In East Asia and Pacific (EAP), people are living longer but not necessarily healthier lives. An epidemic of chronic diseases is taking hold, affecting workers in their prime, eroding productivity, and escalating health care costs. The most effective strategies to address this health crisis are best implemented by a strong primary health care system early on. However, many EAP countries are using outdated models. This new report proposes reforms of primary health care to help deliver a healthier and more prosperous future for people in the EAP region.
The state of health in East Asia and Pacific (EAP) has improved, but challenges remain
Over the past 20 years, the EAP region has seen improvements in key health indicators. Life expectancy has increased, while under-5 mortality rates have fallen. However, the incidence of chronic, non-communicable diseases is growing, lowering quality of life and slowing income growth.
EAP faces a three-dimensional health care challenge across the life cycle:
- Persistent reproductive, maternal, newborn, and child health (RMNCH) challenges in specific populations,
- Increasing burden of noncommunicable diseases (NCDs) among the working-age population,
- Chronic health needs of older adults.
The likelihood of premature death is high
The likelihood of premature death (age 30-70) because of NCDs is more than 30 percent in some EAP countries. Population aging and urbanization—major risk factors for chronic disease—are happening at a faster rate in EAP than in other regions. Rising temperatures and increasing pollution are also contributing to the increase in NCDs.
The promise of primary health care (PHC) lies in its effectiveness, efficiency, and equity
A strong PHC system is best suited to address countries’ current health care needs and future challenges effectively, efficiently, and equitably. NCDs that are not caught early are harder to treat and require lifetime management, resulting in poorer health outcomes, lower quality of life and productivity, and higher treatment costs.
PHC services – from prevention and screening to treatment and disease management – reduce the need for more complex and costly treatments at hospitals, particularly for patients with NCDs. PHC services are based in communities, making them easily accessible to even the rural and marginalized populations.
But the reality of PHC in EAP falls short of this promise
The Universal Health Coverage Service Coverage Index (UHC SCI)—a Sustainable Development Indicator measuring how well a country provides coverage for essential health services—shows overall improvements in EAP over the past 20 years. However, many countries in the region have lower NCD service coverage than is expected at their income level.
Six attributes of well-functioning PHC systems—accessibility, affordability, quality of care, comprehensiveness, continuity of care, and patient empowerment—also vary among countries in EAP.
Access to PHC services is affected by significant gaps and disparities in the density of health care professionals, particularly physicians, both across and within countries.
Although many EAP countries have policies to provide free PHC services to identified vulnerable populations, lower socioeconomic groups often report financial barriers to accessing care.
Poor quality of care accounts for more than one-third of avoidable mortality in EAP, higher than excess mortality from not receiving care at all.
Although most EAP countries include a range of health promotion, prevention, RMNCH, and NCD services in their PHC benefits package, the PHC workforce composition and allocation is generally inadequate to deliver them.
Strategies to enhance this attribute are used to a limited extent in the region.
TABLE 4.4 Use of empanelment, referral requirements for specialized care, and availability of EHRs in PHC
Empanelment and gatekeeping practices are uncommon, and EHR availability varies across EAP.
| Country | Empanelment of population | Referral letter for specialized care | Availability of EHRs at PHC facilities |
|---|---|---|---|
| Brunei Darussalam | Mandatory for all | Required for specific populations | Some |
| Cambodia | No empanelment | Required | Some |
| China | For specific populations | Not required | Most or all |
| Indonesia | Mandatory for all | Required | Some |
| Japan | No empanelment | Required but weakly enforced | Most or all |
| Korea, Rep. | No empanelment | Not required | Most or all |
| Lao PDR | For specific populations | Required | Some |
| Malaysia | No empanelment | Required | Some |
| Mongolia | No empanelment | Not required | Most or all |
| Philippines | Mandatory for all | Required but weakly enforced | Some |
| Singapore | For specific populations | Required for specific populations | Most or all |
| Thailand | Mandatory for all | Required | Some |
| Timor-Leste | No data | Required | Most or all |
| Viet Nam | Mandatory for all | Required but weakly enforced | Most or all |
| Fiji | For specific populations | Required for specific populations | Most or all |
| Kiribati | No empanelment | Required | Few to none |
| Marshall Islands | No empanelment | Required for specific populations | Few to none |
| Micronesia, Fed. Sts. | No data | Required but weakly enforced | Some |
| Nauru | No data | Required for specific populations | Few to none |
| Palau | No data | Required for specific populations | Few to none |
| Papua New Guinea | No empanelment | Required but weakly enforced | Some |
| Samoa | For specific populations | Required | Some |
| Solomon Islands | No empanelment | Required but weakly enforced | Some |
| Tuvalu | No empanelment | Required for specific populations | Few to none |
| Vanuatu | For specific populations | Required | Few to none |
Source: World Bank expert survey.
Note: Data not available for Myanmar and Tonga. EAP = East Asia and Pacific; EHR = electronic health record; PHC = primary health care.
Strategies to enhance this attribute are used to a limited extent in the region.
Why has PHC not realized its potential?
Public health spending as a share of GDP is low in many countries in the region (except in the PICs), which shifts the cost burden to patients, limits availability of services, or both.
Although inadequate financing is a major constraint, inefficient use of current resources is also a challenge, and together they lead to four types of problems: inadequate services, teams, and tools; poor quality monitoring; weak incentives for providers; and a poorly motivated population.
Reform actions in four key areas can help achieve the promise of PHC
Enhancing PHC is the most cost-effective strategy to address current and emerging health challenges. Countries should consider actions within the following four reform areas.
Actions to reorient PHC include:
- Tailor the package of services to population needs and make targeted investments in the teams and tools needed to delivery those services
- Employ task shifting, telemedicine, and mobile medical clinics
- Use public financing to purchase essential, high-quality PHC services from the private sector
- Connect PHC with specialized services using digital technology.
TABLE 6.2 Prioritizing the scope of PHC services according to needs
The scope of PHC services should be prioritized according to each country’s unique population health needs.
| Country | Under-5 mortality rate (per 1,000 live births) | Premature mortality from four NCDs (% of deaths ages 30–70) | Aging (% of the population age ≥65) |
|---|---|---|---|
| Kiribati | 56 | 50.8 | 3.8 |
| Timor-Leste | 49 | 19.9 | 5.2 |
| Papua New Guinea | 41 | 36.0 | 3.2 |
| Lao PDR | 40 | 26.8 | 4.5 |
| Myanmar | 40 | 24.9 | 6.8 |
| Marshall Islands | 29 | — | 4.5 |
| Fiji | 28 | 37.7 | 5.9 |
| Philippines | 27 | 24.5 | 5.4 |
| Nauru | 26 | — | 2.5 |
| Cambodia | 24 | 22.5 | 5.8 |
| Micronesia, Fed. Sts. | 24 | 46.3 | 6.2 |
| Palau | 22 | — | 9.9 |
| Indonesia | 21 | 24.8 | 6.9 |
| Tuvalu | 20 | — | 6.4 |
| Viet Nam | 20 | 21.2 | 9.1 |
| Solomon Islands | 18 | 39.2 | 3.5 |
| Vanuatu | 18 | 39.7 | 3.7 |
| Samoa | 16 | 31.2 | 5.2 |
| Mongolia | 13 | 35.0 | 4.6 |
| Tonga | 11 | 24.8 | 6.2 |
| Malaysia | 8 | 18.4 | 7.5 |
| Thailand | 8 | 13.7 | 15.2 |
| China | 7 | 15.9 | 13.7 |
Source: Original table for this publication.
Note: — = data not available; NCDs = noncommunicable diseases; PHC = primary health care.
Countries should introduce accountability and transparency in quality monitoring by:
- Regularly monitoring a broader range of quality indicators
- Using data systems and digital technologies to enhance real-time quality monitoring
- Engaging patients and communities in monitoring health services.
Community-based monitoring of PHC improved children’s nutritional outcomes in Uganda.
Using improved data, countries can compel providers to improve care delivery by:
- Using empanelment and performance-based capitation to incentivize proactive prevention and health promotion:
- Incorporating lessons from the private sector to inform incentive programs in the public sector.
Countries can drive consumer demand for PHC by:
- Utilizing digital platforms to promote proactive public health measures;
- Sending reminders and nudging people to increase uptake of screenings
- Using financial incentives to promote healthy behaviors
Longer-term improvements
Though many of the reforms described in this report can be implemented today within existing budget and institutional constraints, creating future-ready PHC will require additional resources and investments in infrastructure (digital and physical), medical equipment, and well-trained health workers. Countries must also establish or strengthen public sector institutions to better monitor quality and expand the use of performance-based financing.
Successful reforms will require sustained and cooperative efforts by a range of stakeholders. Evidence-based, credible, and well-sequenced reform agendas developed by ministries of health are crucial. Buy-in and resource allocation by ministries of finance, with emphasis on PHC financing, are critical. Tackling existing and emerging health challenges matters profoundly for both public health and economic growth.
Authors
Zelalem Debebe |
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Young Eun Kim |
Sang Minh Le |
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Ronald Mutasa |
Somil Nagpal |
Son-Nam Nguyen |
Elina Pradhan |
Erin Sowers |
Ajay Tandon |
