Environmental preservation is not the only policy arena where debates about monetizing intangible values has arisen. The value of life saving arises in a number of contexts, including health and transportation as well as environmental policy. Today, economists routinely use a concept known as the Value of Statistical Life (VSL) to measure the value of life-saving investments. Thomas Schelling made the crucial move to this way of thinking, which stresses small mortality _risks_ rather than individual lives, with the hope to dodge the moral thicket of valuing life. But as recent policy debates have illustrated, his move only thickened it. Tellingly, interest in the subject can be traced back another twenty years before Schellings essay, to a controversy at the RAND Corporation following its earliest application of operation research to defense planning. RAND wanted to avoid valuing pilots lives, but the Air Force insisted they confront the issue. Thus, the VSL is not only well acquainted with political controversy; it was born from it.

Well-performing health systems are critical for pursuing universal health coverage and for achieving health-related SDGs. It is important to grasp key concepts such as systems approach, analysis, and thinking before taking a deeper dive into health systems. Health systems can be described in broad or restricted terms. The most widely accepted definition includes all the institutions, actors, and activities whose primary purpose is to promote, restore or maintain health. There are many health system frameworks and models of which four have been reviewed - WHO’s Health System Conceptual Framework, Control Knobs Framework, Kielmann’s and Roemer’s Health System Models. No single framework addresses all aspects of a health system. It is more useful to know the strengths and limitations, and usefulness of each in achieving a specific objective such as for description and analysis, designing system reform, or evaluation. Interventions whether system-led, programmatic or those addressing health determinants are part of the wider health system and offer the best opportunity for improving health outcomes when addressed together.

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

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

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

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

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

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

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

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

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

At the start of 1965, the Johnson administration was primed to act militarily in Vietnam. On the economic front, Secretary of the Treasury Dillon left and Johnson chose his Great Society over fiscal discipline. McNamara began to manipulate the budget to hide the true costs of military escalation. Initially, he staked his hopes on a bombing program: it would ensure civilian control, be cost-effective and quick. When political overtures failed to materialize, however, he became frustrated. In July, McNamara recommended a wholescale escalation with a tax increase and reserve call-up. Johnson chose escalation without aligning the resources to his new commitments. As a result, a rift emerged between the President and his Secretary of Defense. As the year went on, the rift widened and McNamara considered leaving. He grew impatient with the White House and State Department’s inflexibility over negotiations with North Vietnam and threw his weight behind a bombing pause.