A Shared DREAM: Advancing Health Equity in Southeast Asia

Health equity is the central lens that guides all areas of the SEA DREAM programme, shaping how research priorities are identified, how questions are framed, and how evidence is generated and applied. By explicitly centering equity, the programme aims to ensure that scientific advancements, innovations, and interventions are grounded in the realities of marginalized and underserved populations.

This lens cuts across every thematic area: health systems, infectious diseases, mental health, digital health, and climate change, ensuring that research contributes not only to improved knowledge, but also to more just, inclusive, and context-responsive health outcomes for all communities in Southeast Asia.  

What inequities continue to persist in the region, and how does understanding their context help us address them effectively?

Health equity means that every person, regardless of income, geography, gender, ethnicity, or education, has a fair and just opportunity to achieve their highest attainable standard of health. Yet across Southeast Asia, health outcomes remain profoundly uneven. Deep-rooted disparities in healthcare access, quality of services, financing, and infrastructure continue to marginalize vulnerable populations, especially those in rural areas, informal settlements, and conflict-affected communities.  

Despite economic progress in many ASEAN countries, persistent inequities undermine regional health gains. Countries such as Cambodia, Myanmar, and Lao PDR consistently score below equity thresholds in health resource distribution, while higher-income countries like Singapore, Brunei, and Malaysia concentrate a disproportionate share of health resources (Liu et al., 2024). Between 2011 and 2019, ASEAN health systems improved resource use over time, but actual delivery of health services declined (Liu et al., 2024). These disparities highlight why SEA DREAM’s equity-focused approach is essential, ensuring that resource allocation translates into tangible improvements for underserved populations. 

According to a study on health system efficiency and equity in ASEAN countries, health systems in Southeast Asia face two major challenges. First, while nations like Indonesia, Thailand, and Vietnam have improved the efficiency of health resource allocation, these improvements have not consistently translated into better health outcomes. Second, regional disparities persist, with some countries still struggling with inadequate workforce retention, limited infrastructure, and weak governance. These gaps hinder the realization of Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs).  

Globally, approximately 4.5 billion people still lack access to essential health services as of 2021, underscoring the enduring nature of health inequities (Liu, 2024). In Southeast Asia, these inequities are exacerbated by a lack of high-quality, disaggregated data to identify and address underserved populations. While most ASEAN countries collect data on inputs and outcomes, critical indicators such as healthcare access, service utilization, and unmet needs remain under-reported or entirely absent (Barcellona et al., 2023). This lack of information makes it challenging for governments to allocate resources effectively or monitor progress toward health equity. 

Equity is at the heart of the 2030 Agenda for Sustainable Development, reflected in goals related to health, poverty, education, gender equality, and reducing inequalities. The World Health Organization emphasizes that equitable health systems must ensure equal access to care based on need, equal utilization for similar needs, and equal quality of care for all (Chisolm et al., 2023). Achieving this requires dismantling structural barriers, including financing gaps, pricing practices, and weak regulatory systems, that prevent vulnerable populations from receiving adequate care. 

SEA DREAM recognizes that advancing health equity requires transformative, locally led research that centers on the voices of the marginalized and generates context-specific solutions. This means building inclusive research ecosystems, strengthening data systems, and ensuring that policies and interventions reflect the lived experiences of those most affected by inequity. Realizing this vision also demands confronting persistent geographic, economic, structural, and social barriers that limit access to quality healthcare for vulnerable populations across the region. 

In Southeast Asia, particularly in Low- and Middle-Income Countries (LMICs) such as Cambodia, Indonesia, Laos, Myanmar, the Philippines, and Vietnam, many communities live in rural, remote, coastal, or island areas where access to quality healthcare remains limited. Geographic isolation, poor transportation networks, and a shortage of healthcare workers reduce the availability and timeliness of essential health services.  

According to the World Health Organization (2010), between 51 percent and 67 percent of rural populations globally lack access to essential health services, a statistic that reflects persistent barriers in much of Southeast Asia. These geographic constraints are further compounded by economic challenges. High out-of-pocket (OOP) payments, low health insurance coverage, and widespread informal employment make healthcare unaffordable for many low-income households. In several countries in the region, OOP health expenditures account for a large share of total health spending. In 2020, Vietnam reported an OOP expenditure of 45.6 percent, while Cambodia's was 58.9 percent, both significantly above the recommended threshold for financial protection (World Bank, 2023). High OOP costs continue to drive financial hardship and deepen health inequities, especially in underserved areas.  

Healthcare resources in Southeast Asia remain unevenly distributed, with wealthier countries such as Singapore, Brunei, and Malaysia holding a disproportionate share of medical infrastructure, personnel, and financing. In contrast, LMICs like Cambodia, Myanmar, and Lao PDR consistently fall below equity thresholds for resource allocation, reflecting deep-rooted systemic inequities (Liu et al., 2024). These disparities hinder progress toward Universal Health Coverage (UHC) and leave vulnerable populations without adequate care.  

Even in countries that have made strides in improving resource efficiency, such as Indonesia, Thailand, and Vietnam, challenges persist in converting these resources into consistent, high-quality health outcomes. Inadequate retention of healthcare workers and weak health system governance in LMICs limit the delivery of essential services, especially marginalized groups. Within countries, significant subnational disparities further exacerbate inequities. For example, in Thailand, physician density varies dramatically, from approximately one doctor per 1,000 people in central regions to just one per 12,000 in northeastern provinces, resulting in some areas having up to twelve times fewer doctors than others (Witthayapipopsakul et al., 2019).

A 2021 study examining four critical health resources (i.e., health workers, hospital beds, ventilators, and oseltamivir) documented substantial geographic inequalities across Southeast Asia. In Cambodia, 75% of the population lives in provinces classified as underserved, with the lowest resource densities. Similarly, about two-thirds of the Lao PDR population reside in areas with critically limited access to these resources. Vietnam and Thailand also face major gaps, with significant portions of their populations lacking adequate hospital beds, staff, or essential medicines. These inequities are primarily driven by disparities within countries rather than between them, highlighting the urgent need for more equitable subnational resource distribution (Hanvoravongchai et al., 2021). 

An ongoing challenge in Southeast Asia’s health equity landscape is the scarcity of high-quality, disaggregated data to identify and address disparities effectively. Although ASEAN countries have generally improved data collection on health system inputs and general outcomes, critical indicators such as healthcare access, service utilization, and unmet needs among underserved groups are often poorly tracked or missing altogether (Barcellona et al., 2023). This lack of granular data disproportionately affects LMICs, undermining targeted policy responses and resource allocation. Vulnerable populations, including ethnic minorities, informal workers, displaced persons, and women, frequently remain invisible in official statistics, perpetuating cycles of exclusion. 

Critical gaps in capturing marginalized populations’ health service usage and unmet needs hinder targeted program development (Barcellona et al., 2023). As the United Nations Development Programme (UNDP)’s Human Development Report (2022) highlights, “large data gaps and missing information on disadvantaged groups hamper efforts to ensure that development is truly inclusive and leaves no one behind.”  

Beyond geographic and economic limitations, many low- and middle- groups in Southeast Asia face entrenched structural and institutional barriers that shape how, when, and whether they can access healthcare. These barriers are embedded in legal systems, policy environments, and cultural norms, and they disproportionately affect populations that are already socially or politically disadvantaged such as Indigenous peoples, migrants, stateless individuals, LGBTQIA+ communities, and people living with disabilities. 

Legal exclusion is a key concern. In several ASEAN countries, undocumented migrants, asylum seekers, and stateless persons are systematically excluded from public health services due to nationality-based eligibility rules, leaving them dependent on overstretched NGO services or informal care networks. For example, restrictive policies in countries like Thailand and Malaysia limit healthcare access for migrant workers, despite their substantial contribution to the labor force (Moallef et al., 2022). These exclusions are often compounded by language barriers, legal insecurity, and fear of deportation. 

Another persistent challenge is institutional discrimination. Health systems frequently lack culturally competent service delivery models and training, leading to unequal treatment or neglect of specific population groups. Sexual and gender minorities (SGM) often face stigma and discrimination in healthcare settings worldwide, which limits their right to health (WHO & UN Human Rights Office, 2008). They encounter unique barriers, including health systems that are not designed to meet their needs, healthcare providers who lack training in culturally competent care, and fears around disclosing their identity. These challenges, combined with broader social stigma and criminalization in some places, lead many SGM to avoid formal healthcare and instead rely on pharmacies or self-care (Ayhan et al., 2019).  

Recognizing these systemic barriers, an equity-focused approach emphasizes inclusive, locally led research and interventions that directly confront discrimination and marginalization, ensuring that all communities can access culturally competent, high-quality health services. Centering equity in this way supports efforts to strengthen health systems, improve social inclusion, and advance universal access to care across diverse populations. 

Health equity serves as the guiding principle embedded throughout APHDA, though it is not always explicitly named as a standalone priority. Instead, equity considerations permeate key areas such as health system strengthening, health financing reforms, and addressing social determinants of health. This integrated approach ensures coordinated efforts across multiple sectors and levels of governance to reduce disparities and leave no one behind. 

Vulnerable populations including low-income communities, ethnic minorities, persons with disabilities, informal workers, migrants, and women and children face disproportionate barriers to accessing timely and quality care. These barriers often result from structural inequities such as poverty, discrimination, geographic remoteness, and limited health literacy.

Advancing health equity requires needs-based research that is context-sensitive and locally led, emphasizing both what is studied and how research is conducted. Prioritizing studies that examine inequities in healthcare access, utilization, and quality, particularly in lower-resource environments, helps generate evidence that can inform more just and effective health policies and interventions.  

Advancing health equity requires needs-based research that is context-sensitive and locally led, grounded in the meaningful participation of communities, patients, and those most affected by inequities. This approach emphasizes both what is studied and how research is conducted, ensuring that methods, questions, and outcomes reflect local realities rather than external assumptions. Prioritizing studies that examine inequities in healthcare access, utilization, and quality, particularly in lower-resource environments, helps generate evidence that is not only rigorous but also responsive to lived experiences. By embedding co-creation with marginalized groups into research processes, findings are more likely to inform health policies and interventions that are just, effective, and trusted by the communities they aim to benefit.

Equally important is securing sustainable access to new and established health solutions, ensuring that improvements reach all population groups, particularly those historically marginalized. Building the capacity of health systems to adapt and respond effectively to diverse community needs remains critical. When an equity lens is consistently applied across research areas, such work contributes to reducing disparities and improving healthcare for all people in Southeast Asia. Advancing these goals reflects a shared dream, one in which every community, regardless of circumstance, can realize its full potential for health, dignity, and well-being across the region. 

 

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