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The Astana Declaration on primary healthcare in 2018 was the attempt to revive the ideals of the World Health Organization (WHO) Alma-Ata Declaration 40 years later, together with a call for the political will to provide adequate financing at acceptable quality of care. This approach is taken to achieve the past ideals of Health for All, given the new challenges of universal health coverage. The economic case for primary healthcare is justified against the growing demand due in part to the growing costs of chronic conditions and the rise of ageing population, other than the supply-side factors of the healthcare industry. Past healthcare systems have evolved greater roles of the state versus the market, but few have involved the Third Sector or civil society in more integrated ways to provide and finance long-term care (LTC) with population ageing. From the extremes of the communist state to capitalist free markets, an optimal public-private system has to reach a balance in access, cost and quality for health and LTC. Recent studies of health and LTC have distilled newer developments in public-private mixes of provision, financing and regulation, in response to the needs of fast-ageing Asian societies. While Japan was the oldest country in the world, other countries in Asia have caught up and are now acknowledged where innovative models of integrated eldercare under economic limits, hold great promise of their transferability to the rest of ageing societies. Besides other forms of integrated LTC delivery with traditional systems, newer forms of financing like savings funds and superannuation have been developed, with participation from government, industry and civil society. There is much to learn from the new Asian models of financing, using appropriate technology and social innovations, and integrating health and social systems for LTC.

Governments, international sports bodies, and industry must take responsibility for barriers to health experienced by migrant workers involved in events such as the Olympic Games and FIFA World Cup, argue Kristine Husøy Onarheim and colleagues

The Association of South East Asian Nations (ASEAN) has potential in creating regional health governance frameworks. Yet in light of the ASEAN Economic Community 2015, pressing challenges remain. Further integration will likely lead to increased movements of migrants. Protecting the health of migrant workers is thus key to ensure that regional integration's objectives of economic growth and political stability are met. With the potentially negative repercussions of unhealthy migration on ASEAN's economic and political integration, much effort should be directed towards further social integration. Why and how should a regional framework to protect migrant workers' health be negotiated through ASEAN? A key to the successful ASEAN regional framework for migrant workers' health, which is also a key challenge for the region, is the effective inclusion of various stakeholders involved in the protection of migrant workers' health. ASEAN will play a crucial role in coordinating initiatives and in creating common standards regarding treatment of migrant workers.

The government of Malaysia, an early and enthusiastic supporter of the concept of privatization of public services, can also be considered as being highly supportive of more recent strategies such as “public–private partnerships” (PPPs) in the delivery of social services. It established a Public–Private Partnership Unit (UKAS) in 2011. This discussion of Malaysia’s experience with health care PPPs is based on a literature review. The record is mixed, with successes and failures. Critical factors for success include regulation, transparency, clear policy guidance and clarity on operational procedures and responsibilities, proper evaluation mechanisms, sustained financial support, especially for NGO partners, and unwavering commitment from policy-makers.

Singapore, like many developed countries, is facing the challenge of a rapidly aging population and the increasing need to provide long-term care (LTC) services for elderly in the community. The Singapore government's philosophy on care for the elderly is that the family should be the first line of support, and it has relied on voluntary welfare organizations (VWOs) or charities for the bulk of LTC service provision. For LTC financing, it has emphasized the principles of co-payment and targeting of state support to the low-income population through means-tested government subsidies. It has also instituted ElderShield, a national severe disability insurance scheme. This paper discusses some of the challenges facing LTC policy in Singapore, particularly the presence of perverse financial incentives for hospitalization, the pitfalls of over-reliance on VWOs, and the challenges facing informal family caregivers. It discusses the role of private LTC insurance in LTC financing, bearing in mind demand- and supply-side failures that have plagued the private LTC insurance market. It suggests the need for more standardized needs assessment and portable LTC benefits, with reference to the Japanese Long-Term Care Insurance program, and also discusses the need to provide more support to informal family caregivers.

Globalization has led to new health challenges for the twenty-first century. These new health challenges have transnational implications and involve a large range of actors and stakeholders. National governments no longer hold the sole responsibility for the health of their people. These changes in health trends have led to the rise of global health governance as a theoretical notion for health policy making. The Southeast Asian region is particularly prone to public health threats such as emerging infectious diseases and faces future health challenges including those of noncommunicable diseases. This study looks at the potential of the Association of Southeast Asian Nations (ASEAN) as a regional organization to lead a regional dynamic for health cooperation in order to overcome these challenges. Through a comparative study with the regional mechanisms of the European Union (EU) for health cooperation, we look at how ASEAN could maximize its potential as a global health actor. Our study is based on primary research and semistructured field interviews. To illustrate our arguments, we refer to the extent of regional cooperation for health in ASEAN and the EU for (re)emerging infectious disease control and for tobacco control. We argue that regional institutions and a network of civil society organizations are crucial in relaying global initiatives, and ensuring the effective implementation of global guidelines at the national level. ASEAN's role as a regional body for health governance will depend both on greater horizontal and vertical integration through enhanced regional mechanisms and a wider matrix of cooperation.

Stockpiling drugs to prevent and treat influenza would be economically effective., We compared strategies for stockpiling neuraminidase inhibitors to treat and prevent influenza in Singapore. Cost-benefit and cost-effectiveness analyses, with Monte Carlo simulations, were used to determine economic outcomes. A pandemic in a population of 4.2 million would result in an estimated 525–1,775 deaths, 10,700–38,600 hospitalization days, and economic costs of $0.7 to $2.2 billion Singapore dollars. The treatment-only strategy had optimal economic benefits: stockpiles of antiviral agents for 40% of the population would save an estimated 418 lives and $414 million, at a cost of $52.6 million per shelf-life cycle of the stockpile. Prophylaxis was economically beneficial in high-risk subpopulations, which account for 78% of deaths, and in pandemics in which the death rate was >0.6%. Prophylaxis for pandemics with a 5% case-fatality rate would save 50,000 lives and $81 billion. These models can help policymakers weigh the options for pandemic planning.

Southeast Asia is a region of enormous social, economic, and political diversity, both across and within countries, shaped by its history, geography, and position as a major crossroad of trade and the movement of goods and services. These factors have not only contributed to the disparate health status of the region's diverse populations, but also to the diverse nature of its health systems, which are at varying stages of evolution. Rapid but inequitable socioeconomic development, coupled with differing rates of demographic and epidemiological transitions, have accentuated health disparities and posed great public health challenges for national health systems, particularly the control of emerging infectious diseases and the rise of non-communicable diseases within ageing populations. While novel forms of health care are evolving in the region, such as corporatised public health-care systems (government owned, but operating according to corporate principles and with private-sector participation) and financing mechanisms to achieve universal coverage, there are key lessons for health reforms and decentralisation. New challenges have emerged with rising trade in health services, migration of the health workforce, and medical tourism. Juxtaposed between the emerging giant economies of China and India, countries of the region are attempting to forge a common regional identity, despite their diversity, to seek mutually acceptable and effective solutions to key regional health challenges. In this first paper in the Lancet Series on health in southeast Asia, we present an overview of key demographic and epidemiological changes in the region, explore challenges facing health systems, and draw attention to the potential for regional collaboration in health.

The Southeast Asian region is remarkably vulnerable to natural disasters which repeatedly cause devastations to both human lives and properties. However, current disaster relief efforts have not lived up to the high standards. Even worse is that humanitarian efforts have been frequently frustrated by the rejections from national authorities under the name of “sovereignty”. All these problems necessitate a widely accepted, politically neutral, well coordinated and effectively governed organization within the region. We, hereby propose a Disaster Response Training and Logistic Centre under the umbrella of the Association of Southeast Asian Nations (ASEAN), which aims to mitigate the devastation of disasters, to provide accurate relief assessment, and training for relief team on a regular basis, and to allocate and mobilize humanitarian aid. The Centre will be endorsed through an agreement by all ASEAN governments. The philosophy underpinning the organization reflects a regional approach whereby stronger government involvement and regional integration in disaster relief is indispensable in the context of the Southeast Asian region.

Financing care for older adults has surfaced as a critical issue in many Asian countries experiencing rapid population aging. Such population aging is expected to result in increased need for long-term care services and in intensifying demand and expenditure for healthcare. Singapore's national aging policy has taken shape through several successive rounds of policy review. In terms of funding services for older adults and services for the general population, the state applies Western-style copayment principles wherever possible. The 1995 National Survey of Senior Citizens in Singapore found that financial problems and boredom were cited as major concerns during retirement. The healthcare financing system in Singapore emphasizes personal responsibility and family support, yet the community and the national government help the indigent and poor who cannot afford to pay for their basic healthcare needs. In view of projected demographic, epidemiological, social, and economic trends facing Singapore, existing tax-based healthcare financing would have to support the growing needs implied by these trends.

Based on the past lessons of history, public policy priorities during times of crisis should aim at strengthening social welfare and mental health services, monitoring risks and symptoms over critical time periods, and should pay special attention to high-risk and vulnerable groups and render assistance in priority areas of need. Governments play a critical role in providing social protection but face competing demands for funding (Marmot and Bell, BMJ, 338:858–860 b1314, 2009). The onus is on health and social policy advocates to lobby for political action to strengthen and maintain safety nets. Resource allocation needs to be prioritized to make healthcare more affordable, and social and healthcare financing needs to be diversified for this purpose. Investment in prevention and early detection and treatment of illness is good public policy in times of economic crisis, and an urgent priority is the strengthening of mental health services in anticipation of the increased demand (Phua and Kua, Asia Pacific Psychiatry, 1(2):55–57, 2009). Economic crises should provide opportunities and the imperative to implement evidence-based health policies, to protect and expand public health budgets in order to avoid longer-term social and economic costs.

The Technological Change in Health Care Research Network collected unique patient-level data on three procedures for treatment of heart attack patients (catheterization, coronary artery bypass grafts and percutaneous transluminal coronary angioplasty) for 17 countries over a 15-year period to examine the impact of economic and institutional factors on technology adoption. Specific institutional factors are shown to be important to the uptake of these technologies. Health-care systems characterized as public contract systems and reimbursement systems have higher adoption rates than public-integrated health-care systems. Central control of funding of investments is negatively associated with adoption rates and the impact is of the same magnitude as the overall health-care system classification. GDP per capita also has a strong role in initial adoption. The impact of income and institutional characteristics on the utilization rates of the three procedures diminishes over time. authorsversion published

BACKGROUND: All influenza pandemic plans advocate pandemic vaccination. However, few studies have evaluated the cost-effectiveness of different vaccination strategies. This paper compares the economic outcomes of vaccination compared with treatment with antiviral agents alone, in Singapore. METHODOLOGY: We analyzed the economic outcomes of pandemic vaccination (immediate vaccination and vaccine stockpiling) compared with treatment-only in Singapore using a decision-based model to perform cost-benefit and cost-effectiveness analyses. We also explored the annual insurance premium (willingness to pay) depending on the perceived risk of the next pandemic occurring. PRINCIPAL FINDINGS: The treatment-only strategy resulted in 690 deaths, 13,950 hospitalization days, and economic cost of USD$497 million. For immediate vaccination, at vaccine effectiveness of >55%, vaccination was cost-beneficial over treatment-only. Vaccine stockpiling is not cost-effective in most scenarios even with 100% vaccine effectiveness. The annual insurance premium was highest with immediate vaccination, and was lower with increased duration to the next pandemic. The premium was also higher with higher vaccine effectiveness, attack rates, and case-fatality rates. Stockpiling with case-fatality rates of 0.4-0.6% would be cost-beneficial if vaccine effectiveness was >80%; while at case-fatality of >5% stockpiling would be cost-beneficial even if vaccine effectiveness was 20%. High-risk sub-groups warrant higher premiums than low-risk sub-groups. CONCLUSIONS: The actual pandemic vaccine effectiveness and lead time is unknown. Vaccine strategy should be based on perception of severity. Immediate vaccination is most cost-effective, but requires vaccines to be available when required. Vaccine stockpiling as insurance against worst-case scenarios is also cost-effective. Research and development is therefore critical to develop and stockpile cheap, readily available effective vaccines.

When Stamford Raffles, an agent of the British East India Company, signed a treaty with the Temengong of Johor in January 1819 to establish a British trading post in Singapore, the island was mainly composed of orang laut (sea nomads) communities who were dependent for a living on fishing, the collection of jungle produce and small-scale trading and piracy (Turnbull 1977: 1, 5). At that time, Malay traditional medicine, which showed the influence of Ayurvedic medicine and the Arab pharmacopoeia, was the main form of medical treatment on this sparsely populated island (Field 1951: 19).

SARS (Severe Acute Respiratory Syndrome) has been declared by WHO (World Health Organisation) as a global health threat. Within a period of four to five months in 2003, the disease infected some 8,000 people in more than 25 countries and left 774 dead. The many studies that have been done on the spread of SARS in Asia as well as countries as far flung as Germany and Canada have focused on the global dimension of the infectious disease as well as the speed of its spread upon emergence in southern China and then Hong Kong. Less attention has been paid to its spatial distribution at the national and local scales. This discussion focuses on the spread of SARS at the national and local spatial scales. In the process, the study presents the management of a hazard, in this case, an emerging infectious disease by national health care institutions such as the hospitals that ultimately proved to have been wholly unprepared for coping with at least the health aspects of the outcome of a globalised national agenda for growth and economic progress.

Despite the increase in colorectal cancer (CRC) incidence among Chinese in Asia, there are no data on predictors of CRC screening uptake in this population. This study investigated how knowledge and perceptions about CRC correlated with screening behavior in Singaporean-Chinese.A community-based cross-sectional study was carried out on Singaporean-Chinese at least 50 years old in Queenstown Estate, Singapore between 1/1/2006 and 1/2/2006. A questionnaire administered via face-to-face interviews elicited knowledge, perceptions and screening behavior of subjects.The response rate was 72.4%, with 514 completed responses. Expense was the commonest perceived barrier to screening (56.6% agreed), unlike for other populations. Social influence is important, with 67.5% agreeing to the statement "I would go for CRC screening if my family wanted me to". After excluding confounders, Chinese who had been for fecal occult blood test (FOBT) screening had higher knowledge score (p0.001), lower perceived severity (p0.01), were more likely to have been influenced by their family/friends to go for screening (p=0.04) and to have attended screening tests for other diseases (p0.001).FOBT screening uptake is associated with specific areas of knowledge and perception among Singaporean-Chinese. To increase screening uptake within Chinese populations, clinicians should consider these factors in their approach to patients.

International audience; The goal of this paper is to present new comparative evidence on heart attack care in 17 countries showing that changes in medical treatments are universal, but have differed greatly. We have collected a large body of comparable information that show how countries differ in treatment rates and why these differences are relatively marked. Countries appear to differ systematically in the time at which intensive cardiac procedures began to be widely used and in the rate of growth of the procedures. Our results show that differences in treatment rates are greatest for expensive medical technologies. Also strict financing limits and regulatory policies have affected the adoption of intensive technologies. These differences may have important economic and health consequences.

Medical tourism is a growing phenomenon with policy implications for health systems, particularly of destination countries. Private actors and governments in Southeast Asia are promoting the medical tourist industry, but the potential impact on health systems, particularly in terms of equity in access and availability for local consumers, is unclear. This article presents a conceptual framework that outlines the policy implications of medical tourism's growth for health systems, drawing on the cases of Thailand, Singapore and Malaysia, three regional hubs for medical tourism, via an extensive review of academic and grey literature. Variables for further analysis of the potential impact of medical tourism on health systems are also identified. The framework can provide a basis for empirical, in country studies weighing the benefits and disadvantages of medical tourism for health systems. The policy implications described are of particular relevance for policymakers and industry practitioners in other Southeast Asian countries with similar health systems where governments have expressed interest in facilitating the growth of the medical tourist industry. This article calls for a universal definition of medical tourism and medical tourists to be enunciated, as well as concerted data collection efforts, to be undertaken prior to any meaningful empirical analysis of medical tourism's impact on health systems.

The formation of slums need not be inevitable with rapid urbanization. Such an argument appears to be contradicted by evidence of large slum populations in a large number of developing countries and particularly in rapidly urbanizing regions like Asia. The evidence discussed suggests that city authorities faced with rapid urban development lack the capacity to cope with the diverse demands for infrastructural provision to meet economic and social needs. Not only are strategic planning and intervention major issues in agenda to manage rapid urbanization, but city governments are not effectively linking the economic development trajectory to implications for urban growth and, hence, housing needs. In the following discussion, a case study is presented in support of the argument that city governments have to first recognize and then act to establish the link that is crucial between economic development, urban growth, and housing. This is the agendum that has been largely neglected by city and national governments that have been narrowly focused on economic growth with the consequent proliferation of slum formation as a housing solution.