Health systems are made up of multiple interacting components including organisations, people and actions. They perform several functions: delivering healthcare services; maintaining and improving health; protecting households from the costs of illness; enabling economic functioning; and shaping societal norms and values. They are also sites of competition and contestation between actors with different interests and visions.

This chapter outlines the complexity of health systems and explains how they can only be studied and fully understood through a multi-disciplinary lens. It unpacks the different dimensions of health systems complexity, the societal functions performed by health systems, and the contestation between different ideas, values and interest groups. It examines various health systems frameworks and typologies and how they can be used to describe and understand the performance of health systems. It discusses the open and contextual nature of health systems and their relationship with external factors, including shifts in international health policy-making. Finally, the chapter ends with a brief introduction of systems thinking which is discussed further in Chapter 2.

This chapter summarises the key messages and lessons that cut across the individual chapters of this book while also assessing the interactions between the different building blocks of the WHO health system framework. This includes a critique of the WHO health systems framework and some suggestions for other countries that might wish to analyse their own health systems. A key issue discussed in the chapter is the importance of Malaysia’s socio-political and economic context to the development of its health system. The chapter highlights recent developments and the current challenges facing both the health system and the state of the Malaysian population’s health, and it makes some recommendations for future health systems policy.

The protection and management of the natural and built environment and monitoring its relation to and impact on health is an important component of any country’s health system. The first line of defence in disease prevention is controlling the physical, chemical and biological agents in the environment that have the potential to affect populations. Environmental health services were an integral component of the evolution of the Malaysian health system and covered aspects such as the provision of clean water and safe disposal of solid waste and wastewater in rural and urban settings, vector and rodent control, air pollution control, and climate change. Systems thinking analysis demonstrates how the development of environmental health services requires the health system to interface with non-health sectors and re-think the responsibilities and functions of the health systems. Issues include development of the requisite human resources, organisational and financial re-structuring, and governance measures.

Secondary and tertiary care (STC) evolved to progressively improve access and quality of care. For various phases of development, the chapter analyses the dynamic interactions of various components of the health system such as human resources, financing, information, medical products and technology and their influence on STC, and the influence of wider factors such as political, socio-economic, demographic and population behaviour. Challenges include the provision of affordable, integrated, seamless care from primary to tertiary levels. Outcomes are discussed in terms of access, utilisation, client satisfaction and quality of care. The analysis includes the dynamics inherent in the dichotomy between the public and private sectors in financing and provision of STC services. Systems thinking illustrates the challenges in the dichotomous public-private system that is subject on the one hand to increasing specialisation and compartmentalisation in medical care and on the other hand to the need for integrated care for the individual patient.

Democracy is the inspiration for many social movements in today's world. But what does democracy mean to activists or political party leaders? If democracy does not have a taken-for-granted meaning, then understanding how meanings may vary – and how these differences might help to make sense of policy decision-making and political contests – is important. Before turning to the Myanmar context in the following chapters, my argument in this chapter is that an interpretivist approach, and in particular narrative analysis, can open new possibilities in elucidating the concept of democracy across varied linguistic, cultural and political contexts (Schaffer 2016).

From the work of Roe (1989) on complex public policy disputes, to Labov and Waletsky's (1997) seminal work in linguistics, and Moon's (2006) work on narratives of reconciliation, scholars have applied narrative theory in a range of academic disciplines. Some disciplines have even taken a so-called ‘narrative turn’ (Ospina & Dodge 2005). The distinguishing feature of this shift is the desire by researchers to use the framework of story to understand diverse, rather than universal, meanings of concepts or events, meanings that are temporally and spatially defined (Bacon 2012). Attention to plot and characters in the way concepts are communicated by political actors can generate new insights, both into how concepts are understood by these actors and how concepts are used politically to forward certain agendas while undermining others. It is surprising, then, that there is an absence of systematic application of narrative theory to the analysis of meanings of democracy within democracy and democratisation scholarship.

Nay Pyone Latt announced on Facebook that he had won. It was not unexpected. The well-known blogger was a candidate for Aung San Suu Kyi's party, the National League for Democracy (NLD), which was the favourite to win Myanmar's 2015 national elections. Yet, just a few years before, Nay Pyone Latt had been a political prisoner. During the countrywide 2007 protests, the so-called Saffron Revolution, the then seventeen-year-old had been accused by Burmese authorities of mobilising protest through blogs and videos. He was promptly sentenced to more than 20 years in prison. But in 2012, amidst a mass pardon of political prisoners by then President Thein Sein, Nay Pyone Latt was released. By evening on the day after the 2015 election it was clear that he had won his seat for the NLD in a landslide and would soon join the Yangon Region Parliament.

By that same evening, 9 November 2015, there were crowds massing on Shwe Gone Daing Road outside the NLD headquarters in Yangon. Most in the crowd had dark indelible ink stains on their little fingers as a mark that they had voted in the election. Many wore red T-shirts with a picture of Aung San Suu Kyi or red NLD headbands – with the distinctive white star and yellow peacock – while some waved NLD balloons or flags. News was emerging of a decisive victory in which the NLD ultimately won 255 of the 330 possible seats in the Pyithu Hluttaw, or lower house of parliament. The victory was seen by many local reporters and commentators as ushering in a new post-authoritarian era of government for the country.

The NLD victory was celebrated not only domestically but also internationally. Amongst media commentators and diplomats in Europe and North America, the 2015 elections were considered to be a pivotal moment in Myanmar's long struggle for democracy.

In September 2019, Aung San Suu Kyi gave a speech for International Democracy Day in the nation's capital, Naypyidaw. In the previous year she had been stripped of multiple international awards for supporting human rights and democracy – as criticism of her and the NLD reached a crescendo following the crisis in Rakhine State. In the speech, Aung San Suu Kyi (2019) defines democracy as ‘people power’. Yet she stresses that this people power can be used both positively and negatively – it can be used for parahita (‘public interest’) or atta hita (‘self-interest’). ‘Some people think that democracy is just for self-gain’, Aung San Suu Kyi (ibid.) said, ‘basically, human beings are selfish. We can't ignore this fact, if we want a successful system. I would say democracy is a culture, rather than a system as it involves not only politics, but also social, economic and philosophical values.’ The key to these values of democracy, as opposed to a ‘system’, was ‘goodwill’. Aung San Suu Kyi (ibid.) concluded by saying that Myanmar must ‘realize democratic culture through true goodwill towards the country and mankind for the flourishing of democracy’.