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Disclaimer: The views expressed in this paper/presentation are the views of the author

and do no necessarily reflect the views or policies of the Asian Development Bank (ADB),
or its Board of Governors, or the governments they represent. ADB does not guarantee
the accuracy of the data included in this paper/presentation and accepts no
responsibility for any consequence of their use. Terminology used may not necessarily
be consistent with ADB official terms.

Responding to 21st century

challenges and technological
Eduardo P. Banzon
Principal Health Specialist
Asian Development Bank (ADB)

April 2018
• Key 21st Century Challenges which
Hospitals must Face
– Demographic and Epidemiologic Changes
– Increasing Demand for UHC
– The Need to Address Health Security
• Opportunities to Improve Hospitals
I. Demographic Changes
• Share of older population (65 years+) is expected to be 26% in 2050 (OECD
average, 25%)
– In 2012, those aged over 65 was 7% in Asian countries

• Challenges of the speed of aging

– Much shorter time to prepare for population aging
– Brunei Darussalam, India and Mongolia: share of the population over 65
is expected to increase by 4 to 7 fold (from 2012 to 2050)

• Greater demand for income security and health care of older people in the
Asia/Pacific region in the coming decades
(OECD/WHO, 2014)
% Population aged over 65 and
80, 2012 and 2050

Source: OECD/WHO, Health at a Glance: Asia/Pacific 2014

Original source: OECD Historical Population Data and Projections Database 2013; UNESCAP (2014).
Old-Age Dependency (65+/(20-
Percentage below Poverty Line by
(Per capita daily income < US$1.25, 2005 dollar PPP)

Poverty 2006–08 Poverty, 2009–12

Source: World Bank. 2016, Original sources: Giles and Huang 2015 based on data from CHNS 2006, 2011; ThaiSES 2011; World Bank East Asia and Pacific Standardized Household Surveys, various years; and VHLSS 2012.
2. Epidemiological Change: Leading causes and Risk
factors of Disability-adjusted Life Years (DALYs)

• Non-communicable diseases (NCD), e.g., ischemic heart disease, lung

cancer, diabetes, chronic kidney disease, showed the highest growth (IHME,
• 3/4 of NCD deaths occur among persons +60 years (World Bank, 2016)

• Dietary risks were the leading risk factors in most Southeast Asian countries,
high BMI and high fasting plasma glucose ranked high in the Pacific;
Smoking ranked second or third in Cambodia, Indonesia, Laos, Malaysia,
Myanmar, Papua New Guinea, Philippines, Thailand, Timor-Leste, Vietnam
(IHME, 2013)
Shifts in Leading Causes of DALYs in
East Asia and Pacific, 1990-2010

Source: IHME, 2013

Shifts in Risk Factors of DALYs in East Asia
and Pacific
for Top 15 Risk Factors, 1990-2010

Source: IHME, 2013

Prevalence of ADL, IADL Limitation
(selected countries, by Survey Wave)

Beijing Indonesia Philippines

1994 1997 1993 1997 1996 2000

ADL limitation 4.9 4.7 4.2 6.5* 10.9 14.7

IADL limitation 13.4 17.7* n.a. n.a. 20.9 27.2*

*Difference in prevalence estimates across waves is statistically significant at p<0.05.

Source: Ofstedal et al., 2007
3. Increased Demand to Meet
Universal Health Coverage
1) Growth in Health Expenditure
• Health spending was much lower in developing countries (e.g. Myanmar’s
25 USD PPP per capita) compared with developed countries (e.g. OECD
average 3,514 USD PPP per capita) (OECD, 2014)

• Growth of health spending has exceeded economic growth in many Asia-

Pacific countries (2000-2012) (OECD, 2014)

• “Aging” explains one-third of the health spending growth in developed

countries, but it may take greater share in low- and middle-income countries
(by increase of health coverage, urbanization) (World Bank, 2016)
Growth in Health Spending and GDP per capita, 2000-12

Source: OECD, WHO, Health at a Glance: Asia/Pacific 2014

Original source: WHO GHO 2014, OECD Health Statistics 2014.
2) Access to Health Care with UHC

Need government commitment to universal access to health care for all

people including older people

- Need sustainable financing mechanism or prepaid scheme funded by

the (mandatory) public source (government tax or social health
insurance): Thailand, China

- Without subsidy to the poor, pure contribution approach faces

barriers to UHC

- Extend the benefit package of existing schemes and essential

medicines list to cover NCDs and services for older people
Financing Mix and Health Expenditure as a % of GDP

Source: WHO, 2011

3) Aging and Health (and Expenditure)
Does health status of the elderly improve over the years (e.g.,
compare the health of 70 year-old man in 1990 and 2010)

Question: Are the increased life years healthy or unhealthy ones?

- Expansion of morbidity (Gruenberg, 1977; Manton, 1982; Yong et
al., 2010 (for Singapore)): People live longer with ill health, as
longevity increases vulnerability
- Compression of morbidity (Fries, 1980, Jang and Kim, 2010; Liu,
Chen, et al., 2009; Woo, Zheng, et al., 2015): Life years with illness
and disability decreases as the onset of morbidity is delayed more
than life is prolonged
-> People with high socio-economic status (Jung, et al., 2007)
Health Cost towards the End of Life:
Role of Integrated Service Delivery
Proximity of death has bigger impact than demographic change
(medical cost does not rise uniformly with increasing patient age)
- Health expenditure at the end of life decreases with age
(Kuriyama, 2008; Seok, 2012; Shin, et al., 2012)

Hospitalization (vs. dying in hospice or LT care institutions) and clinical

decision on treatment (intensity of care) at the end stage of life has a
crucial impact on medical cost of the elderly: end-of-life care matters

Prevention and health promotion is important: People who were

healthier when young consume fewer resources in later life
(Gandjour and Lauterbach, 2005; Daviglus et al., 2005)

Kwon: Health Systems Asia

Health Expenditure at the Last Year of Life, Korea (2008)
18,000 16,496
1,000 KRW

15,818 15,919
16,000 14,455 14,966
14,000 12,954 12,879

12,000 11,134

10,000 8,861

8,000 7,143



~34 35~39 40~44 45~49 50~54 55~59 60~64 65~69 70~74 75~79 80~84 85~89 90~94 95~

Source: HC Sin, MY Choi and BH Tchoe (2012)

Determinants of Health Expenditure for Older People

Source: OECD, 2013

Kwon: Health Systems Asia

Per Capita Health Expenditure by Age Group, Japan (2010)

(Data Source) MHLW, Japan

Kwon: Health Systems Asia

Climate Change
Climate change has a direct
threat to health – and it could
potentially cause health
systems to collapse, should
countries fail to mitigate risks.

Countries should build health

infrastructure and systems
that is resilient to climate
Regional Health Security

• Emerging and Reemerging

infectious diseases recognized a
continuous threat in Asia –
regardless of the country’s income

• Regional Health Security

measures should be strengthened
to mitigate risks, improve
response of countries and the
international community.
Health Facility Aspects for

Safe and Green and

Resilient Sustainable

centered and
1. New innovative hospitals whose design
and construction can address these
challenges Design
Planning Space for machines
Infrastructure Data room
for processes IT in patient rooms
More mobile care delive

Building in cable

Maintenance Operationalization
Cost of ownership Training staff
2. New technology supported health
care to improves efficiencies
$2bn Examples from Australia

Cost of
events $1.5bn Pathology tests are

Cost of non-
collaboration on duplicates ($306m)
Chronic Disease
of errors due to
wrong medical Info

Cost of
of Physician’s time
medication errors spent on getting
medical info
* Peter Fleming, CEO NeHTA | Canberra, 12 April 2010
IT in service delivery has economic value
Positive socio-economic value after 7-9 years2)

1) DesRoches CM et al. N Engl J Med 2008;359:50-60

Source1) 2) The Socio-economic impact of interoperable EHR and e-prescribing systems in Europe and Beyond, Oct 2009
Technology supported hospitals are
Technology enabled processes are Issues in health care

• Difficult to automate human


• Fragmented poorly- coordinated

systems and processes

• High volume of patients, little

resources, little time
Focus needs to be on IT to improve
2. Process Engineering

Hospital Patient care

construction environment

1. Data Management Management

3. Service Delivery
From the current state of health
facilities to 21st century health facilities?
Thank You!