Essential public health functions (EPHF) are primary responsibility of the state and are fundamental for achieving public health goals through collective action. There are several EPHF frameworks that have core and enabling functions, which should be integrated within health systems. The preferred approach is to identify the framework that best suits the local context. International Health Regulation (IHR) are legally binding set of regulations meant to prevent international spread of diseases and are closely related to EPHF. EPHF focus on building capacity for public health nationally, while IHR respond to the obligations of public health globally. This Chapter makes a case for investing in public health as an obligation and an ethical and moral imperative of governments in every country by ensuring well performing EPHF and IHR.

Just as there are determinants of health of individuals and communities, there are determinants of health system organization and performance which we term structural determinants. This chapter focuses on a set of such determinants considered key in understanding and strengthening health systems in low- and middle-income countries (L&MICs). These determinants include politics and governance; the economy, livelihoods and poverty; climate change, environmental degradation and natural disasters; social and organizational culture; wars and conflicts. Each of these determinants has its own set of issues. For example, with regards to politics and governance, it is intersection of the form of authority, institutional arrangements, political values, citizen participation, corruption, and informal governance channels that determine health system performance. While the influence of structural determinants on health systems is acknowledged, there is still limited attention to integrating work on structural determinants in health system thinking, policies and practice. This chapter argues for a multi-pronged strategy to address this gap: focusing on tackling inequities; removing misconceptions about health determinants among health workers; easing the path to health system work on health determinants; engaging concerned communities; evaluating innovations to address health determinants; and strengthening intersectoral collaboration.

Health systems around the world share common goals, but attainment is widely variable. Universal Health Coverage (UHC) has emerged as a consolidated response to bridge the gap between what a health system should be doing and what it does. Drawing from global best evidence, this chapter explores how countries in practice could translate and achieve UHC, focusing on two central questions: What services and policies should be covered and be implemented; and second, how can health financing meet the UHC requirements? These include both health sector as well as intersectoral policies and interventions prioritized in the DCP3 package. The health sector interventions are distributed across four clusters – age-related, non-communicable disease and injury, Infectious diseases, and health services. The intersectoral interventions and policies fall under four domains – fiscal, regulatory, information and education, and built environment. The second question looks at the key challenges of country-level implementation capacity. It concludes by drawing out generalizable themes of country responses to the UHC Sustainable Development Goal targets to inform the way forward.

Good health is essential to ensure well-being for individuals, society and nations. However, health is determined by a multitude of factors, and hence achieving the targets set for SDG3 would inevitably require equitable progress in other related SDGs. The health systems in many low-and middle-income countries (L&MICs) have been unable to cope with the needs of the population due to lack of health care workers, financial resources, supplies, monitoring and evaluation. Health systems research can help identify existing gaps and challenges and propose customised solutions based on country needs. A preferred approach to move forward would be an inclusive and multi-sectoral approach with the implementation modalities adapted to the local context. In order to assess the implementation and progress of health-related SDGs targets in L&MICs, a framework comprising of nine domains is proposed which represent political, technical and institutional conditions. A greater political commitment with a focus on reducing inequities and greater accountability would be of paramount importance for any real progress and materialization of SDG targets.

Decisions taken by stakeholders at all levels of health systems can benefit from the use of different types of evidence drawn from heterogeneous research fields – including epidemiology, clinical and basic biomedical research, and health policy and systems research (HPSR). However, out of these diverse forms of evidence, HPSR is relatively underused and under-funded. Challenges associated with the use of HPSR in health systems in low- and middle-income countries (L&MIC) include the lack of opportunity and resources, the need for greater capacity for the generation and use of evidence, and fundamental problems around how the research agenda is framed. Evidence informed decision-making in L&MICs can be improved by better alignment of HPSR with health system needs, institutionalizing the use of HPSR evidence, and strengthening individual capacities to generate and use HPSR evidence. Several global, national and local-level initiatives have helped take strides in these areas, but more work and investments are needed to strengthen the use of appropriate evidence, especially HPSR evidence, in health systems.

There has been growing interest in the vertical integration of physicians and hospitals during the past decade, as evidenced by multiple literature reviews and research investigations.1 Historically, physicians operated small firms that provided “physicians’ services” to patients who sometimes used facilities provided by separate hospital firms at which many physicians would have “privileges.” This interest in combining the two types of organizations culminated in a December 2020 issue of Health Services Research devoted to the topic that expressed surprise (and disappointment) that integration is not “a miracle cure”.2 Just months earlier, two of the major proponents of vertical integration published a study in the August issue of Health Affairs that came to a similar, “startling” conclusion: the financial integration of physicians and hospitals (e.g., via employment) had no impact on their clinical integration (and perhaps none on quality).

This chapter documents health policy problems that exist in South Korea, the policy tools that are used to address them, and the outcomes they produce. We see that the Korean government has gone to great lengths to establish mechanisms to provide health care to all while containing financial burden on both households and the government. The root cause of the high out-of-pocket payments in Korea is the fee for service (FFS) mode of paying providers which incentivizes over-supply of services that generate higher returns for providers. Unable to replace FFS with capped payments due to political opposition, the government has had to resort to controlling fees and volume of services and requires co-payments from patients. Korea has also established a detailed decision and monitoring processes to curb over-supply and over-charging which have shown only limited success. The financing and payment arrangements and weak regulations coupled with political power of the vested interests make it very difficult to reduce the burden of out of pocket expenditures on households without shifting the burden to the government, a burden that the latter is unwilling to shoulder.

This introductory chapter conceptualises the absence of universal health care as a policy problem which requires a problem-solving approach if it is to be addressed. It develops the theoretical framing of the book: a policy design approach to health care. The chapter presents five challenges (governance; provision; financing; payment; and setting standards) that governments need to meet in their efforts to achieve universal health care, and the types of policy tools (stewardship and coordination; ownership and management; risk pooling; retrospective and prospective payments; and regulations) available to them. The chapter summarises the core argument around the importance of ownership and management of public hospitals, and the need for regulatory frameworks to manage private providers.

The aim of this chapter is to explain Singapore's health care performance, and the types of policy tools deployed to achieve universal coverage. The chapter argues that Singapore has pursued the goals of affordable health care through a range of policy tools targeting specific problems that work in tandem and are fine-tuned constantly. The island state has an inordinately complex health system comprising a broad range of policy tools and it is their combined working, and not that of any one tool, that explains the system-level performance. By focussing on simply one tool, such as Medical Savings Account (Medisave), observers miss the bigger picture as well as the details of the health care system in the country. And yet, as we shall see, policy makers in Singapore are stymied by blind spots that leave crucial problems insufficiently addressed.

After decades neglect, the Indian government has turned its attention to strengthening the health care system and the country is amidst implementing its most ambitious health care program. The Pradhan Mantri Jan Arogya Yojana (PM-JAY) rolled out in 2019 aims to provide health care coverage to half a billion Indian citizens and offers hope that it will reduce the population’s financial sufferings caused by illness. The chapter assesses the evolution of the health care system in India and examines the policy tools in use to understand the country’s preparation for achieving its goal. In this chapter, we see that health care system continues to be handicapped by a weak public sector and an inadequately regulated private sector which together form an inhospitable context for publicly financed programs to succeed.

This chapter synthesizes social, economic and demographic trends over the past three decades in the countries studied in this book. It argues that health policy is affected by and affects these trends. The chapter synthesizes data on economic and demogrphic trends as well as key health system input and outcomes. The chapter records impressive economic growth rates, decline in poverty, and prudent public finances in the region. It shows that all countries except India enjoy some of the best health status in the world, and that these were achieved at relatively low costs. However, rapid population ageing and rising incomes and expectations present serious health policy challenges that governments must meet.

Hong Kong has one of the best health care systems in the world, noted for its low costs and high equity. It is a rather simple system, with hierarchical governance structures and sparse policy tools centred on public ownership and financing that have undergone only minimal changes since the 1960s. The purpose of the chapter is to describe the development and functioning of the health care system in Hong Kong and examine the policy tools that underlie it. The case shows that it is possible to achieve universal health care through traditional organizational and fiscal policy tools. The case also serves as a cautionary lesson for health policy and international consultants proposing complex mix of policy tools in health care when simpler tools used effectively can achieve universal health care. This vital lesson is lost on the Hong Kong government itself as it promotes privately financed and provided health care to complement the public system.

This chapter presents a comparative portrait of the policy tools employed in health care in Asia, the effects they trigger, and how they affect the achievement of universal health coverage. It examines the design and implementation of key health policy tools in China, Hong Kong, India, Korea, Singapore, and Thailand shows improvements along all main dimensions of health policy design. It also points out the continued under-emphasis on regulation of private providers, which is especially vital in health systems dominated by private provision and financing.

Thailand is widely acknowledged as a successful case of achieving universal heath care at modest costs. In this chapter we show that the success is based on a simple system under strong government stewardship: most health services are provided at publicly owned and operated hospitals, and paid for by the government through tax revenues. Layered to the combination of public ownership and funding, is a purchaser-provider split and frequent changes in policy settings based on data on utilisation and costs. The combination of these tools enable the government to monitor quality of services while maintaining a watchful eye on costs. The only tool that Thailand does not use extensively is regulation which, as we will see in this chapter, is not necessarily damaging due to the other tools in place. Public ownership and funding offers sufficient levers to the government to create incentives for healthcare providers to control costs, promote responsiveness, and improve quality of services without the need for extensive regulations.

This chapter discusses the dismantling and rebuilding of the Chinese health care system in recent decades. It shows that China’s reforms over the past decade have focussed on (i) reiterating the role of the government as steward; (ii) promoting policy coordination of various agencies in the sector; (iii) improving the performance public hospitals; (iv) making healthcare providers more responsive to patients’ needs. It will argue that despite these reforms, regulations controlling the quality and safety of drugs and behaviour of providers remain weak and undermine public trust.