By Min Hung Cheng
21 April 2026
Across Asia, health is a central priority of many governments. Over the past decades, much effort has gone into expanding coverage, strengthening public health systems, and committing fiscal resources to healthcare. Universal or near-universal coverage has been achieved or is within reach in many jurisdictions, and insurance schemes have been introduced or scaled. Infrastructure has also been built.
But, whilst these enhancements have been encouraging and pertinent in addressing the health protection gap, the nature of the risk we face is also changing.
Medical costs are rising faster than medical price inflation[1]. Utilisation is increasing. Expectations of care are expanding. Demographic pressures are becoming more pronounced. In some systems, the issue is no longer how to expand access, but how to sustain what is already in place.
The issue is no longer one of extending healthcare provision but of ensuring that the system remains resilient and sustainable.
That said, much of the current discourse in the wider ecosystem still treats health primarily as a service delivery issue.
Health is not a marginal issue. It is the largest protection gap
According to the Swiss Re Sigma Report July 2024, the global natural catastrophe protection gap was USD 385 bn, whilst the health protection gap was more than double this at USD 940 bn. The issue is even more stark in Asia Pacific, with a natural catastrophe protection gap of USD 152 bn in 2023, whilst the health protection gap was USD 535 bn – more than three times!
Much discourse internationally and regionally among policy-makers focuses on natural catastrophes when discussing protection gaps. This is understandable – these risk events are more visible, episodic, and can bring about significant disruptions at the fiscal level.
Health, on the other hand, is mostly continuous rather than episodic. It does not typically occur as a single event, but accumulates across households, over time, and across systems. Its impact is often only visible when it becomes severe, as was the case of the COVID-19 pandemic.
The difference in the discourse is less about importance but more about visibility, and therefore how the problem is framed and prioritised.
Governments are doing a great deal. But not necessarily solving for protection
Health systems today are typically designed around three core objectives – that necessary healthcare is available, that it is broadly affordable, and that healthcare services can be delivered at scale.
These are pertinent, and in many cases, they have been pursued with considerable success.
But this is not the same as protection.
When it comes to the health protection gap, a protection gap exists when individuals, households, or governments remain exposed to financial or systemic risk even when services are available. This includes situations where treatment is technically accessible but financially burdensome, where care is deferred or forgone, or where fiscal systems come under stress during large-scale health events.
It is possible for a system to perform well on access and still leave significant exposure in place. It is also possible for affordability to be managed on average, while risk remains unevenly distributed and many are poorly protected.
This is not a failure of intent, but a consequence of what the system is designed to optimise.
Most systems are built to deliver care efficiently and equitably under normal conditions. But, when conditions change, can these systems remain resilient and sustainable?
Reframing the “problem statement”
The way a problem is framed shapes what gets measured, and what gets measured influences what gets optimised.
When the focus is on healthcare access, coverage becomes a key metric. When the focus is on affordability, subsidies and out-of-pocket costs get plenty of attention. When the focus is on delivery, capacity and utilisation are front-of-mind.
But these do not capture protection. When health risk is seen through a ‘protection gap' lens, it raises different questions, such as to what extent households are exposed to catastrophic costs, how many people forgo treatment due to financial constraints, how resilient and sustainable the system is when costs rise sharply, how risks are distributed across the population, and how effectively are they pooled?
But these questions also speak to different parts of the system.
Different parts of the system optimise independently due to their different mandates. Health ministries may focus on access, whilst finance ministries may focus on fiscal sustainability. Insurers may focus on pricing and claims, while medical providers optimise their operations within their respective environments.
This fragmentation often results in misalignment of incentives, which becomes more problematic as cost pressures rise. Medical cost inflation affects various parts of the system simultaneously – public budgets, insurance markets, providers and households. Without a framework that brings these elements together, responses tend to be partial and reactive.
A protection gap lens does not replace existing priorities but reframes them within a broader objective.
Health is not only a question of service provision. It is also a question of how risks are managed, how costs are shared, and how systems behave under stress.
This requires a holistic and integrated approach.
Risk reduction, insurance, and fiscal approaches cannot be considered separately. Preventive care influences medical costs. Insurance design affects utilisation and risk pooling. Fiscal policies determine how residual risks are absorbed. Each element interacts with the others.
When these interactions are not explicitly considered, opportunities are missed.
A system may invest heavily in expanding access, but fail to address the underlying drivers of cost escalation. Insurance coverage may increase, but without sufficient risk pooling or incentive alignment. Public financing may expand, but without mechanisms to ensure long-term sustainability.
An integrated, holistic approach to the health protection gap considers these interdependencies and connections, shifting the focus from provision to sustainability and resilience, aligning the system around a clearer objective – ensuring that individuals, households, and governments are protected against the financial and systemic consequences of health risk.
Closing reflection
If we want systems that are resilient as well as accessible, sustainable as well as equitable, then the way we frame and address the problem needs to evolve.
Not because we are not doing enough, but because what we are trying to achieve has not yet been fully defined.
One way to move this discussion forward is to look more closely at the underlying dynamics within health systems themselves. The pressures are not only a matter of funding levels or coverage, but of how incentives, cost structures, and financing arrangements interact over time. In particular, rising medical costs, misaligned stakeholder incentives, and structural constraints in insurance and service delivery are increasingly shaping outcomes.
The first paper in GAIP's health series[2] examines these dynamics in detail, focusing on how they affect the sustainability of health financing. This paper forms part of a broader GAIP effort examining health protection gaps and health financing resilience in Asia under the strategic theme of Health and Retirement Protection Gaps. A companion paper currently in development will extend the discussion to the wider healthcare ecosystem.
