Hoang Van Minh, Nicola Suyin Pocock, Piya Hanvoravongchai, Kyaw Min Soe
The Association of Southeast Asian Nations (ASEAN), home to half a million people, is characterized by its diversities in geography, society, culture and economic development. The region’s healthcare systems, infrastructure and provisions differ widely. Universal Health Coverage (UHC) is a critical component of sustainable development and poverty reduction, and a key element to reduce social inequities. For these reasons, policy makers in ASEAN should advocate for UHC as one of the health priorities beyond ASEAN Economic Community 2015 (AEC 2015) Health Development Agenda. By achieving UHC in member states, the inequities within and between national populations and national workforces could be reduced. However, regional integration could potentially bring both pros and cons to countries’ efforts in achieving UHC. This briefaims to describe the progress toward UHC in the ASEAN countries and discuss how regional integration could influence UHC.
Progress toward UHC in the ASEAN countries
In the last decade, ASEAN countries have made good progress towards UHC. Healthcare services, both preventive and curative care services, have been more and more available in many ASEAN countries. Significant progress has been made in expanding the coverage of Social Health Insurance (SHI), despite the existing gaps of insurance coverage across these countries. However, SHI coverage is still very low in Cambodia (24%) and Laos (15%) while Myanmar is yet to develop its first-ever National Health Insurance.
Table: Selected UHC indicators, ASEAN countries
|Doctors, nurses and midwives per 1,000 population*||Births attended by skilled health personnel (%)*||Government spending on health as a % of total health spending, 2012||OPP as % of total health spending, 2012|
Source: World Health Statistics, 2014
Figure: Coverage of health insurance in ASEAN countries, 2012
Political commitments to UHC in ASEAN countries
The political commitments to endorse UHC have at face value been strong in the ASEAN countries. Despite the fact that policies and strategies have been established and implemented to facilitate progress toward UHC, in reality, it is difficult for policymakers to balance competing interests of the growing for-profit private sector (in most countries) and the moral imperative to ensure equal access to healthcare.
Major barriers to achieving UHC in ASEAN countries
ASEAN countries are facing several common barriers to achieving UHC, namely 1) financial constraints which are mainly due to low levels of government spending; 2) supply side constraints, which comprise of insufficient health workforce and unequal distribution of health professionals; and 3) the ongoing epidemiological transition at different stages, characterized by increasing burdens of NCDs, persisting infectious diseases, and reemerging of potentially pandemic infectious diseases.
ASEAN integration and UHC
The AEC was identified as the goal of regional economic integration by 2015. ASEAN leaders have identified healthcare as a priority sector for region wide integration. The opening of healthcare markets promises substantial economic gains but intensifies existing challenges to promote equitable access to healthcare within countries. The services sector integration goals of the AEC present the biggest challenges as well as biggest opportunities for the region. Some countries such as Singapore and Thailand have already become significant exporters of modern services in sectors such as professional services and information and communication technology (ICT), including business processing outsourcing (BPO), higher education, and health tourism. Some countries face challenges related to the opening of healthcare markets. For example, despite the golden opportunity to tap into the large market of the Indonesian population, multinational healthcare companies had shown lukewarm responses to invest in Indonesia due to the restrictions and regulations on foreign investments in the country.
Progressive liberalization of services of health professionals poses risks to health equity within and between countries. According to the Mutual Recognition Arrangement (MRA) of the AEC, physicians, nurses, and dentists are among seven selected professional groups that are free to work across member countries. Although the financial returns from this strategy seem substantial, issues of equity within UHC have become a concern due to the possibility of health worker flight from poorer regions already struggling to ensure UHC.
Another challenge posed by regional integration to UHC policies is the larger number of migrant workers whose movement will be less restricted following liberalization. Migrant workers are unlikely to be automatically enrolled in national health insurance schemes and thus may not have adequate health service access or benefits.
How can UHC be achieved in ASEAN countries?
UHC can be achieved even among low and middle-income countries by strengthening the health system, securing sustainable and equitable financing, selecting the right benefit package, and reorganizing domestic health expenditures to be used more efficiently. For ASEAN countries, UHC should be explicitly considered to mitigate deleterious effects of economic integration. Political commitments to safeguard health budgets and increase health spending will be necessary given liberalization’s risks to health equity as well as migration and population aging which will increase demand on health systems.
- ASEAN countries should focus on capacity building and technical sharing of expertise on UHC experiences, as well as health systems strengthening (HSS) and health services.
- The mobility of HRH (Human Resources for Health) in the region could be leveraged via expertise sharing, such as training on medical equipment or new technologies or health service delivery methods.
- Policymakers should also consider a policy for free or low-cost emergency health services for short-term ASEAN travelers and a basic package of health services for labor migrants.
- Social protection schemes could be designed in various ASEAN wide packages, including health insurance and elderly care, making health coverage regional. A regional health fund, into which ASEAN countries contribute based on national income levels, could be developed to contribute to disease outbreaks and surveillance.
In summary, there is potential to organize select health services regionally to improve further efficiency at the same time expand coverage of good-quality services and ensure adequate human resources. Regional cooperation in health systems operations toward UHC must be strengthened to accommodate the increased population movement between countries as well as emerging issues in global health, such as emerging infectious disease epidemics, disaster preparedness, NCDs and migration.
Immense challenges are facing ASEAN countries in ensuring UHC. The OOP payments are alarmingly high in most ASEAN countries, and countries have been unable to ensure sufficient human resources for health (HRH) and health facilities and their distribution among more disadvantaged provincial and district areas. The triple disease burden and increasing inter and intra country migration implies that flexibility and adaptation by the region’s health systems is needed. Despite verbal political commitments to UHC in most countries, actual implementation and action have been understandably slow or delayed, given the enormity of some of these challenges (e.g. integrating SHI schemes and stepwise recruitment to a unified UHC scheme in Indonesia). However, with political will and increased investment in public health systems, we believe that ASEAN has significant potential to become a force for better health in the region. Ultimately, we hope that all ASEAN citizens can enjoy higher health and safety standards, comprehensive social protection, and improved health status.
Hoang VH, Pocock NS, Chaiyakunapruk N, Chhorvann C, Ha A D, Hanvoravongchai P, Lim J, Eliseo Lucero-Prisno D III, Ng N, Phaholyothin N, Phonvisay A, Soe K M, Sychareun V et al. Progress toward universal health coverage in ASEAN. Glob Health Action 2014, 7: 25856 – http://dx.doi.org/10.3402/gha.v7.25856