Improving primary health care systems is central to advancing health equity in Southeast Asia. In many countries, the primary health care system is the only accessible option for obtaining specialized treatment, particularly in rural areas. To explore the topic of modernizing primary health care systems in Southeast Asia toward greater cancer control, Asia Society Policy Institute engaged with six key informants to provide policy recommendations. Although the context of each Southeast Asian country is unique, key themes emerged from the discussion that are relevant across the region.
Tackling system-wide barriers to equitable access to care requires a multisectoral approach. While pricing and regulatory harmonization remain ongoing challenges, other strategies can be used to make access to specialized care — particularly outside urban centers — more equitable, such as strengthening the capacity of the health care workforce, leveraging digital innovations, engaging patients and communities, employing evidence-based advocacy, and building on lessons learned from the COVID-19 pandemic. In particular, health care workforce training is crucial to the modernization of primary health care systems in Southeast Asia to achieve greater cancer control.
Improving health care workforce training to increase equitable access to care requires comprehensive multisectoral collaboration, including supporting decentralization and collaboration within the public health system and across all parts of government. Specifically, training and ongoing support that allows for greater task shifting among health care workers would increase equitable access to specialized care. In addition to using digital innovations such as teleconsultation and sharing digital images with specialists, telementoring should be leveraged to further support task shifting. Governments should also invest in improving training for Community Health Workers and provide better compensation, support, and other incentives to increase retention and to better utilize these workers’ skills and positioning. Existing health-focused smartphone apps should be translated into local dialects and tailored for use by Community Health Workers.
Lessons learned from the COVID-19 pandemic highlight the potential of remote training and support, as well as opportunities to build political will to overcome entrenched barriers. The collaboration across sectors spurred by the urgency of responding to the COVID-19 pandemic should be institutionalized for greater cancer control.
Improving primary health care systems[i] is central to advancing health equity in Southeast Asia. In many countries, the primary health care system is the only accessible option for obtaining specialized treatment, particularly in rural areas. To promote greater cancer control, stakeholders must work together to expand access to, reduce barriers to, and ensure the affordability of specialized care. Acknowledging that the policy landscape in each Southeast Asian country must be tailored to its specific context, six key informants provided policy recommendations for fostering multisectoral collaboration, strengthening the capacity of the health care workforce, leveraging digital innovations, engaging patients and communities, employing evidence-based advocacy, and building on lessons learned from the COVID-19 pandemic to strengthen primary health care systems in the region for greater cancer control.
Decentralization. In many countries, cancer care and supportive or palliative care is available mainly in tertiary hospitals, which creates a barrier to equitable access and leads to an overreliance on hospitals. Political will is needed to implement policies that support decentralization of care in practice, not just in theory. Governments should develop policies and allocate resources to make cancer care available in smaller hospitals, primary care clinics, and community settings. For this goal to become a reality, adequate funding and planning are needed to ensure that supportive care — such as pain medicine — is available, in addition to equipment and trained personnel.
Expanding Collaboration within the Public Health System. Even within a country’s public health system, medical professionals can be territorial, competitive over the share of payments, or fearful of liability issues that may arise from collaboration. Case studies from other health areas may be applicable to cancer care. For example, in the past, some psychiatrists were hesitant about primary care physicians prescribing psychiatric medications; however, these drugs are now available by prescription from primary care physicians in many areas, and private-public partnerships support the availability of these medications. Further hindering collaboration, health care leaders who are highly skilled in clinical areas may lack the competence in management, finance, and risk management that is needed for multisectoral collaboration and innovative decision-making. Existing educational courses that would enable local government leaders to better understand universal health care may be too time-consuming for some active policymakers to consider; shorter online trainings should be made available to them.
In health systems that lack a strong referral system, patients with the means to do so may go directly to specialists, exacerbating hospital crowding. The primary health care system should be an effective gatekeeper that reduces financial barriers. Better cooperation among the different levels of the health system — and between public and private systems — could improve not only the patient experience but also health outcomes and the efficiency of the whole system. A streamlined referral system can effectively connect patients with specialized care. Patients should be provided with navigation support so that they do not waste time and money going to the wrong service providers. With proper design, training, and monitoring, follow-up can be managed by the primary health care system.
Expanding Collaboration across Parts of Government. Health care systems are often viewed too narrowly: Many parts of government influence population health outcomes, both directly and indirectly. Health equity cannot be achieved without meaningful collaboration among all the relevant parts of government beyond health care, such as education for improved health care workforce training. Leadership across government is often siloed and working toward different priorities. Alignment of priorities should be institutionalized to motivate the different parts of government to work together to reach common goals. Just as conditions for environmental assessments are often required before undertaking new activities — ones that extend beyond the ministry or department focusing on the environment — health assessments should also be mandated for government projects.
Public-Private Partnerships. Health systems are often viewed narrowly within government, although they include critical stakeholders outside the public sector, such as industry. Fostering collaboration between the public and private sectors can provide critical opportunities to improve health equity for greater cancer control. To assuage government fears about potential conflicts of interest – perceived or actual – when engaging with for-profit companies, government should invest in personnel to provide legal and financial counsel so that it can feel confident in negotiating transparent and cost-effective agreements with industry. The public sector should map, plan, and assess service delivery network and gaps to identify where private sector support is needed. Government should consult with local stakeholders as they may be aware of overlooked needs, such as a lack of chemotherapy rooms in a public hospital, which could be addressed by using available rooms in a nearby private hospital.
Effective existing partnerships should be leveraged and expanded – for example, by building on health education initiatives with garment factory workers to provide opportunities for health screenings. As clothing brands or other businesses may simply lease factory space, formal agreements with factory owners may accelerate successful implementation. Social impact investments — with NGOs serving as implementing partners, industry as funders, and government as supporters — and social impact bonds in which government commits to provide returns to investors in exchange for effective solutions, should be explored to incentivize effective collaborations. Tax incentives should also be used to encourage private companies to work for the social good.
Cancer-focused civil society organizations and other health system stakeholders are well placed to communicate patient needs and connect patients and communities with resources. A formalized database should be created to match providers (e.g., pharmaceutical company corporate social responsibility programs, financial planners, gyms, ride-hailing services) with patients in need. The initiative should have oversight and be registered as an NGO to encourage participation and donations. Major hospitals providing cancer care could be linked to these efforts.
Health Care Workforce Capacity Building
Task Shifting. Task shifting should be promoted as a key strategy for improving access to specialized cancer care, especially in rural areas. At the national level, relevant stakeholders should make decisions about which tasks could be shifted, what training is needed to ensure quality of care, and how support will be provided. Higher-level specialists can create manuals and monitoring systems to be disseminated across the country, possibly starting in pilot regions. Doctors and nurses in rural areas should be trained and use teleconsultation to connect with specialists in urban centers as needed. Doing so would make care more locally available to patients, helping them save time and money that would be required to travel to urban centers. Doctors and nurses who take on extra work should be consulted, trained, and recognized so that the extra work is not seen as a burden. In some cases, legal changes may be required to allow for professional education advancement and responsibilities – for example, allowing nurses to become nurse practitioners. In addition to teleconsultation and sharing digital images with specialists, telementoring should be leveraged to further support task shifting. High-level multisectoral collaboration is needed to improve the training of health care workers and the systems that are put in place to monitor task shifting.
Investing in Community Health Workers. Community Health Workers, who may work for a small stipend rather than a salary, are not professionalized health care workers but often have some basic training in community outreach and health education and sometimes skills such as taking blood pressure readings. Known to the community, they are experienced in talking with community members about health topics and can provide a point of entry into the larger health system. Community Health Workers often use more comfortable, sometimes informal, approaches to discussing health issues with community members. They can help counter disinformation, encourage check-ups and screenings, and support individuals to improve their health literacy. Governments should invest in Community Health Workers through training, compensation, and other support and provide incentives to increase retention and to better utilize these workers’ skills and positioning. Piloting and publicly celebrating local government engagement with expanded training and tools for Community Health Workers may encourage other governments to follow suit.
Telemedicine, Telementoring, and Teleconsultation. As described earlier, telemedicine telementoring, and teleconsultation should become routine to provide greater access to specialized care in rural areas. Although teleconsultation has become more common since the beginning of the COVID-19 pandemic, it is not yet common for cancer care. However, during the pandemic, there were cases in which telemedicine was used to support chemotherapy administration. Considerations such as poor internet connection, lack of technology skills and comfort, and the choice of devices for various tasks (such as encoding data or reviewing dashboards) must be addressed when introducing digital solutions.
Patient Smart Card. Utilization of electronic medical records varies across the region. To empower patients and bolster the effectiveness of electronic medical records, each patient should have their own smart card with a chip containing their medical records from all sources so that the patient owns their medical information and can take it to any provider. Taiwan serves as a good case study for this model.
Heat Maps. Data visualization tools should be used to map clusters of cancer cases, including outcomes, along with available support and oncologists. Mapping these needs and assets could serve as a powerful advocacy tool. Including outcomes of cancer cases in the visualization may be particularly informative.
Smartphone Applications. Relevant health-focused smartphone apps should be translated into local dialects and tailored for use by Community Health Workers. Learnings should be taken from ongoing pilots of other apps, such as those designed to assess the risk of cardiovascular disease or provide information on lifestyle changes to reduce risk. These apps should be engaging and appealing to use, perhaps using celebrities as spokespeople or including human-interest stories about the importance of accessing services or the dangers of believing misinformation.
Patient and Community Voices
Patient Empowerment. Meaningful, not tokenized, patient participation and representation should be formalized in every structure that involves health, from local boards to public hospitals to high-level government decision-making and priority setting. Funding should be provided for patients to attend cancer conferences. Holding conferences in expensive countries where it is difficult to get a visa can prevent the inclusion of patient voices across the region. Patients should be acknowledged as crucial stakeholders, and investments should be made to include their voices.
Community Involvement. Research should prioritize incorporating community preferences and values when making policy. Communities should be engaged to determine the acceptability of new health care programs and identify barriers to adoption. Publicly available feedback mechanisms should be developed for patients to review their experiences with health care providers.
Implementation Science. Real-world evidence should be valued, and implementation science should be supported by bolstering efforts to publish research and use it to drive policy. Equity is not always recognized or captured by evidence-based arguments, depending on the data collection approach. Prioritization of equity should be built into institutional structures, and care should be taken to use evidence-based approaches that incorporate equity whenever possible. One approach is to emphasize subgroup analysis to demonstrate how targeting a high-risk population is a worthwhile investment of resources. Another approach is an extended cost-effectiveness analysis that incorporates traditional methods of examining cost and health impact but also examines the ability to offset catastrophic costs. This type of analysis could support preventive measures that avoid hospitalization, which could help prevent illness-related poverty. Such approaches link social goals and health. Quantifiable evidence-based requests should be used, whenever possible, in local budget advocacy as well. For example, quantifying the number of women with suspicious masses who were deprived of a mammogram because equipment was not working may be more persuasive when health care workers demand that funding for a new machine be included in the budget.
Lessons Learned from the COVID-19 Pandemic
Remote Connection and Support. Necessitated by the restrictions and precautions required during the COVID-19 pandemic, virtual connections were demonstrated to be effective for providing services, convening meetings, and facilitating trainings – which in the past may have been considered appropriate only for in-person communication. Existing digital tools should be leveraged and innovative tools should continue to be prioritized. Digital innovations support many of the policy recommendations listed here, including facilitating communication and information sharing across sectors, enabling remote training and guidance to support quality-controlled task shifting, providing community health workers with training and tools to share information, allowing community participation in high-level decision-making without needing to travel to urban areas, and empowering patients by giving them easy access to their electronic medical records across providers.
Building Political Will to Overcome Entrenched Barriers. One striking lesson learned from the pandemic is that institutional barriers once considered insurmountable can be quickly negotiated to meet urgent needs. Concerns over immediate threats to public health mobilized stakeholders across sectors to work together. Gaps were quickly filled using solutions that may not have been considered previously because of financial or legal concerns, such as government contracting with private health care providers to perform surgeries when public systems were overwhelmed. This spirit of engagement across sectors should be leveraged beyond emergency care. These collaborations should now be institutionalized rather than ad hoc, as they were during the pandemic. If government resources are stretched too thin to provide cancer care, there should be a systematic, national approach to engaging the private sector. Expertise will be needed to design such agreements from a costing and legal perspective. Networks and infrastructure sprung up during the pandemic in an attempt to reach large portions of the population; these success stories should be the foundation for more permanent strategies to reach underresourced populations.
Nirmala Bhoo-Pathy, Professor of Epidemiology in the Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya
Kenneth Hartigan-Go, Senior Research Fellow, Ateneo Policy Center School of Government, Ateneo De Manila University, Philippines
Stephen Jan, Co-Director of Health Systems Research, The George Institute for Global Health, University of New South Wales, Australia
Kara Magsanoc-Alikpala, Founding President, ICanServe Foundation; Vice President, Cancer Coalition Philippines; Member, patient advisory board member of the Lancet Commission on Women and Cancer
Ma. Dominga Cecilia B. Padilla, Public Health Advocate; Clinical Associate Professor, Department of Ophthalmology and Visual Sciences, Philippine General Hospital, UP College of Medicine (2008 to 2021)
Carolyn Taylor, Executive Director, Global Focus on Cancer; Patient Advocate
[i] In A vision for primary health care in the 21st century: Towards UHC and the SDGs, WHO and UNICEF define primary health care as “a whole-of-society approach to health that aims to ensure the highest possible level of health and well-being and their equitable distribution by focusing on people´s needs and preferences (as individuals, families, and communities) as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people’s everyday environment.” https://www.who.int/docs/default-source/primary-health/vision.pdf