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.

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.