Medical products confer enormous benefit to health but also have potential harmful effects, either through their inherent properties or through misuse and abuse. This chapter analyses the role of medical products in the Malaysian healthcare system over a 60-year period. It covers issues of access and affordability alongside those of safety and quality. The initial period focused on ensuring a reliable supply of medicines and vaccines through import, storage, distribution and dispensing. Concerns about safety led to the evolution of national registration of medicines and human resource and governance issues around building capacity for monitoring and enforcement. Subsequent development of the health system experienced growing capacity for local manufacture, appearance of counterfeit medicines in the marketplace, and required strengthening of regulatory systems through international collaboration. Also included are purchase effectiveness, cost of medicines and pricing mechanisms. Systems analysis highlights the conflict between cost of medicines and the advancement of Universal Health Care and illustrates the use of Right to Government use to reduce inequities in access.

The chapter analyses the 60-year evolution of the health workforce as it responded to the evolving demands of various branches of health service delivery. The analysis encompasses the limiting and enabling factors that determined the evolution of the profile of the health workforce. This includes societal education levels, economic growth, and demographic and population behavioural patterns, as well as macroeconomic and health policies. Included also is the influence of governance measures and leadership in shaping the key characteristics of the health workforce and, in turn, the influence of the competence and mobility of the health workforce on equitable access to healthcare services and the satisfaction of clients. The complex but iterative relationship between production and utilisation of the health workforce is explored.

Leadership and governance in Malaysia have been key to success in the planning and implementation of health services and their outcomes and in the shifts and corrections needed. Health is the responsibility of the federal government, but some areas are under the authority of state governments. The chapter illustrates how Malaysia adopted a holistic approach to health policies by embedding them in the context of national development policies. The ministry of health (MoH) is the major provider of health services. Health professionals in the MoH demonstrated leadership by advising on health priorities and taking responsibility for the formulation/implementation of intervention programmes and regulating the private health sector. They have achieved substantial balanced health development with greater equity. Analysis of the role of the MoH illustrates several essential elements of leadership. The MoH is also engaged in international health collaboration, both as a receiver of mostly technical advice from international organisations and as a giver of support to other developing countries.

Recently the publication rate of papers proposing the use of systems thinking to improve health system performance has grown exponentially. Very few of these publications, however, provide examples of practical application. This gap between theory and practice reflects two key issues. First, the difficulty of facilitating the required cross-sector collaborations. Second, the lack of a high-level model of the causal structure of a typical health delivery system.

In this chapter we point out that System Dynamics provides an accessible shared language capable of facilitating effective cross-sector communication and engagement. In Section 2.2 we briefly describe the System Dynamics concepts and tools that are used to support the case studies presented in Chapters 4–12 of this book.

We conclude, in Section 2.3, by outlining the approach taken in Sections 2 and 3 of the book. Attention is focused on understanding the Malaysian health system, leading to the construction of a generic health system model. Such a model, with its high-level focus on the interactions between the health system building blocks, is needed to ensure that cross-sector research is both comprehensive and coherent.

This publication attempts to address important gaps in applying the use of systems thinking to improve health system performance, identified in Chapter 2. In this chapter, we synthesise systems thinking lessons, drawing on both the systems observations made in the book chapters and case studies as well as the process by which these findings were derived. First, we explore the need for and challenges in constructing and communicating complex narratives about health systems. Here, we reflect on the co-production of case studies in this book, noting some of the requirements, challenges and limitations we encountered. We also describe some of the benefits in understanding and communication that resulted from this effort.

Since independence, Malaysia has gone through a major health and socio-economic transformation. This has transformed Malaysia from a mostly rural society with a tropical climate where most people lived in poverty with low health status into a largely urban society with a low unemployment rate - a high-middle-income country with matching improved health status. Socio-economic and health development has resulted from deliberate efforts to reach the people most in need. Both demographic and epidemiological transitions took place as part of this transformation. It was characterised by substantial declines in the incidence of infectious diseases and infant and maternal mortality and higher life expectancy. Improvements in health status were associated with improved education, improved environmental health, and enhanced nutrition. This improved health status was achieved at a relatively moderate level of national health expenditure, with most preventive and disease control services provided by the public sector. Like more affluent countries, Malaysia now faces the challenge of dealing with non-communicable diseases while continuing to manage periodic threats from infectious diseases.

The financing of health care could be viewed as a demonstration of the value society places on health. This chapter explores Malaysia’s financial commitment towards providing access to health care and protection from catastrophic health expenditure during 60 years of evolution of the health system. The analysis includes trends of total health expenditure as a proportion of gross national product and trends in financing from various sources that reflect the dichotomy between the public and private sectors, the related mechanisms for financing health care services and the impact on service delivery. Notable is that high out-of-pocket expenditure was not associated with catastrophic household financial health expenditure. The author notes the role of pooled tax funds in providing relatively affordable health care in the public sector. The growing private sector together with the rising health expenditure due to demographic, epidemiologic and technological changes brings into focus changes that will be needed to sustain the social efficiency of the system.

Primary health care (PHC) evolved during the 60-year period, driven by political priorities, shaped by the health needs and demands of a population that experienced social and economic development and moved from largely rural to 70% urban. This chapter analyses the key characteristics of the strong publically funded Rural Health Service (RHS), which was established relatively early in the development process and which improved access to care and reduced inequities in health outcomes. Ambulatory care services provided in urban and rural hospitals complemented the RHS. The analysis covers the factors that contributed to the growth of primary care provided by private sector medical doctors that patients paid for out of pocket. Subsequently, the chapter analyses how the system responded to the challenges of remodelling PHC to meet new needs created by epidemiological and demographic evolution, changes in the population’s socio-economic profile, evolving medical and information technology, and growing concerns for quality of care.

Health information has been a major instrument in the assessment of health status in Malaysia, the planning and implementation of health services and the evaluation of health outcomes. Earlier, population censuses and estimates, plus the registration of births and deaths, were complemented by surveys of living conditions. Registration of notifiable diseases added to the assessment of the incidence of infectious diseases and progress made in their management; this was later extended to some non-communicable diseases. Health services research and household surveys have become regular features to support health intervention planning and possible changes. Registration of health professionals and inventories of health facilities give an indication of their availability. Initially, health financing information related mostly to the public sector. More recently, the compilation of national health accounts has given annual health expenditure estimates for both the public and private sectors. Progressively, information technology enhanced the collection, analysis and dissemination of health information and the provision of clinical services, such as in the case of telehealth.

Within the first 30 years since independence, Malaysia successfully eradicated or drastically reduced the occurrence of several serious communicable disease. During the second 30 years, Malaysia had some success as well as limited or no progress in dealing with non-communicable diseases, re-emerging diseases such as dengue, and other new and emerging diseases such as influenza H1N1. This chapter analyses the development and evolution in order to identify key features that contributed to the success or limited the progress of control efforts. The discussion covers issues such as design of surveillance and control programmes, the role of ‘vertical’ and integrated approaches, and the limitations faced by the health system in trying to adapt from controlling communicable to non-communicable diseases. The influence of interactions between components of the healthcare system such as the workforce, primary and secondary care, environmental health services, medical products and vaccines is illustrated.