A total of 160 records were identified from the search and 32 articles were included after title and abstract screening (Fig. 2). There were two systematic reviews14, 25, 11 scoping review articles26–36, seven qualitative articles37–43, and six cross sectional analytical articles44–49. The remaining six articles did not conform to any of those categories and involved a variety of techniques50–55, including mixed methods. Notably, there were no articles specifically for Brunei, Laos, Singapore or Myanmar. A summary of evidence extracted from articles reviewed is presented in Table 2 Following data synthesis, six main overarching themes were identified (Fig. 3).Most of these themes are common to the lower middle income and upper middle-income countries (LMIC and UMIC). Each main theme consists of related sub-themes which are further explored.
Table 2
No
|
Journal
Year
|
First Author
|
Country discussed / scope covered
|
Health-financing Challenges related to UHC
|
1
|
PLoS One
2019
|
Chaw-Yin Myint
|
ASEAN in general
|
• Fragmented health insurance scheme
• Low level of government spending
• Low government revenue
• Rising healthcare cost and usage threatening health system financial stability
|
2
|
Health Policy and Planning
2012
|
Bart Jacobs
|
ASEAN in general
|
• Inability to generate cash for unforeseen healthcare needs
• Supply side determined prices leading to inability to afford healthcare
|
3
|
BMC Public Health
2020
|
Wenhui Mao
|
Vietnam
|
• Problem with defining and reaching out to poor population
• Unable to design effective cross subsidization mechanism
• Difficult to ensure sustainability of health insurance schemes
• Rising cost of health expenditure due to epidemiological transition
|
4
|
Review of Development Economic
2019
|
Midori Matsushima
|
Vietnam
|
• Corruptive behaviour hindering the implementation health financing process
• Health insurance scheme not serving its purpose
• Incomplete insurance coverage, no medical check-up meaning higher risk of advance disease during the diagnosis stage
• Inconsistent health financing policy with fluctuating co-payment rates
• Insufficient payment of staff in public practice
|
5
|
Journal of Public Health
2019
|
Nel Jason L. Haw
|
Philippines
|
• Moral hazard issues relating to health financing
• Rising health care cost as a health financing challenge
• Failure of health insurance scheme to achieve its goal of financial risk protection
|
6
|
Health Policy and Planning
2020
|
Fatim Lakha
|
Thailand
|
• High cost of certain novel and expensive treatment as a barrier to healthcare access due to limitations of health insurance scheme
• Imbalance in equitable access due to different entitlements for the health insurance schemes
• Lack of political will to create a regulatory environment that contributes to long term success in UHC health financing in terms of potential benefits gained by research infrastructure investment and capacity building
• Question of sustainability of tax financed policy
• Resistance from health service providers for cost containment by curtailing fee-for-service payment
• Rising cost of healthcare due to epidemiological transition
• Rising healthcare cost as a result to increased expectations for new and expensive intervention
|
7
|
International Journal for Equity in Health
2012
|
Xiaoyun Liu
|
Vietnam
|
• Development of common social health insurance model can be time consuming leading in delayed attainment in UHC
• Incomprehensive coverage of health insurance coverage due to limited benefit package and discrimination against health insurance members
• Long waiting period for receiving health insurance cards because of administrative inefficiency
• Perception of disparity between healthcare quality received between members and non-membersSubstandard care provided to insured member
|
8
|
Human Resources for Health
2015
|
Wilailuk Ruangratanatrai
|
Thailand
|
• Declining government funding
• Government policy that is in disharmony with necessary changes in UHC reform health policies
• Health financing for human resources becoming less pro-poor. inequity in health financing
• Inequity in healthcare distribution in human resource financing (as part of health financing)
• Lack of political will to create changes in favour for UHC goals
• Rising cost of healthcare causing a burden on health financing system
|
9
|
BMC Public Health
2011
|
Hong Teck Chua
|
Malaysia
|
• Expanding private healthcare posing risk to health equity and universal coverage
• Health financing challenged by the lack of allocative, technical and distributional efficiency
• Health financing policies did not address the national health needs, especially the poor and preventive and promotive.
• Lack of focus on cost-effectiveness
• Lack of government and political support for health financing to achieve these UHC goals
• Lack of government will to accelerate development of prepayment financing mechanism in the form of a social health insurance
• Problem of sustainability of health financing plagued by epidemiological transition --> increasing NCD and associated spending
• Rising health care cost due to high end medical equipment and new drugs
• System disparity between public and private healthcare might threaten the three dimension of UHC as it starts to expand its coverage
|
10
|
Applied Health Economics and Health Policy
2015
|
Kannika Damrongplasit
|
Thailand
|
• Chronic underfunding leading to compromise of quality of care
• Discrepancies in amount of healthcare funding requested versus amount of funding actually received
• Sustainability of health financing system is questionable with rising healthcare cost coupled with slowdown in overall economic growth.
|
11
|
Global Health Action
2017
|
Celia McMichael
|
ASEAN in general,
Thailand
|
• General: Migrants are not included in health insurance schemes, migrant health programmes are underfunded.
• Thailand: Migrant workers’ pre-employment insurance only allows them to seek healthcare from certain hospital
|
12
|
Health Policy and Planning
2021
|
Theepakorn Jithitikulchai
|
Cambodia
|
• Incomprehensive coverage of the services by the HEF fund resulting in suboptimal utilisation
• Ineffectiveness of Health Equity Funding to achieve its UHC related goals of increasing public health service utilisation
|
13
|
The Lancet
2018
|
Viroj Tangcharoensathien
|
Thailand
|
• Conflict of interest exist between different stakeholders which might jeopardise the overall achievement towards UHC
• Delay in achievement of UHC because health finance contributory scheme requires administrative capacity due to large size of informal sector in developing countries.
• Difficulty in deciding method to finance uninsured population, between voluntary contribution and general taxation.
• Ensuring sustainable health financing policies under the backdrop of epidemiological transition with rising healthcare cost
• Failing to address the funding issue for non-Thai citizens
• Falsely reporting to increase payment for inpatient care resulting in unnecessary additional expenditure
• Political instability as a hurdle to UHC financing model
• Termination of supply side financing leading to conflict between stakeholders with conflicting interest
|
14
|
The Lancet
2011
|
Viroj Tangcharoensathien
|
ASEAN in general, Cambodia, Laos, Malaysia,
Philippines, Thailand, Vietnam
|
• General:
o Difficulty in identifying the poor in many countries posing as a challenge to health-financing scheme candidate screening
o High percentage of uninsured population leading to risk of financial impoverishment for many
o Insufficient government funding allocation for health
o Lack of suitably developed insurance scheme to cover the informal sector, ie non-poor and not-so-poor
o Low total health expenditure per capita, lower than necessary required for meeting the MDG
• Cambodia:
o Co-payment acting as a barrier to healthcare access for the poor
o Sustainability of the health financing system
• Laos: Insufficient government funding
• Cambodia and Laos: Funding via external donors impacting the long-term sustainability of health financing system
• Malaysia:
o Difficulty in premium collection from informal sector
o High level of OOP from private healthcare
o Lack of social health insurance
o Poorly regulated private fees
o Potential occurrence of institutional conflict of interest with establishment of social health insurance scheme
o Rising health care cost due to epidemiological transition
o The lack of political will as a hurdle to implementation of national social health insurance
• Philippines and Indonesia: Difficult in decentralised system to mobilise political will to improve financial commitment to the poor and vulnerable.
• Philippines:
o Adverse selection within the scheme as most members enrolled are chronically-ill and has high rate of us
o Difficulty in collection of premium for social insurance in the form of expensive administrative cost and mobility of members
o Hard to reach informal sector
o Inadequate coverage of social health insurance schemes leading to inadequate financial protection
o Inconsistency of effort in promoting UHC related schemes, peaking during election years, politically motivated rather than needs based
o Insufficient coverage for poor due to lack of local govt financial commitments
• Thailand:
o Financial feasibility
o Political hindrance
o Technical problem with premium collection in informal sector
• Vietnam:
o Challenging to collect premium in rural areas, high administrative cost
o Challenging to cover the informal sector
o Ineffective health financing policy that failed to have impact on poorest population
|
15
|
International Journal for Equity in Health
2020
|
Haruyo Nakamura
|
Cambodia
|
• Embezzlement problem during premium collection
• High administrative cost associated with premium collection
• Unwillingness to contribute to social health insurance due to low level of awareness
|
16
|
Health Policy and Planning
2017
|
Elizabeth Pisani
|
Indonesia
|
• Political influence on the development on UHC health financing methods
|
17
|
The Journal of Health Care Organisation, Provision and Financing
2020
|
Manushi Sharma
|
Indonesia
|
• High premium insurance for certain services creating a barrier for access for certain treatment like cancer treatment and dialysis
• Insufficient spending per capita on health
• Unregulated health care demand overwhelming the budget available resulting in large financial deficit
|
18
|
International Journal of Social Economics
2017
|
Ravikan Nonkhuntod
|
Thailand
|
• Differences in payment system resulting in discriminatory treatment leading to less than ideal utilisation of health care
• Fragmented schemes causing redundancy and increased administrative cost amounting to inefficiency
• Question of long term sustainability and quality of healthcare if funding is solely reliant on government funding
|
19
|
Global Social Policy
2020
|
Somsak Chunharas
|
Thailand
|
• Conflict of interest due to establishment of new authority that undermine the autonomy in fund allocation
• Attempt to harmonise fragmented insurance schemes raising resistance from civil servants who had the best funded public scheme
• Question of long term sustainability with tax-financed budget
|
20
|
Social Science & Medicine
2011
|
Cheng Li
|
Thailand
|
• Presence of large informal sector makes it difficult for premium collection
|
21
|
Bulletin of World Health Organisation
2019
|
Viroj Tangcharoensathien
|
Thailand
|
• Budget decision did not lie on ministry of health but finance ministry
• Inadequate budget allocation for healthcare
• Presence of adverse selection for voluntary health insurance scheme because more sick people joined than healthy people
• Presence of informal sector is a major barrier in achieving UHC
• Resistance from different strata of the society regarding financial reforms as certain groups might be disadvantaged
|
22
|
The Economics of Peace and Security Journal
2020
|
Chantal Herberholz
|
Thailand
|
• Stateless people not covered by health insurance thus undermining UHC achievement
|
23
|
Asia-Pacific Development Journal
2011
|
Giang Thanh Long
|
Vietnam
|
• Challenging to change people's mindset towards health insurance,
• Presence of large informal sector and non-working family
• Health insurance not fulfilling its function, health insurance holder from vulnerable groups has low accessibility
• Discriminatory attitude towards those who hold insurance cards
• Low income, poor quality of public service, poor marketing, poor flexibility in payment causing low uptake of voluntary insurance scheme
• Presence of regional inequalities, both horizontal and vertical, in state's allocation funding for health insurance.
|
24
|
Social Science & Medicine
2015
|
Minchung Hsu
|
ASEAN in general,
Thailand
|
• General: Rapidly rising medical price inflation
• Thailand:
o Long term sustainability of the financing system
o Presence of large informal sector and rapid population aging
o Rapid aging population increases health care cost and informal sector reduces ability to raise tax revenue
|
25
|
International Journal for Equity in Health
2021
|
Mohammad Bazyar
|
ASEAN in general, Indonesia, Thailand
|
• General: Fragmentation of health insurance reduces potential degree of redistribution, high administrative costs, duplication of benefits, loss of negotiation power with health services providers
• Indonesia:
o Employers worrying that premiums paid would be used to subsidise services for poor and unwaged
o Fragmented health financing system, decentralisation, demographic transition, high out-of-pocket spending, low level of spending on health
o Low enrolment of national health insurance scheme because of informal sector workers
o Low enrolment rate jeopardising the long term financial stability of national health insurance
o Resistance from private employers to join national health insurance worrying that contribution rates might increase
• Thailand: Inequality between the three different health insurance schemes
|
26
|
National Public Health Journal
2021
|
Atikah Adyas
|
ASEAN in general, Indonesia, Myanmar
|
• General: Lack of legal framework to cover the informal sector and lack of political will
• Indonesia:
o Gap exist between enrolment and actual utilisation of health facilities owing to lack of knowledge
o Epidemiological transition in the form of rising NCDs putting pressure on health budget and NHI
• Myanmar and Indonesia: Unequal presence of health service providers as a challenge to providing insurance
|
27
|
Global Health Action
2018
|
Konrad Obermann
|
Philippines
|
• Lack of long term sustainability due to source of budget from a non-governmental third party source
|
28
|
Global Public Health
2022
|
Hien Thi Ho
|
Vietnam
|
• Cumbersome reimbursement process deterring members to join FHI
• FHI not affordable
• Informal sector workers feel that insurance is more relevant for older people as they are more at risk, while young people report other financial priorities
• Perception of low quality of healthcare service provided by FHI
• Presence of adverse selection, only purchasing when a family member or themselves are ill
• Presence of large proportion of informal sector workers falling through gaps of UHC financing due to lack of formal salary or taxation
|
29
|
Health Policy and Planning
2020
|
Erniaty Erniaty
|
Indonesia
|
• Political forces fail to consider the technical operations from financial perspective
|
30
|
Bulletin of World Health Organisation
2019
|
Kanitsorn Sumiriddetchkajorn
|
Thailand
|
• Ageing population contributing to rising health care cost
• Fragmented insurance schemes resulting in disparity in healthcare access
• NCD contributing to rising healthcare cost
• No unifying mechanism to control expenditure under three fragmented schemes
• Question of long term sustainability with tax financed policy
• Rising healthcare cost with expectation of population and increasing cost of technology
|
31
|
The Lancet
2019
|
Rina Agustina
|
Indonesia
|
• Equity gap in insurance coverage
• Inadequate government spending on health expenditure
• Members not paying their contribution routinely
• Presence of large informal sector worker makes it challenging to implement health care insurance system
|
32
|
Applied Health Economics and Health Policy
2020
|
Teguh Dartanto
|
ASEAN in general, Indonesia
|
• General:
o Health utilisation decreasing affecting premium payment
o Lack of health literacy leading to increased premium payment dropout rates
o Perception of poor quality of healthcare resulting in dropout from health insurance
• Indonesia:
o Administrative difficulty in collecting contribution in cost effective manner among informal workers
o Failure of NHIS from raising revenue resulting in question in long term sustainability
o Other financial hardship making household to prioritise other essential expenditures over paying for premium insurance
o Premium cost for insurance too expensive
|
i) Unsustainability of revenue raising methods
- Low level of government spending
According to the statistics provided by WHO, in Malaysia, the Philippines, Indonesia, Vietnam and Laos, the government budget allocated to health is less than 9% of the total budget32. Low level of government healthcare expenditure was found to be a barrier to achieving UHC as vulnerable populations are heavily dependent on public financing14. Inadequate government spending in Indonesia is reported in several articles33, 35, 36. A similar situation is also present in Thailand where the hospital operating cost from government budget has been decreasing steadily46, 52. This chronic underfunding leads to rising shift of costs to providers as well as patients, contributing to medical impoverishment29, 52 and retards progress towards UHC.
- Tax-funded scheme dependent on economic growth
A predominantly tax-funded scheme is largely dependent on economic performance55. In Thailand, poor economic performance might diminish the government tax revenue and questions regarding the long-term sustainability of the health finance system arise25, 27, 48, 51. Given the cyclical nature of the economy, the inconsistent government tax revenue may not match the growing healthcare cost and hence jeopardize the sustainability of the health finance system.
- Reliance on external funding
In Laos and Cambodia, large sums of funding originate from external donors (14.5% and 16.4% of the total health expenditure respectively)32. The long-term sustainability is questionable since the autonomy of the external funding does not lie with the government itself. Furthermore, the national health needs of the country might not align with the donor-funded programmes. A similar pattern is found in the Philippines, where the government subsidies for health care did not come from the regular budget but from third parties41. Lack of control of funding sources is a major obstacle to health finance planning.
- Execution challenges of social health insurance
There are numerous challenges with regards to implementation of social health insurance (SHI) schemes. The presence of a large informal sector of workers hinders the process of premium collection in Thailand as it is technically unfeasible31, 32, 48, 52, 56. In Vietnam, in addition to high administrative costs, it is also difficult to reach rural areas where approximately 60% of the informal sector workers reside32, 37, 42. The same issue is observed in both Cambodia and the Philippines32, 50. Even for those who managed to enroll, the long waiting period between payment and receiving the health insurance card might undermine the effectiveness of SHI38.
Indonesia faces a similar predicament as the local authority struggle to seek a cost-effective way to collect premiums49. Income instability, inflexibility in the payment system, unaffordable premium rates, prioritizing other essential expenditure over health insurance are causes for deferring premium payment36, 49. In addition to jeopardizing the long-term financial viability of the SHI schemes, low enrolment rate ensues35, 36. There are also gaps between SHI enrolment and actual utilization of health facilities49. The development of SHI tailored to the needs of the local community can be time consuming38.
The lack of health insurance literacy in Cambodia and Indonesia has contributed to the unwillingness to pay for SHI premium49, 50. In Vietnam, many informal sector workers perceive themselves as having low health risks and therefore deem SHI unnecessary42.
ii) Fragmented health insurance schemes
- Inequity in healthcare access / treatment
Fragmented health insurance schemes limit the potential degree of risk distribution as a result of inequitable healthcare access or treatment35. In Vietnam, the insurance coverage at a community health centre is lower than at district level hospitals14. Due to differences in health insurance schemes and capitation payment method, general practitioners in Indonesia have restricted autonomy in prescribing medicines resulting in disparity in quality of care provided to patients14. The equity gap in insurance coverage contributed by heterogeneous benefits across different age groups and socioeconomic status magnifies this issue36.
The three different SHI schemes in Thailand accentuate the issue of inequitable healthcare access as one scheme has expenditure per capita four to five times higher than another scheme27, 51. Each scheme offers different healthcare benefits as well as different levels of access to medication25. Inequality between three different schemes is an impediment to progressing towards UHC.
- Challenges in merging different schemes
Merging different health insurance schemes can be politically difficult as certain groups might lose insurance benefits35. In Thailand, for example, civil servants who have the greatest health insurance benefits resisted a government plan to harmonize the different insurance schemes51, 52. Legislative hurdles exist as the three schemes are governed by different legal frameworks. The proposed implementation of a SHI scheme in Malaysia also was met with resistance from the civil servants and private sector employees who would have to make mandatory contributions if the proposal comes into effect32.
- High administrative cost and loss of negotiating power
Multiple management structures for each insurance schemes incur high administrative costs25. More importantly, multiple fragmented health insurance schemes may lead to a loss in negotiating power with health service providers which is detrimental for cost-containment35. The existence of several packages with similar benefits could be streamlined into one and be managed by a single authority body. Therefore, the duplication of existing benefit packages might also result in redundancy and inefficiency.
- Marginalisation of stateless people
As a result of fragmented health insurance schemes as opposed to a unifying and non-discriminatory scheme, vulnerable groups like the stateless people who do not possess any formal documentation are deprived of their right to access healthcare 30, 31, 40. Although a voluntary health insurance for migrants was introduced in Thailand, it only covered one-third of the 3.4 million migrants31.
iii) Incongruity between insurance benefits and people’s need
- Incomplete insurance coverage
Health insurance in Vietnam excludes medical check-ups and certain technologically advanced treatments44. Qualitative evidence indicates the limited use of outpatient services can be due to limited benefit packages38. In Thailand, novel and expensive treatment is a barrier to healthcare access due to limited coverage of health insurance schemes27. Essential services for non-communicable diseases funded by the Health Equity Fund in Cambodia are not readily available47. The inadequate insurance coverage in the Philippines has coerced the poor to make OOP if the hospital charges exceed a benefit ceiling14, 45. The mismatch in health needs and insurance benefits provided by the SHI hampers the progress towards UHC by negatively affecting health seeking behaviour. High premium rates for maternal health services and dialysis have resulted in the inaccessibility of these essential treatments for the poor in Indonesia33.
- Inequitable distribution of resources
Disparities between different insurance schemes influence healthcare provider payment methods, resulting in limited control over resource allocation by hospitals27. As a result, both financial and human resources available at the hospital might be inadequate to meet the patients’ demands. The budget for civil servants working at public hospitals in Thailand depends on the hospital size or number of beds46. Instead of prioritizing hospitals with greater needs, bigger hospitals in more affluent provinces receive more resources. This inequitable distribution of resources is counterproductive towards UHC.
iv) Political and legislative indifference
- Conflict of interest between stakeholders
Health financing planning involves various stakeholders with different vested interest. In Malaysia where establishment of SHI failed after many years of planning, institutional conflict of interest between the proposed National Health Financing Authority and Ministry of Health were identified as one of the cardinal factors as there would be a loss of financing power from the latter to the former32. There was also resistance from the private sector with concerns on diminishing profits32.
A similar conflict is also observed in Thailand with tension between Ministry of Public Health and National Health Security Office over the allocation of public funds51.
Balancing the interests of National Health Security Office, civil society and the citizens is also crucial towards UHC achievement31. A lack of coherent policies between authorities as a result of conflicts of interest should be avoided for stability in health financing planning.
- Dominant role of politics in policy making
The political influence over health financing manifests itself in various ways. For example, the yearly enrolment for the Philippines SHI peaked during the election years32.The political motivation to improve health financing is blatant but inconsistencies undermines previous cumulative efforts. The absence of political will to implement SHI in Malaysia is reflected in the inaction despite many years of discussion at national level32. The politicization of Indonesia’s SHI system impedes progress towards UHC39, which is exacerbated by the dominant role of politics in policy making and the lack of medical, economic and financial perspective in technical operations of SHI43. Political instability was also identified as a hindrance towards UHC in Thailand31.
- Lack of legislative framework
In many countries, the absence of legal frameworks to support inclusive coverage for informal sectors contributes to failure to achieve UHC37, 54. In Vietnam, the lack of legal frameworks is indirectly linked to the inconsistent policies and results in fluctuating co-payment rates which had tremendous impact on the poor44. Likewise, poorly regulated private fees as a consequence of laxity of legislation in Malaysia have nocuous effects on the rising OOP trend32.
v) Intractable and rapidly rising healthcare cost
- Epidemiological transition and ageing population
The rising cost of healthcare as a result of epidemiological transition from communicable diseases to non-communicable diseases (NCD) are observed in several countries27, 28, 37, 54. NCDs are generally chronic illnesses that require more healthcare resources. The ageing population is another global trend in many countries that can compound the healthcare cost. With the continuing rise in people over the age of 60 years, Thailand is projected to become an aged society by the year 202555. Age-related health problems like dementia, will translate into increasing healthcare costs while simultaneously a decline in tax revenue will be observed as the proportion of the working population decreases48, 55.
- Rising demand and rapidly developing health technology
In Indonesia, the population’s growing health awareness and changes in health seeking behaviour has resulted in rising healthcare demand and associated costs33. Medical price inflation is another reason for rising healthcare cost48. The thriving pharmaceutical industry has accelerated developments in health technology. Healthcare expenditure has increased in Malaysia due to procurement of sophisticated medical equipment and novel drugs28. Increased expectations for new and costly cancer drugs coupled with increasing demand also contributes to rising healthcare costs27.
vi) Morally reprehensible behaviours
- Insurance-based discrimination
Capitation and diagnosis-related groups are unpopular with the healthcare providers in Thailand due to relatively lower overall payment compared to fee-for-service payment31. As a result, there were reports of lower quality of care for patients insured by a certain scheme27. Similarly, in Vietnam, insured patients perceived that the quality of care received was lower compared to the non-insured members14, 38. The capitation system was originally implemented to discourage over-serving but that has led to discrimination against insured patient44. Services to the insured were scaled down with the objective to increase hospital’s revenue. Price discrimination is observed in the Philippines where users and non-users of SHI are charged different rates by the hospital45.
Embezzlement of collected funds for SHI was highlighted as a challenge in Cambodia50. In Thailand, attempts of bogus claim reporting comorbidity and complications to increase payment claims for inpatient care were detected31. Insurance fraud involving upcoding of inpatient conditions for higher reimbursement were also observed in the Philippines45. Conversely, actual overutilization of healthcare also occurs when unnecessary treatments are provided with the objective of increasing insurance claims by the health providers45.
The main themes and sub-themes synthesised are summarised in Figure 3.