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CORR® International - Asia-Pacific

Poverty and its Implications on Orthopaedic Care

Kim, Tae Kyun, MD, PhD

Clinical Orthopaedics and Related Research®: June 2018 - Volume 476 - Issue 6 - p 1154–1156
doi: 10.1097/

T. K. Kim, Department of Orthopedic Surgery, TK Orthopedic Surgery, Seongnam, Korea

T. K. Kim MD, PhD, TK Orthopedic Surgery, 55 Dongpankyo-ro, Bundang-gu, Seongnam, Republic of Korea, Email:

A Note from the Editor-in-Chief: I am pleased to introduce the next installment of “CORR International – Asia-Pacific.” In this quarterly column, Professor T. K. Kim covers the issues of moment to orthopaedic surgeons and scientists practicing in the Asia-Pacific region, where nearly a quarter of CORR’s readers are located. Prof. Kim, from Seoul, South Korea, is an internationally renowned knee surgeon and one of CORR’s Deputy Editors.

The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Received March 20, 2018

Accepted April 02, 2018

Fueled by the advances in China, Indonesia, and India, the Asia-Pacific region has seen a steady rise in economic growth over the past year, a decline in poverty, and improved quality of life [1]. But close to 400 million people in the region still live in extreme income poverty, with a large concentration of the poor and vulnerable in South Asia [7]. According to a 2016 World Bank report, of the 767 million extremely poor individuals who live below the poverty line globally, about 33% live in South Asia and 9% live in East Asia and the Pacific [14, 16]

The socioeconomic inequalities across Asia and the Pacific have only broadened the healthcare access gap in the region. Although the world’s total health expenditure as a percentage of gross domestic product (GDP) is close to 10%, most countries in the Asia-Pacific region spend less than half of that fraction of their GDP on health-related expenses [15]. And because of this, the region faces many problems including unequal access to care, poorly executed national healthcare policies, and inefficiency at all levels of service.

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Access to Health Services

In a 2017 report on healthcare access, The Economist called the Asia-Pacific region “a study in contrasts” [3]. It’s an apt description. While developed countries like Japan, South Korea, Taiwan, and Thailand are home to advanced healthcare systems, inequalities among Asia’s urban, rural, and mountainous areas are pronounced, and the region struggles to deliver care to more-remote regions including the distant island chains in southeast Asia [3].

Developing countries in the region have limited healthcare budgets, and funds for orthopaedic diseases generally are small compared to infectious diseases and more high profile noncommunicable diseases like heart disease, diabetes mellitus, and cancer [6]. As a result, orthopaedic research, education, and training suffer. Indeed, many countries in the Asia-Pacific region lack accurate data about the local epidemiology of common orthopaedic problems like back pain, osteoporosis, fractures, and osteoarthritis. If we cannot quantify the scope of the problems we treat, it will be difficult to convince national policymakers to allocate funds to ensure access to care for those who can’t afford proper treatment. For example, the prevalence of osteoarthritis has increased 30% worldwide between 2006 and 2016 [4]. Considering that the average age in many countries in the Asia-Pacific region is increasing, and as a function of changing demography, the number of patients with osteoarthritis and the usage of joint replacement surgery in the region likely will rise sharply. But because of insufficient healthcare funding, most poor patients in western China cannot access joint replacement surgery [10], and the same could very well be true for other Asia-Pacific countries.

One solution to this could be the development of indigenous and locally produced joint replacement prostheses like what is being done in India [9]. With comparable mid-term survivorship and clinical outcomes at one-third the cost [8] of imported prostheses, these devices are more accessible to those living below the poverty line.

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Poorly Executed National Policies

Countries in the Asia-Pacific region are acutely aware of the coverage crisis in the region. China and India have implemented ambitious initiatives to extend basic coverage to a large swath of the population. In fact, according to The Economist report, some Indian states went from insurance coverage of approximately 3% to around 80% within a few years [3]. However, overall, the Asia-Pacific region continues to struggle to find a way to provide the poorest members of the population adequate access to healthcare.

Countries in the Asia-Pacific region should be lauded for their willingness to experiment and implement programs with the goal of providing basic healthcare coverage for their citizens. But for every success story, there have been plenty of missed opportunities. For example, China’s medical financial-assistance program has facilitated coverage for poor families in the region, but its impact in reducing poor families’ medical debt remains quite limited [5]. Government-funded health insurance programs in India, where the promise of Universal Health Coverage has not yet been achieved [2], gave preference to tertiary services above primary and secondary healthcare, which is not only a step backwards, but is unfair to those who have limited access to these services [13]. Private insurance mainly benefits middle-income families, and with scant help from nongovernment organizations, the poorest people in the region remain on their own. Poor patients generally must pay the costs of most drugs and medical devices out of their own pockets. For many, the resulting healthcare debt pushes these individuals deeper into poverty.

But all is not lost. Some experimental initiatives have managed to make a practical impact on those living below the poverty line. For example, the state government’s Vajpayee Arogyashree program in Karnataka, India focuses on healthcare outreach by offering free medical treatment (no premiums, fees, or copayments) for heart disease, cancer, burns, accidents, kidney problems, and newborns at specialty hospitals for those living below the poverty line [12]. Increasing the coverage in remote areas and to the poorest of the population has resulted in the reduction of patient mortality and out-of-pocket expenditures [11].

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Inefficient Healthcare Services – Issues at the Grass-root Level

When low-income patients do get access to care, many must contend with staff shortages at government hospitals. In fact, it is not uncommon to find family members routinely providing nursing support for their hospitalized relatives. An ethnographic report from an orthopaedic ward in a government hospital in Bangladesh [17] found that at the grass-roots level, clinicians sometimes are apathetic towards poor patients. Indeed, public hospital wards tend to work in a hierarchical manner and poor patients remain at the bottom of the hierarchy. It will take a major change in attitude and mindset to reverse the perception that the poorest patients are simply not cared for.

Although “healthcare coverage for all” sounds great, it may not be a realistic benchmark in such a diverse region like the Asia-Pacific. Still, implementing well-planned and carefully executed healthcare initiatives aimed at improving access of care to those living below the poverty line with orthopaedic or noncommunicable diseases is an achievable and worthy goal.

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The author would like to thank Dr. Prashant Meshram for his assistance in researching the topic.

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