hannahjara

Health Systems of ​Southeast Asian ​Countries

An article by Hannah Pellejo Jara

Note: This paper was originally submitted in 2018 as a comparative paper for a class requirement in my Master in Public ​Health degree, with the original title being "Health Systems of Southeast Asian Countries: A Comparative Paper". This ​paper outlines the differences and similarities in the health systems in nine countries including the Philippines, Malaysia, ​Cambodia, Laos, Vietnam, Myanmar, Singapore, Indonesia, and Thailand.

Keywords: Southeast Asian countries, non-communicable diseases, universal health care, out- of-pocket payments, ​healthcare provider

1. Introduction

Just as varied as the different countries in Southeast Asia (SEA) ​are, more so are their individual health sectors. Given the ​differences in the economic standing of each country and the ​political administration catering to the public needs, there are ​multiple ways that a country approaches issues towards health ​with specific policies generated to address specific issues. ​However, despite the vast differences, there are similar ​patterns in management and service delivery. One of the most ​important points that the SEA countries have in common is the ​fact that they have all recognized problems in their health ​system and identified solutions for these. Despite that, most, if ​not all, have problems in implementation of the said solutions ​resulting to persistence of the issues for a prolonged time. This ​is because these are caused by multifactorial problems which ​require the cooperation of the health sector (both public and ​private), the community, the individual persons, and other ​sectors of the government—a gargantuan task to achieve.

A persistent problem commonly seen in many SEA countries is ​the lack of cooperation of the private and public sectors of ​healthcare, resulting to poor integration of health information ​in the country and a poor network of communication. Even in ​the government itself, there is poor cooperation of the different ​sectors resulting in contradicting policies, parallel and ​redundant services and eventually, wasting of resources.

Global trends have also influenced how the governments cater to ​the public. One example is the rising prevalence of non-​communicable diseases (NCDs) that are equally seen in all SEA ​countries, possibly aggravated by globalization. Easily accessible ​and widespread mass media has also influenced health behaviors ​among the people. There is also more focus on maternal and child ​health across all countries with little priority for the elderly. ​However, this is expected to change given the predicted increase in ​the aged population in the coming years. Although most of the ​countries have identified the importance of strengthening the rural ​units and supporting the healthcare providers (HCPs) in these ​areas, implementation has been challenging hence the persistence ​of inequity in healthcare. Equity in healthcare is recognized as one ​of the most important pillars to achieve universal healthcare (UHC) ​but this vision has been blurred due to lack of, or inability to identify ​the specific steps needed for this to come about.

A good example is the persistence of high out-of-pocket (OOP) ​expenditures for healthcare in low to middle income SEA countries ​despite the knowledge that this brings about inequity and ​catastrophic effects to families. There is a clear desire to achieve ​the millennium development goals (MDGs) but many of these have ​proved to be too ambitious for the time period they are expected to ​be accomplished. Issues arise due to (1) lack of policies, (2) lack of ​coordination, (3) lack of awareness of the public and (4) lack of ​sufficient subsidy. Political will is a huge factor as the government is ​supposed to spearhead the contact of all sectors and the people to ​encourage participation and coordination. Without a clear, united ​political will, the issues will keep coming about.

At present, each country is trying to maximize its resources in ​the best way it knows how. Management also varies ​depending on the economic and financial status of the ​country. As some form of management works for one country, ​it has proven to be detrimental to another. A good example of ​this is the decentralization of the health sector. Malaysia ​desires devolution and sees it as a solution [2] while in the ​Philippines, it has wrecked and fragmented the health sector, ​resulting to greater inequity [6]. There are also specific policies ​and programs that arose due to specific events unique to a ​particular country. For example, there is a trend for widespread ​road traffic accidents in Thailand warranting the government ​to give it ample attention [5]. In Myanmar, they try to advance ​their disaster management due to their experience with ​Cyclone Nargis [7].

Comparison of the different health systems is best described ​using the health system building blocks by the World Health ​Organization (WHO). These will be compared with the healthy ​system approach of the Philippines to provide a glimpse of ​how we may learn from the mistakes and successes of our ​neighbors.

2. Leadership and Governance

Although most of the countries have a Ministry of Health ​(MOH) or Department of Health (DOH), leadership and ​governance can be integrated or scattered among the private ​and public sectors, non-government organizations (NGOs) and ​foreign assistances.

As previously mentioned, political will is a key factor for the ​improvement of a country’s health system. Substantial political will ​for healthcare will result to adequate government subsidy that will ​eventually improve healthcare delivery services across a country. In ​Malaysia, the government’s strong support for increasing awareness ​of one’s responsibility for health resulted to multiple platforms ​emphasizing healthy living [2]. However, there are still issues on ​different policies that are not in line with the MOH’s objectives given ​lack of coordination. This is also evident in the Philippines as the ​other departments of the government are not in line with the goals ​of DOH [6]. Since overseas Filipino workers (OFWs) are a major ​source of national income, other government branches encourage ​the export of HCPs resulting to poor health outcomes in the country ​for DOH due to lack of health workers staying. However, when there ​is a recognized importance of the government to health, health ​outcomes have a positive domino effect. In Singapore, consistent ​prioritization of the government for health has resulted to a healthier ​workforce and better healthcare with lesser expenditure [1]. The ​same is true for Thailand when the government prioritized pro-rural ​health development as a means to fight poverty [5]. Their ​government has continuously increased the budget for universal ​healthcare despite political turmoil or economic crisis, giving due ​priority to health [5]. The opposite is likewise true—the more that the ​government does not prioritize health, the more problems arise. For ​example in Myanmar, there is a low subsidization for health resulting ​in high catastrophic incidence of health expenditure to the people, ​as the government has more focus on promoting political stability ​and economic growth [7]. One of the most important points ​overlooked by some administrations is the fact that when you have ​a healthier population, you have a greater opportunity for a thriving ​economy.

Although leadership is spearheaded by the government, it ​cannot be overlooked that the people have an equally ​important role. In most SEA countries, the individual persons ​are seen more as recipients of care rather than partners. This is ​evident in the Philippines [6] and Vietnam [10] while countries ​like Singapore have inculcated the importance of individual ​responsibility for one’s health [1]. There is also a trend for ​decentralization of governance of health facilities throughout ​the country, evident in the Philippines [6] and Myanmar [7]. ​However, the health systems in these countries are not well ​coordinated; that of the Philippines is affected largely by the ​devolution of services [6]. Despite this, countries like Indonesia ​and Malaysia seek for decentralization as a perceived solution ​to issues with healthcare delivery [2,4].

3. Healthcare Financing

Financing is a huge issue for low to middle income countries ​that have a lot to improve on. This, coupled with a lack of ​political will, is the perfect formula for low government subsidy, ​high OOP expenditure, and limited financial protection for the ​people. Indeed, this is such the case in countries where health ​is not a top priority. There is consistently high OOP in countries ​like the Philippines [6], Vietnam [10], Myanmar [7] and ​Indonesia [4] while for countries with better subsidy from the ​government like Singapore [1] and Thailand [5], OOP is ​significantly lower. In Thailand, government financing is ​directly lifted from general tax, and budget requests are ​supported by evidence [5].

For countries with a lower government subsidy like Indonesia and ​Cambodia, they are highly reliant on NGOs and donor funding [4,8], ​making health program sustainability questionable. OOP health ​expenditure is mostly consumed by medications or service fees and ​health facilities. Sadly, this high OOP by the population aggravates ​inequity and decreases the likelihood of achieving UHC. Although all ​of the SEA countries have some form of social health insurance, the ​extent of coverage and financial protection greatly varies. Usually ​for countries with high OOP, there is an inverse relationship to social ​health insurance coverage—the more health services and facilities ​are covered, the less likely a person is to spend out of their pockets. ​Hence, countries like Thailand and Singapore are able to enjoy free ​or cheaper health services given the vast insurance coverage than ​their neighboring counterparts [1,5]. High OOP expenditure for ​Singaporeans reflect preference for HCP rather than lack of ​coverage [1].

4. Health Workforce

In a country, a HCP’s decision is mostly affected by (1) a desire to ​further one’s career and learning, (2) monetary compensation, (3) ​empathy for the sick, (4) non-monetary benefits and (5) current ​trends in the healthcare system.

A desire to improve one’s profession is vital as opportunities will ​keep a person interested and motivated. For governments who ​cannot provide wide opportunities for their HCPs, there is usually a ​trend to seek employment abroad or shift to other sectors that offer ​better opportunities.

This is most evident in the Philippines where a lack of ​permanent job positions in the government and private sector ​results in the huge export of HCPs abroad [6]. For Thailand, on ​the other hand, there is investment in postgraduate training of ​HCPs with the public health experts returning to the country to ​serve in high positions [5]. Monetary compensation is likewise ​crucial for sustenance, especially if the workload is beyond the ​person’s job description. Low compensation does not attract ​new HCPs and even more so for specialized professionals. In ​countries like Myanmar that have low compensation, HCPs ​turn to secondary jobs to sustain themselves and their families ​[7]. Some governments have gone to the extent to require ​doctors who are fresh graduates to have mandatory service ​like Indonesia and Thailand, to compensate for the lack in ​HCPs especially in the rural areas [4,5]. Empathy, on the other ​hand, is not ingrained in all HCPs, although it is highly ​expected to be second nature. It is an intrapersonal source of ​motivation that is not just philanthropic, but nationalistic to say ​the least.

Many professionals across different countries may choose to ​stay despite the poor compensation purely because they have ​the “heart to help”. However, this is a privilege that can only be ​enjoyed by those who have financial security and can extend ​their services beyond the monetary compensation. Others, ​although they may have the desire to help, are squeezed by ​circumstances or pressure to provide and may need to look for ​other alternatives. Non-monetary benefits like job security, ​health insurance, housing benefits, and education of their ​children may motivate HCPs to stay.

In Thailand, giving awards and recognition to outstanding health ​professionals and giving house benefits motivate the workforce to ​stay in their posts [5]. Countries like Thailand and Laos are starting ​to realize the importance of giving incentives to their healthcare ​workers as a means to help them stay. Lastly, current trends may ​affect the decision making of HCPs as the decisions and opinions of ​their colleagues, friends and even family members may affect their ​choices, resulting to a somewhat “societal pressure” to conform to ​the trend. This is difficult to battle as people who trail blaze and ​choose the “road less taken” are initially or persistently ridiculed or ​told that they may have made the wrong decision.

There is also a widespread inequity in the geographical distribution ​of healthcare workers, as the majority are concentrated in urban ​areas, resulting to limited healthcare access to the rural poor. This is ​especially evident in archipelagic countries like the Philippines [6], ​Malaysia [2] and Indonesia [4] and even non-archipelagic ones like ​Vietnam [10] and Myanmar [7]. Distribution is affected by the HCP’s ​preference depending on the stated factors above. Thailand has ​sought solutions to geographical inequity by recruiting students ​from underserved areas to study medicine on the condition that ​they return to their home after graduation and get the same quality ​of education as the privileged population [5].

5. Medical Products and Technologies

Access to medical products and technologies are highly dependent ​on financial capability as these are not commonly covered by social ​health insurances.

For countries like Myanmar and the Philippines, medication ​composes the majority of OOP payments [6] and in Vietnam, ​patients pay for all drugs and material costs [10]. Hence, there ​are countries that turn to traditional medicine since these are ​cheaper. Luckily for some, the government is very supportive ​for growing herbal medicines like Myanmar [7], Cambodia [8], ​Indonesia [4] and Laos [9]. However in the Philippines, ​traditional medicine has not completely come to full fruition as ​there is high preference for western medicine. Generic ​medicines have also attracted the public, especially the poor ​as they are more affordable. In the Philippines, however, ​physicians prefer to have the autonomy to choose if they will ​prescribe branded or generic drugs [6]. Supplies in health ​facilities are also limited in the Philippines and other low to ​middle income countries in the SEA region due to limited ​government allocation— the largest percentage of the budget ​of government hospitals in the Philippines go to salaries ​(14.63% in 2005) and only 0.33% for capital outlay [6]. However ​in countries like Singapore, equipment and facilities are more ​advanced [1]. Political will of hospital administrators play an ​important role since prioritization of upgrading equipment ​requires a greater budget allotment. In the end, if there is ​inadequate government allotment for health products and ​better equipment, access will depend on one’s financial ​standing.

6. Information and Research

If the health system is fragmented, chances are the health ​information is fragmented as well.

This results in multiple problems, especially in redundancy of ​services or decreased sustainability of health programs as one ​provider is unable to endorse to the succeeding provider. Many SEA ​countries are faced with the difficulty of having an integrated health ​system network or information system that involves both the public ​and private sectors.

For Vietnam, the private sector is not obligated to report to ​authorities hence, the incomplete information system [10]. This ​shares similarities with Myanmar as the national health information ​system is only limited to the government sector with a lack of ​systematic reporting and documentation in instances of adverse ​events [7]. In Laos, within the government there is fragmented data ​since each health program has its own mechanism for reporting [9]. ​In Cambodia, there are no formal linkages between the public and ​private sectors [8]. In the Philippines, although the private sector is ​well represented in advisory committees to the government, there is ​still poor integration of health information systems [6]. This common ​trend for lack of integrated health information results in fragmented ​service delivery, and a lack of a clear picture of the true complete ​health state of the country. Although SEA countries have ​recognized the importance of close collaboration and an integrated ​system, achieving this is not as easy as it looks as radical changes ​will be made in systems that have been used for several years and ​would require additional training of HCPs or hospital personnel. This, ​as well, needs significant funding which may not be attractive for ​everyone’s participation. Personality or viewpoint differences may ​also affect and may make 100% participation difficult—if not ​impossible— to achieve.

7. Service Delivery

Service delivery, as seen in previously, highly depends on the ​other building blocks. An unmotivated health workforce will ​worsen the service delivery. Poor leadership will result to lower ​subsidy or financing and prioritization and therefore, a ​compromised health service delivery. Presence of policies do ​not necessarily mean an efficient service delivery but even ​more so for lack of policies, where service delivery is not ​justified nor supported by the government. Decreased ​availability of up-to-date equipment will result to poor quality ​of service. A limited information system will result to ​fragmented and redundant services. There are also other ​factors like the incidence rate of communicable or non-​communicable diseases and even culture and beliefs of a ​portion of the population. For example in Indonesia, long term ​care is not developed properly due to a culture of families ​taking care of a chronically sick family member [4]; in Myanmar, ​religious influence of Theravada Buddhism has encourage ​people to engage in relief services [7]. For Malaysia, the ​increased incidence of NCDs have resulted to a shift in focus ​from curative to wellness and health maintenance [2]. Some ​countries have the private sector as the dominant one, e.g., ​Cambodia [8] and the Philippines [6], while in others, the public ​sector is more dominant (e.g., Thailand [5]). Geographical ​inequalities in workforce distribution also has a negative effect ​as more urban areas have better health access than those in ​the outskirts. To equalize this, efforts have been created to ​establish telehealth systems, for example in Malaysia [2].

In the Philippines, service delivery is also fragmented as there is no ​established referral system, resulting to bypassing of the primary ​level and overcrowding in hospitals [6]. Service delivery is also ​influenced by the level of participation or involvement of the ​different stakeholders. Service delivery is different for countries with ​a more proactive population that is more responsible for their ​individual health than a population who heavily relies on HCPs to ​make the decision for them.

8. Health Maximization: An ethical health issue

Given the pattern of inequity in SEA countries, especially in the low ​to middle income countries, it is unlikely that health is maximized in ​the public. For many of the countries, those who have better ​financial standing and live in urban areas are more likely to have ​greater health service utilization than the rural poor. The persistence ​in inequity due to lack of prioritization of health and a strong reliance ​on OOP health financing becomes unethical, as only the rich few ​are able to avail of the majority of services (e.g., in the Philippines, ​the dominant private sector that hires 70% of the HCPs only caters ​to 30% of the population [6]). This is a strong ethical issue that ​needs to be dealt with by the government as the lack of health ​maximization will result to a sickly population which will be costlier ​and have graver consequences to the country’s economy.

9. Conclusion

Regardless of the imperfections in the health systems of the ​SEA countries, efforts have been made to correct and improve ​the different health system building blocks of each country. ​Hopefully, a greater knowledge of the similarities and ​differences can also help generate ideas and programs that ​may be applicable across countries with slight cultural ​variations.

Hannah Jara is a current MBA student

at the Asian Institute of Management in

the Philippines. She has worked for over five

years in government and private organizations

related to public health. She obtained her

Master in Public Health from the University of

the Philippines Manila.

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