According to the World Health Organization (WHO), primary health care (PHC) addresses most people’s health needs throughout their lifetime, including physical, mental, and social well-being. PHC is vital in making health systems more resilient and prepared for crisis situations. Good management and well-trained teams make it more efficient. High-functioning PHC systems are essential for achieving all 17 Sustainable Development Goals (SDGs) of the 2030 Sustainable Development Agenda.

With Asia being home to more than half of the world’s population, the region has experienced an increasing rise in non-communicable diseases such as heart disease, stroke, cancer, diabetes, mental illnesses, and injuries and outbreaks of infectious diseases that stall progress on health indicators. Though the private health sector has expanded rapidly, public health services continue to be under-financed and over-burdened to meet the needs of the patients.

For example, In Japan, the number of medical facilities with surgical and pediatric departments is declining along with shortages of doctors in emergency, obstetrics and gynecology, internal medicine, and anesthesia departments. The region’s uneven geographical distribution of health workers is a serious concern. This leads to poor availability of health services, particularly for the vulnerable population.  Pakistan is the fifth most populous country in the world but has 0.5 primary care centers per 10,000 population with a life expectancy of 66.5 years. Though there is an elaborate network of nearly 200,000 Government Primary Health Care Facilities (GPHCFs) in rural and urban areas in India, there are significant disparities in the quality and availability of PHCs between different regions. Most PHC centers do not have essential infrastructure and facilities like a well-equipped operation theatre, labor room, observation ward, generator, drinking water, ambulance, and lady doctor, which are basic requirements. Rural India comprises 70% of the population but has only 40% of the beds in the country.

Public health measures in Asia

A strong public health system plays a vital role in the status and stability of national and regional economies. It is the primary driver for achieving UHC. In the post-pandemic world, Asian countries have realized the importance of establishing the right policies and financing arrangements to support the development of a people-oriented PHC. As a result, many have started to strengthen the basic structure of the healthcare system. For instance, the challenge of a weak PHC network has been increasingly recognized and acknowledged by the Indian government. The National Health Policy (NHP) 2017 proposed strengthening PHC systems and investing two-thirds or more government health spending in PHC centers. The Ayushman Bharat Program (ABP), launched in 2018, offers holistic and integrated healthcare services and insurance facilities to the poor at all levels. All the schemes launched under NHM are available free of cost at all public health facilities at district and sub-district levels.

Meanwhile, Malaysia has regarded health system development as an integral component of national development. The government-funded PHC sector is the main service provider. Similarly, Singapore has achieved universal health coverage through a hybrid financing system. To further strengthen PHC, the government focuses on one doctor, one resident, and general practitioners as a driver of preventive care and long-term chronic care. It is working towards shifting acute hospital funding to a capitated regime to concentrate on healthcare outcomes. The government has also created Individual Health Plans emphasizing regular screenings, immunizations, lifestyle adjustments, and linking acute and primary care health records to common IT and data backend.

Hong Kong aims at early detection, prevention, and health promotion, emphasizing primary care. Like Singapore, the Hong Kong government has also opted for one resident and one doctor and general practitioner rule to provide attention to preventive and long-term chronic care. It is also planning to personalize health records that are universally accessible. In China, population health, prevention, and health promotion has been the main agenda for developing the healthcare sector. It has emphasized chronic disease prevention and management through increased healthcare service delivery capacity.

Building a pan-Asian ecosystem

An efficient PHC system must leverage all the services offered by digital technologies, including telemedicine, EHR system, and home monitoring, among others, to support health outcomes. We need to focus on early diagnosis and better lifestyle management to reduce the burden on tertiary care. There is also an underlying need for strong collaboration and knowledge-sharing beyond borders to strengthen PHC in the region. Asian countries should prioritize enhanced regional cooperation in the health sector to rationalize operations, thereby achieving quality, equitable, and cost-effective care for their diverse populations. They must also harness their talent collectively to address immediate health priorities and contribute to ongoing research and development efforts.

Asian countries have already started leveraging their expertise and networks to design solutions tailored to improve domestic PHCs. As large sections of the population in the region still lack access to consistent and effective primary care, building a pan-Asian ecosystem could be a significant step in the right direction.

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Erin Reynolds had battled bulimia since childhood, but the weeks before she entered treatment were among her worst. At 22, she was preparing to leave her home in Helena, Montana, for an inpatient program in New Jersey with round-the-clock medical care.

Looking back six years later, Reynolds said seeking help was one of the most difficult parts of the recovery process. “I just kept bingeing and purging because I was so stressed,” she said. “I’m leaving my job that I love, leaving all my friends and my town and saying goodbye to normal life.”

Eating disorders, including anorexia, bulimia, and binge-eating disorder, are some of the most fatal mental illnesses. Yet treatment options are sparse, particularly in rural states such as Montana.

Emergency department visits for teenage girls dealing with eating disorders doubled nationwide during the pandemic, according to a study from the Centers for Disease Control and Prevention. The same report notes that the uptick could be linked to reduced access to mental health services, a hurdle even more acute in rural states.

The National Eating Disorders Association’s provider database shows only two certified providers across all of Montana, the country’s fourth-largest state as measured by square miles. By comparison, Colorado, which is nearly three-quarters of the size of Montana but has five times the population, shows nine providers.

That means many people like Reynolds must leave Montana for treatment, particularly true for those seeking higher levels of care, or drive for hours to attend therapy. It also means more individuals go untreated because they lack the flexibility to give up a paying job or leave loved ones behind.

“A lot of people are not able to access treatment, just given the geography and vast ruralness of the state,” said Caitlin Martin-Wagar, a University of Montana assistant professor and psychologist who specializes in eating disorder research.

The most intense treatment involves inpatient or partial hospitalization programs, best for those in need of round-the-clock care and acute medical stabilization. Residential treatment is a step down from there, usually outside a hospital setting at a place akin to a rehab facility.

Once a person in recovery can manage with less hands-on care, a variety of outpatient options may include therapy, meal support, or group counseling. “Finding people with those specialties and availability is often a challenge,” said Lauren Smolar, vice president of mission and education at the eating disorders association.

When Reynolds sought treatment in 2016, not one facility in Montana offered inpatient care, residential treatment, or partial hospitalization. Only one came close: the Eating Disorder Center of Montana, a treatment program based in Bozeman and established in 2013.

Jeni Gochin, who co-founded the center, said there were many barriers to starting an eating disorder treatment facility in Montana, where there were none. There was no licensure process, and challenges abounded, from insurance coverage to the high level of specialization required to provide appropriate care.

The Eating Disorder Center of Montana added a partial hospitalization program in 2017, which provides housing for out-of-towners and requires five to seven days of nearly all-day treatment programming led by a team of experts. The center also plans to open an outpatient therapy facility 200 miles west in Missoula later this year.

A third of people with eating disorders are men, a group that is underdiagnosed and undertreated. Although Black, Indigenous, and other people of color are no less likely to develop an eating disorder, they are half as likely to be diagnosed or receive treatment.

A few studies have shown a higher rate of eating disorders in urban centers, but it’s difficult to know whether that’s due to reduced stigma and more treatment options in metropolitan areas compared with rural settings.

“We know eating disorder rates are quite high,” Martin-Wagar said. “We’ve been seeing them rise pretty consistently, so this isn’t a niche or specialty issue. It’s something that’s impacting lots and lots of folks.”

The pandemic has made telehealth treatment options more common, which could relieve bottlenecks at treatment facilities. For example, the Eating Disorder Center of Montana is launching virtual outpatient care for any Montana resident this month. Emily Wish treatment center in Great Falls, Montana, provides telehealth appointments for individual, family, and group therapy. But telehealth treatment for eating disorders is limited in its effectiveness. Many interventions are best in person, such as meal support and helping people establish healthier patterns around eating.

Cost is a barrier to treatment everywhere, but especially in a place like Montana, where about 1 in 5 residents are covered by Medicaid or Healthy Montana Kids, the state’s Children’s Health Insurance Program. It can cost thousands of dollars and take many months for a person to receive adequate care, whether a person is insured or not. And there’s no formula to know how long treatment will take, or how many times a patient will have to move up and down the ladder of levels of care.

Few insurance companies provide meaningful coverage. Their reimbursement might time out after only a few weeks — far sooner than the average course of treatment takes — or not cover it at all.

Martin-Wagar, the University of Montana researcher, said that eating disorder research also receives very little funding relative to other mental health concerns. Without federal and state dollars going directly into treatment and research, eating disorder symptoms can’t be identified early in adolescents, the easiest way to drive down the costs of overall treatment; stigma is harder to combat; and there’s little incentive for new providers to create treatment programs in places outside urban areas with well-documented demand.

“Even if we create more eating disorder centers, if people can’t afford them, then we are only servicing the most privileged in our society,” Martin-Wagar said. “And that means we are not doing a good job.”

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