The Asian Development Bank is supporting countries across Asia-Pacific in reforming and updating their healthcare systems, which requires proper management and funding. ADB health expert Dr Susann Roth goes into detail.
The following interview was taken from our Healthcare in Innovation report, download the full report for free here: App’ortunities for Everyone
Southeast Asia, as a region, dedicates the lowest percentage of GDP to health care in the world. How does this impact your work in financing healthcare projects?
Every country, regardless of its income status, faces challenges in providing for and financing of health care. Asia Pacific governments spend less than 3% of GDP for health care and rely heavily on the population to pay out-of-pocket for health care. But quality health care requires investments also from the public sector in infrastructure, technology, medical goods, human resources, capacity development, and reforms. As countries prosper, expectations of better health service infrastructure and healthier living conditions rise.
Many governments in Asia Pacific now prioritize reforming and strengthening of health systems toward achieving universal health care (UHC) and recognize that investing in health is important for sustainable and inclusive economic development. Almost all countries in Asia and the Pacific, irrespective of their level of development, have embraced the goal of UHC—providing quality health services to all those in need without undue financial hardship. To achieve these aspirations, the “business-as-usual” attitude needs to make way for innovative and integrated policies and solutions to build, manage, and finance quality supply of health services. Many countries are now exploring different ways to mobilize additional resources and technical expertise to strengthen their health services by moving toward UHC, often within a broader social protection agenda. This presents an opportunity for ADB to provide effective health sector assistance by focusing its support on operations that meet the needs and demands of the developing member countries, which are practical and support implementation of health sector reforms aligned with the strengths of ADB in infrastructure financing, and by carrying the potential to combine lending with knowledge services.
ADB, thanks to these new commitments to UHC, has been presented with avenues to partner with countries on developing responsive and effective health systems that promote inclusion, and good use of public and private resources.
The focus on UHC also offers ADB a means to build a long-term health practice and to usher in assistance beyond health infrastructure. Building knowledge and lines of investment that support countries with different levels of income in achieving UHC will provide a practice that will remain relevant as developing member countries evolve from low- to middle- to high- income levels.
In short, we believe that the trend is changing and that governments will increase their health sector budgets, and will invest in social health insurance or health equity funds and in reforms which make health care of better quality, affordable and accessible. For that, they will seek development assistance from partners like ADB.
How will greater regional cooperation and integration (RCI), one of ADB’s key mandates, help to support the building of healthcare institutions, especially with PPPs?
Regional integration and cooperation are of great importance to the strategic directions of ADB. ADB will continue to seek cofinancing, develop projects, and provide technical assistance to help build and institutionalize capacity to manage Regional Public Goods. This will form part of support of ADB toward strengthening health sector governance. ADB has accumulated impressive experience in health Regional Public Goods. The SARS crisis, avian influenza, and H1N1 events provided ample evidence that DMCs sought ADB support. The involvement of ADB in combatting HIV/AIDS in the region, more recent support to malaria control and elimination through the Asia Pacific Leaders Malaria Alliance (APLMA) and the Regional Malaria and Other Communicable Disease Threats Trust Fund (RMTF), including regulatory convergence of medical goods and pharmaceuticals, and nascent initiatives in the area of climate change and health are proof that the region can benefit from ADB’s convening power, interdisciplinary approaches to regional health governance, and the ability to combine technical knowledge with development and private sector finance.
For Public Private Partnerships, we understand that the experience in the health sector in the Asia Pacific region is still very limited and there are still very few success stories to share if we look only at for-profit PPPs. If we also consider PPPs between the public sector and civil society organizations, we do see many of those in Asia Pacific– and they are quite successful. ADB supports technical assistance projects in selected countries to advance capacity to identify and execute PPPs. For health sector specific PPPs, ADB has provided technical assistance to the governments of the Philippines and Thailand to establish PPP units within Ministries of Health.
At a regional level, specifically for ASEAN countries, there is need to build capacity across countries to identify and execute PPPs. Experience in other countries including the UK and South Africa have demonstrated that PPPs are not the answer for everything and a solution for financing any kind of health care facility. As ASEAN countries move towards UHC and as they acknowledge that they must collaborate with the private sector to provide quality health services for their population, countries will benefit from cross regional knowledge sharing and sharing of best practices. With the ASEAN economic integration, countries will also benefit from establishing standards for PPP project terms of references and bidding documents to attract international investments. For example, the International Infrastructure Support System, a secure, scalable service developed by the Sustainable Infrastructure Foundation (SIF), which was established with the support of the ADB and other multilateral development banks, could develop health infrastructure specific PPP project specific management tools, which help countries to manage PPP project execution. In order to develop sound health PPPs, governments also need to establish standards for construction and management of health care facilities and health care services. This is another area, which ADB can support at the national and regional level.
These days, especially in developed nations, we are hearing a lot about innovation in PPPs that include non-profit collaboration. What innovative partnerships such as this has the ADB been involved in, or is planning to be involved in?
Before giving examples of innovative partnerships, we need to define PPP. For the health sector group at ADB, PPPs are long-term partnerships between a government and a private provider. The partnerships share investment or the asset distribution and the investment risk. The public sector is accountable for providing an enabling environment and financial incentives for PPPs and the private sector has to be made accountable for achieving defined results. Asian countries started only recently to invest in health PPPs. Key lessons learned are:
- Health PPPs are different from infrastructure PPPs.
- Public sector needs to provide certainty about the financial risk to attract the private sector (use social insurance to finance PPP services).
- Public sector needs to invest in streamlined and clear tendering processes (Ministries of health often have no capacity to manage the tendering process) within legal and regulatory frameworks.
- Defined standards for construction and operation for the private sector have to be in place (the private sector needs incentives to provide a certain service standard, e.g. being accredited, licensed, certified as Center of Excellence).
- Systems for performance management and M&E have to be established (information systems and results based management capacity need to be strengthened).
More capacity development is needed to increase the often-weak capacity of ministries of health to manage PPPs. This includes: strengthening the weak legal and regulatory environment; developing a better understanding of the financial risks of PPPs; providing technical assistance for the public sector to fund feasibility studies for potential PPP projects; and strengthening accountability mechanisms for the private sector to deliver quality health care infrastructure and services.
ADB is planning to provide such capacity development and technical assistance to address the above listed challenges and foster private and public sector dialogue to define better what the public sector needs from the private sector and what the private sector can realistically deliver and at which cost.
ADB has supported PPPs between public and non-for profit organizations (civil society organizations) in Bangladesh and in Cambodia, where the government contracted out health service delivery to non-government organizations. Key lessons learned are that in the case of service delivery through NGOs, clear definition of service packages, ideally with output and performance-based contracts need to be in place to ensure that the private sector feels accountable for the quality of services provided and that quality assurance measures through standard operating procedures are in place. In addition comprehensive health information system management has to be in place to enable the public sector to lift relevant health information through the non-public sector service providers
The ADB plans to double its assistance of health-related projects to $750 million dollars a year by 2020. What are the largest projects the ADB is currently running, and what ASEAN countries can expect to benefit from this rising tide of funding?
ADB is currently implementing health sector projects in Mongolia, in countries in the Greater Mekong Subregion, in Bangladesh and in India. In 2015, ADB approved a $300 million health sector program in India to support the National Urban Health Mission. This is one of the largest-ever approved health programs for ADB and marks the beginning of a new era in ADB’s health sector. ASEAN countries can expect ADB’s support for their health sector reforms and investment needs to achieve UHC. This support will prioritize loans, and grant-blended loan products for the public sector and commercial debt and equity investments for the private sector through our private sector department.
As described in ADB’s Operational Plan for Health 2015-2020, ADB’s key priority areas for loans, grants and private sector investments are:
i. Health Infrastructure. Optimize health outcomes and increase the reach of health care from infrastructure projects such as health facilities and hospitals, and water and sanitation investments. Promote infrastructure investments designed to deliver on concepts such as healthy cities, healthy islands, etc., and ensure that infrastructure is integrated into health systems, managed and staffed efficiently, and properly operated with sustainable financing.
ii. Health Governance. Advance health care through good governance and regional public goods by strengthening institutions, planning, financial management, and health information and regulatory systems.
iii. Health Financing. Expand health care though innovative financing that promotes allocation and technical efficiency.
To fund health care efforts over the next 5 years, ADB will increase health sector investments from 1% to 2% of its total portfolio in 2014 to 3% to 5% (or an annual approval of around $1 billion in health projects) by 2020.
Innovation in healthcare is being realized through telehealth mobile applications. How is the ADB supporting this, and are their lessons elsewhere in Asia/the world that could be applied to ASEAN in this field, especially concerning adoption?
Information communications and technology (ICT) will play a crucial role in achieving equitable access to affordable, quality health care and ADB acknowledges that ICT enhanced solutions are a cornerstone for reforming and strengthening health systems to move toward UHC. ADB also acknowledges that meeting these aspirations will require not only stand-alone investments in e- or mhealth including telehealth projects but in innovative and integrated policies and interventions within comprehensive national ehealth frameworks. ADB supports and collaborate with the Asia eHealth Information Network (AeHIN), the largest network of ehealth experts and practitioners globally, and contributes to the organization’s unique peer-to-peer and capacity development support to countries and across regions (e.g. Asia and Africa). AeHIN and a united and growing collaboration with development partners stand ready to work together to address national health priorities and the Sustainable Development Goals in the post-2015 development era, collaborating with private sector ICT providers and ultimately achieving and measuring UHC with ICT.
To mitigate project investment risk and to stimulate public and private sector innovation in health ICT, ADB plans to support together with AeHIN the establishment of a regional m/eHealth Development & Innovation Center. Such a center will be modeled after similar labs in Canada and South Africa. The mandate of the lab will be to provide expertise and services in four key areas: training, tooling, teaming, and testing of ICT applications for the health sector.
To answer your question in more concrete terms, ADB doesn’t see its role in supporting stand-alone telehealth projects but to support countries in comprehensive health sector reforms, which include development of ehealth plans, which cover the legislative, the governance and the implementation aspects of ehealth. (Please note: ehealth or digital health includes mhealth and telehealth). What is important is to work with countries on the business case of ehealth investments and to assist countries in advancing and investing in the best ICT tools at the right time of their health sector reform. Telehealth might be one of the tools. For more information and country examples see ADB AND WHO POLICY BRIEF Universal Health Coverage by Design: ICT-enabled solutions are the future of equitable, quality health care and resilient health systems
The Philippines is said to spend the least on healthcare of the large ASEAN economies. Why is this and how do you believe telemedicine will offset this lag?
Philippines public health care spending is definitely at the lower end of ASEAN countries but overall health care spending is pretty similar to other ASEAN countries, which reflects the still high out-of pocket spending. Public health services are still weak and not able to provide the population with full coverage of quality health services. However, overall spending is expected to grow and the Philippine government has promised to respond to the growing need to improve health care coverage, and this promise came one step closer to reality with the 2013 passage into law of the Universal Healthcare Bill, which promises health insurance for all Filipinos, especially the very poor.
The health insurance, Philhealth, was able to increase its membership base over the last 20 years to more that 80% of the population, however, the benefit packages remain very small. To increase the benefit packages, to implement standard operating procedures for health service and define service packages as well as improve quality control and accountability mechanisms are now the challenge and the top agenda items for the government.
In order to leverage the potential of telemedicine to improve access to quality health services, the government will need to approve the proposed bill on telemedicine which calls for a comprehensive national telehealth system and governance framework. The framework includes licensing of telehealth providers and facilities, quality control, patient safety and privacy and accountability mechanisms. Beside the necessary legal andvgovernance framework, the Philippines as well as other ASEAN countries still need more investment in internet and mobile phone coverage. The fact is that the coverage is still low in remote areas and these areas are the ones which need access to telehealth services the most.
To enable better coverage, the public and private sectors need to collaborate and the public sector needs to create incentives for the private sector to expand internet and mobile phone networks in less profitable geographic areas.
What are some of the key Millennium Development Goals the region has been able to meet? Which goals have they struggled with?
The region demonstrated great success in halving extreme poverty ahead of 2015.
While no country will fail of all goals, none will achieve all goals either. Achievements of Asia Pacific countries on most MDG indicators lag behind Latin America and the Caribbean, though are generally higher than sub-Saharan Africa. The size of the poverty challenge remains large and underestimated. Basic non-income deficits – food insecurity, undernutrition, poor sanitation, maternal and child deaths – remain huge concerns. The region shows good progress on access to basic education but quality issues are serious. Aspects of the environment show progress, but pressure on natural resources is mounting with globalization and quest for growth.
New development challenges are emerging. The quality of GDP growth is becoming an issue: the vulnerability of the near-poor to extreme poverty, rising inequality, the working poor and jobless growth. Lifestyle changes are contributing to a rising incidence of non-communicable diseases. As people live longer, aging and the bulge in the youth population are simultaneously increasing the need for pensions and jobs; and health promotion and prevention of diseases. Unplanned urbanization is stretching municipal capacities including urban health services. Growing exposure to environmental stresses, disasters, and the threat of climate change could reverse long-term development gains and require investment to establish resilient health systems.
Susann is currently the Officer-in-Charge Technical Advisor, of the Asian Development Bank’s (ADB) health sector group secretariat. She co-led the preparation of ADB’s new Operational Plan for Health 2015-2020, a plan that aims to double ADB’s health sector operations by 2020. Besides the strategic work, one of her focus areas is to increase ADB private sector health investments, which includes developing sustainable public–private partnership solutions for health service delivery. Susann believes in the need for close dialogue between the public and private sector to find innovative solutions for the changing health needs of Asia Pacific’s population.
One of the innovative health sector solutions Susann promotes is digital health and she coordinates, from ADB side, the collaboration with the Asia ehealth Information Network (AeHIN).
Susann holds a Medical Doctor degree and a PhD in medical science from the University of Heidelberg in Germany, and a Master of Public Health degree from the University of the Philippines.