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www.thelancet.com Vol 377 January 29, 2011 429

Lancet 2011; 377: 42937

Published Online

January 25, 2011

DOI:10.1016/S0140-

6736(10)61507-3

See Online/Comment

DOI:10.1016/S0140-

6736(10)62192-7,

DOI:10.1016/S0140-

6736(10)61426-2,

DOI:10.1016/S0140-

6736(10)62143-5,

DOI:10.1016/S0140-

6736(10)62181-2,

DOI:10.1016/S0140-

6736(10)61923-X, and

DOI:10.1016/S0140-

6736(10)62140-X

This is the frst in a Series o

six papers about health in

southeast Asia

Prince of Songkla University,

Hat Yai, Thailand

(Pro V Chongsuvivatwong MD);Lee Kuan Yew School of Public

Policy, National University of

Singapore, Singapore

(Pro K H Phua PhD,

N S Pocock MSc); Institute of

Policy Studies, Singapore

(M T Yap PhD); United Nations

University and National

University of Malaysia,

Kuala Lumpur, Malaysia

(Pro J H Hashim PhD); Schulich

School of Medicine and

Dentistry, University of

Western Ontario, London, ON,

Canada (Pro R Chhem MD);

Gadjah Mada University,

Yogyakarta, Indonesia(S A Wilopo MD); and University

of Queensland, Brisbane, QLD,

Australia (Pro A D Lopez PhD)

Correspondence to:

Pro Kai Hong Phua, National

University o Singapore, Lee

Kuan Yew School o Public Policy,

469C Bukit Timah Road,

Singapore 250772, Singapore

[email protected]

Health in Southeast Asia 1

Health and health-care systems in southeast Asia: diversity

and transitions

Virasakdi Chongsuvivatwong, Kai Hong Phua, Mui Teng Yap, Nicola S Pocock, Jamal H Hashim, Rethy Chhem, Siswanto Agus Wilopo, Alan D Lopez

Southeast Asia is a region o enormous social, economic, and political diversity, both across and within countries, shapedby its history, geography, and position as a major crossroad o trade and the movement o goods and services. Theseactors have not only contributed to the disparate health status o the regions diverse populations, but also to the diversenature o its health systems, which are at varying stages o evolution. Rapid but inequitable socioeconomic development,coupled with diering rates o demographic and epidemiological transitions, have accentuated health disparities andposed great public health challenges or national health systems, particularly the control o emerging inectious diseases

and the rise o non-communicable diseases within ageing populations. While novel orms o health care are evolving inthe region, such as corporatised public health-care systems (government owned, but operating according to corporateprinciples and with private-sector participation) and fnancing mechanisms to achieve universal coverage, there are keylessons or health reorms and decentralisation. New challenges have emerged with rising trade in health services,migration o the health workorce, and medical tourism. Juxtaposed between the emerging giant economies o Chinaand India, countries o the region are attempting to orge a common regional identity, despite their diversity, to seekmutually acceptable and eective solutions to key regional health challenges. In this frst paper in the LancetSeries onhealth in southeast Asia, we present an overview o key demographic and epidemiological changes in the region, explorechallenges acing health systems, and draw attention to the potential or regional collaboration in health.

IntroductionSoutheast Asia consists o the ten independent countrieslocated along the continental arcs and oshore archi-

pelagos o AsiaBrunei, Singapore, Malaysia, Thailand,the Philippines, Indonesia, Vietnam, Laos, Cambodia, and

Myanmar (Burma) (gure 1)collectively known as theAssociation o Southeast Asian Nations (ASEAN). Theregion contains more than hal a billion people spread over

highly diverse countries, rom economic powerhouses likeSingapore to poorer economies such as Laos, Cambodia,

Key messages

Thediversityofgeographyandhistory,includingsocial,

cultural, and economic dierences, have contributed to

highly divergent health status and health systems across

and within countries o southeast Asia.

Demographictransitionistakingplaceatamongthe

astest rates compared with other regions o the world,

whether in terms o ertility reductions, population ageing,

and rural-to-urban migration. Rapid epidemiological

transition is also occurring, with the disease burden

shiting rom inectious to chronic diseases. Rapidurbanisation,populationmovement,andhigh-

density living raise concerns about newly emerging

inectious diseases, but these outbreaks have stimulated

regional cooperation in inormation exchange and

improvement in disease surveillance systems.

SoutheastAsiaspeculiargeologycontributestoitbeing

the most disaster-prone region in the world, more

susceptible to natural and man-made disasters aecting

health, including earthquakes, typhoons, oods, and

environmental pollution. Climate change along with rapid

economic development could exacerbate the spread o

emerging inectious diseases.

(Continues on next column)

(Continued rom previous column)

Healthsystemsintheregionareadynamicmixofpublic

and private delivery and nancing, with new

organisational orms such as corporatised public

hospitals, and innovative service delivery responding to

competitive private health-care markets and growing

medical tourism.

Thehealth-caresystemsarehighlydiverse,rangingfrom

dominant tax-based nancing to social insurance and

high out-o-pocket payments across the region. There is a

greater push or universal coverage o the population, butmore needs to be done to ensure access to health services

or the poor.

Privatehealthexpenditureisincreasingrelativeto

government expenditure, where new orms o nancing

include user charges, improved targeting o subsidies,

and greater cost recovery. Health-care nancing could be

urther restructured in response to uture demographic

shits in age-dependency, as in introduction o medical

savings and social insurance or long-term care.

Thereispotentialforgreaterpublic-privateparticipation

with economic growth through ASEAN integration and

urther regional health collaboration, despite the current

division o the region under two WHO regional ofces.

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430 www.thelancet.com Vol 377 January 29, 2011

and Myanmar (table).17 By comparison with India andChina, southeast Asia is less visible in global politics andeconomics. The same is also true o global health.

In the rst paper in this Lancet Series on health insoutheast Asia, we analyse the key demographic andepidemiological transitions o the region to delineate thechallenges acing health systems and to emphasisepotential or regional collaboration in health. Thisregional overview sets the scene or more detaileddiscussion o specic health issues presented in the vesubsequent reports in this Series, proling maternal andchild health,8 inectious diseases,9 non-communicable

diseases,10 health workorce challenges,11 and health-care

nancing reorms.

12

Population and health transitionUrbanisationSoutheast Asia contains about 600 million people, or 9%o the worlds population, with Indonesia having thelargest population (and ourth largest in the world) andBrunei the smallest (see table). Nearly hal (43%) o theregions population live in urban areas, which is less thanthe world average, but there is much variation betweencountries, rom 15% in Cambodia to 100% in Singapore.The regions average population density o 133 people perkm also masks substantial intercountry and in someinstances intracountry dierences. Population densities

range rom a low o 27 people per km in Laos to a high o7022 per km in Singapore.16 Population densities insoutheast Asias only two megacities, Jakarta and Manila,are much higher, at more than 10 000 people per km.17Although their population sizes are similar (around14 million), the greater sprawl o Manila and Jakarta makethem less densely populated (ranked 15th and 17th in theworld) than Mumbai and Delhi (ranked 1st and 13th,respectively). The next largest city in southeast Asia,Bangkok, is ranked 39th. Although urbanisation isexpected to continue to rise in the region, urban slumpopulations seem to be less deprived than they areelsewhere, with about a quarter living in extreme shelterdeprivation (dened by UN Habitat as a slum householdlacking three or more o the ollowing conditions: accessto water, access to sanitation, access to secure tenure, adurable housing structure, and sucient living space).18,19

Trends in mortality and ertilityAlthough lie expectancy in all countries in the region hasimproved, there have been signicant variations in therate o progress. Most countries have enjoyed continuousrises in lie expectancy since the 1950s, and these areconverging. In some cases (Myanmar, Cambodia) politicalregimes and history o conict have aected progress, ashas HIV in Thailand (gure 2). Where lie expectancygains have slowed, this trend has been mainly attributable

to slow progress in reduction o adult mortality.15 Therehas been little progress towards reduction o intercountrydierence in lie expectancy during the past 50 years, withthe gap remaining at around 20 years.

As elsewhere, decreased ertility has been the mainactor contributing to ageing o the populations in thesecountries. The speed and timing o ertility reduction hasvaried widely across the region (webappendix p 1).Singapore had the earliest and sharpest reductionthetotal ertility rate ell rom more than six children perwoman in 1957 to 21 in the mid-1970s, and since 2003, ithas ranked among countries with ultra-low ertility(table).20 Thailands ertility decrease mirrors that oSingapore, although beginning somewhat later; it iscurrently the only other country in the region withFigure 1: Southeast Asia

M A L A Y S I A

I N D O N E S I A

PAPUA

NEW GUINEA

C H I N A

PHILIPPINES

THAILAND

VIETNAMCAMBODIA

LAOS

BRUNEI

TAIWAN

SINGAPORE

Irra

wadd

y

Meko

ng

Sa

lw

een

Ch

ang

J iang

E

A

S

T I N D IE

S

E a s tC h i na

Se a

S o u t h

C h i n aS e a

C e l e b e s

S e a

P

h

i

l

i

p

pin

eS

eaBangkok

Kuala Lumpur

Bandar Seri Begawan

Jakarta

Ho Chi Minh

Shanghai

Manila

PhnomPenh

Pontianak

Tai-pei

Yangon

Hanoi

Hong Kong

Da Nang

Vientiane

Wuhan

Hue

Xian

Moulmein

MYANMAR

Search strategy and selection criteria

We used quantitative and qualitative data rom academic and

grey literature to review the health situation in southeast Asia.

Search terms used were health, health statistics, health

systems, socio-economic development, and southeast

Asia. Data were gathered ater a call or inormation rom

regional experts on selected subthemes related to health

(geography, history, demography, epidemiology, and health

systems). Data collection took place between June, 2009, and

June, 2010. Quantitative data were retrieved rom databases

o WHO, the World Bank, and the UN Population Fund, as well

as rom the scientic literature. Qualitative inormation was

retrieved rom grey literature (eg, WHO reports) as well as

academic literature, including a mix o peer-reviewed journal

articles and book chapters rom established publishers. Datawere critically appraised and analysed to elaborate trends,

projections, and associations between socioeconomic and

population health measures.

See Online or webappendix

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lower-than-replacement ertility. Vietnam, Brunei, andIndonesia all have close to replacement-level ertility.Total ertility rates in Laos, Cambodia, and the Philippinescontinue to exceed three children per woman.

Rapid socioeconomic development and strong amilyplanning programmes are likely to have driven thisreduction. Interestingly, this statement was true orIndonesia, but less so or Brunei and Malaysia, althoughall three countries share a common dominant religion,Islam.21 Malaysia adopted a pronatalist policy in the late1970s under the then Prime Minister MahathirMohammad.22 Catholicism has been a major contrib-uting actor to the slow uptake o amily planningprogrammes in the Philippines, alongside the persistenceo cultural norms that support large amily sizes. 23

The high ertility rates recorded in Cambodia and Laosare related to low educational levels, as reected in theirlow proportion o enrolment in secondary school2544%compared with 6190% elsewhere in the region (including72% in Vietnam).24 According to Cleland,25 although

literacy coners cognitive abilities to use contraception,the social and psychological skills conerred by highereducation probably enable people to translate the desireto postpone or limit childbearing into contraceptivepractice [and] they are also more likely to use allopathichealth services or a range o needs including ante- andnatal-care, child immunization and curative care [thatlead to better child survival].

MigrationEconomic and demographic developments have promptedthe movement o people across the region, mainly orshort-term employment, but also or settlement.26 Rapideconomic growth and the slowing o domestic populationand labour orce growth due to ertility reduction have

prompted countries such as Singapore to open its doorsto in-migration o oreigners at all skill levels oremployment, with the option o permanent settlementor the highly skilled. The Philippines, Indonesia, andVietnam are major labour-exporters, whereas Malaysiaand Thailand both receive and send nationals abroad.Besides this internal labour market, countries in southeastAsia also send and receive migrants rom outside theregion. Since the 1980s, however, destinations within Asiahave replaced labour migration to countries such as theUSA and to the Middle East.26

There is signicant undocumented or illegal migrationas well as movement o displaced people in the region.27,28These groups are particularly vulnerable since[u]ndocumented migrants are disproportionately moreexposed to health risks due to inadequate workingconditions and irregular movements, but are unlikely toseek medical attention because o their status, and arealso oten let out o assistance programmes in times odisasters and emergencies.27

Population ageingPopulation age structures o countries in the region varywidely as a result o past dierences in ertility, mortality,and migration trends (gure 3). These trends are in turnaected by economic, social, cultural, and politicaldevelopments. Singapore and Thailand have among theastest ageing populations in the world, with theproportion o elderly residents projected to double rom7% to 14% in 19 and 22 years, respectivelyshorter thanthe 26 years expected or Japan2931 because o more rapidertility reduction in these two countries. With increasinglongevity, the pace o increase in numbers o the oldestold, aged 80 years and older, in southeast Asia is projectedto exceed that o east Asia over the period 202550.32 This

Population

(millions)*

Population

density(people per

km)

Urban

population(% o total

population)*

Adult

literacyrate

(%)

Lie

expectancy,both sexes

(years)

Lie

expectancy,women

(years)

Lie

expectancy,men

(years)

Population

aged 65years or

older (%)*

Total

ertilityrate

(children

per

woman)||

Inant

mortalityrate

(deaths

per 1000

livebirths)

in 2010**

Under-5

mortalityrate

(deaths

per 1000

livebirths)

in 2010**

Maternal

mortalityrate (deaths

per 100 000

livebirths)

in 2008

Mortality o

people aged1560 years

(deaths

per 1000

population)

in 2010

Brunei 04 66 72% 95% 76 80 75 4% 205 6 8 37 104

Singapore 50 7022 100% 94% 81 83 78 9% 126 2 3 16 67

Malaysia 283 86 68% 92% 72 77 72 4% 251 5 5 42 118

Thailand 678 132 36% 94% 70 72 66 7% 182 9 9 47 150

Philippines 922 307 63% 93% 71 74 70 4% 303 21 29 84 170

Indonesia 2433 128 43% 92% 68 73 69 6% 213 30 37 229 173

Vietnam 873 263 28% 90% 72 76 72 7% 203 11 13 64 141

Laos 63 27 27% 73% 61 66 63 4% 342 49 68 339 216

Cambodia 148 82 15% 76% 61 63 59 3% 286 50 60 266 243

Myanmar 500 74 31% 90% 56 63 59 5% 228 42 55 219 219

*Data are rom reerence 1. Data are rom reerence 1; population size and density or Singapore are based on Singapore Department o Statistics data (reerence 3). All data are or 2007 apart rom those or

Vietnam (1999), Myanmar (2000), Laos (2005), and Indonesia (2006); see reerence 4. Data are rom reerence 5. Data or 200510, rom reerence 6. ||Data are rom reerence 7. **Data are rom reerence 13.

Data are rom reerence 14. Data are rom reerence 15.

Table: Basic demographic indicators

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rise will have important implications or management othe burden o disease and health-care provision orelderly people.

The other major actor contributing to populationageing has been the decrease in mortality. Figure 4 showsestimated trends in risk o child death (ie, between birthand age 5 years) in countries o the region during thepast our decades. Child survival has improved substan-tially in all countries, but particularly in Indonesia,Vietnam, Thailand, Malaysia, Brunei, and Singapore,where the risk o child death is now typically less thanabout 05%, compared with 1520% in the 1970s.13Measured by the risk o dying between ages 15 and60 years, regional diversity in levels o adult mortality iseven greater than or child mortality (gure 5). Typically,the risk o dying at these ages or men is 2030%, and ishigher (32%) in Cambodia, Laos, and Myanmar (2627%),and signicantly lower in Singapore, where the level issimilar to those in Australia and Japan (78%). Thisregional diversity in risk o adult death is similar or

women, but with rates typically 2030% less than thoseor men.15

Changing disease burdenMortalityIncreasing longevity is a result o diminishing burdenrom communicable, maternal, and perinatal diseases(group 1 diseases; webappendix p 2), whereas countrieswith aged populations have a higher burden o non-communicable diseases (group 2 diseases). Interestingly,mortality rates rom these two groups o diseases, aswell as rom injuries, are correlated. Countries with highmortality rates rom communicable diseases also havehigh death rates rom chronic diseases (webappendixp 2). Deaths rom communicable diseases are still

prominent in Cambodia, Myanmar, and Laos. Injuries

are an important cause o death in all countries, but lessso in Singapore and Brunei.Few countries in the region have complete cause o death

data systems to inorm health policy and planning, and othose that do only Singapore has reliable cause o deathcertication and coding. Although not representative opresent health conditions in neighbouring countries,understanding o how leading causes o death havechanged in Singapore during the past 40 years or so canprovide important insights into what other countries o theregion could expect to achieve, provided there is a similarlystrong public health commitment to disease control andinjury prevention. Figure 6 summarises trends in selectedcauses o death or both sexes in Singapore since 1963.

In the early stages o transition, striking reductions ininectious diseases such as tuberculosis were achieved,oset by increases in non-communicable diseasesincluding cardiovascular diseases and cancers, as well asinjuries. Although deaths due to road trac accidentshave subsequently decreased and cardiovascular diseasesseem to have reached a plateau, breast cancer hascontinued to rise. Except or stomach and cervical cancer,mortality rom all other cancers is still rising (data notshown). These data illustrate the success o Singapore inreducing mortality rom the diseases o poverty, as well asthe eects o inadequate chronic disease controlprogrammes, although there is evidence o some successin control o liestyle-related diseases in recent years. Asother countries in the region succeed in bringingcommunicable diseases under control, the importance oinjury prevention and chronic disease control programmeswill become increasingly pressing.

Health and wealthThe region as a whole does not have reliable longitudinaldata or disease trends. However, evidence rom studieso disease prevalence shows a strong inverse associationwith national wealth, which can be largely attributed tothe social determinants o health, including the provisiono more ecient health systems with greater populationcoverage. The gure provided on p 3 o the webappendix

shows the relation between prevalence o tuberculosisand per head income (log-log scale). The regressionequation (not shown) suggests that a doubling o perhead income is associated with a reduction in tuberculosisprevalence o 73%. For diabetes mellitus prevalence,countries can be roughly divided into three groups thatare positively correlated with income, although the eecttapers o at higher levels o per head income,(webappendix p 4), possibly because o more eectivedisease control programmes with greater coverage.

HIV was introduced into the region in the 1980s.Transmission peaked in the early 1990s in Thailand,ollowed by Myanmar and Cambodia.33 HIV/AIDS hasbeen a major cause o death in some countries o theregion (eg, Thailand),34although its spread has been partly

Figure 2: Average lie expectancy at birth in southeast Asia, 19502010

Data are or both sexes combined, rom reerence 16.

90

80

70

60

50

40

30

20

10

Averagelifeexpectancyatbirth

(years)

0

1950

54

1955

59

1960

64

1970

74

1965

69

1975

79

1980

84

1985

89

1990

94

1995

99

2000

04

Brunei

Singapore

Malaysia

Thailand

Philippines

Indonesia

Vietnam

Laos

CambodiaMyanmar

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controlled by the promotion o condom use.35 In the

early 2000s, more eective antiviral therapies emerged,ollowed by the introduction o compulsory licensing.36Although universal access to treatment has beenattempted, patient compliance and losses to ollow-up careare still prevalent.37,38 AIDS mortality in southeast Asia hasstabilised since the mid-1990s, although prevalenceremains high in Myanmar, Laos, and Cambodia.15

Regional environment and healthThe environment continues to be an importantcontributing actor to disease and mortality in thedeveloping world, including countries in southeast Asia,accounting or up to a quarter o all deaths.39 Regularmonsoons and typhoons occur in southeast Asia. The

El Nio and La Nia phenomena also intensiy theannual variation o the hot and wet climate, leading todroughts, oods, and the occurrence o inectiousdiseases such as malaria and cholera.40 Countries in thenorthern part o the region such as the Philippines andVietnam are badly aected by seasonal typhoons thathave increased in intensity over time.

The Philippines and Indonesia are located on thePacic Ring o Fire,41 a zone o earthquakes andvolcanoes where around 90% o the worlds earthquakesoccur.42 Southeast Asia is one o the most disaster-proneregions in the world; the Indian Ocean earthquake othe coast o Sumatra in 2004 caused a devastatingtsunami in Aceh, Indonesia, and countries on the ringeo the Indian Ocean, one o the worst natural disastersever recorded.

Uncontrolled orest res raged in the Indonesian stateso Kalimantan and Sumatra in 1997. The severity o theres was also closely linked to the occurrence o the El NioSouthern Oscillation, which has historically brought severedrought conditions to southeast Asia, creating conditionsripe or res. In 1997, the severity and extent o hazepollution was unprecedented, aecting some 300 millionpeople across the region.43 The health-related cost o thehaze was estimated to be US$164 million.44

The health eects o the 1997 haze in southeast Asia havebeen well documented.45,46 An increase in concentration o

particulate matter with diameter 10 m or less rom50 g/m to 150 g/m was signicantly associated withincreases o 12% in upper respiratory tract illness, 19% inasthma, and 26% in rhinitis rom public outpatient careacilities in Singapore.47 Time-series analyses in peopleadmitted to hospital in Kuching, Malaysia, showed thatsignicant re-related increases occurred in respiratoryhospital admissions or chronic obstructive pulmonarydisease and asthma. Survival analyses suggested thatpeople older than 65 years who had been previouslyadmitted to hospital or cardiorespiratory and respiratorydiseases were signicantly more likely to be readmittedduring the 1997 haze episode.48

Climate change could exacerbate the spread o emerginginectious diseases in the region, especially vector-borne

diseases linked to rises in temperature and rainall.49Southeast Asia has been identied as a region that couldbe vulnerable to eects o climate change on health,because o large rainall variability linked to the El Nioand La Nia oscillation, with attendant consequences orhealth systems.50

Figure 3: Population distribution by age in southeast Asia, 2005

Data are rom reerence 16.

Figure 4: Under-5 mortality rates in southeast Asia, 19702010


Figure 5: Trends in mortality in (A) women and (B) men aged 1559 years in southeast Asia, 19702010


0% 20% 40% 60% 80% 100%

04 years 514 years 1524 years 2559 years 60 years

BruneiSingapore

Malaysia

Thailand

Philippines

Indonesia

Vietnam

Laos

Cambodia

Myanmar

1970

0

50

100

Under-5mortalityrate(deathsper1000livebirths)

150

200

250

1980 1990 2000 2010

BruneiSingapore

MalaysiaThailandPhilippinesIndonesia

VietnamLaosCambodiaMyanmar

0

50

100

150

200

1970 1990

Year Year

2010 1970 1990 2010

250

300

350

400

450

500

Women Men

Deathsper1000

population

BA

Brunei

Singapore

Malaysia

Thailand

Philippines

Indonesia

Vietnam

Laos

Cambodia

Myanmar

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Health systems in southeast AsiaSoutheast Asias rich history and recent industrialisationand globalisation have raised new challenges or theregions health systems. Modern medical technology isavailable in the world market but at costs higher thanmost o the regions population can aord. Manytraditional health practices persist alongside the use onew medical technologies and pharmaceutical products,presenting regulatory problems in terms o saety andquality. With increasing educational levels, ageingpopulations, and growing consciousness o human rightsin the recently developing democratic environment, thedemand or better care is increasing. Health systems inthe region ace more serious adjustment problems thanever beore.51 Health services have become an importantindustry, with a mix o public and private non-prot andor-prot actors, along with the growth o trade andmedical tourism. The provision, nancing, and regulatoryunctions o the public sector have to adapt accordinglyto these transormations. The need to restructure health-care delivery and nancing systems becomes crucial tobalance new demand and supply equilibriums.52,53

Countries in southeast Asia and their health systemreorms can thus be categorised according to the stages

o development o their health-care systems. A typologyo common issues, challenges, and priorities aregenerated or the diverse mix o health systems osoutheast Asia at dierent stages o socioeconomicdevelopment (see webappendix pp 58). The pressuresplaced on national health-care systems by the recentdemographic and epidemiological transitions that wehave described are amplied by the growing demands oan increasingly educated and afuent population or highquality health care and the supply o the latest medicaltechnology. Beore the east Asian nancial crisis in199798 and the recent global economic recession, anexpanding middle class in the urban populations o thelarger cities pushed their demand or high quality careinto a booming private sector. As a result, market orces

have turned many aspects o health care into a new

industry in countries such as Singapore, Malaysia, andThailand, contributing to labour-orce distortions or theproduction and distribution o health workers bothwithin and across countries.

The 1990s began with the opening up o socialist statesand rapid growth among market economies in the region.While they were each nding ways to reorm their healthsystems, the Asian nancial crisis in 199798 posed morechallenges or countries o the region. The depreciationo local currencies resulted in increased costs o importeddrugs and other essential supplies, at the same time asaccess to basic health care was reduced or the mostvulnerable population groups.54 However, reported spikesin suicides and mental illnesses in the other aected east

Asian economies such as South Korea, Taiwan, andHong Kong were not as signicant in southeast Asia. 55Following the lessons learnt rom the past nancial crisis,most countries have strengthened their social protectionmechanisms and essential health services. There is agreater push among countries to increase universalcoverage o basic health services, especially to vulnerableand disadvantaged populations.56,57 Throughout theregion, many innovative pro-poor nancing schemeswere implemented, such as the Health Card and 30-bahtSchemes in Thailand, the Health Fund or the Poor inVietnam, Health Equity Funds in Cambodia and Laos,and, even in afuent Singapore, the Mediund, a means-tested hospital ees subsidy scheme or indigent patients.

So ar, the health-care systems with dominant taxunding are airly stable, in view o the strong role ogovernments and eective controls by health agencies toovercome inequity problems. However, crucial issuesinvolve rising costs, uture sustainability o centralisedtax-nanced systems, eciency and quality o the publicservices, and higher public expectations. In both Malaysiaand Singapore, the health-care systems are changingrom government-dominated health services towardsgreater private-sector involvement. Attempts to privatisepublic hospitals have been controversial, thus resulting inmany hybrid orms o corporatised entities that continueto be controlled or subsidised by governments.5861 Some

o the most innovative and advanced orms o publicprivate mix in health services have developed within theregion, or example the restructuring or corporatisationo public hospitals in Singapore rom as early as 1985 andthe later Swadana (sel-nancing) hospitals in Indonesia.62With the anticipated rise in the ageing population anduture problems o intergenerational unding throughpay-as-you-go mechanisms, there are experiments withnew health-care nancing such as compulsory medicalsavings and social insurance or long term care.6365 Somecountries such as the Philippines, Vietnam, and Indonesiahave radically decentralised their health-care systems withthe devolution o health services to local governments, arestructuring that has aected aspects o systemsperormance and equity even though the impetus or

Figure 6: Trends in mortality rom selected causes o death in Singapore,

19602009

Data are rom reerence 5. RHD=rheumatic heart disease.

Deathsper100000

populationperyear

1

1970 1980 1990Year

2000

10

100

200 Cardiovascular diseases excluding RHD

Breast cancer

Tuberculosis

Road traffic accidents

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decentralisation was mainly political.66 Consequently, to

ensure increased nancial coverage and aordability,many governments have passed laws to establish nationalhealth insurance systems and mandated universalcoverage, although implementation is problematic. Withexisting policies o decentralisation and liberalisation,equity issues and poor inrastructure will continue tochallenge the development o the health sector.57,67

Towards regional collaboration in global healthThe severe acute respiratory syndrome (SARS) epidemichas emphasised the need to strengthen regional healthcollaboration. This cooperation has occurred via twochannelsdirect bilateral collaboration by individualcountries (ministries o health and oreign aairs) and

those under the aegis o ASEAN. The Mekong BasinDisease Surveillance project is an example o successulhealth cooperation. It was established under the collectiveagreement o each Ministry o Health o member stateso the Greater Mekong subregion to share importantpublic health inormation. The emergence o inuenza AH5N1 and H1N1 outbreaks has led to common eorts tostrengthen epidemiological surveillance and stockpilingo antiviral drugs.

Enthusiasm or regional economic collaborationcontinues to grow, evident rom the explicit goal o theASEAN Free Trade Area to increase the regionscompetitive advantage as a production base geared towardsthe world market. ASEAN leaders have identied healthcare as a priority sector or region-wide integration. Froman economic perspective, opening o health-care marketspromises substantial economic gains. At the same time,however, this process could also intensiy existingchallenges in promotion o equitable access to health carewithin countries. It could also lead to undesirableoutcomes whereby only the better-o will receive benetsrom the liberalisation o trade policy in health.

Health and trade policy can and do appear to contradicteach other. Tobacco use is the major preventable cause onon-communicable disease and death among thepopulations o ASEAN countries.68 All ASEAN membersexcept Indonesia have embraced the Framework

Convention on Tobacco Control (FCTC)69 and all countriesendorse some orm o tobacco control policy. However,most o these states are, to varying degrees, still involvedin investment in or promotion o the tobacco industry,oten using the justication o poverty alleviation. Thereare clear contradictions inherent in the state seeking toprevent tobacco use in the interests o health, whileactively promoting tobacco or the economic benet o itspopulation, resulting in both substantial and symbolicharm to eorts to implement the FCTC.70 For example,tobacco production is legitimised; rational policyprinciples are violated, and direct cooperation betweenthe state and multinational tobacco corporations is madepossible by modication o control policies. Tobaccoexports within ASEAN also threaten the groups health

solidarity. Divestiture o state ownership o capital in

tobacco corporations

71

and a much stronger commitmentby states to control the use and promotion o tobacco areurgently required in ASEAN countries.

Issues o intellectual property rights surroundingproducts such as essential pharmaceutical drugs aspublic health goods are also o concern to countries.Thailand started compulsory drug licensing in 2008.Indonesia has called or the urgent development o a newsystem or virus access and a air and equitable sharingo the benets arising rom the use o the inuenza virusin research (now commonly reerred to as viralsovereignty). Additionally, Indonesia has pressed or thedevelopment o medical products to replace the existingpatent system in global health governance.72

With globalisation, ensuring o accessible healthservices or citizens is no longer the sole responsibilityo the state; health care in southeast Asia is astbecoming an industry in the world market. The privatesectors in Singapore, Thailand, and Malaysia havecapitalised on their comparative advantage to promotemedical tourism and travel, combining health servicesor wealthy oreigners with recreational packages toboost consumption o such health services. Patientsrom elsewhere, including the developed countries, arechoosing to travel or medical treatment, which isperceived to be high quality and value or money.Because o poor local economic conditions, thePhilippines had a policy to export human resources orhealth to the world and to richer countries in the regionas an income-generating mechanism. Although thenancial returns rom this strategy seem substantial,equity issues have suraced concerning the negativeeects o international trade in health services andworkorce migration on national health systems,especially in widening disparities in the ruralurban orpublicprivate mix.

Regional collaboration in standards o data collectionand health systems analysis is hampered by WHOsdivision o the ASEAN region into two areas underseparate regional oces: the South-East Asia RegionalOce, encompassing Indonesia, Myanmar, and

Thailand, and the Western Pacic Regional Oce,consisting o the remaining countries. Potential benetsrom enhanced WHO regional cooperation includeimproved health surveillance, inormation-sharing, andhealth systems strengthening in all ASEAN countries.

ConclusionSoutheast Asia is a region characterised by muchdiversity, including public health challenges. Social,political, and economic development during the pastew decades has acilitated substantial health gains insome countries, and smaller changes in others. Thegeology o the region, making it highly susceptible toearthquakes and resultant tsunamis, along withseasonal typhoons and oods, urther increases health

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risks to the population rom natural disasters and long-

term eects o climate change. Public policy in thesecountries cannot ignore such risks to health, whichcould have important social and economic consequences.Regional cooperation around disaster preparedness andin the surveillance o and health systems response todisease outbreaks has obvious advantages as a publichealth strategy. Concomitantly, all countries in theregion are aced with large or looming chronic diseaseepidemics. Even in the poorest populations o theregion, non-communicable diseases already kill morepeople than do communicable, maternal, and perinatalconditions combined, with many o these deathsoccurring beore old age. Greatly strengthened healthpromotion and disease prevention strategies are an

urgent priority i the impressive health gains o the pastew decades in most countries o the region are to bereplicated. Further growth and integration o theASEAN region should include as a priority enhancedregional cooperation in the health sector to shareknowledge and rationalise health systems operations,leading to urther public health gains or the regionsdiverse populations.

Contributors

All authors contributed to data collection, interpretation, writing, andrevision o the report.

Conficts o interest

We declare that we have no conicts o interest.

Acknowledgments

This paper is part o a Series unded by the China Medical Board,Rockeeller Foundation, and Atlantic Philanthropies.

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