世界走出 COVID-19 疫情陰影後，更需要重新關注健康問題。我們勢必要經過許多年才能充分瞭解因疫情逝去的生命與疫情對全球健康的巨大影響。但許多國家的醫療體系已明顯不堪重負，因此必須進行改革，才能在未來的衝擊來襲前做好準備。亞太地區在 COVID-19 疫情中首當其衝，未來仍持續面臨挑戰，但這也為國際社會提供寶貴的問題解決方案和經驗教訓。
完整呈現亞太地區的現狀並不容易，因為不同國家面臨的情形不盡相同也難以複製。亞太地區幅員遼闊，世界銀行將其劃分為東亞和太平洋地區，這些地區存在許多固有差異，尤其是經濟發展方面——亞太地區有世界收入最高的經濟體（如日本與南韓），也有收入位於最低四分位的經濟體 （如柬埔寨和所羅門群島）。經濟不平等的情形自然會為各地區的醫療體系帶來顯著差異。
然而，在評估各地醫療體系共同面對的問題和解決方案時，區域內外連結的重要性也越發顯著。舉例而言，醫療勞動力短缺有一部分是因為國家和地區之間的「人才外流」，數位醫療解決方案則有可能緩解人力短缺問題。此外，在面臨共同挑戰的情況下，亞太各國與整個地區的獨特因應措施也為國際社會提供寶貴的學習機會，突顯出展開泛區域合作，以建立更永續、更有韌性的醫療體系的重要性。
醫療體系永續性及韌性合作夥伴（PHSSR）對亞太地區的醫療體系進行深入的研究，並針對日本、南韓、馬來西亞、太平洋島國（特別是馬紹爾群島、東加和萬那杜）、台灣和越南等國發表國別報告。選擇這些區域，目標是希望能夠策略性地涵蓋各種經濟發展程度不同的國家，包含高收入、中高收入和中低收入經濟體。 此外，選定的地區地理特徵多樣，牽涉各種氣候相關問題，突顯出打造適應性強、有韌性之醫療體系的需求。
林夏如
亞堅會董事長
姜敏娥（Minah Kang
韓國梨花女子大學公共行政系教授
許瑞慶（Swee Kheng Khor）
Angsana Health 執行長
蔡奉真
臺北醫學大學全球衛生暨衛生安全博士暨碩士學位學程主任兼教授
Collin Tukuitonga
紐西蘭奧克蘭大學健康與醫學學院副院長
世界走出 COVID-19 疫情陰影後，更需要重新關注健康問題。我們勢必要經過許多年才能充分瞭解因疫情逝去的生命與疫情對全球健康的巨大影響。但許多國家的醫療體系已明顯不堪重負，因此必須進行改革，才能在未來的衝擊來襲前做好準備。亞太地區在 COVID-19 疫情中首當其衝，未來仍持續面臨挑戰，但這也為國際社會提供寶貴的問題解決方案和經驗教訓。
完整呈現亞太地區的現狀並不容易，因為不同國家面臨的情形不盡相同也難以複製。亞太地區幅員遼闊，世界銀行將其劃分為東亞和太平洋地區，這些地區存在許多固有差異，尤其是經濟發展方面——亞太地區有世界收入最高的經濟體（如日本與南韓），也有收入位於最低四分位的經濟體 （如柬埔寨和所羅門群島）。經濟不平等的情形自然會為各地區的醫療體系帶來顯著差異。
然而，在評估各地醫療體系共同面對的問題和解決方案時，區域內外連結的重要性也越發顯著。舉例而言，醫療勞動力短缺有一部分是因為國家和地區之間的「人才外流」，數位醫療解決方案則有可能緩解人力短缺問題。此外，在面臨共同挑戰的情況下，亞太各國與整個地區的獨特因應措施也為國際社會提供寶貴的學習機會，突顯出展開泛區域合作，以建立更永續、更有韌性的醫療體系的重要性。
醫療體系永續性及韌性合作夥伴（PHSSR）對亞太地區的醫療體系進行深入的研究，並針對日本、南韓、馬來西亞、太平洋島國（特別是馬紹爾群島、東加和萬那杜）、台灣和越南等國發表國別報告。選擇這些區域，目標是希望能夠策略性地涵蓋各種經濟發展程度不同的國家，包含高收入、中高收入和中低收入經濟體。 [i] 此外，選定的地區地理特徵多樣，牽涉各種氣候相關問題，突顯出打造適應性強、有韌性之醫療體系的需求。
亞太堅韌研究基金會 (Center for Asia-Pacific Resilience and Innovation, CAPRI) 為 PHSSR 的亞太研 究中心，主導上述六份國別報告的其中四份，ii 並將內容統整為此份綜述報告。本報告著重於闡述分 析亞太地區醫療系統的常見問題，並劃分為以下四大章節：
高齡化社會 – 低出生率和預期壽命延長導致亞太地區多個國家的人口逐漸老化，為傳統醫療體系帶來壓力。
氣候變遷 – 環境變遷加劇健康風險並威脅基礎設施，島嶼地區尤其如此。
數位醫療 – 科技進步正改變醫療照護服務的樣貌，為醫療服務的可及性和公平性提供機會，同時也帶來新的挑戰。
醫療勞動力 – 工作條件不利和發展機會受限，迫使醫療工作者離開本業遠赴他鄉，因而衝擊醫療照護服務供應。
除非另有說明，本報告每一節為引述 PHSSR 國家研究報告的結論，以闡述這些問題對此地區的影響，並點出克服這些問題應採取的措施。
PHSSR 是一項非營利、跨界別的全球合作倡議，旨在共同建立更永續、更有韌性的醫療體系。PHSSR 在 30 多個國家積極展開研究，迄今已發佈 29 份受託獨立研究報告，提供實證建議，協助強化當地醫療體系。PHSSR 攜手全球醫療體系的專家，利用第一手知識和經驗，提出相關國別研究結果，以及全球層面的整體見解與特定疾病的分析。
疫情過後，面對持續增加的照護需求，許多醫療體系仍然不堪重負，已達到危險的臨界點。PHSSR 旨在促進國際知識交流，並與醫療體系相關各方合作，推動跨國及跨界合作，加速強化醫療照護體系。
亞太堅韌研究基金會為非官方、超黨派的國際組織，致力於透過務實的比較研究，從亞太的觀點引領全球政策討論，推動創新治理，打造堅韌社會。
亞太堅韌研究基金會為 PHSSR 第一個區域研究中心，負責統整協調亞太地區醫療體系永續性及韌性的研究報告。以倫敦經濟學院先前對日本和越南的研究 (表 1) 為基礎，亞太堅韌研究基金會於 2024 年對馬來西亞、太平洋島國地區 (PICT)、南韓與台灣的國家醫療體系進行研究 (表 2)。這項研究由下列研究負責人主持，未來數年將擴展到更多國家與地區。
表 1：由倫敦政治經濟學院統整協調的 2021-2022 年亞太地區 PHSSR 國別報告與研究負責人
| 報告 | 研究負責人 |
|---|---|
| 日本 | 宮田裕章 (Hiroaki Miyata)，慶應義塾大學醫學院健康政策管理科教授暨主任；日本醫療體系永續性及韌性研究負責人 |
| 越南 | Tran Thi Mai Oanh, 衛生策略與政策研究所所長；越南醫療體系永續性及韌性研究負責人 |
表 2：由亞堅會統整協調的 2024 年亞太地區 PHSSR 國別報告與研究負責人
| 報告 | 研究負責人 |
|---|---|
| 馬來西亞 | 許瑞慶，Angsana Health 執行長 |
| 太平洋島國 | Collin Tukuitonga，奧克蘭大學醫學和健康科學學院副院長 |
| 南韓 | 姜敏娥 (Minah Kang)，梨花女子大學公共行政學系教授 |
| 台灣 | 蔡奉真，臺北醫學大學全球衛生暨衛生發展博士/碩士學位學程教授暨主任 |
林夏如 為亞太堅韌研究基金會創辦人暨董事長、維吉尼亞大學米勒公共事務中心研究教授、布魯金斯研究院非常駐資深研究員。聯絡方式： [email protected]。
Alistair Lang 為亞太堅韌研究基金會行政專員暨研究協調員。聯絡方式： [email protected]。
i 世界銀行根據 2022 年以美元計的人均國民總收入數據將經濟體分為四個收入組：低收入組 (<$13,846 美元)，中低收入組 (1,136-4,465 美元)，中高收入組 (4,466 -13,845 美元) 和高收入組 (>$13,846 美元)。參見世界銀行 World Bank Country and Lending Groups，瀏覽日期：2024 年 1 月 22 日，https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups。
ii 在倫敦政治經濟學院的統整協調下，PHSSR 已分別於 2021 年和 2022 年發表越南和日本的報告。本報告其他資訊請參照表 1。
完整的醫療照護體系包含對個人健康的醫療服務與其他非個人醫療的公共衛生兩個重要元素，才能夠將個人的健康與其所屬的社區及居住環境連結起來。台灣的醫療體系係由公部門和私人機構兩個支柱共同支持。台灣的公共衛生主管機構為中央政府的中華民國衛生福利部 (MOHW) 和 地方政府的22 個縣市衛生局。中央及地方衛生主管機關會透過定期在各個社區中施行內容涵蓋傳染病與慢性病控制、疫情應對、疫苗接種、疾病篩檢和菸害防制…等的健康防護和倡議宣導計畫以促進民眾的健康。此外，廣義的公共衛生還可以延伸到職業、環境和動物健康的領域，這一部分的公共衛生工作則分別由勞動部、環境部和農業部監管。
台灣自1995 年以來的強制性單一保險人全民健康保險 (NHI) 制度一直是提供住民個人保健的主要醫療系統，這一個健保制度由衛生福利部下的中央健康保險署負責管理，透過涵蓋幾乎所有醫療專業人員、診所和醫院的醫療系統為納保者提供醫療諮詢和治療。全民健康保險提供保險者的照護項目廣泛且多元，包括門診、住院、牙科、傳統中醫、腎臟透析、處方藥等醫療服務項目。
台灣的醫療體系中政府的角色最為重要，原因是它有責任監督整個醫療體系。在檢視台灣醫療體系時我們必須特別關注全民健康保險，因為它是台灣醫療體系運作的核心制度。然而，我們無法忽視非個人保健的公共衛生政策和作為對大眾健康的重要性，持續中的新冠肺炎大流行 (COVID-19 Pandemic) 疫情肆虐全球造成的高死傷的悲劇和惡化中的地球暖化所帶來的健康威脅，是必須重視公共衛生的兩個顯而易見例子。
新冠肺炎大流行疫情是這個時代最令人難過的事件之一，它改變了整個世界也衝擊了所有人的生活。自 2020 年爆發新冠肺炎大流行以來，台灣登錄的 新冠肺炎確診數已突破 1000 萬例，更有超過 2 萬人因此死亡，其中老年人和患有非傳染性疾病 (NCD) 共病症的人的新冠肺炎發病率和死亡率較高，而2021 年和 2022 年台灣的預期壽命更是連續兩年因為新冠肺炎所增加的死亡人數而下降。儘管全民健康保險在提供多樣且易取得的醫療服務方面功不可沒，但是這一個制度至今仍未能完全解決非傳染性疾病、照護品質、醫生和護理人員短缺、透明度和治理問題，以及疫情前就存在的政府在醫療投資偏低等問題的挑戰，而這一些全民健康保險乃至台灣醫療體系中早已存在的問題都因情新冠肺炎大流行而加劇惡化。因此，現在是好好檢視全民健康保險所面臨的種種問題和困難的時候，抓出核心的問題並且適時改正才能使台灣的醫療體系在面對未來新的的公共衛生危機時能夠快速反應、妥善因應，而新冠肺炎大流行疫情的教訓也顯示出，台灣的醫療體系必須更具有韌性才能在此次及日後疫情時避免疾病擴散失控並挽救更多生命。
這份由「醫療體系永續性及韌性合作夥伴」(PHSSR) 委託撰寫的報告中，蔡教授等人為台灣醫療體系的挑戰和解決方案提出深刻的見解，以期實現台灣醫療體系的永續發展和韌性。根據 PHSSR 跨國報告通用的架構 (借鑒世界衛生組織的醫療體系建構方法)，本報告指出醫療體系中需要改革的七大領域：大眾健康、環境永續發展、醫療照護人力、藥物和技術、醫療照護服務供應、醫療體系財政和醫療體系治理。報告中也提出必要的政策建議以填補台灣醫療體系的落差，例如：在行政院下設立政策協調部門、增加經費財務和人力資源，以及促進病人本位的照護。台灣全民健康保險改革的核心目標是：支付專業人員合理的報酬，並以社會可負擔的費用提供更有效、更優質的照護，同時確保身處不同社會經濟地位和地理區位的人民均能享有均一品質的醫療保健服務。
隨著台灣當地和全球人口老化、氣候危機、數位發展和疫情問題持續發展，全民健康保險改革更迫在眉睫。報告中呼籲政府做出承諾、提供更多資源，以及給予人民更多關注，這一切都反映出現代社會中醫療保健的範圍早已超出醫事人員提供的醫療，在像台灣這樣一個民主社會中的醫療體系改革確實必須和社會和政治方面的變革進程相互激盪。
報告中所闡述的全民健康保險的現況可以放在系統演進的歷史觀點進行了解。台灣的全民健康保險於 1995 年問世，時間就在台灣 1996 年第一次民選總統選舉前不久。此後 30 年每一次台灣選舉候選人和政黨都會針對全民健康保險提出各種補救辦法的選舉政見，嘗試將健保問題變成政治議題來解決：藥物、診斷和治療涵蓋範圍不斷擴大的問題、總額預算分配之爭、私人醫療機構新建擴建的許可，以及部分負擔和自行負擔制度實施等全民健保所面臨的種種問題。
2024 年總統大選，是歷史上第一次出現三位候選人當中有兩位是醫生參選的情形，這兩位醫師總統候選人的競選政見中都提到要將國內生產毛額的 8% 投入醫療支出，此舉將醫療體系改革議題帶到國家重大政策辯論的最前線。而台灣近四年來公共衛生這個議題在公共政策討論中深受社會各界重視，這樣子豐厚的社會底蘊為大膽改革全民健保制度以因應 21 世紀全民健康保險所面臨的挑戰提供必要性和合理性。這一份「醫療體系永續性及韌性合作夥伴台灣報告」發表的正是時候，我們可以藉此一報告的內容為基礎來針對台灣醫療體系改革議題來展開廣泛深入的社會對話，提出新政策來建構更好的健康照護體系做出貢獻。
詹長權
國立臺灣大學公共衛生學院全球衛生學位學程特聘教授
亞太堅韌研究基金會董事
Overall, Taiwan’s health system is designed to feature wide coverage, high affordability, high efficiency, and effective budget control. Taiwan’s National Health Insurance (NHI) system, a single-payer health system administered by the National Health Insurance Administration (NHIA), is a high-performance model compared with those of other countries, exemplified by universal health coverage and increasing life expectancy. The system has served as the foundation for Taiwan to weather public health emergencies. Taiwan’s ability to learn from past experiences and its pursuit of digitalization in healthcare service administration enabled its swift response to the COVID-19 crisis in 2020, which was extolled by international society.
Despite these strengths, structural challenges to the resilience of the health system remain; the NHI has become inefficient in adapting to the changing demographics and aging society. In subsequent waves of the pandemic, Taiwan’s health system produced suboptimal results, demonstrated by the increasing death toll and the reversal from increasing to decreasing life expectancy over the past two years. This reflects structural deficiencies that restrict Taiwan’s potential to provide its population with sustainable, high-quality care in the long term.
As part of the Partnership for Health System Sustainability and Resilience (PHSSR), this report contributes to an international research effort to enhance global health and facilitate regional dialogue by using a research framework originally developed by the London School of Economics and further adapted for the Asia-Pacific region by the Center for Asia-Pacific Resilience and Innovation (CAPRI), the Asia-Pacific research hub of PHSSR. This report reviews the strengths and weaknesses of the health system through a lens of sustainability and resilience, as well as draws lessons from the COVID-19 pandemic, to provide recommendations for improvement across seven domains: population health, environmental sustainability, workforce, medicines and technology, service delivery, financing, and governance.
Taiwan has made remarkable progress in improving population health, with an average life expectancy of 79.84 years – one of the highest in the world. Yet, Taiwan faces challenges from an aging population and a rising incidence of chronic diseases, which have caused increased mortality and stressed healthcare resources. The COVID-19 pandemic underscored Taiwan’s health inequities; most people affected were older adults (i.e., aged 65 years or older), those with preexisting conditions, and people in indigenous communities with limited healthcare access. Although Taiwan’s rapid pandemic response helped contain COVID-19 in its initial stages, subsequent waves diverted resources from non-COVID-19 healthcare needs. This resulted in rising excess mortality, reflecting broader health system issues for long-term population health.
Climate change in Taiwan has caused temperature increases, altered precipitation patterns, and increased the frequency of extreme weather events. This has impacted health in terms of increased heat-related illnesses, respiratory issues, and infectious diseases. Although Taiwan has initiated greater efforts to combat climate change, the healthcare sector’s response has been slow. Hospitals contribute significantly to greenhouse gas emissions, necessitating policy monitoring and eco-friendly practices. The COVID-19 pandemic reminded people that the One Health approach should be emphasized when facing the threat of zoonotic diseases. Taiwan has strengthened its infectious disease reporting system across animal health and environmental surveillance, but challenges, such as limited interagency collaboration, remain.
Taiwan’s healthcare system faces workforce challenges. In particular, nurses experience high risk, high stress, low pay, and long hours, leading to a declining practice rate. Limited funding for hospitals affects hiring, resulting in overworked staff and high turnover. Meanwhile, physicians are unevenly distributed between rural and urban areas, which creates inequitable care across communities. During the COVID-19 pandemic, the government provided financial support and subsidies to maintain the health workforce, but long-term cost concerns persist. Short-term funding does not resolve chronic underinvestment in talent. Enrollment in nursing programs has also dropped significantly, which may cause future workforce challenges.
Taiwan’s adoption of new medicines and technologies in its healthcare system involves two processes: market review by the Taiwan Food and Drug Administration and inclusion in the NHI payment list by the NHIA. Despite adherence to international standards, the adoption of new medicines and technologies is hampered by NHI budget constraints, insufficient investment, and insufficient review capacity, thereby affecting patient access to breakthrough drugs and treatments. Hesitancy over the use of generic drugs limits treatment to the more expensive and limited supply of name-brand drugs. Vaccine shortages during the COVID-19 pandemic highlighted the weaknesses of the Taiwanese health system regarding timely access to essential drugs and technology. Although Taiwan developed a domestic COVID-19 vaccine, its approval process raised transparency concerns. Nevertheless, traditional Chinese medicine was effective in treating mild COVID-19, showcasing Taiwan’s strength in integrating traditional with Western medicine.
Taiwan’s healthcare service delivery is marked by high accessibility and efficiency but faces challenges of limited healthcare resources such as acute care beds and advanced medical equipment. The private sector dominates healthcare, and public hospitals must be self-sustaining; this fosters competitiveness but hinders integration in service delivery. The health system struggles with chronic disease management and provides lower quality of care for chronic conditions. The COVID-19 pandemic caused delays in medical care and revealed challenges in resource coordination, especially for older people, who accounted for 80% of COVID-19 deaths. Many had underlying chronic conditions, which required integrated care and prevention. The fragmented nature of care delivery contributes to gaps in managing chronic diseases.
Financing is essential for sustaining healthcare delivery. A major issue in Taiwan’s health system is underinvestment in long-term health outcomes; short-term spending is viewed as a cost rather than an investment. This hesitancy toward investment limits innovation. Taiwan’s global budget payment system effectively controls the cost of healthcare. However, the fixed budgets do not allow for adjustments to meet evolving healthcare needs or technological advancements over time, limiting institutions’ ability to invest in the future. This financing system incentivizes quantity over quality of healthcare supply and hinders collaboration, leading to fragmented care. Underinvestment has also affected pandemic readiness, necessitating ad hoc budgets for COVID-19 relief. Moreover, Taiwan lacks long-term care insurance, relying on immediate government spending. Efforts to strengthen postpandemic resilience must include significant budget allocation to ensure sustainable health system financing.
Taiwan’s healthcare system is highly accessible and ranks well globally but lacks clear long-term goals. Facing global geopolitical and climate risks, Taiwan must develop a more creative and inclusive approach for health system governance. Balancing different health system values, such as economic development and equity, is challenging but necessary. Transparency issues and debates over prioritization of different social values has somewhat eroded public confidence in the health system. Nevertheless, there is a growing consensus on the need for a proper legal framework to govern health decisions. A democratic process is crucial for long-term health system sustainability.
Taiwan’s experiences during the COVID-19 pandemic demonstrated the overall resilience of its health system but exposed the following critical structural challenges that threaten its sustainability. First, lack of strategic planning on national health and inadequate interministerial coordination lead to a health system that favors short-term needs over long-term planning for future success. Second, workforce shortages and burnout among healthcare professionals has resulted from insufficient financial and operational investment in health system capacity. Finally, ineffective coordination among different components in the health system results in fragmented care services across specialty areas and a dearth of patient-centered healthcare.
To overcome the aforementioned challenges, this report proposes the following major policy recommendations aimed at transforming Taiwan’s health system across the seven domains into a sustainable system that benefits the population and demonstrates greater resilience in preparing for future public health crises.
First, the Ministry of Health and Welfare (MOHW) and the National Health Research Institutes (NHRI), the public think tank supervised by the MOHW, should streamline data collection and interpretation across different components of the health system to produce regular analysis and provide recommendations to update the national health strategy. The Executive Yuan should establish an independent unit responsible for leading subsequent policy coordination.
Second, additional financial and human resources should be allocated to the health system to provide necessary incentives for healthcare workers and build capacity to meet the increasing healthcare demands. Such investments include salary subsidies and training programs for healthcare workers.
Third, the MOHW should lead a multipronged approach at an operational level to facilitate coordinated, patient-centered care. This includes building a well-being-oriented healthcare data platform, enhancing alliances across healthcare institutions for scalable service and encouraging payment innovation for patient-centered healthcare.
To implement these recommendations, the government must not only develop a sustainable scheme to finance the NHI and allocate budget for additional institutional setup but also actively engage public communication channels to explain the cost–benefit calculation behind such schemes to wider society. The government must take a forward-thinking approach toward healthcare expenditure as an investment in the long-term resilience of society.
For Taiwanese society, consensus is crucial for the health system’s strategic goal of managing population health instead of managing patients. This requires targeted engagement with the public and education campaigns on preventive health and healthy lifestyles.
With small population groups scattered across vast distances, the Pacific Islands Countries and Territories (PICTs) face several unique and interconnected developmental challenges, including unreliable and expensive transport, small and fragile economies, and vulnerability to climate change and natural disasters, as well as resource limitations and human resource constraints. These factors hinder sustainability and resilience not only in health but also in economic development and climate change response. Despite these obstacles, most islands have been working toward achieving universal health coverage (UHC), focusing appropriately on primary healthcare and public health while also engaging in strong regional collaboration to meet international standards for population health and health promotion.
As part of the Partnership for Health System Sustainability and Resilience (PHSSR), the present report contributes to an international research effort to enhance global health and facilitate regional dialogue by using a research framework developed by the London School of Economics and further adapted for the Asia-Pacific region by the Center for Asia-Pacific Resilience and Innovation (CAPRI), the Asia-Pacific Hub of PHSSR. This report provides an overview of health systems in the Pacific region, focusing on the three countries: the Republic of the Marshall Islands (RMI), the Kingdom of Tonga, and the Republic of Vanuatu. Across seven domains of population health, environmental sustainability, workforce, medicines and technology, service delivery, financing, and governance, this report highlights the strengths and weaknesses of health systems in PICTs and proposes policy recommendations at the national, regional, and global levels.
Population health has improved in recent years among PICTs, with declining death rates and an average life expectancy at birth of 69 years in 2021. However, life expectancy at birth in some island nations has plateaued or declined due to noncommunicable diseases (NCDs). Despite a median population age of 20–30 years, the burden of NCDs remains significant, accounting for three-quarters of premature and preventable deaths. Rates of obesity and people who are overweight in PICTs are among the world’s highest. Although there is notable regional commitment to NCD prevention and control, such as the “Healthy Islands” vision and the Pacific NCD Roadmap, as well as local initiatives, such as Tonga’s taxes on unhealthy foods, more resources are required to fully implement national and regional plans to achieve global and regional NCD targets. Additionally, other health challenges, such as injuries and infectious diseases, have resulted in a triple burden of disease affecting population health. Fortunately, most PICTs had low case and mortality rates during the COVID-19 pandemic, despite substantial impacts of the pandemic on routine healthcare delivery.
The climate crisis is the most important threat to the lives and livelihoods of people in the Pacific Islands, despite their minimal contribution to global greenhouse gas emissions. These areas face severe weather events, water scarcity, rising sea levels, increasing ocean temperatures, and ocean acidification, all of which have adverse impacts on both livelihoods and health. Reduced fishing and agricultural yields, for example, have led to increased reliance on imported and highly processed foods, contributing to the rise in NCDs. A rise in vector-borne diseases and pollution also threatens health, while persistent natural disasters and the threat of displacement take a toll on mental health in island communities. While Pacific leaders have consistently advocated for more action from major polluters and recognition of losses and damage to their communities, proactive policy measures, such as Fiji’s health plan, are still required in more PICTs.
Ensuring the appropriate number of trained healthcare workers (HCWs) to sustainably meet current and future healthcare needs is a critical challenge in the Pacific region. These shortages are driven by a mix of “push” factors (e.g., heavy workloads, low compensation, lack of professional development opportunities, and challenging working conditions in the Pacific Islands) and “pull” factors (e.g., higher remuneration, better working conditions, and greater opportunities for advancement abroad). HCW shortages disproportionately affect rural and outer island communities. Consequently, residents of PICTs often rely on healthcare by visiting medical teams from Pacific Rim countries or traveling to these countries to access healthcare. Although some strategies aimed at retaining HCWs, such as bonding students to government services, have shown limited success, other promising initiatives, such as deploying various types of HCWs in primary healthcare settings, are beginning to emerge.
Health infrastructure in many PICTs is dated and fragile, often lacking the necessary equipment for comprehensive care, leading to reliance on development partners for funding and equipment donations. Additionally, limited budgets for pharmaceuticals in these regions result in inconsistent medication supplies, prompting patients to seek medications from the internet, family members abroad, or donations from development partners. While telehealth holds promise for healthcare accessibility, it is limited by poor internet connectivity and a lack of digital literacy. Although the establishment of the Pacific Health Information Network demonstrates a regional commitment to health information systems, most nations still lack well-functioning systems for data collection and management.
RMI, Tonga, and Vanuatu are making strides toward achieving UHC by offering government-provisioned healthcare services to residents for free or with minimal copayments. However, delivering healthcare in the Pacific Islands presents unique challenges and high costs due to dispersed and isolated communities, and more effort is required to attain true UHC. Typically, healthcare systems in these nations are structured around primary health and public health services delivered through public healthcare centers, district or regional hospitals, and referral hospitals located in the capital cities, although a small private healthcare sector exists. Specialized services, such as for cancer, cardiology, and other surgical specialties, are inconsistently available on the islands and often rely on periodic visits by medical specialist teams from Pacific Rim nations. Residents with sufficient financial resources may also be referred for healthcare services in Pacific Rim countries.
Many PICTs allocate less than 5% of their GDP to healthcare, limiting their capacity to provide essential health services, especially in the case of Vanuatu. The exception is RMI, which allocated 13.01% of its GDP to health in 2020, one of the highest rates in the region. However, health outcomes in RMI remain comparable to those of other PICTs with lower budgets, necessitating a reassessment of healthcare expenditure. These nations rely heavily on official development assistance (ODA), foreign aid, and diaspora remittances, with limited internal revenue sources due to residents’ reliance on subsistence activities for their livelihoods. Consequently, ensuring the long-term financial sustainability of healthcare systems is a critical concern, prompting the need to explore alternative healthcare funding models. Healthcare budgets prioritize curative and treatment services, with limited funding for services such as dental care and mental health.
Governments of PICTs play a dominant role in healthcare financing and delivery. Ministers of Health are supported by permanent heads of the health service, and additional governance arrangements exist at the village and community levels. Nonetheless, short political cycles, high turnover of political leaders, interministerial accountability gaps, and inadequate funding hinder the necessary support and stability for long-term healthcare commitments. Despite these challenges, PICTs are generally regarded to have managed the COVID-19 pandemic well due to strong political leadership and support from development partners.
Although regional coordination and ODA have facilitated progress in the Pacific Islands, glaring gaps in Pacific health systems that span the seven domains impede advances in health outcomes. Governments, as the primary healthcare funders and providers, face constraints due to a low share of GDP allocated to health and limited financial resources. Consequently, many PICTs struggle to consistently deliver comprehensive care and maintain an adequate healthcare workforce, particularly in remote areas and outer islands. Moreover, the impact of the climate crisis has made the need to build resilient health systems more urgent. Ocean warming and acidification as well as shifting precipitation patterns are destabilizing fishery and agricultural systems. As a result, diets traditionally consisting of local seafood and crops are changing to include more imported, processed foods responsible for the increasing incidence of obesity, diabetes, and other NCDs that the health systems are ill equipped to respond to because funds are typically allocated to curative care.
Achieving sustainability and resilience among the Pacific Islands will depend on national, regional, and global commitments across health, economic, and ecological systems. The recommendations in this report (outlined in Table 1 below) are crucial steps toward addressing the interconnected challenges identified across the seven domains. Nationally, meeting NCD targets and accelerating UHC will involve significantly increased investments in health and a skilled workforce that can consistently deliver health services.
At the regional level, efforts to coordinate policies and advocate for the region should continue, focusing on talent circulation and accessibility to key medicines and technologies through regional and global partnerships. Collective action on climate change in the region should address mental health and well-being, especially among young people affected by high unemployment and uncertainty about the future due to climate change. This is also where global adherence to international targets to mitigate climate change will profoundly affect the Pacific Islands. Continued and consistent support from global partners across health, economic development, and environmental sustainability will be crucial for a resilient Pacific.
A Discussion on Prioritizing Health System Development in the Pacific
Four years since the start of the COVID-19 pandemic, Malaysia’s health system has proven remarkably resilient because of efforts by the Ministry of Health (MOH), as well as many actors within the health system, along with civil society, government agencies, and international bodies. As the financially and operationally strained health system recovers and transitions back to normal, the lessons learned must be integrated with critical questions on how to build, restore, and strengthen the health system’s sustainability for long-term functioning and resilience in an increasingly interconnected world.
As part of the Partnership for Health System Sustainability and Resilience (PHSSR), the present report contributes to an international research effort to enhance global health and facilitate regional dialogue by using a research framework originally developed by the London School of Economics and further adapted for the Asia-Pacific region by CAPRI, the Asia-Pacific Hub of PHSSR. This report identifies the strengths and weaknesses of the Malaysian health system, investigates its sustainability and resilience, and proposes policy recommendations across seven domains: population health, environmental sustainability, workforce, medicines and technology, service delivery, financing, and governance.
Malaysia is an upper-middle-income country; it had a life expectancy at birth of 74.8 years in 2019, among the top three of the Association of Southeast Asian Nations (ASEAN) countries. Despite this, healthy life expectancy at birth was 65.7 years (2019), as Malaysia faces challenges related to noncommunicable diseases (NCDs). Further compounding the strain of NCDs on the health system is Malaysia’s rapidly aging population and inequitable health outcomes among vulnerable populations. Although initiatives such as the National Strategic Plan for NCDs and school and community health programs have been implemented to tackle these concerns, greater crossministerial and community efforts related to education/training and long-term care are required to reduce health inequities and ensure these efforts benefit the broader community and population.
Significant efforts have been made to monitor and protect environmental quality, including that of water, air, and waste management, and the sustainability of the healthcare sector. However, Malaysia’s geography makes it vulnerable to the health impacts of climate change, such as water shortages, flooding, and droughts, and the spread of vector-borne diseases. Effective solutions require a holistic approach that leverages cooperation among ministries, accounts for how the environment affects human health, and promotes the adoption of sustainable practices in healthcare.
Malaysia faces a critical shortage of healthcare professionals, with projections indicating a deficit of over 103,000 nurses by 2030, exacerbated by uneven distribution across public–private sectors and geographies. The COVID-19 pandemic highlighted the need for flexibility in reallocating healthcare workers and involving external groups, such as the military and police, to optimize patient care and manage workforce shortages efficiently. Going forward, strategies such as task shifting offer a remedy for addressing workforce shortages; however, systematic adoption will require clear guidelines for task delineation, ensuring that healthcare professionals understand their roles and incentives for this model of care. Sustainability and Resilience in the Malaysian Health System The Partnership for Health System Sustainability and Resilience 3
Malaysia maintains rigorous processes to evaluate and approve pharmaceutical drugs and digital health services, spearheaded by the National Pharmaceutical Regulatory Agency and the Malaysian Health Technology Assessment Section. Policies such as the inclusion of generic drugs in the National Essential Medicines List promote access to life-saving medication, although local production capacity remains limited. The COVID-19 pandemic demonstrated the value of telehealth in patient care, as 500,000 patients were monitored remotely by virtual COVID-19 assessment centres, and investments in a national electronic medical record system are in progress. While these initiatives are promising, challenges such as internet access, data interoperability, and financial sustainability of innovative technology require attention.
Malaysia’s healthcare system operates on a dual healthcare service model, with public services funded by taxes and operated by the MOH and private service providers financed through out-ofpocket (OOP) payments and insurance. While both private and public facilities adhere to strict quality standards, the two sectors exhibit disparities in workforce distribution, geographical access, and service comprehensiveness and affordability. Nonetheless, the COVID-19 pandemic highlighted the system’s ability to effectively mobilize healthcare services, from establishing a rigorous national COVID-19 vaccination program to modifying workflows to address the surge in hospital capacity. The healthcare landscape in Malaysia demonstrates the potential for bridging gaps and providing quality healthcare services through public–private collaboration.
The COVID-19 pandemic strained Malaysia’s national healthcare expenditure, peaking at 5.1% of the GDP in 2021. This surge in healthcare costs was largely due to the extensive care required for patients with COVID-19, the expansion of immunization programs, and increased public health spending. As Malaysia transitions into a postpandemic world, persistently low public health spending will continue to result in a range of issues, including chronic understaffing, high workloads, and critical infrastructure shortages. Increased OOP payments and the rising costs of pharmaceuticals pose threats to the health system, particularly affecting patients with limited f inancial protection. While the MOH increased its budget by 12% in 2023 compared with 2022, it remains essential to mobilize resources from other governmental and multilateral sources and prioritize economic evaluation to justify funding in health policy planning. Moreover, conversations on social health insurance, employer contributions, and user fees are warranted to diversify funding sources, reduce the MOH’s financial burden, and encourage shared responsibility for health.
Malaysia’s healthcare system operates within an efficient and well-structured framework led by the MOH alongside various national, local, and private stakeholders. Internal mechanisms, such as quality management systems, audits, and performance monitoring frameworks, and external entities, such as the Auditor-General’s Office and the Malaysian Anti-Corruption Agency, play a role in maintaining accountability within the health system. The MOH’s Health White Paper (HWP), which was passed by the Parliament in June 2023, outlines a comprehensive 15-year roadmap to reform the healthcare system. Governance of data collection and usage, collaboration among stakeholders, and accountability in financial and resource management can be strengthened according to evolving norms and international standards.
Despite its strengths, the Malaysian health system faces critical gaps that cut across the seven domains. A lack of coordination and interoperability among actors in the health system may create silos among ministries and between the government and other segments of society. Malaysia’s dual system of private and public health services may result in discrepancies in the accessibility and affordability of healthcare, medications, and technologies. It also may cause duplication of diagnostic and treatment efforts and threatens the system’s financial sustainability. Moreover, inadequacies in the maintenance, funding, and staffing of public facilities may lead healthcare workers to experience burnout and high work burdens.
These gaps highlight the fact that complex health systems require support beyond the scope of the MOH alone. Therefore, models of health system governance and financing must evolve beyond simply providing basic healthcare and treating acute disease to promote holistic and comprehensive health services. Civil society organizations (CSOs), industry leaders, and entrepreneurs have much to offer in driving health promotion, social support, and innovative solutions in healthcare and public health, but they require infrastructure, incentives, and information to contribute to the MOH’s efforts.
In recognizing the intersections among challenges in the health system, policy approaches to address them also interact across the domains of health system sustainability and resilience. With Malaysia predicted to “graduate” from middle-income to high-income status in the next 10 years, the 2023 HWP marks the beginning of a multi-decade process of strengthening the health system in its transition from simply meeting basic health needs to promoting holistic and preventive healthcare. The recommendations in this report are outlined in Table 1 and represent crucial steps toward enhancing the sustainability and resilience of healthcare, public health, and the health system to complement the aspirations outlined in the HWP.
Among the recommendations outlined in the table, the involvement of civil society can be strengthened to promote healthy lifestyles, fill workforce gaps, and deliver care at the community level by expanding and financing the social support structures of CSOs and nongovernmental organizations (NGOs). To fully leverage the potential of data and technology in healthcare delivery and decision-making as well as enable interoperability among ministries and institutions, the availability of open data can be continually enhanced.
Technology can also be used to mobilize volunteers and social workers to support a sustainable and resilient health system in facing future challenges. Finally, disease burden projections should be integrated into health budgeting and operational planning to prepare for and address future known challenges as well as known shocks, be they environmental, economic, or health related. The following table outlines all the recommendations identified in the report, organized by domain, and presented in order of priority.
| DOMAIN 1 POPULATION HEALTH | |
|---|---|
| 1A | Integrate cross-functional and multisector approaches to health promotion into Korea’s National Health Plan |
| 1B | Enhance key performance indicators (KPIs) within the National Health Plan and other health initiatives to measure their effectiveness in addressing public health issues |
| 1C | Establish a robust system for the management of patients with rare and chronic diseases, particularly during health crises |
| 1D | Revise existing policies to combat low birth rates by considering a broader spectrum of issues affecting family planning |
| DOMAIN 2 ENVIRONMENTAL SUSTAINABILITY | |
|---|---|
| 2A | Establish a comprehensive system to assess the impact of environmental pollution on public health |
| 2B | Promote policy coherence through integrated governance across ministries and enhance regional and international cooperation to effectively address environmental health issues |
| 2C | Assess the financial implications of environmental factors on the healthcare system |
| 2D | Evaluate the impact of healthcare on environmental sustainability |
| 2E | Evaluate environmentally friendly initiatives at healthcare institutions and consider setting higher health insurance reimbursements accordingly |
| 2F | Address the potential health risks faced by residents living near medical waste incineration facilities and establish appropriate monitoring and management measures |
| 2G | Establish more specific policies regarding antibiotic use |
| DOMAIN 3 HEALTH SYSTEM WORKFORCE | |
|---|---|
| 3A | Develop a payment system that ensures appropriate compensation for highly skilled healthcare professionals in essential medical areas |
| 3B | Ensure the appropriate deployment of healthcare workers across different healthcare settings |
| 3C | Implement guidelines and regulations for the integration of APNs into the healthcare system |
| 3D | Revise healthcare education and licensure to incorporate additional training in primary care, geriatric care, and chronic disease management |
| 3E | Develop a comprehensive plan for the recruitment, training, and retention of LTC workers |
| DOMAIN 4 MEDICINES AND TECHNOLOGY | |
|---|---|
| 4A | Simplify and expedite health technology assessment procedures to reduce the time to market for innovative technologies |
| 4B | Enhance digital health literacy among vulnerable populations to enable widespread adoption of digital health infrastructure |
| 4C | Establish a centralized governing authority for chronic disease management programs |
| 4D | Clarify and refine existing standards and guidelines pertaining to the use of telemedicine |
| 4E | Institute comprehensive data protection measures |
| 4F | Support and incentivize health data standardization and exchange among healthcare institutions |
| DOMAIN 5 HEALTH SERVICE DELIVERY | |
|---|---|
| 5A | Strengthen and expand primary care infrastructure through increased funding, streamlined programs, and dedicated governances |
| 5B | Improve the LTC system |
| 5C | Promote health literacy across the population |
| 5D | Institutionalize the coordination of care between the public and private sectors, to prepare for future crises |
| 5E | Enhance preventive care services and align them with primary care and health promotion |
| 5F | Assess the efficacy of government measures to address health inequalities during the COVID-19 pandemic |
| DOMAIN 6 HEALTH SYSTEM FINANCING | |
|---|---|
| 6A | Strengthen health economic data reporting by providing comprehensive national statistics at the subcategory level and developing health finance satellite accounts |
| 6B | Diversify health insurance funding sources through increased government subsidies |
| 6C | Reform provider payment systems away from the fee-for-service approach |
| 6D | Align the growth rate of health insurance expenditures with the total government expenditure growth rate or GDP growth rate |
| 6E | Broaden the scope of Medical Aid assistance to reach more individuals |
| DOMAIN 7 HEALTH SYSTEM GOVERNANCE | |
|---|---|
| 7A | Restructure existing health system governance using a novel participatory governance framework |
| 7B | Develop community-centered health infrastructure and a collaborative primary care approach |
| 7C | Promote the harmonized use, sharing, and evaluation of medical technology and data |
| 7D | Establish a cross-institutional “control tower” for damage mitigation and prevention |
