Our results show profound geographic variation in the distribution and availability of health system resources both between and within countries of the Greater Mekong Subregion of Asia. These results reflect the high socio-economic diversity in Southeast Asia and, alongside the wide range of public health challenges in the region[2, 25], echo suggestions that Southeast Asia represents a microcosm of global health. We show, moreover, that inequalities in resource distribution in the region result principally from within country differences. For example, even though Lao PDR and Cambodia are both relatively low-income countries, they share very different health system resource distribution patterns. In Lao PDR, resources are more homogeneously and equitably distributed with relatively few clusters or mismatches. This is, perhaps, the result of centralised governance and planning systems and relatively limited donor investment. Cambodia, by contrast, shows a greater degree of diversity in resource distribution, with some pockets of high resource density. Though a model of central planning exists, Cambodia has been a recipient of considerable donor investment, and activities of non-governmental organisations in some programmatic areas is substantial. Whether these investments have resulted in some distortions in resource distribution is an area that is open to further research.
Overall, both Lao PDR and Cambodia have few resources relative to the region as a whole. But northeast Thailand, too, shows similarly poor availability of key health system resources, a not insignificant finding given it is home to about 35 percent of Thailand’s population. We found particularly wide variation in the availability of ventilators and oseltamivir in Thailand where, consistently with previous studies, our results suggest that there is an inequitable distribution of health system resources rather than simply an overall nationwide shortage.
Through determinations of resource distribution and highlighting relative shortages and distributional mismatches, new investments and re-distribution of resources offers policy makers the potential to correct inequalities in resources, and ultimately in health outcomes. Several of the resources we have mapped serve generic purposes, with oseltamivir being the only influenza-specific resource. Thus, improved distribution of resources has the potential to benefit public health outcomes beyond mitigation of pandemic influenza, and shortages or maldistribution may hinder control and mitigation efforts. But for public health to benefit effectively from improved distribution of resources, political, administrative and contextual hurdles may need to be overcome, including the mobilisation of resources across administrative boundaries. Whilst drugs and ventilators may be readily re-distributed, other resources such as hospital beds and human resources may be more challenging. Our analysis suggests, however, that inequities, at least within countries if not regionally, are most profound for resources that would be most readily mobilised. National policy and strategies to address these discrepancies through better resource allocation across areas are needed. Stronger coordination of resource availability and use for pandemic responses is likely to be particularly important in more decentralized systems.
A number of other contextual challenges for optimum distribution and utilisation of healthcare resources were identified in our previous qualitative analysis of pandemic preparedness programmes in relation to national health systems in our four GMS study countries (along with Indonesia and Taiwan). These include the need for: (i) greater emphasis on strategies for pandemic mitigation (since planning in the region was found to focus overwhelmingly on early detection and containment); (ii) translation of existing plans into operations, particularly at sub-national administrative levels; and, (iii) greater national ownership of preparedness activities, particularly in low resource countries where external funding is prominent, to ensure that the allocation of pandemic-related investments is aligned with national systems and priorities.
The inequalities observed between, as well as within, countries in this study also highlight an important role for supranational mechanisms to mitigate the public health impact of future pandemics. Regional bodies and networks such as ASEAN and the MBDS could play a supportive role in providing evidence, such as findings from this study, to member countries to identify resource needs and discrepancies, and help pinpoint specific areas for cooperation. Supranational mechanisms could also help coordinate support from external funding agencies, to ensure it is directed towards the geographic areas most in need in order to address the existing gaps at the national and subnational levels.
A limitation of this study is that data were not available from all districts, with missing data an issue particularly for districts in Thailand. To address this problem, we extrapolated using country-specific mathematical models that acknowledged province characteristics and we validated our findings through comparison with aggregate national data collected separately from ministries of health questionnaires. Another limitation is that the analysis that could not extend to cover potential determinants of resource availability, such as level of economic development and relative political power, due to such data not being available at subnational levels. This could be an area of future research when disaggregate data on potential determinants of resource availability are available at province level.
In conclusion, we show that considerable diversity exists in the distribution of healthcare resources within and across countries of the GMS, and that much of the geographic inequalities result from within countries. We also identify substantial mismatches and clustering in the distribution of resources, which has the potential to reduce the public health benefits that may accrue from their use. Future investment towards reducing inequalities in the distribution of health system resources, and policies to facilitate sharing and mobilisation of resources across administrative boundaries (both intra- and internationally), are likely to be important for mitigating the impact of public health challenges such as pandemic influenza. These lessons and our results can be drawn upon by national policy makers and the international donor community to support investment choices.