Taiwan is a thriving democracy with a population of 23.3 million and a prosperous market economy. Taiwan’s gross domestic product (GDP) grew by 2.45% in 2022 [21]. Development of the digital infrastructure in health care is one of the Taiwan government’s major goals in the next few years [22]. Although there seems a lower overall usage of EMRs or electronic health records (EHRs) in SCS for Taiwan (71/623, 11.4%) (Figure 2), there was a noticeable increase in their usage from 2.8% (1/36) to 19.4% (20/103) from 2017 to 2022 [6]. As shown in Figure 2, Taiwan has a high percentage of CER in their SCS (410/623, 65.8%). Inversely, the trend for higher CER is not seen in the CCCS (14/51, 27.5%).

Taiwan has a robust health care system, which is reflected in the percentages describing their RWD publications. Following the creation of the National Health Insurance (NHI) in 1995, Taiwan has set a benchmark in the region with a successful universal health coverage (UHC) scheme in their health care system [23]. Enrollment in the NHI provides coverage for essential medical care and pharmaceuticals for all residents [24]. The success of this system is exemplified in Taiwan’s favorable result on the world’s health and health systems ranking in 2023 [25], on which they were placed fourth (based on the Legatum Prosperity Index that also accounts for economic and social well-being). Furthermore, most health care facilities in Taiwan upload the claims data of each visit to NHI, including patient visits, drug prescriptions, surgeries, and examinations [23]. However, Taiwan’s NHI has changed since its creation in 1995 and continues to evolve [26]. In 2007, Taiwan implemented its HTA within their Centre for Drug Evaluation to evaluate the financial suitability and clinical effectiveness of new drugs for reimbursement decisions [27]. This evolved into the formation of the Division of HTA in 2008 [28]. The high proportion of NHI drug expenses was a huge burden on Taiwan’s health care system, and there were general recommendations to have a reduction in drug expenditure [29]. As such, with this goal of reducing drug expenditures, some behind-the-counter products were delisted from Taiwan’s national Drug Reimbursement Scheme [23]. Along with this, coverage change was aimed at reshaping patient expectations and attitudes toward health. Taiwan’s vision for 2030 includes “precision health,” which places an important focus on health promotion. This concept of precision health involves using data to gather sufficient information that can be used to predict health risks and prevent diseases at the population level [30]. This vision relies on adopting descriptive RWD to produce RWE that can aid in the refinement of specific health policies that contribute to precision health and less comparative research. This also partially explains why there was a decrease in the publication of CER studies most notably from 75% in 2018 to 60% in 2022 [6]. It is worth noting that the literature search on the publication of RWE from linked databases in Taiwan was conducted in September 2022 on PubMed, and the analysis assumed a linear distribution for studies in 2017 and 2022.

Taiwan stands out as a significant contributor to RWD studies in Asia, predominantly through SCS, because it employs a diverse array of databases and holds a wealth of insurance claims data.

The key identified databases contributing to RWD publications included the following [6]:

Singapore is a prosperous nation with one of the highest GDP per capita in Asia. In 2022, Singapore’s GDP grew by 3.6% [46]. In 2023, the Singapore government announced the plan to spend US $2.5 billion on info-communications technology with the redevelopment of major hospitals [47]. Compared with Taiwan, Singapore relies on higher use of EMRs or EHRs for real-world SCS (43/80, 53.8%), which is balanced with their use of clinical registries (46/80, 57.5%) [7]. Although Singapore SCS was predominantly in CER style (54/80, 67.5%), unlike Taiwan, the percentage of CCCS publications remained relatively high (57/77, 57.1%; Figure 3).

In 2023, Singapore was regarded as top-ranking in the world’s health and health systems, 3 places ahead of Taiwan [25]. Despite emerging issues surrounding health care services and the affordability of health care, Singapore is able to achieve good health outcomes with a health index score of 86.9 through a hybrid public and private health care model that is dominated by public hospitals in the hospital sector and private clinics in the outpatient sector [25,48]. Trusted Research and Real World Data Utilization or TRUST platform stands as the cornerstone for national data exchange in Singapore by facilitating the secure and anonymized sharing of health-related RWD between public and private health care sectors [49]. The Ministry of Health (MOH) aimed to increase health care capacity to enhance health care affordability in the Healthcare 2020 Masterplan [50]. Within the MOH, the Agency for Care Effectiveness was established in 2015 as the national HTA agency with the aim of evaluating drugs for subsidization and medical technologies [51,52]. This may partially explain Singapore’s relatively high percentage of CER publications in both SCS and CCCS, particularly as these types of studies enable a comparison of different medications and health management strategies. This is further magnified by the observation that the percentage of SCS CER publications from Singapore increased from 2018 to 2023 (analysis of these publications assumed a linear distribution for studies in 2018 and 2023) [7].

The key identified databases contributing to RWD publications from Singapore included the following [7]:

India is the largest lower-middle-income country in the world and accounts for around 18% of the total population [64]. According to Nexdigm, the Indian health care industry is expected to reach more than US $610 billion by 2026, as there is a growing demand for specialized and higher-quality health care facilities [65]. Hospitals, clinical trials, telemedicine, medical tourism, medical devices, medical and diagnostic equipment, and health insurance are among the key products and services that would drive this growth [66].

Compared with Taiwan and Singapore, India has a less extensive health care system [25], which is also reflected in its comparatively lower percentage of SCS (12/81, 14.8%) and CCCS (10/52, 19.2%; Figure 4). India attracts a growing medical tourism market with a growth of 22%-25% from 2014 and advocacy for adoption of EMR across the country [67]. Among RWD databases, the studies primarily use EHR or EMR (45/81, 55.6%), with an increasing trend from 20% in 2017 to 48% in 2022 [6]. Its usage is expected to continue to rise with the National Digital Health Mission, since 2020 [68]. India has made commitments toward achieving UHC and has been producing policies and institutional changes that are directed toward increasing health coverage and access to health services [69]. Government-funded health care sector is the provider of health care to lower-income populations; however, the private health care sector is the dominant health care provider [70]. In 2020, 70% of hospital market share was controlled by private sector providers, and 63% of hospital beds were provided by the hospital sector [71,72].

India launched Ayushman Bharat—one of the most ambitious health missions ever to achieve UHC in 2018 [73]. Ayushman Bharat encompasses 2 complementary schemes, Health and Wellness Centres and the National Health Protection Scheme [69]. Along with this, there have been other initiatives to achieve UHC [69]. The Pradhan Mantri Jan Arogya Yojana scheme provides secondary and tertiary hospital care insurance to the bottom 40% of the population [68]. Previously called the “Medical Technology Assessment Board,” HTAIn, founded in 2017, is the HTA agency within the Ministry of Health and Family Welfare tasked with developing an HTA system to aid in decision-making for resource allocation at the national and state levels [74,75]. Reflecting these policy aims, the proportion of CER for SCS and CCCS was low in India but increased from 2017 to 2022 (12/81, 14.8% and 10/52, 19.2%, respectively, Figure 4), assuming a linear distribution for studies in 2017 and 2022 [6].

The key identified databases contributing to RWD publications from India included the following [6]:

Health care services in Hong Kong are provided by both private and government-funded public sectors, with public medical services provided by the Department of Health and the Hong Kong Hospital Authority (HA) [86]. Hong Kong has a well-developed health care system that ranked 14th among the health and health systems ranking of countries worldwide in 2023 [25]. Hong Kong’s system is a parallel, segmented public and private financed and provided health care, where the public sector accounted for 51% of total health expenditure and the private sector accounted for 49% in 2017/18 [87]. With the government’s commitment to provide UHC, the Drug Advisory Committee is used to evaluate and advise on new drugs listed on the Hospital Authority Drug Formulary, which is the largest public health care service provider in Hong Kong. One of the missions of the Drug Advisory Committee is to ensure equal access of patients to cost-effective drugs with proven safety and efficacy [88].

As shown in Figure 5, CER publications made up 66.3% (57/86) of SCS publications and 70.5% (31/44) of CCCS. To put these high percentages into context, the drug appraisal and review process involves an assessment of clinical evidence and health economic evidence that is then used to make recommendations on reimbursement of new drugs [89]. In Hong Kong, there has been an increase in the requirement for a systematic HTA, placing emphasis on the value and comparison of emerging and conventional drugs [88]. In line with this, there is an upward trend in the percentage of SCS CER publications for Hong Kong from 2018 to 2023, assuming a linear distribution for studies in 2018 and 2023 [7].

The key identified databases contributing to RWD publications from Hong Kong included the following [7]:

Malaysia is an upper-middle-income country with a population of about 34 million [94]. It is located at the heart of Southeast Asia and represents one of the regional hubs for information and communication technology and medical travel [95]. Digitalization of information forms across major industrial sectors will help secure Malaysia’s role in the future global economy. As of 2023, Malaysia was ranked 42nd on the health and health systems of countries worldwide [25]. Malaysia’s health care system consists of tax-funded and highly subsidized government-led services, with a fast-growing private sector [96]. Their dual-tier system consists of a government-led public sector with an existing private sector, and in 2019, their public health expenditure amounted to 52% of their total health expenditure.

Malaysia’s 2023 Health White Paper outlines a transformative masterplan for health management information and data system [97]. They aim to improve the health outcomes and well-being of Malaysians and the use of the Malaysian Health Technology Assessment, also termed as MaHTAS. HTA has been formalized in Malaysia as a central structure within the MOH since 1995 and is a trusted medical evidence source [97]. Their generation of RWD publication used registries, with no, or low contributions from other database types [7] (Figure 6). In line with other countries that use HTA, 56% (28/50) of SCS were CER, as were 54% (27/50) of the CCCS [7].

The key identified databases contributing to RWD publications from Malaysia included the following [7]:

Thailand is also an upper-middle-income country but with the second largest economy (after Indonesia) in the Association of Southeast Asian Nations (ASEAN). Its GDP in 2022 was US $526 billion [100]. Thailand has the fourth greatest number of Joint Commission International accreditation–certified hospitals after Saudi Arabia, the United Arab Emirates, and Brazil. Yet the medical expenses in Thailand are 50%-80% lower than those in Europe, the United States, and Canada [101].

On the health and health systems ranking of countries worldwide in 2023, Thailand was ranked 13th [25]. In 2020, the private health expenditure in Thailand accounted for about 71.2% of the total health expenditure [102]. Furthermore, Thailand has become internationally known for its success with UHC policy since its development in 2002 [103]. The National List of Essential Medicines is a drug reimbursement list for the public health insurance schemes in Thailand, and the Health Intervention and Technology Assessment Program is a Thai HTA agency established in 2007 that supports reimbursement decisions [104]. Thailand used a relatively low percentage of EHR or EMR warehouses in their RWD publications, with only 22% contribution in SCS publications and 16.1% in CCCS publications (Figure 7). Surprisingly, they also had a relatively low percentage of CER publications with 26.5% of their SCS being CER publications and 29% of the CCCS being CER publications [6].

The key identified databases contributing to RWD publications from Thailand included the following [6]:

Indonesia is a country of 279.5 million people and is South East Asia’s largest economy with a GDP of ~US $1.32 trillion in 2022. Ranked 97th in the 2023 health and systems ranking, Indonesia is progressing their UHC through the expansion of NHI (Jaminan Kesehatan Nasional scheme) [25,114,115]. The Indonesian government established the Indonesian Health Technology and Assessment Committee as an HTA committee in 2014 to be the center of HTA activity, and as a starting point for the development of HTA [116]. Similar to the other Solo Scholars in this study, Indonesia was responsible for a relatively low number of RWD publications [7]. Of their SCS, 28.6% (2/7) used EMR and 42.9% (3/7) were CER (Figure 8).

The key identified databases contributing to RWD publications from Indonesia included the following [7]:

Health care has been identified as one of the best industry prospects for Pakistan, a country with a population of more than 240 million and a GDP growth rate of 0.29% in 2023 [120]. Ranked 124th on the health and health systems ranking of countries in 2023, Pakistan’s health care comprises a 3-tier system of primary, secondary, and tertiary levels. The public and private sectors work together to provide the best possible care, but there have been tremendous concerns about the failure of the delivery of quality care due to various factors, ranging from inadequate infrastructure to inequitable distribution of health care facilities [121]. Of note, to our knowledge, there are currently no formal HTA programs in Pakistan [122].

These challenges are reflected in their low number of publications and, more specifically, their low number of SCS. Among the SCS, only 7.7% (1/13) were CER studies. Alternatively, due to their inadequate infrastructure, more CER was conducted in CCCS (12/18, 66.7%) (Figure 9).

The key identified databases contributing to RWD publications from Pakistan included the following [7]:

In the 2022 ASEAN Business Outlook Survey, AmCham Singapore members indicated Vietnam as the top Asia Pacific country (30%), where companies are considering expansion, followed by Malaysia (25%), Thailand (24%), and Indonesia (23%) [126]. The per capita GDP for Vietnam was US $4086 in 2022 and is meant to increase to at least US $18,000 by 2035. A large population of almost 100 million (half of which are younger than 30 years), consistent strong economic growth, and ongoing reform have created a dynamic and rapidly evolving commercial environment in Vietnam [126].

Vietnam was ranked 44th on the health and health systems ranking of countries in 2023 [25]. The Vietnamese MOH manages 3 levels of health service delivery: primary level in districts and communes, secondary level in provinces, and tertiary level in national institutions under central government control. Working within this hierarchical system, Vietnam aims to build a solid health care infrastructure from the grassroots [127]. Despite the significant progress, the health care system still faces challenges to keeping ahead of the country’s escalating population [127]. Vietnam is making significant progress toward achieving UHC and is committed to delivering UHC [127]. In 2014, Vietnam introduced the HTA, working closely with the Health Strategy and Planning Institute to facilitate its institutionalization [128].

Similar to the other Global Collaborators, Vietnam generated a low percentage of publications. However, 71.4% (5/7) of SCS and 55% (11/20) of CCCS were CER (Figure 10). Based on the literature search of RWE publications from linked databases in Vietnam conducted in May 2023 on PubMed where the analysis assumed a linear distribution for studies in 2019 and 2023, Vietnam also exhibited the most significant increase with a growth rate of 24.5% in RWD publications in the last 5 years [7].

The key identified databases contributing to RWD publications from Vietnam included the following [7]:

The health care system is shared between the public and private sectors in Philippines and was ranked 96th on the health and health systems ranking of countries worldwide in 2023 [25]. To respond to health financing gaps, the Philippines made major reforms including the passage of the Universal Health Care Law in 2019; however, there are ongoing issues with expenditure [131]. Following this passage, there were increased efforts to institutionalize HTA in the Philippines and as a result, a health technology assessment unit was set up and is under development [52]. During the time period of 2018-2023, the majority of the Philippines’ RWD publications were CCCS (19/22, 86.4%) and only 33.3% (1/3) each of SCS were CER and used EMR (Figure 11). Although the adoption of EMR for research is low and the publication count has been scanty in the last 5 years [7], the Philippines is estimated to spend approximately US $4.4 billion on digital infrastructure over the next 6 years [132].

The key identified databases contributing to RWD publications from the Philippines included the following [7]:

RWD plays a significant role in informing policy decisions across Asia. There are differing trends and patterns in the use of databases for published RWD across Asia and clear gaps in usage of warehouses across countries. However, based on the economic and health care development trends, there seems a great potential in generating fit-for-purpose RWE across distinct health care systems. Global Collaborators demonstrate a reliance on international partnerships for CCCS, due to a strategic drive to overcome infrastructural limitations. The review stresses the necessity for enhanced data-sharing strategies and more robust database integration, which are critical for countries with limited health care system resources. Furthermore, the consistent naming and use of databases, especially EMRs, are pivotal for advancing disease surveillance and RWD generation across Asia. The findings call for joint efforts by HTA agencies and stakeholders to fortify RWD frameworks, which would not only aid reimbursement decisions but also support the broader spectrum of health care stakeholders.