An Uneven Lifeline: Understanding Health Systems and Access to Care in Southeast Asia

Health inequities, or unfair and preventable differences in health outcomes and access to services, exist at every level: between and within countries, across communities, and among specific population groups.  These disparities are rooted in the social determinants of health, the conditions in which people are born, grow, live, work, and age, and are shaped by structural factors largely beyond individual control, such as education, income, housing, nutrition, and environmental conditions (WHO SEARO, 2023). Health is a fundamental human right, defined as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity (WHO, 2025d). 

Health systems in Southeast Asia face increasing pressure to provide equitable, high-quality, and affordable care. Despite progress in expanding maternal and child health services, advancing universal health coverage, and adopting digital health innovations, major gaps remain. Rural and marginalized communities, including migrants and mobile populations, often face structural barriers to essential services (Chavez, 2007). Fragmented financing, shortages of trained health workers, and uneven adoption of technology further hinder progress toward sustainable and inclusive systems (Tangcharoensathien et al., 2011).  Strengthening health systems and improving access to care is essential to safeguarding population health and building resilience against ongoing and emerging challenges. 

Rapid and uneven socioeconomic development, coupled with demographic and epidemiological transitions, has deepened health inequities and created major public health challenges, including the dual burden of emerging infectious diseases and rising non-communicable diseases in ageing populations (Lopez et al., 2010). At the same time, new models of care have emerged. Corporatised public health systems, which are government-owned but operate with private-sector principles, and innovative financing schemes aimed at universal health coverage provide lessons for other countries (Preker and Harding, 2003). Decentralisation and ongoing reforms have also contributed valuable insights, while pressures from health workforce migration, medical tourism, and expanding regional health trade continue to shape system performance (Lopez et al., 2010).  

Building on the recognition of persistent health inequities and the complex challenges facing Southeast Asia’s health systems, there is a pressing need to strengthen the capacity, resilience, and inclusiveness of care across the region. Locally led research and exploratory studies that deepen understanding of system performance, alongside evidence-informed interventions, are critical for generating practical knowledge, identifying effective solutions, and guiding policy and practice. Such efforts can improve access to quality health services, empower communities, and support sustainable health system improvements that benefit all populations, particularly those most at risk. 

To close persistent inequities and strengthen health system resilience, several critical challenges must be addressed across the domains of access, quality, financing, and service delivery.  

Persistent Inequities in Maternal and Child Health: Persistent inequities in maternal, neonatal, and child health hinder access to life-saving services, requiring targeted strategies to improve care and reduce preventable deaths. 

Adolescent pregnancy is a global phenomenon with clearly known causes and serious health, social, and economic consequences (WHO, 2025a). In 2023, over 700 women died globally every day from preventable causes related to pregnancy and childbirth (WHO, 2025e), with more than 100 deaths per 100,000 live births occurring annually in Southeast Asia (The Lancet Regional Health – Southeast Asia, 2024). On average, a maternal death occurred almost every two minutes worldwide in 2023 (WHO, 2025e). 

Between 2000 and 2023, the maternal mortality ratio, defined as the number of maternal deaths per 100,000 live births, fell by about 40% globally (WHO, 2025e). Despite this progress, over 90% of all maternal deaths occurred in low- and lower-middle-income countries, reflecting persistent inequities in access to quality health services (WHO, 2025e). Skilled care before, during, and after childbirth remains essential to saving the lives of women and newborns (WHO, 2025e). Major complications responsible for approximately 75% of maternal deaths include severe bleeding, infections, high blood pressure during pregnancy, complications from delivery, and unsafe abortion (Cresswell, Alexander, and Chong, 2025). 

In the South-East Asia Region, around 52% of under-five mortality occurs during the neonatal period, with the first month of life being the most vulnerable for child survival (WHO, n.d.). The leading causes of neonatal deaths are prematurity, birth asphyxia, and neonatal infections, while under-five mortality is predominantly driven by complications of prematurity, pneumonia, and diarrhea (WHO, n.d.). In 2022, 2.3 million newborns died worldwide during the first month of life (WHO, n.d.). 

Children are especially vulnerable to environmental hazards, receiving higher doses of pollutants in any given environment and often lacking equitable access to social protection mechanisms such as health and environmental services (Sly et al., 2019; Landrigan et al., 2018). Pollution was responsible for 16% of global deaths in 2015, approximately 9 million, three times more than deaths from AIDS, tuberculosis, and malaria combined, with around 92% of these deaths occurring in low- and middle-income countries (Landrigan et al., 2018; Sly et al., 2019). 

Even low-level exposures during fetal development or early postnatal life increase lifelong risks of chronic disease (Landrigan et al., 2018). Children in South and Southeast Asia therefore face a heavy disease burden driven by environmental, social, and economic factors (WHO, 2008). Widespread exposure to outdoor and household air pollution, heavy metals, industrial chemicals, and pesticides continues to threaten child health, while many children still lack access to clean water and adequate sanitation, leaving them vulnerable to infectious diseases, especially those living in poverty (Sly et al., 2019). 

The region also faces a dual nutritional challenge, with persistent undernutrition and stunting alongside rising rates of overnutrition and obesity (Landrigan et al., 2018). These persistent inequities in maternal, neonatal, and child health illustrate the critical need for strengthened health systems that ensure equitable access to quality care and protective interventions across all populations. 

Maternal and newborn deaths are largely preventable, yet access to quality care remains uneven, particularly for adolescents, rural populations, and marginalized communities. 

Research that explores access to SEA DREAM to contraception, safe abortion services, post-abortion care, and skilled maternal care before, during, and after childbirth is needed (WHO, 2023b). Investments in high-impact interventions such as emergency obstetric services, midwife-led continuity of care, and care for small and sick newborns can significantly reduce maternal and newborn mortality, stillbirths, and preterm births, generating substantial health and economic returns (WHO, 2024). 

Child health remains a major concern, with stunting and growth failure affecting more than a quarter of children in Southeast Asia. Chronic malnutrition in early life compromises growth, development, and long-term productivity (Azriani et al., 2024; WHO, 2014).  

Improving child nutrition, strengthening early-life health interventions, and expanding equitable access to preventive and curative services are essential to reducing avoidable illness and death among children across the region. Hence, by improving research, service delivery innovations, and capacity-building initiatives can help close gaps in maternal, neonatal, and child health, improve survival and developmental outcomes, and ensure that all mothers and children in Southeast Asia receive high-quality, evidence-based care. 

Barriers to Achieving Universal Health Coverage: Persistent gaps in access, affordability, and system capacity hinder equitable health care, requiring targeted strategies to strengthen health systems, expand primary care, and ensure all populations in Southeast Asia can obtain essential services without financial hardship. 

Health outcomes are closely linked to socioeconomic position, with those in lower income groups consistently facing higher risks of poor health. Promoting health equity is therefore central to achieving universal health coverage (UHC) and improving both population health and socioeconomic development (WHO, 2023a). 

Universal health coverage ensures that everyone can access the full range of quality health services they need, when and where they need them, without experiencing financial hardship (WHO, 2025b). UHC spans the entire continuum of essential services, including health promotion, disease prevention, treatment, rehabilitation, and palliative care across the life course (WHO, 2025b). Its two key dimensions are access to needed care and financial protection. 

In Southeast Asia, the regional average for the UHC essential health services index rose from 46% in 2010 to 61% in 2019, while the UHC service coverage index increased from 45 to 68 between 2000 and 2021 (WHO, 2025b; WHO, 2025c). Despite these gains, progress has slowed, with the UHC service coverage index increasing by only three points between 2015 and 2021 and showing no improvement since 2019 (WHO, 2025c) .At the same time, over 65 million people in the region are pushed into poverty due to health expenditures (WHO, 2025c). 

UHC rests on three dimensions: who is covered (population or breadth coverage), which services are included (service or depth coverage), and the share of costs covered (financial or height coverage) (WHO, 2010). Health systems in Southeast Asia are complex, combining public and private delivery and financing, with new organisational forms such as corporatised public hospitals and innovative service delivery models responding to competitive private healthcare markets and growing medical tourism (Lopez et al., 2010). 

Many countries have implemented pro-poor financing schemes to improve coverage and equity. Examples include Thailand’s Health Card and 30-baht Schemes, Vietnam’s Health Fund for the Poor, Health Equity Funds in Cambodia and Laos, and Singapore’s Medifund, a means-tested hospital fees subsidy for indigent patients (Lopez et al., 2010). Despite this impressive progress toward universal health coverage, countries in the region face mounting challenges in sustaining and improving their health-care systems. These pressures are increasingly evident as rising costs, limited fiscal space, growing out-of-pocket spending, and persistent efficiency and governance constraints undermine the long-term viability of existing financing models (Lim et al., 2023). Regional health-care spending is projected to rise by US$320 billion between 2017 and 2025, a 76 percent surge that will strain government budgets as systems struggle to serve an older and sicker population (Patel, 2023).

Much of this escalation is driven by a shift from acute to chronic care, with long-term illness overwhelming systems originally designed for short, episodic treatment in a poorer population, leaving them inefficient, outdated, and increasingly costly to operate (Patel, 2023). 

These pressures are rooted in historical system design. The region’s health systems were shaped by past poverty and early priorities, with young governments establishing centralized hospitals to address trauma and infectious disease while leaving primary care to a fragmented, out-of-pocket private sector; UHC expansions consequently concentrated on the public hospital system, while private insurers avoided primary care due to persistent fraud risks (Tandon et al., 2021; Zaki, 2021). 

Today, these structural arrangements are poorly aligned with a rising burden of non-communicable diseases, which are far better managed through strong, integrated primary care networks (World Economic Forum, 2017). Health systems built under earlier resource constraints thus prioritized acute hospital care, shaping the way UHC schemes and insurers evolved, yet these earlier structures now struggle to meet the needs of populations requiring more continuous and coordinated care (Patel, 2023).

In response, value-based care, delivered through technology platforms and strengthened primary care, is gaining attention as a promising approach that shifts payment from volume to outcomes and improves efficiency so that limited resources can better meet rising UHC demands (Smith & Doe, 2017).

The region also faces challenges from demographic changes, including an ageing population, which strains intergenerational funding through pay-as-you-go mechanisms. In response, some countries are experimenting with compulsory medical savings and social insurance schemes for long-term care (WHO, 2005). Health system decentralisation, such as in the Philippines, Vietnam, and Indonesia, has affected performance and equity, with local governments assuming responsibility for service delivery, often with variable infrastructure and capacity (World Bank, 2005). 

Consequently, even where national health insurance systems and UHC laws exist, implementation remains uneven. Equity gaps, limited infrastructure, and system decentralisation continue to challenge the expansion of UHC, leaving vulnerable populations at risk of limited access to essential health services (WHO, 2009). 

Unmet health needs are a key measure of health inequity, reflecting people who require health services but are unable to access them for various reasons. These unmet needs consist of two components: forgone care, when someone recognizes the need for services but cannot access them, and unexpressed demand, when individuals are unaware of their health needs (WHO, 2023a). Understanding the reasons behind unmet needs is essential for monitoring progress toward UHC and addressing inequities in access. 

Universal health coverage ensures that everyone can obtain quality health services without suffering financial hardship, covering the full continuum of care from prevention and health promotion to treatment, rehabilitation, and palliative services (WHO, 2025b). Scaling up primary health care interventions in LMIC could save 60 million lives and increase life expectancy by 3.7 years by 2030 (WHO, 2025b). 

Health systems across Southeast Asia are diverse, ranging from tax-funded models to social insurance schemes and high-out-of-pocket payments. Although political commitment has driven notable progress toward UHC, significant challenges remain, including financial constraints such as limited government health spending, supply-side limitations including shortages and uneven distribution of health workers, and the dual burden of non-communicable and infectious diseases (Minh et al., 2014). 

Sound health policies, effective health financing strategies, and functional health systems are essential to ensure access, quality, and equity. Social health insurance has emerged as a key instrument in the region, expanding coverage even amid gaps in access and affordability (Minh et al., 2014). 

Strengthening health system capacity, expanding primary health care, and improving financial protection mechanisms are central to advancing universal health coverage. Through efforts in policy development, service delivery innovations, and workforce expansion can reduce barriers to care, enhance equity, and accelerate progress toward health systems that provide essential services for all people in Southeast Asia without exposing them to financial hardship. 

Limited Inclusion of Migrants and Mobile Populations: Persistent gaps in policy, service access, and health system responsiveness hinder the ability to meet the needs of migrant and mobile populations, requiring targeted strategies to promote inclusive and equitable health care. 

Migrant health has gained growing international attention, highlighting both the persistent health inequities faced by many migrant groups and the need for health systems to respond more effectively to their diverse needs. Southeast Asia is experiencing one of the fastest demographic transitions globally, characterized by fertility reductions, population ageing, and rural-to-urban migration. Simultaneously, rapid epidemiological transition is shifting the disease burden from infectious to chronic diseases (Lopez et al., 2010). 

Economic and demographic developments have prompted significant movement of people across the region, primarily for short-term employment but also for settlement (Skeldon, 1998). Rapid economic growth and declining domestic population and labour force growth have led countries such as Singapore to open doors to foreign workers at all skill levels, with permanent settlement options for highly skilled migrants (Lopez et al., 2010). The Philippines, Indonesia, and Vietnam are major labour-exporting countries, whereas Malaysia and Thailand both receive and send nationals abroad (Lopez et al., 2010). 

Undocumented or irregular migration, alongside displacement due to emergencies, remains a significant challenge (Abella, 2005; Chavez, 2007). These populations are particularly vulnerable, as “[u]ndocumented migrants are disproportionately more exposed to health risks due to inadequate working conditions and irregular movements but are unlikely to seek medical attention because of their status and are also often left out of assistance programmes in times of disasters and emergencies” (Chavez, 2007). 

The health system capacity to respond to migrant needs remains uneven across the region. Some countries, such as Thailand, have introduced migrant health policies, bilateral labor agreements, and health insurance schemes to improve coverage, while Vietnam has implemented measures to safeguard the health of emigrant workers (McMichael & Healy, 2017). Despite these efforts, many migrants, particularly irregular workers, continue to face elevated health risks, inadequate coverage, and heavy reliance on out-of-pocket payments (McMichael & Healy, 2017). 

Mobile populations pose additional challenges to countries already managing day-to-day demands on health systems. Access to care is often contingent on legal and administrative status, further limiting migrants’ ability to obtain quality health services (WHO, 2016). Addressing these barriers is critical to ensuring inclusive and equitable health systems that meet the needs of all populations in Southeast Asia. 

Addressing the health needs of migrants in Southeast Asia remains a significant challenge across multiple strategic areas. These include the absence of long-term national policies and frameworks, persistent barriers to accessing health services, fragmented health information systems, gaps in health financing, and inadequate public health responses during crises (WHO, 2025f). 

Diseases do not respect borders, and migrants are particularly vulnerable to health risks due to limited legal status, precarious working conditions, and social exclusion. Effective responses require robust health information systems, inclusive policy frameworks, and health systems that are responsive to the unique needs of migrant populations (WHO, 2016). 

The COVID-19 pandemic further highlighted these vulnerabilities. Migrant workers in the region faced overcrowded living conditions, limited access to timely health care, and exclusion from vaccination statistics, as seen in Singapore and among Cambodian migrants in Thailand (BBC News, 2020; Kashyap & Bhattacharya, 2021; Kliem, 2021). The pandemic also exposed the lack of regional coordination, contributing to disparities in public health protection across ASEAN states (Kliem, 2021). 

Addressing these gaps requires research and action that strengthen migrant-inclusive health policies, improve access to essential services, and build more responsive health systems. Key priorities include developing integrated health information systems, aligning and improving financing arrangements, and enhancing preparedness and response mechanisms during public health emergencies. By targeting these areas, countries can reduce inequities, protect vulnerable migrant and mobile populations, and foster stronger regional collaboration for health equity across Southeast Asia. 

Uneven Adoption of Digital Health Solutions: Uneven adoption and integration of digital health innovations limit the ability of health systems to deliver equitable, efficient, and resilient care across Southeast Asia. 

The rapid development of digital health, including technologies such as mobile health (mHealth), telemedicine, digital health information systems, Internet of Things (IoT), machine learning and artificial intelligence (AI), personalized digital nudges, large language models, and generative AI, has ushered in a new era of health care possibilities (WHO, 2021). 

Southeast Asia’s rich history, coupled with recent industrialisation and globalisation, has created new challenges for the region’s health systems. While modern medical technologies are available on the global market, their costs remain beyond the reach of much of the population (Lopez et al., 2010). Traditional health practices persist alongside modern technologies, generating regulatory challenges related to safety, quality, and standardisation (Phua & Chew, 2002). 

Rising educational levels, ageing populations, and growing awareness of human rights in emerging democratic environments have increased public demand for better healthcare (Lopez et al., 2010). Health systems face unprecedented adjustment pressures, with health services evolving into a complex industry involving public and private actors, non-profit and for-profit providers, and expanding trade and medical tourism (Tangcharoensathien et al., 2000; Lopez et al., 2010). These transformations necessitate that the public sector adapt its provision, financing, and regulatory functions, while restructuring delivery systems to balance supply and demand (Phua, 1999; Lopez et al., 2010). 

Thailand provides a regional example, where the healthcare system is undergoing digital transformation to address inefficiencies, resource limitations, and rising costs, while simultaneously driving innovation and quality improvement (Thailand Market Research, 2024). Interoperability is central to creating a cross-border digital health ecosystem, enabling seamless data exchange and continuity of care for patients across ASEAN (Ayuanshari, 2025). However, most ASEAN countries operate in silos, with national health systems lacking standardised data formats and shared protocols (Kashyap & Bhattacharya, 2021). This absence of operational consensus poses a significant barrier to effective data sharing and interoperability, particularly given the diversity of health systems and regulatory environments in the region (Iyamu et al., 2022; Ayuanshari, 2025). 

The COVID-19 pandemic further highlighted the critical role of digital health innovations in strengthening public health responses. In South and Southeast Asia, a region defined by cultural diversity and complex healthcare landscapes, these technologies present both significant opportunities and persistent challenges, emphasizing the need for coordinated adoption strategies and system-wide integration (Yi et al., 2024). 

The pandemic accelerated digitalisation across Southeast Asia, making online health services increasingly essential. Approximately 60 million new digital consumers emerged in the region, accessing telehealth, online health information, and digital payment platforms for healthcare services (EAF editors, 2022). Telemedicine platforms surged in popularity, enabling remote consultations and ensuring continuity of care despite mobility restrictions (Ahmadi Shad et al., 2025). 

Digitalisation and enhanced health information systems are now central to improving healthcare delivery, reducing geographic barriers, and enabling more efficient use of health data (EAF editors, 2022). Interoperable and accessible digital health infrastructure is crucial, as health data can be shared without being depleted, whereas restrictions on data flow limit efficiency and patient care (EAF editors, 2022). 

Challenges remain, including fragmented regulations, limited cross-border collaboration, cybersecurity risks, and public distrust (Ayuanshari, 2025; Kashyap & Bhattacharya, 2021). Despite important strides, such as Indonesia’s SATUSEHAT, Thailand’s Mor Prom, and Singapore’s HealthHub, persistent inconsistencies in standards and uneven adoption across countries continue to restrict the full potential of digital health (Ayuanshari, 2025). 

Research that advances digital health and robust health information systems across Southeast Asia is essential to achieving more equitable, efficient, and resilient care. Priority investments include building interoperable infrastructures, promoting cross-border collaboration, and integrating digital tools into primary and secondary care, alongside continuous capacity building for health professionals. A “researcher-in-the-loop” approach, where digital solutions are rigorously evaluated, iteratively refined, and supported by continuous learning, helps ensure that digital health tools are implemented responsibly and in alignment with evidence (WHO, 2021). When paired with strong governance and system-wide integration, these efforts can help transform the region’s uneven lifeline of care into one that is more connected, equitable, and responsive for all. 

 

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