Function 1: Formulating Policy and Strategic Plans

Countries throughout the Asia-Pacific have adopted pro-UHC policies and strategic plans and many have explicitly expressed their aspiration to progress toward UHC.⁵ Some incorporate UHC directly into their national plans, and others have implemented functionally pro-UHC policies (for example, expanding financial coverage or access to services) without explicitly acknowledging UHC as their ultimate aim. In Myanmar, the government has endorsed the National Health Plan 2017–2021, formulating a three-phase plan to achieve UHC by 2030, aiming to increase access, equity, and financial protection²¹; Vietnam has set out a Master Plan for UHC, setting targets to increase coverage levels and reduce out-of-pocket (OOP) expenses by 2020²²; Malaysia set achieving universal access to quality health care as a national goal in the 11th Malaysia Plan²³; and China’s 2009 Health Reform Plan lays out key reform priorities to establish UHC.⁷

Though some countries throughout the region have enacted policies supporting UHC goals in all of its dimensions, others have thus far prioritized particular aspects (for example, service coverage or financial coverage). Though Pacific island countries have committed to ensuring service delivery is based on UHC principles as part of the “Healthy Islands Vision” and the 2015 Yanuca Island Declaration, different approaches have been used in acting on these commitments.^24–26 Fiji has endorsed increased government spending to expand access to health services for the poor.^24,25 Papua New Guinea’s Department of Health has worked with provinces to develop annual health service plans, informed by facility audits, covering services in health facilities including aid posts, rural health centers, and hospitals.²⁴ The Solomon Islands have developed their pre-existing Role Delineation Policy (2011) in response to the national commitment to UHC made in 2013. As a result, the health system was reclassified from five to four levels, and the Ministry of Health and Medical Services undertook development of integrated service delivery packages, specifying essential services, staffing, equipment, and infrastructure at each level of the health system, in collaboration with development partners.^5,24,27

One broad public-sector governance reform pursued by a number of countries across the region has been decentralization, with success in some cases in improving efficiency, stakeholder participation, and accountability.^3,28–30 However, decentralization has also been a major governance challenge for implementing UHC reforms, shaping and constraining the external environment in which governments and other health systems actors can make and enact policy. In Vietnam, though central decision making has facilitated formulating UHC reforms, decentralization coupled with a lack of alignment between UHC reforms and broader government strategies has constrained progress, particularly around the reduction in OOP expenditure and expansion of coverage. Benefits of decentralization have been unequal and favor urban populations.^2,31 In China, the high responsibility placed on subnational governments to generate funding and carry out service provision, coupled with poor accountability between subnational and central governments, has produced inequity and limits the ability of the central government to ensure compliance with reforms.^2,7

Broader changes in governance like decentralization have also shaped the structure and role of organizations. In Fiji, decentralization has been attempted multiple times with limited success. The present policy of deconcentration of outpatient services from hospitals to peripheral health centers in Suva has resulted in greater service capacity but has not had the anticipated results of transferring administrative or decision-making power, with decision making remaining largely centralized.^32,33 This presents an interesting contrast with Thailand, where centralized governance at the time of UHC reform design enabled the government to effectively plan and implement reforms and where decentralization, though legally mandated and planned, has progressed slowly, due in part to concerns about system fragmentation.^2,30

Function 2: Generating Intelligence

Countries throughout the region have set up systems to use intelligence to inform policy. For example, Thailand, Australia, New Zealand, Singapore, Hong Kong SAR (China), the Philippines, China, and Malaysia use health technology assessments (HTAs) to inform policy and decision making.^34–37 Other countries, including Indonesia, India, and Myanmar, have begun to use HTAs, though in an unstructured and informal way.^21,34 HTAs have been used to develop the universal health benefit package and the National List of Essential Medicines in Thailand, and the National Health Security Office (NHSO) works with a large group of stakeholders in deliberative processes to foster legitimacy and transparency.^38,39 In Fiji, the health information system (which collects core public health data and clinical-level data via electronic patient records linked to a national health number) provides information that guides decision making in both clinical and management settings.⁵ The Ministry of Health of Lao People’s Democratic Republic (PDR) began in 2012 to implement a web-based reporting platform to provide timely and accurate data to policy makers and inform decision making, planning, and program implementation. Standardized report forms have been developed, and routine data from health facilities are collected and can be aggregated to district, provincial, and national levels.⁵

Countries throughout the region have established, or are developing, health information and information technology systems to generate information for monitoring, evaluation, and accountability and to support decision making. Financial protection has been a focus domain for most countries for monitoring and evaluation. Data collected from Thailand’s socioeconomic survey are used to estimate the incidence of catastrophic health expenditure.⁴⁰ Similarly, in China, the national health services surveys have been providing information for estimating the overall impoverishment rate.⁴¹ In Singapore, indicators of access, quality, and affordability of services are regularly tracked and reported to government as part of key performance indicators given to the Ministry of Health.⁴² In the Republic of Korea, the Health Insurance Review and Assessment Agency processes insurance claims, and the claims database is linked with health facilities, enabling the monitoring and evaluation of services and drug utilization.⁵ Other countries have developed systems to monitor specific aspects of their health systems. States in India, including Tamil Nadu, have established information technology systems to track and monitor the delivery of drugs from the manufacturer to the patient.²⁹

Some countries, however, have difficulty generating information. Major barriers include limited resources available to rural health facilities to establish electronic medical records systems, as in the Philippines,³⁷ and inconsistent formats of databases and fragmented health information systems that are difficult to integrate, as in Indonesia.²⁸

Countries throughout the region (including Viet Nam, Malaysia, Lao PDR, Cambodia, China, and Mongolia) are developing their capacities for research and analysis via research, health strategy, and policy institutes.⁵ These can be set up and supported in a number of ways; for example, via government decree (Viet Nam), under the umbrella of a national health institute (Malaysia) or ministry of health (Cambodia, Lao PDR, China), via think tanks (China), and in association with universities and other research institutes (China, Mongolia).⁵

Function 3: Implementing Policy: Levers and Tools

In their efforts to progress toward UHC, countries across the Asia-Pacific have deployed a wide range of tools and policy levers to implement policies across the health sector. These take a number of forms, including regulation and legislation, standard setting, incentives, and organizational design and change. Often action has focused on key functions of health systems, including health financing, health workforce, services and facilities, and medicines and drugs.

Changes to how organizations operate and interact within the health system to support pro-UHC aims and policies have occurred in several countries throughout the region. Some countries have created new roles for existing institutions and/or created new institutions. During Thailand’s implementation of the Universal Coverage Scheme, the Ministry of Public Health shifted roles from provider to having enhanced responsibility for the oversight, management, regulation, and stewardship of the health sector, ceding some of its other responsibilities to semi-autonomous public bodies, including the Thai Health Promotion Foundation, the Healthcare Accreditation Institute, and the NHSO, created to administer the Universal Coverage Scheme.² The creation of the National Health Commission established both the structure and processes for stakeholders participation in health policy making. However, interactions between institutions have faced challenges, with the Ministry of Public Health delaying transfer of the health budget to the NHSO and retaining control of salary budgets, in part due to the influence of doctors in senior hospitals.² In South Korea, the establishment in 2000 of a single insurance agency, the National Health Insurance Corporation, introduced (along with the separation of prescribing and dispensing roles) major structural changes in the health system, resulting in it becoming more pluralistic, participatory, and democratic, though interest groups (mainly private providers and doctors) frequently resist government reforms.^43,44 Tamil Nadu, in India, has created quasigovernmental organizations, such as the Tamil Nadu Medical Services Corporation, to help circumvent slow-moving bureaucratic processes. Action has also been taken to bolster managerial capabilities, via methods including the creation of a dedicated public health management cadre⁴⁵ and a system of career progression to attract and retain high-caliber staff.^46,47

UHC programs increasingly adopt approaches including purchaser–provider split, greater provider autonomy, and greater engagement of private providers, as well as making explicit the roles and responsibilities of actors within the health system, using tools such as benefit packages.⁴⁸ Some countries are making use of public–private partnerships (PPPs) to address workforce and service delivery challenges.^{45–47,49–54} In Andhra Pradesh, India, the government engages with private providers to improve diagnostic service capabilities.⁵⁵

The creation and implementation of new regulatory systems has also occurred throughout the region. China, with the support of the WHO, has implemented drug price regulation, new essential drug list development, and regulated drug procurement procedures.⁵⁶ These support improved value for money, help ensure that primary health facilities (in both urban and rural areas) are only using essential drugs, and encourage the rational use of drugs by local health authorities,⁵⁷ though they are undercut by the weak implementation of regulations in the pharmaceutical market and under-qualified staff.⁵⁸ The Cheaper and Quality Medicines Act (2008) and the Pharmacy in the Village Program in the Philippines laid the groundwork for regulation of prices and encourage availability of drugs.⁵⁹ Conversely, in Cambodia, deregistration is used to control the sale and distribution of substandard products.⁵ A lack of comprehensive regulation has hindered some countries in implementing reforms. In Viet Nam, the 2009 Law on Health Insurance neither stipulates compliance-assurance measures nor lays out mechanisms to enforce compliance with mandatory insurance, resulting in low joining rates to the Social Health Insurance scheme.²

Countries also regulate their workforces. Though most countries throughout the region have systems of professional registration, certification, and licensing, there are concerns about the ability of some countries to enforce these systems.⁵ Australia has transformed its system of health workforce regulation, establishing a national scheme under a single national organization (the Australian Health Practitioner Regulation Agency) and a single legislation framework to manage the annual registration of all registered health practitioners via national regulation standards. It has also developed a National Code of Conduct for unregistered health practitioners, which sets standards for conduct and practice.⁵ Indonesia reformed its accreditation process and standardized certification processes to address the problem of unqualified health workers.⁵²

Multiple kinds of incentives are also used to influence the behavior of the health system throughout the region. Thailand has sought to engage the pharmaceutical sector, using strong negotiation and leveraging provider payment systems to increase benefits for the population.⁵² Financial incentives (for example, double pay for rural postings) and social incentives (awards, social recognition) have been deployed to alter workforce capacity, capability, and distribution (for example, rural–urban) and to improve service delivery and accessibility.^52–54 These include the introduction of quota systems and mandatory or bonded service and financial compensation.^45,49–51 For example, in Japan, the Ministry of Health, Labour and Welfare has worked with prefectures, universities, and hospitals to encourage more doctors to work in remote regions via scholarship models in return for work commitments.⁵ The financing of health systems also sets up incentives that can both benefit and hinder progress toward UHC. Fee-for-service payment can act as a perverse incentive, encouraging overprovision of services; for example, in China, where overprescription has accompanied the transition from a centralized pharmaceutical supply system to a commercialized one.⁶⁰ Hospitals in Viet Nam continue to emphasize profit-making services, despite policies establishing ceilings for fees.²

Function 4: Collaboration and Coalition Building

A number of countries in the region have engaged in collaborations with actors both within and outside of government to facilitate implementation of UHC policies. For example, interministerial collaboration has taken place in Thailand, South Korea, and China.^61,62 China’s 2009 health system reform plan followed four years of consultation and collaboration with stakeholders, including service providers, policy analysts, think tanks, academic institutions, and international organizations.⁷ In Cambodia, the Ministry of Health worked with the Department of Drugs and Food to collaborate with a wide range of agencies internal and external to the government, including law enforcement agencies (national and international), nongovernmental organizations, and the WHO to reduce the circulation of poor-quality medicines. This has been supported by the creation of a number of interministerial committees that range across a wide variety of government ministries.⁵ However, in some countries, complex institutional arrangements and the multiplicity of institutions and organizations involved in administering and implementing programs (for example, social health insurance) have created difficulties facilitating coordination, as in Viet Nam.²

In many countries, international organizations such as World Bank, UNICEF, and WHO are involved in shaping the direction of policy formulation and strategy implementation through providing funding support and capacity building. In particular, some countries (for example, Viet Nam, Myanmar, and Cambodia) work with international organizations in strengthening their health systems.^21,35,63

Efforts to facilitate greater collaboration between the public and private sectors have been undertaken by countries in the region. A number of countries throughout the region have entered into PPPs. Hong Kong SAR’s (China) experience with PPPs suggests that forming collaborative partnerships rests on fostering good stakeholder relationships and involvement and building mutual trust.⁶⁴ Other forms of collaboration across sectors in the region include consultation with academics for evidence and expert advice,³⁹ partnerships with nongovernmental organizations to improve access and quality of care,⁶⁵ and public engagement for agenda setting and policy formulation.^39,55

Function 5: Accountability

Strengthening accountability is one of the governance functions that helps to ensure that health system objectives and population needs are met and resources are used effectively.⁶⁶ There are a number of accountability relationships at play, extending between actors including service providers, health ministries, and legislatures. Each actor has its own “accountability focus” (for example, responsiveness, meeting quality standards, meeting set targets, and meeting public expectations). Accountability can be further categorized into “answerability,” referring to the government’s obligation to provide information on decisions and actions, and “sanctions,” which constitute the “teeth” of accountability and refers to the presence and application of sanctions where allowed.⁶⁷

A number of tools to ensure financial accountability across health system actors are in place throughout the region. For example, audits of cost claims are routinely conducted in countries such as Viet Nam and Thailand in case of any under- or over-reimbursements.^68,69 In the Republic of Korea, the Health Insurance Review and Assessment Agency provides explicit guidelines and criteria about its review process, which enables more transparency.⁴³ Thailand conducts reviews of medicines and interventions included in its benefits package, to protect citizens against catastrophic medical expenditures.⁶⁹

Countries put in place regulations and sanctions to facilitate greater performance accountability. Most countries in the region regulate doctors, nurses, and pharmacists, and some regulate allied health professionals and traditional medical practitioners.⁷⁰ Regulations are also set up in most countries to license and accredit health facilities in both the public and private sectors. In Thailand, in accordance with the Medical Premises Act 1998, the Medical Registration Division of the Ministry of Health regulates private clinics and hospitals. Noncompliance with licensing standards results in sanctions, including probation, suspension, and license revocation.²⁹ These arrangements promote accountability by creating a framework of standards and procedures.⁶⁷

Throughout the region, countries have developed ways to engage civil society and feed community concerns and suggestions back into the policy and decision-making processes. Mechanisms include improving access to information via awareness campaigns, system “report cards” and scorecards, and social audits.^48,71 Others include using the judicial system to redress perceived problems, as in Indonesia.⁶⁵ Countries have also established institutions to facilitate civil engagement. In 2012, the Republic of Korea established the Citizen Committee for Participation, a lay citizens council, to inform priority setting and benefits coverage.⁷² This occurred after a lengthy period of public requests for expanded benefits coverage (starting in the early 1980s) and following an initial expansion of benefits coverage in 2005. This expansion triggered a series of public debates regarding the criteria by which coverage decisions were made and culminated in the creation of the Citizen Committee, which makes recommendations to the Health Insurance Policy Committee on service priorities. This has been largely successful, with the Citizen Committee participating in revising benefit coverage decisions.⁷² New Zealand has also institutionalized the participation of civil society in decision making. The New Zealand Public Health and Disability Act 2000 requires the involvement of Māori and other groups in decision making, planning, and delivery of health and disability services. District health groups also consult with community groups regarding their health needs.⁵