Credits: © 2008 Le Thai Son, Courtesy of Photoshare
Since the Asia Pacific region committed to eliminate malaria by 2030, we have seen extraordinary progress. Malaria has declined by 27% across the region since 2012, whilst domestic financing has increased by well over 50%. However, to steal a phrase from Marshall Goldsmith, what got you here will not get you there. The financing landscape in Asia is changing rapidly, and all those concerned with the mission of regional elimination and global eradication must pay close attention.
Asia’s ability to deliver coverage that is affordable and equitable will define the life quality of two generations. The outlook is concerning. Demographic and lifestyle changes indicate rapidly rising costs, as aged care and non-communicable diseases place unprecedented burdens on budgets.
Whilst the demand-side challenges of decades of chronic care for aging and obese populations are daunting; the emerging supply-side responses are driving medical inflation. Rising costs, together with falling ratios of working vs. aged populations, risk pushing governments into fiscal deficit. The outlook for overall public health, let alone components like malaria elimination, is concerning.
In Indonesia and India, social health insurance schemes will soon extend care services to over 700 million people; the equivalent of every person in geographical Europe. Any substantial increase in health coverage can improve productivity and wellbeing, but not all investments are equal. Care must be taken to ensure the most cost-effective interventions, those into public health and preventative services (including malaria elimination) feature most prominently.
We must be pleased that investments in healthcare are politically attractive and capture the mind of our leaders. Indeed, public expectations are high, and promises made are politically impossible to revoke. Yet, where new financing is focused on expensive curative services, there is a real risk that cost escalation will drastically exceed growth in GDP. As new expensive health technologies become available, there will be no shortage of demand from aging populations. India, Indonesia, Viet Nam and China all find themselves in a similar situation, with increasing pressure to deliver highly visible curative care, at the expense of prevention and public health.
In any discussion around financing malaria elimination and disease control, the broader macro demographic trends and fiscal constraints must be considered. Japan introduced aged care to their population in 1973, with 10 working-age taxpayers for every over 65. By 2060, this figure will be 1.2, with 45% of the population over 65. The figure for Thailand is 37%, and ultimately all the ASIAN+3 are heading in the same direction. With healthcare inflation now sitting at an alarming 10%, the Asian macro-fiscal context is radically different to the European experience in the 1950s; here we saw a far smaller number of people, mostly economically productive, financing modest services, with employers often funding the risk pool.
2019 presents a unique opportunity to engage a broader community into this debate. June’s Joint Session of G20 Health and Finance Ministers Meeting in Osaka, plus the UN High Level Meeting on UHC in September will bring these issues to the fore. The 2020 Prince Mahidol Award Conference will also address the challenges of delivering UHC in Asia head on.
Advocates working in health security and communicable disease, including malaria elimination, will need to embrace this agenda. Ultimately, public policy is not what is written in policy documents on Universal Health Coverage, it is what governments choose to fund. Our ability to engage meaningfully in this complex agenda will, to a great extent, define the level of success we can expect, and ultimately our ability to eliminate malaria by 2030.
Dr Ben Rolfe
Chief Executive Officer
Asia Pacific Leaders Malaria Alliance