In this episode we’re joined by a panel of experts from the World Bank to discuss universal health coverage in Southeast Asia and the Pacific.
We explore the current state of UHC in Southeast Asia and the Pacific post-pandemic and what the Covid-19 pandemic has highlighted about the intersection between global health security and UHC.
We also discuss:
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Ms Jane Pepperall 00:35
Hello, and welcome to Contain This. I'm Jane Pepperall, Senior Health Advisor for the Department of Foreign Affairs and Trade. Firstly, I'd like to acknowledge the Traditional Owners and Custodians of Country throughout Australia and the Indo Pacific region. We recognise the continuing connection to land, waters, and community and pay our respects to Elders past and present. In this episode, I'm joined by a panel of experts from the World Bank to discuss the universal health coverage, or UHC, agenda in Southeast Asia and the Pacific. Joining me today are Toomas Palu, advisor on global coordination based in Geneva, Switzerland; Aparnaa Somanathan, practice manager for health, nutrition and population in East Asia and Pacific based in Sydney Australia; Wayne Irava, health specialist currently based in Honiara, in the Solomon Islands; and Chindavanh Vongsaly, health specialist, who joins us from Vientiane in Laos. We explore the current state of UHC in Southeast Asia and the Pacific post pandemic. And what the COVID-19 pandemic has highlighted about the intersection between global health security and UHC. We also discuss how the World Bank is working with partners like DFAT to help strengthen health systems through the Advance UHC Multi-Donor Trust Fund, and how gender equality is being addressed in this context. We hope you enjoy the conversation.
Dr Toomas Palu 02:03
I'm Tomas Palu, I'm the advisor in global coordination in World Bank's health, nutrition, and population global practice based in Geneva where the global health is.
Dr Aparnaa Somanathan 02:13
Hi, I’m Aparnaa Somanathan, I'm the practice manager for health, nutrition and population for the East Asia Pacific region of the World Bank. I'm based in Sydney, Australia. So nice to be here. Thank you, Jane for inviting us.
Ms Chindavanh Vongsaly 02:26
Hi, good morning, good afternoon. My name is Chindavanh Vongsaly, I'm the health specialist here based in Laos -Vientiane. It's very nice to be here thanks for the invite.
Dr Wayne Irava 02:39
Hello, everyone. My name is Wayne Irava. I'm a health specialist largely working in the Pacific Island countries, and I'm currently based here in Honiara in the Solomon Islands.
Ms Jane Pepperall 02:52
So, thank you, everyone, and welcome. We're so looking forward to your various perspectives on universal health coverage, or UHC. But first let's set the scene by actually asking what is UHC? And let me ask that of you Toomas.
Dr Toomas Palu 03:05
Well, universal health coverage means that everyone receives quality health service when and where they need them, and without incurring financial hardship when doing so. You want universal health coverage also has a very strong equity dimension reflected as leaving no one behind. It is also one of the targets for the Sustainable Development Goal number three, that is about health and well-being. And in fact, universal health coverage is important for achieving most other sustainable development goal for health targets as well. Just from the World Bank perspective, we see universal health coverage as a key for investing into health and human capital, to help societies to develop and prosper, and also help them to eliminate absolute poverty. As for example, healthcare cost is among reasons people fall into poverty and stay there. In World Bank, we are jointly with WHO tracking progress towards universal health coverage. And the latest official figures are still before pandemic, but they say that the world was making some progress towards better health service coverage, but with far too slow pace to reach the target. And on preventing financial hardship, unfortunately, we have not made progress and there are still almost a billion people incurring financial hardship every year because I want to have to pay for accessing health services. But we don't know exactly yet full impact of the pandemic on universal health coverage. We are doing it right now, but anecdotal evidence suggests that reversal of some of the health service coverage gains has happened. And pandemic induced poverty increase may have also increased financial hardship. So, in short, there is a lot to do. In 2019, at United Nations General Assembly, UN member states issued political declaration where they're committed to accelerate progress towards UHC. And next year 2023 they will take stock on progress. It will be very different global context post pandemic and at the time of several overlapping crises.
Ms Jane Pepperall 05:44
Thank you so much for that introduction and for contextualising UHC for us. I think it's really important to note what you said that UHC is not only about essential health services, but also financial protection for people to access the services that they need. So, Aparnaa in the Pacific and Southeast Asia region where the Australian development programme is most engaged and where World Bank is also very much engaged. What is the level of political commitment to progressing UHC? And how has it been framed and does the UHC agenda look different across those two regions?
Dr Aparnaa Somanathan 06:21
Thank you, Jane. Those are great questions. In Southeast Asia, it will be fair to say that political commitment to UHC over the last 20 years has been up and down. Historically, public expenditures on health and social services more broadly, have been low in Southeast Asia, which would signal relatively low public commitment to UHC. However, in the 2000s, a period of economic growth in the region, many governments made explicit commitments to progress towards universal health coverage. And examples of that include Vietnam, Thailand, Indonesia. A commitment are accompanied by ambitious policy commitments, as well as increases in public expenditures on health. But it didn't necessarily mean there were better services available to everyone in all of these countries. Then, during COVID, most countries in Southeast Asia did prioritise health and government budgets. But that priority was given to COVID the COVID response itself, often at the expense of other priorities. And now given the bleak economic growth prospects, our projections of public health spending are not all that optimistic. As published in the recent World Bank report Double Shock Double Recovery recovery, we find that without significant public commitments to help, many Southeast Asian countries may well see a reversal of important UHC gains made over the past decade or so. Turning to the Pacific. In the Pacific, governments have consistently allocated large shares of government spending to help. UHC commitments in the Pacific are not as explicit as they are in Southeast Asia. But publicly financed and publicly funded services are the norm, and imply universality. But even in the Pacific, weak economic growth prospects and projected declines in government spending imply that health expenditures will be cut in future years. The sustaining high levels of political commitment to help will be critical for ensuring that past gains are not lost. And just on the main differences on what UHC looks like in the Pacific and Southeast Asia, I'd like to quickly highlight three dimensions in which the UHC agenda looks different in these two parts of our region. One, as I've already touched on, is the explicit versus implicit commitment to UHC. In Southeast Asia commitments to UHC are made explicit through high level political commitment to achieve UHC. In the Pacific, it's an implicit commitment through very high levels of public financing, and delivery of public health services. A second difference is in relation to out-of-pocket payments for health. Almost all Southeast Asian countries rely quite a lot on out-of-pocket financing for health and inevitable consequence of low public spending on health. This also means that Southeast Asian populations see a lot of financial hardship due to higher out of pocket payments. Historically, Malaysia has been an exception to this and now increasingly Thailand as well. In the Pacific, on the other hand, out-of-pocket payments tend to be minimal given high public health spending. A third distinction is on private healthcare, private provision of health care. There's quite a lot of private health care provision in Southeast Asia, and as Southeast Asian countries undertake UHC reforms, they need to also consider how to contract these private sector providers and monitor the performance of these providers. Private sector provision does not always mean high quality health care.
Ms Jane Pepperall 10:00
Thank you Aparnaa, I think that really highlights such a mixed picture in terms of both political and practical commitment to UHC. And Toomas, I know you earlier sort of said progress hasn't always been as hoped. So, I'm just interested to to dive a little bit more into progress and challenges. And Wayne, I know that you're based in the Pacific region, so I’d be really interested to have some of your thoughts and perspectives on progress and challenges on UHC. Thanks.
Dr Wayne Irava 10:28
Thanks very much, Jane. Yes, so let me talk first about progress. We don't have UHC index scores for post pandemic. However, you know, our reading of writings and most predictions seem to indicate that UHC may have worsened because of COVID-19. I guess one of the reasons were, was that a lot of effort was directed towards COVID-19 preparedness and response efforts, but these came at the expense of reduced efforts in other areas. What are some of the challenges? And I would like to maybe just mention three. In the Pacific Islands, one of the biggest challenges is dispersed islands giving rise to isolated populations, which really makes the logistics of health service delivery, and the implementation of public health programmes very challenging. You know, often these isolated populations, they are much smaller. And they can often be forgotten, you know, relative to the heavily populated urban centres. But if the UHC agenda is that no one is left behind, then these isolated persons must also be reached. But given the geographical dispersion, the logistics, and the costs to reaching them are just so much higher putting added strain on health budgets. We saw this in the COVID-19 vaccine rollouts, where people in these areas or these outer islands were in fact the last to be reached when it came to vaccination. The second challenge, I think, on the path to universal health coverage is human resources for health and the limitations around that. And, and I think it's not just about lack of numbers. But in some areas, I think it's also a lack of skills. The right number of health workers, the right mix of health workers. And the right distribution is critical if efforts to achieve UHC are to be successful. And the third challenge I would just like to highlight is health information. Access to reliable health information is really core to health sector improvement, we cannot manage our progress on the path to UHC if we cannot reliably measure it. Health information helps inform us and tells us where we're doing well and where we need to improve. So we can then manage how we allocate resources across the various sectors of the health sector. You know, in the Pacific Islands, there are many health information systems, they have the ability to disaggregate data to a more granular level than what we currently see presented. But it's not quite happening. We need data disaggregated by gender, we need data by age, we need data by geographical regions within the country. We need data by ethnicity, we need data by social economic status, etc. This will help us target the health interventions where the needs are greatest and help us progress. You know, much better than what we're doing now, on the path to universal health coverage.
Ms Jane Pepperall 13:58
So many interesting issues there Wayne, thank you. And I'm just thinking about one of them and that's COVID. And as with so many other issues, it has clearly set back the UHC agenda, but maybe also shone a light on some of the health sector issues that really needed attention. So just thinking about global health priorities with both health security now and UHC writ large, that for me raises the interesting question of the intersections between the two. And I wonder Toomas if you have any perspectives on that?
Dr Toomas Palu 14:32
I do and globally we do as well. Universal health coverage and health emergency preparedness are often referred as, as the two sides of the same coin being protected and prepared against infectious disease outbreaks should be the most universal health coverage there is. And it's not only within countries, but also across countries regionally and globally. We do know that the weakest link, the weakest community in the country, or the weakest country, in region or globally, can determine the tipping point between a small localised outbreak and pandemic. Universal health coverage and underlying health systems play a really outsized role in health emergency preparedness. The primary health care services is the first line of defense for detecting something unusual happening with people's health. And, as Wayne said also, for gathering data for surveillance. The frontline health services play an important role in testing and treatment, and also for a continuation of other essential health services during crises. So it's a universal access to vaccines, tests and therapeutics in pandemics is is very much about universal health coverage, leaving no one behind. And now, having experienced the pandemic and when it has understated has really underscored the importance of health systems in pandemic response. And preparedness. And learning from these lessons and building back better towards more agile and resilient health systems that are able to surge to accommodate increased demand, reconfigure itself themselves and reorganise resources would be very much integral to the strengthening health systems for universal health coverage. So that linkage, interlinkages are many. And really, they are that two sides of the same coin.
Ms Jane Pepperall 16:58
Thank you, Toomas, very interesting to hear about the sort of the intersections and the synergies that we need to build on between the two. And thinking, thinking about how to get UHC back on track and progressing again, I'd really like to talk more about how best the likes of the World Bank and development partners such as DFA can support UHC in the regions. And I suspect that you will all have a variety of views on that, but maybe I'll turn first to Aparnaa for some thoughts on that.
Dr Aparnaa Somanathan 17:27
Thank you, Jane. UHC is key to achieving the World Bank Group's twin goals of ending extreme poverty and increasing equity and shared prosperity. And as such, it's a driving force behind all of the World Bank Group's health and nutrition investments across the world, including in this region. So the bank supports UHC in two ways. One is through our lending. The other is through knowledge and advisory services. With respect to the lending, in Cambodia, Laos, Papua New Guinea to name few examples, the bank's investment project financing supports health system strengthening towards promoting universal health coverage. Another kind of lending in Indonesian Samoa, the World Bank's Program-for-Results Financing essentially a share of the government's overall health programme. And the financing is linked directly to the achievement of key results in the programme. And then in several other kinds of lending development positive project finance thing in several Pacific islands including Samoa, Tonga, and Tuvalu, the bank's development project financing or budget support operations finance key reforms, such as taxes on tobacco and sugar sweetened beverages. And then there are the advisory services and analytics. So we also said that we're a knowledge bank. And we support the generation and use of evidence and analysis that's needed to promote better policies for universal health coverage. Then turning to development partners, like DFAT. I think what the what the experience of the last few years of working really closely with this administration has shown us is that partners like DFAT can help leverage the financing provided by multilaterals, like the Bank, and they do this in several ways. One is by supporting and promoting greater knowledge generation and sharing lessons learned for cross country. Another is, for instance, through the advantage of the trust fund, DFAT has, has increasingly used UHC as an important platform, for DFAT’s own investments in health care. And again, I think Toomas will talk a bit more about this later. So I might stop there for now and see Wayne would like to add anything.
Dr Wayne Irava 19:48
Thanks, Aparnaa. Maybe I can just mention two examples. One from the project operations and then one from the analytics and advisory services. So on the first one with regards to operations, you know, I mentioned earlier one of the challenges about dispersed islands and isolated populations. Well, in Kiribati, we have the a health system strengthening project that has a large investment component that is directed or targeted towards the outer island health facilities. Now, part of the package is not just about upgrading some of these, the infrastructure of these facilities, but it also involves equipping these facilities, it includes training of these outer islands staff, there's the the activity on increasing the connectivity between the outer islands and the central hospitals on the bigger islands. And there's also an investment in in procuring a sea ambulance for the country. The objective of this operation was really to strengthen health service delivery in the outer islands. And in doing that, you know, give them access to health services, but also to lower the costs that were associated with unnecessary domestic patient referrals that would come from the outer islands to the main hospital in Tarawa. And I think this is, this is an example of, I guess, a project that that is trying to address universal health coverage. Another example, I think, from the analytics and advisory services is is some work that we do in in Solomons and it's it's to do with the the allocation of resources. In Solomons you know, during the annual health budgeting process, there was always the question of ‘how can we better distribute the public funding that we get across the 10 different provinces?’. The question was not whether the amount was sufficient, no, it was with the amount given, how do we equitably and confidently say that we've done an equitable job of distributing this across the many needs of the provinces. So our analytical work with the Minister of Health and working with them was to help, you know, come up with a formula that they could use so they could better allocate the minimum resources they have across the provinces, rather than using, you know, historical budgets year after year to inform resource distribution. The objective was to ensure equitable resource allocation so this could improve health coverage across the different provinces in Solomon Islands.
Ms Jane Pepperall 22:56
Thank you, Aparnaa and Wayne. Let's talk a little bit more now about the partnership between World Bank and DFAT on UHC. And you touched on it earlier in referring to the Advance UHC Trust Fund, I’m keen to talk about that a little bit more. It was established between us back in 2015, and for DFAT, it is very important and valued instrument for working with them through the World Bank on UHC. But I wonder Toomas if you could sort of give us a summary of that partnership, a little bit about its objectives, maybe some highlights. I'm also interested to hear to what extent it's an innovative way of working around UHC.
Dr Aparnaa Somanathan 23:35
Well thanks, Jane. This multi donor Trust Fund Advance UHC, advancing universal health coverage, that is supported by DFAT, but also contributed by GAVI Global Fund, and Gates, Bill and Melinda Gates Foundation. This trust fund aims to support lower middle-income countries to make progress towards UHC just to put it in short. And doing so through improving the use of financial human and other resources for a more effective, equitable, and sustainable health services and for strengthening financial protection. It takes on the equity dimension of universal health coverage by recognising the significance of gender inequality, and so also actively seeks to address gender equity issues on the path towards universal health coverage. And it has spurned really several innovations in the ways of working. First, Advance UHC was ahead of times to use broader health systems approach to look at sustainability challenges and options for health programmes that depended on external financing. It pioneered the new analytical instrument health financing system assessment that opened up broader perspectives to financial and programmatic sustainability. This was first used in Indonesia, and later on in many other countries. Second, the Advance UHC Trust Fund, it has today by to date already leveraged about $1.8 billion of World Bank funding to support countries and as well as co-financing from Global Fund, GFF which is Global Financing Facility, GAVI. The Korean the KfW, which is a Korean development assistance, the Asian Infrastructure Investment Bank, Japan, and Gates Foundation. So it's been really catalytic in helping to mobilise resources to support countries in the path towards UHC. Third, it has supported some innovative blended financing modalities, including the first World Bank cooperation globally to be co-financed by the Global Fund under the co-financing framework agreement between the World Bank and Global Fund, and this operation is being implemented in Lao PDR. And Chindavanh may talk a little bit more about it. But this operation really demonstrates how integrated health system reforms can deliver towards progress towards universal health coverage. Fourth, it has put gender more firmly into mainstream health systems, strengthening and UHC operations in the World Bank has done so in Laos, Cambodia, Papa New Guinea, Vietnam, and it has introduced some really operational innovations such as gender equity and innovation fund in Lao PDR. And again, Chindavanh who is actually based in Laos can talk more about it and will. And finally, and fifth throughout its existence, the Advance UHC Trust Funds has supported knowledge exchange in the region that bring together countries as well as development partners active in the region to align understanding and share experience and evidence on what works and how to advance UHC in countries in Asia Pacific region.
Dr Aparnaa Somanathan 27:32
A follow up with a specific example from Indonesia. But just listening to some of the things we realised that catalytic, I think, is the important word when I think about a UHC. And the Indonesian example is a very good one for that, where defense long partnership with the World Bank has led to extensive policy dialogue that's really catalysed greater government attention towards priority health programmes, and towards better financing for these programmes. So Toomas mentioned the health financing system assessment in Indonesia, for instance. So this health financing system assessment, or HFSA, as we call it, has led to much improved evidence base or evidence for policy dialogue, on a whole range of issues from primary care to health insurance reforms, integration of programmes, the interoperability of information systems, and so on. And over the years, also, with support from the government, my sphere programme supported by the World Bank has led to a really strong foundation for the current health system transformation agenda that the current Minister of Health is really pushing forward. And today also, I should note the government of Indonesia is preparing a major TB project with the World Bank and global funds financing, which addresses the TB challenge, the challenge of TB in Indonesia but taking a very UHC-focused approach. And it's that early analytical work that has helped the government implement these reforms and push the agenda forward.
Ms Jane Pepperall 29:09
Thank you, Toomas and Aparnaa for that. And Toomas, I was really pleased to hear you mention gender. And as we've talked, we've touched on equity and leaving no one behind in the context of UHC. And so I did want to ask a final question on gender equality. And gender remains a key priority for Australia development programme and as we know, there are significant gender-related constraints to both supply and demand of essential health services and therefore, to UHC. So it was just interesting in hearing a little bit more about how the Advance UHC Trust Fund goes about addressing gender constraints and Chindavanh I wondered if you could please help us with that one.
Ms Chindavanh Vongsaly 29:53
Thank you, Jane. Let me firstly also talk about the genders as to parity for World Bank as well. You know, gender equality is also very important for the bank programmes and men and women must have equal power to shape the whole life and contribute to the prosperity of their own family and community and country, they will not be able to achieve a made the commitment to UHC unless they are championing equal participation of women and girls. So turning to the into the UHC Trust Fund, it is a very important tool, playing an important roles in helping us expand our knowledge of gender constraints to UHC, and enhance our engagement around empowerment of women, in particularly adolescent girls. Understanding and quantifying challenges faced by girls and women in the poorest countries, and at the community level improved targeting. The UHC Trust Fund, the World Bank have focused on poverty and the team working in the health traditional public population conducting analysis that look beyond national average, and assist our clients intervene among segments of the population and people living in the area of the highest need. This is very important for setting the targets and have to be combined with a measure that address the hurdle faced by women in the poorest countries to achieve those targets. I just would like to give a concrete example in Laos. The gender assessment conducted in 2020 had contributed to increase awareness and understanding on gender inequality and health equity inequity in the countries. The assessment results have really informed the designing of our current health operation, which is we call the Health and Nutrition Services assess projects. The project has targeted women, girls and children living in their hard-to-reach areas where undefined stunting is high, approximately 40 to 45% higher than the national average of 33%. And, of course, the low coverage of maternal and child health services is instrument and unfinished agenda. Notably on the immunisation, family planning, antenatal and postnatal care. So this really helps to understand how the project is needed to be better targeted to the most vulnerable population in the countries. And I would like to touch upon a piece that Toomas mentioned already on the gender innovation fund, this is the thing that we are trying in Laos for a year and a half now, because we want to really listen to what's happening at the local levels. And what is the local solution that being proposed by the local community, I can give a concrete examples on two health centres that we visited. One health centre has midwives who speak the same languages of the community. And this makes a lot of difference because the service utilisation, for example, the delivery at health activity is higher than the other health centre that we visited, where the health centre doesn't have the midwife and most of their staff or volunteer staff and not well trained to deliver the services to the community. So this is scary that I see the difference. And lastly the local solution is very important when we are visiting at the field level. And we observe what happening at the field level. And now we should bring it back to discuss at the official level, particularly at the district level where they are closer to the health centre and the community level to address those issues.
Ms Jane Pepperall 34:32
I think it's clear that addressing gender constraints and other equality challenges has to go hand in hand with our overall efforts on UHC. So thank you Chindavanh for sharing those experiences with us. And indeed, thank you all for sharing your thoughts and experiences today. It's been a fascinating conversation on universal health coverage. There are so many different avenues that we could have gone down. So let me just close by thanking you all very much for having this conversation with me today.
You've been listening to a panel discussion about universal health coverage in Southeast Asia and the Pacific, and how the World Bank is supporting progress towards UHC in the region. We discussed how UHC compares in Southeast Asia and the Pacific in terms of political commitment, progress, and challenges. And the extent to which the Advance UHC Multi Donor Trust Fund is an innovative way of progressing UHC. We heard examples from countries such as Indonesia, Laos and the Solomon Islands. Thanks for your company. I'm Jane Pepperall. Contain This aims to bring you fresh insights analyses and updates on what is shaping the future of global health in our region. We look forward to having your company on the next episode.
Contain This is produced by the Indo Pacific Centre for Health Security. You can follow us on Twitter at @centrehealthsec.