Health policies without evidence lead to mixed results in Asia

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800 million people in the Asian region still do not have full coverage of essential health services and pay high sums in out-of-pocket expenditure for health. Asia as a region has diverse health system capacity, resources and contexts. While Japan, Thailand, South Korea, Singapore, Taiwan and Malaysia have made good progress in achieving Universal Health Coverage (UHC), there is no UHC for one-quarter of the world’s Asian population who account for 40 per cent of the global poor.

It is essential that Asian member states commit to action at the UN High-level Meeting to achieve UHC. This should focus on resourcing primary health care service provision (rather than excess reliance on insurance models), ensuring funding to increase capacity for health services and policy research and developing effective regulatory structures to ensure policy and health service provision are evidence based.

The need for evidence to support policies and programs

The Philippines, Indonesia and India have attempted to drive UHC by scaling up access to health insurance with mixed results. While social health insurance can improve use of health care services and protect households from catastrophic health expenditure this cannot be a substitute for strengthening primary healthcare and broader health systems. A recent regional win for UHC has been the Philippines UHC Act (2018), the first of its kind in the region to prioritise policy and resources for health.

Countries as diverse as India and Mongolia exemplify how fragmented policies can slow down the path to UHC. Health policy and programmes in India are still not strongly supported by research or evidence. Many state health schemes are politically motivated and instituted more as populist initiatives to garner votes than as substantial policies backed by evidence. This has led to a fragmented policy response, and a plethora of insurance schemes, vertical programmes and district level initiatives with little integration between centre and state.

Is India on the path to UHC?

Although India improved many key health indicators, huge disparities continue to exist between Indian states with India falling behind other South Asian counterparts such as Nepal, Sri Lanka and Bangladesh in key health indicators like universal immunization over last two decades. Key challenges are the disconnect between central and state level health policies that do not account for the diversity in local contexts and do not regulate predatory private providers leading to irrational care and catastrophic expenditure for urban and rural poor.

In response to these health system gaps, India has recently launched the Ayushman Bharat programme in 2018 which includes first, a national health insurance scheme (PMJAY) and second, 150,000 proposed primary health and wellness centres (HWCs) by 2022. Yet when resources allocated to these schemes are scrutinised, underfunding is glaring, trivialising the goal of UHC. The 150,000 HWCs have been allocated just USD1100 per centre while the PMJAY scheme is expected to cover 500 million people with a budget (for 2019-20) of USD 914 million (less than USD 2 per person). India needs increase delivery of Comprehensive Primary Health Care, through responsiveness to local contexts, embedded technology- based innovations, new types of partnerships, and more training and remuneration for frontline providers. While there is strong empirical evidence on the need and importance of primary health initiatives, there is still a significant disconnect between the organisation of evidence and its use by decision-makers.

Missing data in Mongolia

In Mongolia there are other challenges. During the period of Soviet influence from 1921 to 1990, the health sector was fully financed out of central state funds, coverage was universal and health services were free at point of use. Transition to a market economy in 1990s and government funding cuts led to large increases in the numbers of poorly regulated private providers making the health system more complex and pluralistic.

In 2016 Mongolia’s UHC service coverage index was 63 per cent with free (state-funded) primary healthcare and public sector hospital care largely funded from the state fund and national mandatory health insurance scheme. Despite this, there is no or limited disaggregated data to understand issues around UHC, public and private out-of-pocket expenditure, use of private sector and health insurance contracting although there are some preliminary reports citing 41 per cent out-of-pocket expenditure as a share of total health expenditure.

A key limitation for strengthening health systems in Mongolia is lack of data and evidence due to inadequate investment in health policy and systems research and few collaborations between academic institutions and the Ministry of Health. Policy decisions are mainly made by politicians, who are replaced often due to political instability, rather than technocrats using evidence. This leads to limited capacity to robustly evaluate reforms, policies or programmes.

What should member states at the High-Level Meeting on UHC do next?

There are three important steps that can be taken by Asian nations at the High-level Meeting.

• Member states need to think beyond conventional top-down insurance driven models and make strong investments in innovative primary healthcare models and human resources for health. In India, this must include investment in human resources to run primary and community health centres and ensure availability of essential medicines.
• Asian nations should ring-fence funding for health policy and systems research and to increase capacity for monitoring and evaluation of health systems and associated policies. In Mongolia in particular, strengthening national and institutional capacity to conduct relevant policy research is critical to get progress on UHC.
• When policies and programs are not informed by research and evidence, they fail to reflect and address the health needs of the population. Governments must commit to building and using evidence about what works, recognising that diverse settings and cultures require diverse healthcare solutions. In all Asian countries this should include development of evidence-based clinical protocols that are supported by regulatory processes to ensure provision of rational and high-quality care.

Universal health care is a core human right. All Asian countries need to commit to a large increase in public health expenditure and radical restructuring of primary care services as well as ensuring there is space for local, contextually adaptations to national policy at district and state level.