Statistical Yearbook for Asia and the Pacific 2012
 
   
B. Health
 
B.6. Financial and human resources for health
Investments in health, as with other elements of social protection, are often seen as vital to achieving sustainable and inclusive development. With the Asian and Pacific region acting as the engine of global economic growth it might be expected that more resources would be directed to health. In reality, many countries exhibit low levels of health spending and limited coverage of health workers. There are, however, some positive trends, including countries that have achieved or are close to achieving universal coverage of health care, and these need to be built upon.
Although the Asian and Pacific region is a key source of global economic dynamism, its growth has generally not led to relative increases in health spending, and the level of spending is still significantly lower than the global aggregate, particularly government spending on health.

Asia and the Pacific has an abundance of financial resources, with substantial economic investments taking place across the region. However, health expenditure has not reached the same level. In fact, the regional aggregate figure for total health expenditure as a percentage of GDP, at 6.43 per cent in 2011, is considerably lower than the global aggregate of 10.07 per cent.

Figure B.6-1
Total health expenditure as a percentage of GDP, Asia and the Pacific, 2010 and 2011

Figure B.6-1 Total health expenditure as a percentage of GDP, Asia and the Pacific, 2010 and 2011At the subregional level, East and North-East Asia and South and South-West Asia experienced decreases in total health expenditure as a percentage of GDP between 2009 and 2010, and an increase between 2010 and 2011, but this was not enough to return to 2009 levels. During the same period, South-East Asia decreased in consecutive years from 4.05 per cent in 2009 to 3.65 per cent in 2011. North and Central Asia experienced an increase in 2010 to 6.23 per cent from 6.02 per cent a year earlier, and then a decrease back down to 5.94 per cent in 2011. Although the Pacific has remained constant since 2009 at around 9.05 per cent, if Australia and New Zealand are excluded from that aggregate, there was a modest decrease from 5.03 per cent in 2009 to 4.93 per cent in 2011. The five countries with the highest rates of total health expenditure as a percentage of GDP were all in the Pacific (Tuvalu, Marshall Islands, Niue, Federated States of Micronesia, and Palau).

With regard to total health expenditure per capita, significant variations exist between countries, but several countries stand out for having achieved large increases, often facilitated by economic growth. Afghanistan, China, Maldives and Russian Federation more than doubled per capita expenditure over the period 2005 to 2011, while in Nauru the figure experienced a reduction of 25 per cent. In Bangladesh, Georgia, Tajikistan, Turkey, Uzbekistan and Viet Nam the increase from 2005 to 2011 was in the range of 80 per cent to 95 per cent. Only three countries recorded decreases in the same period: Nauru (25 per cent), Timor-Leste (16 per cent), and Tonga (9 per cent).

General government health expenditure as a percentage of total government expenditure tends to be higher in East and North-East Asian and in Pacific countries than in countries in other subregions. Some of the lowest rates are found in several least developed countries in the region, such as Myanmar (1.3 per cent) and Timor-Leste (2.9 per cent).

Figure B.6-2
Total health expenditure per capita, Asia and the Pacific, percentage change from 2005 to 2011

Figure B.6-2 Total health expenditure per capita, Asia and the Pacific, percentage change from 2005 to 2011

In terms of general government health expenditure per capita, East and North-East Asia and the Pacific are the only subregions where all countries with reported data have figures over the WHO recommended minimum spending of $60 per capita purchasing power parity (PPP) to achieve the health-related Millennium Development Goals.1 In South-East Asia, six countries spend less than this amount, in South and South-West Asia five countries spend less, and in North and Central Asia one country spends less.

The five countries with the largest declines in general government health spending per capita between 2010 and 2011 were Afghanistan (33 per cent), Malaysia (29 per cent), Vanuatu (19 per cent), Brunei Darussalam (14 per cent) and Pakistan (11 per cent). In the same period, the five countries with the largest increases were Solomon Islands (31 per cent), India (23 per cent), the Lao People’s Democratic Republic (23 per cent), Tuvalu (22 per cent) and the Cook Islands (22 per cent). Interestingly, in Solomon Islands there was a 84 per cent increase from 2007 to 2011 and a more than doubling between 2004 and 2011.

There are large disparities across the Asian and Pacific region in the proportion of health spending from the private sector.

Private health expenditure as a percentage of total health expenditure varies considerably across the region and, with few exceptions, has shown little change at the individual country level in recent years. In East and North-East Asia, the rate is between 42 per cent and 45 per cent, apart from Japan with 20 per cent. Rates for countries in the Pacific range between 0 and 32 per cent. In the remaining three subregions, there are large variations, with some rates at 80 per cent or more, and others at or considerably below 38 per cent.

People in the Asian and Pacific region spend more on out-of-pocket health expenses than people in any other region in the world, affecting access to health-care services and potentially exacerbating health and socioeconomic inequalities.

The high percentage of out-of-pocket health expenditure in total private health expenditure is a concern in the region. It especially affects the poor and marginalized and often contributes to a vicious cycle of poverty and ill health, especially when the spending becomes catastrophic. At the regional level, the figure is 79.77 per cent (2011), having shown a very marginal fall in recent years from 80 per cent or just above that. This is higher than all other regions and significantly higher than the global figure of 60.45 per cent. At the subregional level, the rate is highest in North and Central Asia, at 89 per cent, having risen steadily from a little under 70 per cent in 1995. In South and South-West Asia, the rate is 83 per cent; yet, there has been a steady fall from 95 per cent in 1995. The rate in East and North-East Asia is 80 per cent, with little change over the years. In South-East Asia, the rate is 76 per cent, with a slow decline from about 80 per cent in the mid- to late 1990s. The Pacific, with 63 per cent, has the lowest rate in the region, but it also displays the greatest subregional variation, with several countries having rates of 100 per cent and several others having rates of about or considerably below 60 per cent.

The Asian and Pacific region is facing difficulties in deploying enough physicians, nurses, midwives and hospital beds to address people’s health needs.

Figure B.6-3
Number of health workers,* latest data available

Figure B.6-3 Number of health workers,* latest data availableHealth expenditure is often an important indicator of government commitment to health and social development in general. However, the success of delivering effective health care depends to a large extent on the quality of resources, and this is where human resource development in the health sector is vital. Data for the region are not comprehensive, but, from what is available, it is evident that many challenges remain in order to increase human resources for health; this is especially the case in remote and rural areas.

The number of physicians per 10,000 population is higher in countries in North and Central Asia than in countries in other subregions, with figures above 18 and as high as 43. In East and North-East Asia, the figures are in the range of 15 to 33. In the Pacific, Niue, Australia, the Cook Islands and New Zealand have the highest rates of 60, 39, 29 and 27 respectively, while in the remainder the figure is about 10 or below. Low rates of under 3 are found in South-East Asia and South and South-West Asia, such as in Afghanistan and Indonesia, both having a rate of 2.

Nursing and midwifery personnel play a vital role in maintaining health and in reducing morbidity and mortality, including infant, child and maternal mortality. Again, the numbers per 10,000 population are highest in North and Central Asia, with a range of 45 to 107, except for Georgia. The figures are also high in the Pacific, though five countries have a figure at about or below 20. China has a figure of 15 and the other countries in East and North-East Asia have a figure in the range of 35 to 53. South- East Asia and South and South-West Asia, where, apart from Brunei Darussalam, Malaysia, Maldives, the Philippines, Singapore and Turkey, the figures are at about 20 or considerably below. In fact, several countries have a figure well below 10 or even 5; these countries tend to be those with the highest levels of maternal and child mortality, which stresses the need to invest significantly more resources in this domain of health care.

A consideration of hospital beds per 10,000 population shows a picture similar to that of physicians, nursing and midwifery personnel. The highest figures are in East and North-East Asia. North and Central Asia has figures in the range of 31 to 97. The Pacific again exhibits considerable variations, with several countries over 45, and two below 20. South-East Asia and South and South-West Asia are quite similar in having a few countries with a figure above 30 and several with a figure below 10.

Box B.6.1
Progress in achieving universal health-care coverage in the Asian and Pacific region

Experiences in Asia and the Pacific, as well as beyond, show that universal health-care coverage allows for the realization of the inalienable right of every person to access health care. Universal health-care coverage has also proven to be critical in enabling the poor and marginalized to gain access to health-care services, many of which would have otherwise been unavailable or would have contributed to impoverishment.

In the region, a number of countries have achieved or are close to achieving universal health-care coverage. They include the high-income economies of Australia; Brunei Darussalam, Japan, New Zealand, the Republic of Korea and Singapore as well as Hong Kong, China. They also include the lower-middle-income economies of Mongolia and Sri Lanka, and the upper-middleincome economies of Malaysia and Thailand. In addition, China is endeavouring to achieve universal coverage over the next few years.

Malaysia, Sri Lanka and Thailand have made significant progress in expanding health-care coverage to achieve universal coverage and to contribute to successes in socioeconomic development, including the achievement of the Millennium Development Goals. In all cases, there has been political commitment at the highest level, along with pro-poor strategies, including targeting to enhance access to health-care services.a

Political commitment has contributed to an increased availability of financial resources for health as well as an enhanced capacity of health workers. Strategic planning, developing managerial capacity and raising awareness among Governments and populations have also played roles in ensuring greater sustainability, especially in the context of global financial uncertainty and the rising health-care costs related to ageing populations.

WHO estimates that 20 per cent to 40 per cent of all health spending is currently used inefficiently. Successful examples in the Asian and Pacific region show a move away from a reliance on direct payments, including user fees, and a greater reliance on raising funds through required prepayment and the pooling of funds. Such strategies have the greatest impact on those who are the least able to pay for health-care services and have proven to be the most efficient and equitable way of expanding health coverage to a greater percentage of the population.

In the region, where to a large extent the coverage of health-care services remains low, there is an urgent need to use the gains from economic growth for greater investments in health so that development may be more inclusive and sustainable.

____________________
a ESCAP. Development of Health Systems in the Context of Enhancing Economic Growth towards Achieving the Millennium Development Goals in Asia and the Pacific. Bangkok, 2007. ST/ESCAP/2449.

Further reading

The Lancet. “Universal Health Coverage”. September 2012. Available from www.thelancet.com/themed-universal-health-coverage.

Stuckler, D. and others. The political economy of universal health coverage. Background paper for the First Global Symposium on Health Systems Research. 2010. Available from www.pacifichealthsummit.org/downloads/UHC/
the%20political%20economy%20of%20uhc.PDF
.

World Health Organization. The World Health Report 2010: Health Systems Financing – The Path to Universal Coverage. Geneva, 2010. Available from www.who.int/entity/whr/2010/en/index.html.

Technical notes

Total health expenditure (percentage of GDP, 2005 PPP dollars per capita)
Total expenditure on health is the sum of general government and private expenditure on health. Expressed as a percentage of GDP and in per capita PPP dollars. Indicator calculations: Per capita figures are based on population figures (WPP2012). Aggregate calculations: Weighted averages using current GDP in United States dollars as weight (percentage of GDP). Missing data are not imputed.

General government health expenditure (percentage of government expenditure, PPP dollars per capita)
The sum of outlays for health maintenance, restoration or enhancement paid for in cash or supplied in kind by governmental entities, such as the ministry of health, other ministries, parastatal organizations or social security agencies (without double-counting governmental transfers to social security and extrabudgetary funds). Such expenditure includes transfer payments to households to offset medical care costs and extrabudgetary funds to finance health services and goods. The revenue base of such entities may comprise multiple sources, including external funds. General government expenditure corresponds to the consolidated outlays of all levels of government: territorial authorities (central/federal Government, provincial/ regional/-state/district authorities, municipal/ local government), social security institutions and extrabudgetary funds, including capital outlays. Indicator calculations: Per capita figures are based on population figures (WPP2012).

Private health expenditure (percentage of total health expenditure)
The sum of outlays for health by private entities, such as commercial or mutual health insurance providers, non-profit institutions serving households, resident corporations and quasicorporations not controlled by governmental authorities with health services delivery or financing, and direct household out-of-pocket payments.

Out-of-pocket health expenditure (percentage of private health expenditure, percentage of total health expenditure)
The direct outlay of households, including gratuities and payments in kind, made to health practitioners and suppliers of pharmaceuticals, therapeutic appliances and other goods and services, whose primary intent is to contribute to the restoration or to the enhancement of the health status of individuals or population groups. Such expenditure includes household payments to public services, non-profit institutions and non-governmental organizations, as well as non-reimbursable cost sharing, deductibles, co-payments and fee-for-service. It excludes payments made by companies that deliver medical and paramedical benefits, whether required by law or not, to their employees, and payments for overseas treatment. Aggregate calculations: Weighted averages using current GDP in United States dollars as weight. Missing data are not imputed.

Physicians and nursing and midwifery personnel (per 10,000 population)
Physicians: Physicians include generalists and specialists. Nursing and midwifery personnel: Nursing and midwifery personnel include professional nurses, professional midwives, auxiliary nurses, auxiliary midwives, enrolled nurses, enrolled midwives and other personnel, such as dental nurses and primary care nurses.

Hospital beds (per 10,000 population)
In-patient hospital beds include hospital and maternity beds and exclude cots and delivery beds.

Source

Sources of resources for health data: WHO Global Health Observatory. Expenditure data: WHO collects national health accounts and other data from countries. National sources collected by WHO include national health accounts reports, national accounts reports, general government accounts, public expenditure reviews, government expenditure by purpose reports (Classification of the Functions of Government), institutional reports of public entities involved in health-care provision or financing, notably social security and other health insurance compulsory agencies and ministry of finance reports. The most comprehensive and consistent data on health financing are generated from national health accounts. If national health accounts data are not available, WHO estimates are based on technical contacts in-country and publicly available documents and reports that are adjusted to the national health accounts framework. WHO sends estimates to the respective ministry of health every year for validation. Medical personnel and hospital bed data: WHO collects data from countries. Data collected include population censuses, labour force and employment surveys, health facility assessments and routine administrative information systems reports (on public expenditure, staffing and payroll, as well as professional training, registration and licensure). Most of the data from administrative sources are derived from published national health sector reviews and/or official country reports to WHO offices. Data obtained: 28 August 2013.

____________________
1 This excludes the Democratic People’s Republic of Korea, for which the latest data (2008) show a figure of $46 PPP.
 
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