The Lancet series on health in Southeast Asia

Note: A launch of the Series will take place at Prince Mahidol Award Conference, Bangkok, Thailand on Tuesday 25 January 2010. Any journalist wishing to attend should contact Rebecca Firestone, China Medical Board, USA. E) rfirestone@cmbfound.org

For author contact details, see end of release.

The 10 countries analysed in the Lancet Series on Southeast Asia are: Brunei, Cambodia , Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam, with a combined population of 580 million people. For links to all the papers, see the individual links beneath each part of the press release; however if you wish to provide a link for your readers to a page containing the whole Series, please use the link below (but please note this first link will only be live once the embargo has lifted).

http://www.thelancet.com/series/health-in-southeast-asia

The first paper (Prof Kai Hong Phua, National University of Singapore, and colleagues) examines the current health situation in Southeast Asia. The diversity of SE Asia has led to social, cultural and economic differences in very disparate health systems and indicators in different countries. Yet the pace of demographic change in the region is one of the fastest worldwide, whether it is due to population aging, fertility decline, or rural to urban migration. As elsewhere, the disease burden continues to shift from infectious to chronic diseases; yet increased urban population density has created concerns about emerging infectious diseases. For example, the SARS experience and recent outbreaks in avian flu have raised fears about the possibility of new pandemics spreading from the region.

SE Asia's location and geology makes it prone to natural disasters with all the health-related consequences these can bring. Health systems are varied, containing a mix of public and private delivery and financing. They range from dominant tax-based financing in Brunei, Malaysia and Myanmar to fledgling social insurance schemes in Thailand, Vietnam, Laos, Cambodia, Indonesia and the Philippines, with mixed medical savings schemes and public-private cost-sharing in Singapore and high out-of-pocket payments across the region. Private health expenditure is increasing relative to government expenditure, where new forms of financing include user charges, improved targeting of subsidies, and greater cost recovery. There are also interesting hybrid forms like corporatised public hospitals amidst the rapid development of medical tourism and the biomedical industry in many countries. Further restructuring towards universal coverage and risk-pooling will be needed to address ageing populations and social care.

The authors conclude that through ASEAN (The Association of Southeast Asian Nations), there is potential for great public-private and regional collaboration and harmonisation of standards, despite the division of the region under the jurisdiction of two WHO regional offices.

For full Series paper 1, see: http://press.thelancet.com/seasia1.pdf

Maternal and child health is addressed in paper 2 (Cecilia S Acuin, University of the Philippines, and colleagues). As one might expect, wide variations exist in mortality and trends in mortality. The authors identify three major patterns of maternal and child mortality reduction: early, rapid, downward trends (Brunei, Singapore, Malaysia,Thailand), initially high declines (sustained by Vietnam but faltering in the Philippines and Indonesia) and high initial rates with a downward trend (Cambodia, Laos, Myanmar).

The authors note that some countries are notable success stories. For example, Thailand has shown that its policies have resulted in rapid, persistent reductions in maternal, infant and child mortality. These include giving priority to the needs of rural areas and the less able, followed by improvements in the training and distribution of health manpower, a more equitable allocation of facilities and resources, and sustained by financing mechanisms that ensure support for the poor.

The authors propose that increasing coverage of key interventions to 60% would substantially reduce maternal mortality due to unsafe abortion, birth-related haemhorrage and on newborn deaths caused by pneumonia, sepsis, and asphyxia. ASEAN should lead more regional co-operation in maternal and child health, the authors conclude.

For full Series paper 2, see: http://press.thelancet.com/seasia2.pdf

The third paper (Richard Coker, London School of Hygiene and Tropical Medicine, UK) addresses emerging infectious diseases in the region. The severe acute respiratory syndrome (SARS) crisis of 2003 devastated tourism in the region and H5N1 bird flu has profoundly affected the poultry industry and also raised tourism worries. SE Asia contains a cocktail of diverse ecosystems, population movements, food production processes, land use, water and sanitation systems, and drug resistance that all interact in a way that allows microbes to exploit ecological niches.

Controlling the threat of emerging infectious diseases is difficult due to the variety of economies across SE Asia (Singapore US$37,500 per head GDP, Laos $850), and political tensions both between and within countries.

While there has been investment in surveillance, it remains poor in many areas, and research in the region relating to infectious diseases is scarce. The authors conclude: "The regional challenges in control of emerging infectious diseases are formidable and range from influencing the factors that drive disease emergence, to making surveillance systems fit for purpose, and ensuring that regional governance mechanisms work effectively to improve control interventions."

For full Series paper 3, see: http://press.thelancet.com/seasia3.pdf

Paper four (Prof Antonio Dans, University of the Philippines) says that, without fanfare, chronic diseases including cancer and heart disease now cause 60% of all deaths in SE Asia. The impact of chronic diseases over time has increased due to the relative decreasing impact of infectious diseases, ageing populations, and large increases is prevalence of risk factors such as tobacco use, unhealthy diet and lack of exercise. Chronic conditions and their risk factors are linked to poverty, and some modifiable risk factors are increasing as more of the population migrate to cities. Primary care and referral services must be improved across the region for the situation to improve, as well as addressing risk factors.

The authors also highlight that chronic diseases are no longer diseases of affluence in SE Asia – they are now diseases of poverty. This devastates families because of the double burden of increased expenses and loss of income. It also delays development for countries with lower income. From the medical standpoint, there are cost effective clinical and public health interventions. However, the rest of society must help as well, in making it easy to undertake lifestyle changes.

The authors conclude: "All branches of government and all sectors of society have to get involved in establishing environments that are conducive to healthy living. ASEAN is in a unique position to make a united stand against chronic non-communicable diseases in the region. Inaction will affect millions of lives—often, the lives of those who have least."

For full Series paper 4, see: http://press.thelancet.com/seasia4.pdf

There is a unique mix of situations regarding health workers in SE Asia, say the authors of the fifth paper (Dr Churnrurtai Kanchanachitra, Mahidol University, Thailand, and colleagues). Singapore and Malaysia import health workers to meet domestic demand and to provide services to international patients. Thailand has a booming health tourism economy (which must be staffed!), and these situations result in a brain drain from pubic to private institutions. The Philippines and Indonesia are the main exports of doctors and nurses in the region. Overall, like other regions, SE Asia suffers problems due to shortages of workers, skill mix imbalances, and poor distribution of health workers across nations.

Low-income countries face common problems of health-worker density and distribution, reduced employment opportunities for graduates and poor public sector pay. The low quality of training and services means that migration of health workers from these countries is not yet a big concern. However wealthier patients often seek care in other SE Asian countries. All SE Asian countries, regardless of income, need to do more to attract doctors and nurses to rural posts.

An ASEAN Framework Agreement on Services could make it even easier for health worker migration in the future. So each country's population is adequately served, migration management and retention strategies need to be integrated into ongoing efforts to strengthen systems in SE Asia. The authors conclude: "There is also a need for improved dialogue between the health and trade sectors on how to balance economic opportunities associated with trade in health services with domestic health needs and equity issues."

For full Series paper 5, see: http://press.thelancet.com/seasia5.pdf

There are efforts underway in seven of 10 SE Asian countries to reduce dependence on out-of-pocket payments for healthcare. The sixth paper (Dr Viroj Tangcharoensathien, Ministry of Public Health, Thailand, and colleagues) reviews progress to date. In Laos and Cambodia (low income), donor-supported health equity funds have been used to reach the poor. Reliable funding for the future and appropriate identification of who qualifies as poor are major challenges preventing national roll-out of the scheme.

For Thailand, Indonesia, Vietnam and the Philippines, social health insurance financed by payroll tax is commonly used for workers. For the informal sector and the rest of the population challenges remain, with countries such as Vietnam and the Philippines and Vietnam looking to increase coverage through contributory arrangements while Thailand is using tax funding. While all Malaysians are covered by some form of financial protection, this drops to 24% in Cambodia and 8% in Laos.

The authors say efforts should also be increased to make the financial protection through expanding coverage enough, and to design an appropriate mix of provider payment methods that allows doctors to rationally use medical technologies and services.

For full Series paper 6, see: http://press.thelancet.com/seasia6.pdf

In one of six Comments with the Series, Lancet Executive Editor Dr Bill Summerskill and Editor-in-Chief Dr Richard Horton say health professionals, from within ASEAN, must show leadership and "stand apart from the narrow interests that have too often fettered, rather than fostered, progress in the region."

They conclude: "Until public health trumps private wealth, progress in health across the region will be disjointed and inequitable. Only by placing human rights at the heart of development will the right of the region's 580 million people to the highest attainable standard of health be realised."

For full Summerskill/Horton Comment see: http://press.thelancet.com/seasiarhws.pdf

For other Comments, please see links below

Southeast Asia: an emerging focus for global health: http://press.thelancet.com/seasiafocus.pdf

Challenges in infection in ASEAN: http://press.thelancet.com/seasiainfection.pdf

Mental Health in Southeast Asia: http://press.thelancet.com/seasiamentalhealth.pdf

Civil society in ASEAN: a healthy development? http://press.thelancet.com/seasiacivil.pdf

A stormy future for population health in SE Asia? http://press.thelancet.com/seasiapopulation.pdf

Paper 1: Prof Kai Hong Phua, National University of Singapore. T) +65 9628 0800 / +65 6468 0800 E) spppkh@nus.edu.sg

Paper 2: Dr Cecilia S Acuin, University of the Philippines. T) +632-525-4098 / +63 917-527-2693 E) cesacuin@gmail.com

Paper 3: Prof Richard Coker, London School of Hygiene and Tropical Medicine, UK. T) +442079272176 / +6623546180 E) richard.coker@lshtm.ac.uk

Paper 4: Prof Antonio Dans, University of the Philippines. T) +63 917 539 0929 / +632 521 7793 E) tdans@skybroadband.com.ph

Paper 5: Dr Churnrurtai Kanchanachitra, Mahidol University, Thailand. T) +66 81 648 1964 E) prckc@mahidol.ac.th

Paper 6: Dr Viroj Tangcharoensathien, Ministry of Public Health, Thailand. T) +66 2 590 2366 / + 66 81 848 0297 E) viroj@ihpp.thaigov.net

Lancet Press Office T) +44 (0) 20 7424 4949 E) tony.kirby@lancet.com