Public resources for health programmes in the Asia-Pacific region fall far short of the level needed for ensuring equitable access to essential services. Meanwhile, private expenditures on health are growing, mostly as direct, out-of-pocket payments, which work against goals of universal health care coverage. Inadequate numbers and inequitable distribution of health workers continues to hamper access to services in most of the region.

Healthcare financing is key in sustaining and developing health systems that aim at improving human health. Resource mobilization, risk protection, pooling resources and effective purchasing are critical functions of health-system financing. In the Asia and the Pacific, countries exhibit large differences in the mobilization of healthcare financial resources. In 2009, highincome countries in the region spent 8.0% of their GDP on health while low-income countries spent only 4.1%. In the same year, per capita total expenditure on health in “international dollars” or units of purchasing power parity (PPP$) ranged from low (below PPP$100) in some countries (PPP$23 in Myanmar, PPP$48 in Bangladesh, PPP$63 in Pakistan, PPP$69 in Nepal, PPP$71 in Papua New Guinea, PPP$86 in the Lao People’s Democratic Republic and PPP$99 in Indonesia) to high (above PPP$2,000) in others (PPP$2,086 in Singapore, PPP$2,667 in New Zealand, PPP$2,688 in Niue, PPP$2,713 in Japan and PPP$3,382 in Australia).

Total expenditure on health includes governmental spending from tax-funded health budgets and social health insurance funds, private health insurance, out-of-pocket spending on personal healthcare (including medicines) and external financing by international partners. Total expenditure on health as a percentage of GDP in the region declined in recent years from 6.3% in 2000 to 6.0% in 2009 (in contrast to all other regions).

Note that aggregate expenditure by subregion as a share of total GDP is influenced by the share of GDP for each country in the subregion. For example, in East and North-East Asia the expenditure as percentage of GDP fell from 6.9% to 6.5% however, all the individual country values (with the exception of Mongolia) show a constant or increased expenditure on health. The decrease in the subregional average is thus attributed to the increasing weight of China in the subregional average coupled with the decreasing weight of Japan in that same figure. This indicates that in the case of China health expenditure as a percentage of GDP has not increased and is still below the average for the subregion, despite favourable economic conditions.

Although the total expenditure on health as a share of GDP remained constant or increased for most countries in Asia and the Pacific, 14 countries experienced a decrease between 2000 and 2009 (Afghanistan, Armenia, Bhutan, Fiji, India, the Maldives, the Marshall Islands, Mongolia, Myanmar, Pakistan, Papua New Guinea, Turkmenistan, Tuvalu and Uzbekistan).

Figure I.30 – Total health expenditure, countries in East and North-East Asia, 2000 and 2009

Government expenditure

General government health expenditure largely depends on the degree of political commitment to health. In Asia and the Pacific, governmental commitment to health varies; in some countries health was deprioritised in the allocation of public resources from 2000 to 2009. Specifically, Afghanistan, Azerbaijan, Bangladesh, China, Fiji, the Lao People’s Democratic Republic, Kyrgyzstan, Maldives, Myanmar, the Marshall Islands, Mongolia, Myanmar, Papua New Guinea, Philippines, the Russian Federation, the Solomon Islands, Tajikistan, Timor-Leste, Tonga and Turkmenistan all experienced reduced government health expenditure as a proportion of government expenditure (note that almost half of these countries also experienced a decrease in total health expenditure as a percentage of GDP).

Although per-capita government expenditure on health is based on a very wide range of health and economic situations, it is considered an important indicator of the adequacy of healthcare financing. In 2001, the WHO Commission on Macroeconomics and Health suggested US$35 per-capita expenditure on health as the benchmark for the cost of a minimum package of essential health services. In 2009, the WHO High Level Taskforce on Innovative International Financing for Health Systems estimated that low-income developing countries need to spend at least US$60 per person on health in order to make progress in meeting the Millennium Development Goals. As of 2009, Myanmar has the lowest per-capita governmental expenditure on health in the Asia-Pacific region at PPP$2. In Asia and the Pacific, the per-capita governmental expenditure on health ranged from PPP$0 to PPP$34 in 7 countries and from PPP$35 to PPP$60 in 5 countries. As PPP is equivalent to the purchasing power of US$1, these figures demonstrate that many countries have not mobilized resources of the recommended US$60 that is considered necessary to ensure equitable access to essential public health services.

Private expenditure

Private health expenditure is mainly a function of per-capita wealth and it also fills the gaps in public financing. In 2009, private health expenditure accounted for more than 60% of total health expenditure in 11 Asian countries (none in the Pacific). In the Pacific subregion, private health expenditure as a percentage of total health expenditure ranged from 1% in Niue and as high as 32% in Australia.

Figure I.31 – Government health expenditure per capita, countries less than PPP$60, 2000 and 2009

In the Asia-Pacific region, more than 80% of private health expenditure is reported as direct, out-of-pocket payment (much higher than the world average of 60%). Evidence is mounting that direct, out-of-pocket payment is a highly inequitable and inefficient method of resource mobilization for health. It affects equity in access, coverage and utilization of health services, and it impacts unfavourably and unpredictably on household income.

In 2010 WHO published the World Health Report – Health Systems Financing: the path to universal coverage with estimates that globally about 150 million people spend more than 40% of their household disposable income on health while about 100 million people are newly impoverished every year because of such direct, out-of-pocket payments (often called “catastrophic” expenditures for this reason). Many Governments in the Asia-Pacific region express serious concern about excessive household payments for healthcare services and have initiated policy measures to reduce out-of-pocket payments by improving financial risk protection and safety nets, especially for the poor and vulnerable population segments. Such efforts are likely to yield reductions in private expenditure on health in many countries.

Figure I.32 – Out-of-pocket health expenditure, Asia and the Pacific, 2000 and 2009

Nevertheless, private health expenditure as a percentage of total health expenditure still remains high for many countries. In the Pacific, the dominant governmental role in financing health services precludes private health expenditure from carrying a large proportion of healthcare financing. Over the past decade, private health expenditure as a percentage of total health expenditure was below 35% in all countries of the Pacific subregion.

Figure I.33 – Private health expenditure, Asia and the Pacific, 2000 and 2009

Mobilizing needed resources

If the guiding principle is universal healthcare coverage and improved health outcomes in the region, reducing direct, out-of-pocket, health expenditure and removing financial barriers to seeking care will be the most important healthfinancing policy issues for many countries. Policy analysis and discussions of health financing data are essential in monitoring and evaluating public efforts in mobilizing financial resources for health, to ensure that they are adequate and access to services is equitable. Such discussions can lead to improved resource mobilization with adequate financial risk protection and safety nets, a necessary condition for attaining universal healthcare coverage.

Human resources for health

Apart from financial resources, the human resources available for public health interventions are critical in terms of their numbers, competencies, productivity and support. Availability of timely and reliable data, particularly regarding human resources in the health sector, both public and private, remains a challenge.

Simple trends are evident in the most recent data available. North and Central Asian countries tend to have the highest density of doctors, nurses and midwives, ranging from 20 to 45 physicians and 39 to 108 nurses and midwives per 10,000 population. The number of hospital beds follows the same pattern, ranging from 33 to 97 beds per 10,000 population. The South and South-West Asian subregion suffers the lowest density of doctors, nurses and midwives, ranging from 0.23 to 16 physicians and 2.7 to 45 nurses and midwives per 10,000 population, with 4 to 50 hospital beds per 10,000 population.

Among the countries in between those extremes, East and North-East Asia has better healthcare workforce densities than South-East Asia, followed by the Pacific.

The World Health Report 2006: working together for health provided evidence that 23 health workers (includes doctors, nurses and midwives) per 10,000 population is the health workforce density threshold, below which essential health services are hampered and maternal and child mortality rates increase. Only 35 countries in Asia and the Pacific have workforce density figures above that threshold, which includes all 5 of the East and North-East Asian countries with available data and all 9 of the North and Central Asian countries.

In South-East Asia, 6 of the 11 countries fall below the threshold of 23 health workers per 10,000 population, with Cambodia having the lowest density at 10 physicians plus nurses and midwives per 10,000 population. In the Pacific, 4 of the 16 countries with available data fall below the threshold, with Papua New Guinea having the lowest density at 6 health workers per 10,000 population. Among South and South- West Asian countries, 6 of the 10 fall below the threshold.

Unsurprisingly, countries beset with continuing poor health indicators, particularly high maternal and infant mortality and morbidity rates, are the very ones suffering from lack or inadequate numbers of health workers. It is likely that further data availability and analysis would show that these countries also have an inequitable distribution of health workers within their borders, with density of health workers much higher in urban than rural areas, where the population is more vulnerable. Health workforce density data have implications for achievement of universal access and delivery of essential health services. Improvements in health outcomes are directly related to investments in the adequacy, competence, productivity and support of the human resource sector.