The world is emerging from the COVID-19 pandemic with a renewed focus on health. The tragic loss of life and immeasurable impact on human health worldwide will take many years to be fully understood, but it is clear that many health systems were stretched to a breaking point; reforms will be needed if we are to be better prepared for future shocks. The Asia-Pacific region, bearing the initial brunt of the pandemic, remains vulnerable to ongoing challenges but offers valuable solutions and lessons for the global community.
Painting a comprehensive picture of an entire geographical region is always precarious with no two countries ever experiencing the exact same set of conditions. The vast expanse of the Asia Pacific, as classified by the World Bank under East Asia and Pacific, introduces inherent variations, especially in economic development; the region has some of the highest income economies in the world (e.g., Japan, South Korea) and others that fall into the lowest quartile (e.g., Cambodia, Solomon Islands). This economic disparity will naturally result in significant variation in the health systems of each territory.
However, in characterizing the common problems and solutions, the connections both within and beyond the region become increasingly evident. For example, healthcare workforce shortages are partly driven by “brain drain” between countries and regions, and digital health solutions have the potential to alleviate these shortages. Moreover, amid shared challenges, the distinctive responses from both the region as a whole and individual countries provide valuable learning opportunities for the global community, highlighting the need for pan-regional collaboration to build more sustainable and resilient health systems.
The Partnership for Health System Sustainability and Resilience (PHSSR) has conducted an in-depth examination of health systems in the region, resulting in published country-level reports on Japan, Republic of Korea, Malaysia, the Pacific Islands (with specific attention to the Republic of Marshall Islands, Tonga, and Vanuatu), Taiwan, and Vietnam. The selection of these areas is purposeful, strategically capturing a spectrum of economic classifications, including examples of high, upper-middle and lower-middle income economies. Furthermore, the chosen areas exhibit diverse geographical characteristics that influence climate-related issues, underscoring the need for adaptable and resilient health systems.
Syaru Shirley Lin
Chair, CAPRI
Minah Kang
Professor, Department of Public Administration, Ewha Womans University
Swee Kheng Khor
Chief Executive Officer, Angsana Health
Feng-jen Jean Tsai
Director and Professor, PhD and Master Program in Global Health and Health Security, Taipei Medical University
Collin Tukuitonga
Associate Dean, Health and Medical Sciences Faculty, University of Auckland
The world is emerging from the COVID-19 pandemic with a renewed focus on health. The tragic loss of life and immeasurable impact on human health worldwide will take many years to be fully understood, but it is clear that many health systems were stretched to a breaking point; reforms will be needed if we are to be better prepared for future shocks. The Asia-Pacific region, bearing the initial brunt of the pandemic, remains vulnerable to ongoing challenges but offers valuable solutions and lessons for the global community.
Painting a comprehensive picture of an entire geographical region is always precarious with no two countries ever experiencing the exact same set of conditions. The vast expanse of the Asia Pacific, as classified by the World Bank under East Asia and Pacific, introduces inherent variations, especially in economic development; the region has some of the highest income economies in the world (e.g., Japan, South Korea) and others that fall into the lowest quartile (e.g., Cambodia, Solomon Islands). This economic disparity will naturally result in significant variation in the health systems of each territory.
However, in characterizing the common problems and solutions, the connections both within and beyond the region become increasingly evident. For example, healthcare workforce shortages are partly driven by “brain drain” between countries and regions, and digital health solutions have the potential to alleviate these shortages. Moreover, amid shared challenges, the distinctive responses from both the region as a whole and individual countries provide valuable learning opportunities for the global community, highlighting the need for pan-regional collaboration to build more sustainable and resilient health systems.
The Partnership for Health System Sustainability and Resilience (PHSSR) has conducted an in-depth examination of health systems in the region, resulting in published country-level reports on Japan, Republic of Korea, Malaysia, the Pacific Islands (with specific attention to the Republic of Marshall Islands, Tonga, and Vanuatu), Taiwan, and Vietnam. The selection of these areas is purposeful, strategically capturing a spectrum of economic classifications, including examples of high, upper-middle and lower-middle income economies.[i] Furthermore, the chosen areas exhibit diverse geographical characteristics that influence climate-related issues, underscoring the need for adaptable and resilient health systems.
The Center for Asia-Pacific Resilience and Innovation (CAPRI), serving as the PHSSR’s Asia-Pacific research hub and having spearheaded four of the six aforementioned country-level reports,[ii] has prepared the following Asia-Pacific Summary Report. This report considers the common issues affecting health systems in the region, and is divided into four main sections accordingly:
Aging societies – Low birth rates and high life expectancies are increasing the age of populations in several Asia-Pacific countries, straining conventional healthcare systems.
Climate change – Environmental changes exacerbate health risks and threaten infrastructure, especially in island states.
Digital health – Technological advancements are reshaping care delivery, offering both opportunities and challenges in access and equity.
Healthcare workforce – Challenging working conditions and limited opportunities drive healthcare workers out of the sector and abroad, threatening care delivery.
In each section, this report demonstrates the impact of these issues on the region and highlights measures taken to overcome them, citing findings from PHSSR country-level reports, unless otherwise indicated.
The PHSSR is a nonprofit, multisector, global collaboration with a unified goal of building more sustainable and resilient health systems. It is active in over 30 countries and has published 29 reports to date on its commissioned independent research, providing evidence-based recommendations to strengthen health systems. This work, which includes country-specific findings as well as combined overarching global insights and disease-specific analysis, is conducted by experts worldwide with first-hand knowledge and experience of their national health systems.
After the pandemic, many health systems remain in a perilous state as accumulating pressures and increasing demands have reached a crisis point. The PHSSR seeks to facilitate cross-border and cross-sectoral collaboration to accelerate the strengthening of health systems by enabling international knowledge exchange and collaboration with health system stakeholders.
CAPRI is a nongovernmental, nonpartisan, international organization committed to enhancing global resilience and promoting innovative governance by drawing on the experience of the Asia-Pacific region through comparative public policy research.
CAPRI hosts the partnership’s first regional research hub, coordinating reports on the sustainability and resilience of health systems in the Asia-Pacific region. Building on previous studies of Japan and Vietnam facilitated by LSE (Table 1), in 2024, CAPRI conducted research into national health systems of Malaysia, the Pacific Islands Countries and Territories (PICTs), South Korea, and Taiwan (Table 2). This research was led by the listed research leads, and will expand to additional countries and territories in the coming years.
Table 1: 2021-2022 Asia-Pacific PHSSR country reports and research leads, coordinated by LSE
| Report | Research Lead |
|---|---|
| Japan | Hiroaki Miyata, Professor and Chair, Department of Health Policy Management, Keio University School of Medicine |
| Vietnam | Tran Thi Mai Oanh, Director, Health Strategy and Policy Institute |
Table 2: 2024 Asia-Pacific PHSSR country reports and research leads, coordinated by CAPRI
| Report | Research Lead |
|---|---|
| Malaysia | Swee Kheng Khor, Chief Executive Officer, Angsana Health |
| Pacific Islands | Collin Tukuitonga, Associate Dean, Health and Medical Sciences Faculty, University of Auckland |
| South Korea | Minah Kang, Professor, Department of Public Administration, Ewha Womans University |
| Taiwan | Feng-jen Jean Tsai, Director and Professor, PhD and Master Program in Global Health and Health Security, Taipei Medical University |
Syaru Shirley Lin is Founder and Chair of the Center for Asia-Pacific Resilience and Innovation (CAPRI), Research Professor at the Miller Center of Public Affairs at the University of Virginia, and a Nonresident Senior Fellow in the Foreign Policy Program at the Brookings Institution. She can be reached at [email protected].
Alistair Lang is a Research Coordinator at CAPRI. He can be reached at [email protected].
i The World Bank classifies economies into four income groups based on gross national income per capita data in U.S. dollars: low (<$1,135, in 2022), lower-middle ($1,136–$4,465), upper-middle ($4,466–$13,845), and high (>$13,846) income. See World Bank. World Bank country and lending groups, accessed January 22, 2024, https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups.
ii The reports on Vietnam and Japan were published by the PHSSR in 2021 and 2022, respectively, and coordinated by LSE. See Table 1 of this report for additional information.
An integrated health system consists of both personal healthcare and other important elements of public health, or nonpersonal health, which connects individuals with their communities and the environment. The health system in Taiwan is supported by both public and private institutions. Taiwan’s Ministry of Health and Welfare (MOHW) and 22 health bureaus at the city and county levels are the main administers of personal healthcare in Taiwan. Governmental health protection and promotion programs in communities, covering infectious and chronic disease control, pandemic response, vaccination, disease screening, and smoking cessation, are routinely executed to promote population health. In addition, broader areas of public health, namely occupational, environmental, and animal health, are regulated by the Ministry of Labor, Ministry of Environment, and Ministry of Agriculture, respectively.
Taiwan’s mandatory single-payer National Health Insurance (NHI) program has been the main system of personal care since 1995 and covers medical consultations and treatments by virtually all medical professionals, clinics, and hospitals for nearly all of Taiwan’s residents. It is administered by the National Health Insurance Bureau under the MOHW. NHI covers comprehensive health services including outpatient visits, inpatient care, dental care, traditional Chinese medicine, renal dialysis, and prescription drugs for Taiwan’s citizens and residents.
In Taiwan’s health system, the government is the most important player because it has a mandate to oversee the entire health system. Accordingly, a review of Taiwan’s health system needs to focus on the NHI, given that it is the de facto healthcare system. However, we should not overlook the importance of nonpersonal care in population health, as illustrated by the worldwide tragedy of the COVID-19 pandemic and the continued threat of global warming.
The COVID-19 pandemic is one of the greatest tragedies of our time, changing the world and every one of us. Taiwan has registered over 10 million cases and over 20,000 deaths by COVID-19 since 2020. Life expectancy in Taiwan decreased consecutively in 2021 and 2022 due to high rates of COVID-19 morbidity and mortality among older people and those with comorbidities, such as noncommunicable diseases (NCDs). Although the NHI has been successful in providing generous and accessible medical service, it has not fully addressed the challenges of NCDs, quality of care, shortages of doctors and nurses, issues in transparency and governance, and low national investment in health before the pandemic. These preexisting issues with Taiwan’s NHI, or even Taiwan’s health system broadly, have been exacerbated by the COVID-19 pandemic. Thus, it is time to review the NHI to make Taiwan’s health system more resilient to future public health crises. The lessons from the COVID-19 pandemic show that Taiwan’s health system needs to become more resilient to control disease spread and save lives in the current pandemic as well as future pandemics.
In this report commissioned by the Partnership for Health System Sustainability and Resilience (PHSSR), Tsai et al. provide insightful perspectives of challenges and solutions for Taiwan’s health system to achieve sustainability and resilience. Based on the common PHSSR framework that draws from the World Health Organization’s building-block approach to health systems, this report identifies needed reforms across seven domains of the health system: population health, environmental sustainability, workforce, medicines and technology, service delivery, health system financing, and health system governance. It also makes needed policy recommendations to fill gaps in Taiwan’s health system, such as establishing a policy coordination unit under the Executive Yuan, increasing financial and human resources, and promoting patient-centered care. The core purpose of NHI reforms in Taiwan is to provide more effective and better-quality care with reasonable payments to professionals and affordable costs to society, while maintaining the equity of universal healthcare across socioeconomic and geographic differences.
Reforming NHI is even more urgent than before in Taiwan, as population aging, the climate crisis, digital evolution, and the pandemic are ongoing both locally and globally. The call for governmental commitments, more resources, and more attention to people from this report reflects that the scope of healthcare in modern society is larger than the medical practice by healthcare providers; health system reform is indeed a social and political process in a democratic society.
The current state of NHI described in this report must be supplemented with a historical perspective of the system’s evolution. The launch of NHI in 1995 was timed just before Taiwan’s first democratic presidential election in 1996. In every election in Taiwan over the 30 years since then, patchwork remedies for NHI have been on the political agenda, meant to address problems of ever-growing coverage of medications, diagnoses, and treatments; fights over the global budget; the expansion of privately owned medical centers, and the implementation of co-payments and out-of-pocket payments.
The 2024 presidential election was the first time two of the three candidates were physicians, and they both campaigned to invest 8% of gross domestic product in health expenditure, bringing health system reform to the forefront of the policy debate. The prominence of public health in Taiwan’s recent policy discussion provides the legitimacy needed for bold reforms that can address the NHI’s challenges in the 21st century. This report is a timely publication to promote social dialogue and future policy discussion on health system reform in Taiwan.
Chang-Chuan Chan
Distinguished Professor, Global Health Program, College of Public Health, National Taiwan University
Board member, Center for Asia-Pacific Resilience and Innovation
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 |
