* PrCtP ratio* MMI (RM) Poverty incidence†

Sabah 132 2,864,883 1:21 1:89 1:32 4,879 4.0

Sarawak 118 1,876,571 1:15 1:83 1:28 4,934 0.9
Kedah 125 1,899,751 1:15 1:78 1:27 4,478 0.3
Perlis 15 225,590 1:15 1:54 1:27 4,445 0.2
Kelantan 113 1,347,056 1:11 1:33 1:24 3,715 0.9
Pahang 120 1,408,092 1:11 1:29 1:20 4,343 0.7
Melaka 72 790,136 1:10 1:28 1:19 6,046 0.1
Perak 190 1,950,173 1:10 1:27 1:17 4,268 0.7
P. Pinang 165 1,526,324 1:9 1:26 1:16 5,993 0.3
Terengganu 112 1,011,363 1:9 1:23 1:15 4,816 0.6
Johor 294 2,466,320 1:8 1:20 1:12 6,207 0.0
N. Sembilan 100 853,371 1:8 1:18 1:11 5,271 0.4
Selangor 971 6,750,823 1:6 1:16 1:7 8,252 0.2
Malaysia 2,527 24,952,453 1:9 1:38 1:13 6,141 0.6

CtP, dental clinic to population; DC, dental clinics; MMI, mean monthly household income in RM ; PrCtP, private dental clinic to population;
PuCtP, public dental clinic to population; RM, Ringgit Malaysia
*All ratios are per 1,000 population.
†
For 2014.

availability of services, affordability of services,
acceptability of services and how accommodative the
services are to the population. It is known from previ-
ous Malaysian studies that available spatial access to
dental services is not always associated with optimal
oral health19–21. This is an indication that although
access to health services plays an important role in
improving a population’s overall health, many other
factors also contribute, including the social determi-
nants of health22–24.
The results of this study are in agreement with the
hypothesis that dentists are distributed relative to high
population density and relative wealth. The uneven
distribution of dental services in Malaysia is similar to

12.4%
Selangor 47.5%
38.0%
13.8%
Johor 10.9%
11.6%
11.2%
Perak 6.2%
7.5% % of public dental clinics
4.3%
Pulau Pinang 7.3% % of private dental clinics
6.5%
4.9%
Sabah 5.3% % of dental clinics
5.2%
8.6%
Kedah 3.7%
4.9%
3.7%
Sarawak 5.0%
4.7%
10.4%
Pahang 2.8%
4.7%
8.7%
Kelantan 3.0%
4.5%
9.7%
Terengganu 2.6%
4.4%
6.9%
Negeri Sembilan 2.9%
4.0%
4.1%
Melaka 2.4%
2.8%
1.2%
Perlis 0.4%
0.6%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0%

Figure 3. Percentage of public and private dental clinics for each state in Malaysia.

4 © 2018 FDI World Dental Federation

 Malaysian dental services distribution

Table 2 Number of districts with number of dental clinics stratified according to Malaysian State
State Number of clinics Total districts
per state n (%)
≤10 11–20 21–30 31–40 41–50 >50

Sabah 15 3 0 0 1 0 19 (16)
Sarawak 16 2 0 0 1 0 19 (16)
Kedah 6 3 1 1 0 0 11 (9.2)
Perlis 0 1 0 0 0 0 1 (0.8)
Kelantan 6 2 0 0 1 0 9 (7.5)
Pahang 7 3 0 1 0 0 11 (9.2)
Melaka 1 1 0 0 1 0 3 (2.5)
Perak 3 5 1 0 0 1 10 (8.4)
P. Pinang 1 0 2 1 0 1 5 (4.2)
Terengganu 2 3 2 0 0 0 7 (5.8)
Johor 1 2 2 2 0 1 8 (6.7)
N. Sembilan 5 1 0 0 0 1 7 (5.8)
Selangor 1 3 1 0 0 4 9 (7.5)
Total districts 64 (54) 29 (24) 9 (8) 5 (4) 4 (3) 8 (7) 119 (100)

Values are given as n or n (%).

the situation in other countries10,25–27, with dental
services being more saturated in the major cities and
along the coastlines.
The highest poverty incidence is found in Sabah
and Sarawak (Table 1), and these are also the states
with the highest CtP ratios28. Our findings indicated
higher concentrations of clinics in population-dense
areas, such as cities, but it would be a challenge to
increase accessibility of dental services to rural areas
because of result of lack of accessible roads or trans-
portation, especially in the inland areas of the penin-
sular and Malaysian Borneo. Other than access to
services, major contributory factors affecting health in
these areas include social determinants, such as educa-
tion, income and job security, which are inadequate
in these communities28,29.
Moreover, 11.3% of the entire Malaysian popula-
tion does not reside within a 20-km radius of a dental
clinic; the majority of these people reside in Malay-
sian Borneo. Some of these people have to travel a
long distance to a health facility to access basic medi-
cal or dental care30,31. The study is consistent with
other studies which report that those in poverty, and
minority groups, often live further away from these
basic services11,12. It is also evident that public clinics
are more evenly distributed throughout the Malaysian
Peninsular than are private clinics. There are a larger
number of private clinics, which are more saturated in
bigger cities in the west coast, especially in Kuala
Lumpur, the capital city of Malaysia. This is very sim-
ilar to the situation in other countries22,27, where pri-
vate dental clinics are not sustainable in rural areas as

Figure 4. Malaysian population within 20 km of all dental clinics (blue dots); each dot represents 500 people. Pink dots represent the population who do
not live within a 20 km radius of a dental clinic. The white areas (33 of 160 districts) are areas for which population data could not be ascertained
because appropriate information was unavailable.

© 2018 FDI World Dental Federation 5

Md Bohari et al.
a result of lack of dentists, high costs and low popula-
tion density.
Previous studies found that the burden of oral dis-
eases is higher in the more rural areas, especially in
Malaysian Borneo, as well as in the northern region
and the east coast of the Peninsular Malaysia32,33,
and these are also the areas found, in the current
study, to have the lowest number of dental clinics
(with high dental CtP ratios). There were some limita-
tions in this analysis, such as the absence of data
regarding education level, road networks and trans-
portation modes. It is not a matter of only incorporat-
ing the geographical context; other variables must
also be considered but these may be more difficult to
consider. Future studies may attempt to incorporate
these variables.
CONCLUSION
Dental services were distributed relative to high popu-
lation density and were unevenly distributed across
Malaysia. The majority of people with the highest
inaccessibility to a dental service resided in Malaysian
Borneo, which has a higher incidence of poverty in
comparison with other states in Malaysia.
Acknowledgements
None.
Funding
None.
Conflict of Interest
None.
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© 2018 FDI World Dental Federation 7

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