Lecture No.1
How can healthcare connect across borders?

Shinjiro NOZAKI

Compliance and Risk Management Officer, Office of the Regional Director,

World Health Organization, Western Pacific Region

Rabindra ABEYASINGHE

WHO Representative to Malaysia, Brunei Darussalam, and Singapore

(1) Introduction to the lecture

Norie KAWAHARA welcomed students to the autumn 2025 semester lecture series Surviving Cancer in Asia: Cross-boundary Cancer Studies, the theme for which is “Beyond Borders: Navigating Health Knowledge for Well-being.” She noted that students would be exploring why tackling health challenges today demands going beyond national boundaries and beyond traditional silos.

Dr. Kawahara explained that the lecture series has been running since 2011 as an interdisciplinary program at the University of Tokyo, organized with the support of UICC-ARO (Union for International Cancer Control Asia Regional Office).. Professor Hideyuki Akaza was a key figure from the inception of the series. He put it best when he said, “cancer is a mirror reflecting the diverse challenges across Asia.” The aim of the course is to consider cancer in Asia as a shared challenge, taking an interdisciplinary approach that spans medicine, economics, politics, culture, history, and diplomacy. It is particularly meaningful that speakers and students are attending the course from non-medical fields to consider healthcare issues together. This infusion of non-medical perspectives is what makes discussions so rich and giving the lecture series its special value.

During the spring/summer semester 2025, the lecture series explored a central question: “What does well-being mean in Asia?” The reports written by the students in that course　were carefully reviewed by experts from across Asia. They shared very positive feedback, noting the depth of analysis and the quality of ideas throughout. It is to be hoped that this same spirit of inquiry—and the curiosity that connected scholars across Asia—will guide speakers and students alike in the autumn term, as they explore how knowledge and collaboration can cross borders to advance well-being in our region.

The central question for this term’s series is “How can we realize ‘UHC × Well-being” through cross-border collaboration-linking knowledge and capital across Asia. Health challenges such as cancer and other NCDs are not only medical issues —they are deeply connected to many social, economic, and cultural factors. This term, the central theme is public–private partnership.　Many lecturers will come from the corporate sector, bringing perspectives from real-world practice. In January and February 2026 several company visits are being planned to deepen understanding of how these partnerships work in practice.

On January 6, it is planned that there will be a special session led by Prof. Nirmala Bhoo Pathy from the University of Malaya, who will provide guidance on how to write a policy brief, which would be forming part of the final assignment. Outstanding reports will be recognized with the Excellence Award, and the awardees will have the opportunity to attend an international meeting in Malaysia at the end of February. It is to be hoped that through this lecture series students will reflect on their own research from a new perspective—and perhaps find insights that will shape their future career paths. 

Dr. Kawahara noted that for the first lecture of the series for autumn/winter 2025/2026, two senior figures from the World Health Organization (WHO) would be providing talks about their long years of shaping health policy on the global stage. 

(2) Lecture 1 

History and Future of Global Health 

Shinjiro Nozaki explained that he has 40 years’ experience of working in the global health arena and that he would be talking about the history of global health. The history of global health can be traced back to the founding of the WHO in 1947. The WHO Constitution states that “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” and “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” These statements demonstrate that well-being and the social determinants of health have been a fundamental part of the outlook and modus operandi of the WHO since its inception. 

The concept of good health and well-being was further elaborated on in the SDGs, especially in SDG3. Achieving UHC is one of the targets of the UN, set when they adopted the 2030 SDGs in 2015. At the United Nations General Assembly High Level Meeting on UHC in 2019, countries reaffirmed that health is a precondition for and an outcome and indicator of the social, economic and environmental dimensions of sustainable development.

The concept of UHC through primary healthcare was established back in 1978, in the Declaration of Alma-Ata, at the International Conference on Primary Health Care, Alma-Ata. It was at this conference where it is was stated: 

The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.

This demonstrates that almost 50 years ago the importance of primary healthcare was already well-recognized and understood. 

The Alma-Ata Declaration was revisited at the Global Conference on Primary Health Care in Astana, Kazakhstan, which was held as a celebration of the 40th anniversary of the Alma-Ata Declaration in 2018. This conference provided impetus to further reconsider primary health concepts. 

One particular event that highlighted the interconnectedness of health issues was the diphtheria outbreak that occurred in the former Soviet states in the early 1990s. This outbreak was the largest since the 1950s, and from 1990 to 1998 more than 157,000 people were affected and more than 5,000 died, By 1994 the epidemic had spread to all the NIS countries. The majority of cases were characterized by generations ranging from adolescence to adulthood rather than children, and in the European NIS and Baltic countries, 64% to 82% of cases were in the age group of 15 years and older. The 40-49 age group was particularly prominent, accounting for half of all deaths. In 1994, approximately 48,000 cases were recorded in the NIS countries, and in 1995, when the epidemic peaked, approximately 50,000 cases (88% of the world's cases) were recorded in the NIS countries. The epidemic spread beyond the NIS countries to other countries, with cases possibly related to the NIS epidemic recorded in Belgium, the United Kingdom, Finland, Germany, Greece, Mongolia, and the United States. Large-scale vaccination campaigns began in 1992, and the epidemic peaked in 1995. The epidemic peaked in 1995 and has since ended. In addition to the efforts of the countries concerned, international cooperation contributed to the end of the epidemic. In 1991, WHO began providing technical support, followed by the United States (USAID) and others. The Japanese government established the Interagency Immunization Coordinating Committee (IICC) in Kyoto, Japan in 1994, which provided financial support with the participation of many developed countries, WHO, and UNICEF. This IICC was the first donor coordination mechanism in the global health arena. Former WHO Director-General Lee Jong-wook was one of the strongest proponents for the establishment of the IICC, which engaged in assistance to the former Soviet Union in its actions against diphtheria. The establishment of the IICC prompted various commitments from more than 25 countries in addition to Japan, marking the start of the global health journey. 

Another turning point came in 1997 at the G8 Summit in Denver. This was the first time for the Russian Federation to join the summit, and for the global health community it was a very important summit because then-Japanese Prime Minister Ryutaro Hashimoto proposed an initiative on global parasite control for the 21st century, which would become known as the “Hashimoto Initiative.” This was significant because until 1997 the G8 had hardly discussed global health issues of any kind. Prime Minister Hashimoto was the first of the G8 leaders to raise the issue of parasitic diseases, including malaria, etc. The Hashimoto Initiative was formalized at the 1998 G8 Summit at Gleneagles and provided the starting point from which future G8 initiatives on health-related matters would develop. 

The G8 Kyushu-Okinawa Summit in 2000 provided another turning point for global health, when Japan took up the issue of infectious diseases in developing countries as one of the main topics of discussion as the G8 chair, and announced the "Okinawa Infectious Disease Initiative (IDI)" to provide comprehensive support for infectious disease control with a total of US$3 billion in Japanese official development assistance (ODA) over the five years from FY2000 to FY2004. Japan's appeal to the international community on the importance of tackling these infectious disease issues triggered widespread interest from the international community, and after discussions at the UN Special Session on AIDS and the Genoa Summit in 2001, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the "Global Fund") was established in 2002. 

The Hashimoto Initiative was also a trigger to establish the UN Millennium Development Goals (2000-2015) (MDGs), which were the forerunner of the SDGs. 

In the domain of UHC, Japan was among the first countries to establish universal health coverage with the establishment of its national health insurance scheme in 1962 that covered the entire population. 

In Asia, another example of the successful introduction of UHC is the “30 Baht Policy” in Thailand. The “30 Baht Policy” is a public healthcare initiative introduced by the Thai government in 2001 under Prime Minister Thaksin Shinawatra. Officially known as the Universal Coverage Scheme (UCS), it aimed to ensure that all Thai citizens—especially low-income groups—had access to affordable healthcare. At the time of the establishment of the system the Prime Minister of Thailand sought assistance from JICA, but it was JICA that observed that the Thai economy at the time was predominantly an informal economy, which would make it challenging to introduce a health insurance scheme. As an initial step, JICA assisted the Thai government in registering people at the district level for the purposes of health coverage and treatment. This initiative helped to greatly enhance accessibility to health services for Thai people living in rural areas.

Another turning point for global health came with the emergence of the SARS epidemic (2002-2003). For the WHO, SARS was much more than just a medical challenge. There was also the political, social and economic dimension of disease to deal with, particularly in the area where our mission of safeguarding public health had to be balanced against the genuine interests of Member States. At all levels, WHO worked with Member States to share information and to find common ground in a situation that was new to all of us. On a number of occasions, this required liaising with senior officials, including ministers of health.

COVID-19 was an unprecedented challenge and it highlighted public health arena issues once again, in that it particularly hit hard in vulnerable populations.

The Asian region is facing a double burden of responding to communicable and non-communicable diseases, coupled with the aging of societies in many Asian countries. Disease control and treatment for NCDs, etc., are increasing medical expenditures by all countries throughout Asia. While some countries have achieved success in controlling costs associated with communicable diseases, a growing challenge is the burgeoning cost of NCDs among aging populations. 

Aging is the biggest threat for achieving UHC, in that it brings with it population decline, economic slowdown, and increasing medical expenditures. In Japan, long-term care insurance was established as part of the universal health insurance coverage, for the purpose of ensuring that people can receive nursing care in old age and defray the costs of nursing care. 

Many countries in Asia and Africa are on an aging trajectory and by the 2050s or 2060s their aging populations will reach an equivalent size to that of Japan. It is therefore imperative to consider ways to tackle NCDs, which are the biggest driver for increased medical care expenses.

With that future outlook in mind, it is important to consider a number of key questions. First, is the hypothesis that achieving universal health coverage (UHC) is the ultimate goal of global health correct? Second, what will be the biggest obstacle to achieving UHC in the future? Third, Some say that countries should simply follow Japan’s model – is this feasible?

Cancer is perhaps the most symbolic of the NCDs, and treating cancer will be an indivisible part of any strategy for NCDs going forward. It is therefore important to consider ways in which communities can come together to tackle cancer, from prevention through to diagnosis, treatment and palliation.

Discussion 

Dr. Kawahara noted that in global health, everything ultimately depends on the people who are involved: their vision, their passion, and their commitment to make a difference. She noted that the story of the Hashimoto Initiative was truly impressive, showing clearly how strong leadership can shape global health priorities. She asked whether in today’s Asia there are any similar movements or leaders who have the ability to set such agendas and drive collective action in the region, and what kind of leadership is needed now to create that kind of momentum. 

Dr. Nozaki responded that the Hashimoto Initiative and the results of the 2000 G8 Kyushu-Okinawa Summit opened up the global health arena to many stakeholders. This has helped to nurture the next generation of leaders in the field of global health. 

(3) Lecture 2 

Advancing Universal Healthcare in Malaysia 

Rabindra ABEYASINGHE noted that his lecture would be focusing on the reality that there can be no UHC in individual countries without a coordinated global health approach. In today's world it is necessary to consider the key global health challenges that are no longer limited to individual countries, but are affecting multiple countries. Among these are climate change, non-communicable diseases, continuing outbreaks of communicable diseases, anti-microbial resistance (AMR), and the issue of health inequities, which actually worsens the problem of access to health services.

The significant impact of large-scale outbreaks like SARS and COVID-19 has exposed the gaps in health systems at national and sub-national level, and also at a global and regional level. This makes it imperative that all countries cooperate more closely in creating safety nets for citizens.

Climate change is a significant issue for global health, which is directly related to heat-related illnesses, food insecurity, and vector-borne diseases. Climate change is also aggravating air pollution in many countries, which is now responsible for approximately 7 million deaths annually. The need to address climate change-related issues as well as global health issues is therefore clear and from the WHO's perspective, the building of resilient climate-resilient health systems is fundamentally important for advancing universal healthcare. It is for that purpose that the WHO established the Alliance for Transformative Action on Climate and Health (ATACH), which works to realize the ambition set at COP26 to build climate resilient and sustainable health systems, using the collective power of WHO Member States and other stakeholders to drive this agenda forward at pace and scale; and promote the integration of climate change and health nexus into respective national, regional, and global plans.

Antimicrobial resistance (AMR) is one of the key drivers increasing the costs of healthcare around the world. There are projected to be approximately 10 million deaths attributable to AMR by 2050, with an accompanying economic burden of up to US$100 trillion by 2050. Stronger policies and implementation of the WHO Global Action Plan are important tasks in this area, because the potential for vast cost increases in managing infections is very real and urgent. There is an urgent need for countries to come together as they advance their own UHC programs to recognize the challenge post by AMR. 

With regard to noncommunicable diseases (NCDs), it is estimated that 74% of global deaths are attributable to NCDs (41 million deaths annually). The four main diseases contributing to NCDs mortality are cardiovascular diseases, cancers, diabetes and chronic respiratory diseases. Japan stands out as one of the countries that has successfully tackled the NCD burden by addressing the main risk factors. There are significant lessons to learn from Japan because this will then help other countries to nurture a generation of people who could potentially live longer, which is what is termed “healthy aging.” In order to realize healthy aging, therefore, it is important not just to strengthen surveillance screening and diagnostics. It is also critically important to look at strengthening management of NCDs, including examining risk factors, including obesity, tobacco and alcohol, etc.

When tackling NCDs it is important to be far more proactive in having a promotive preventative approach. It is also necessary to encourage changes in lifestyles so that countries can cope with the increasing burden of NCDs. This requires an approach toward advocating for health literacy and understanding what drives behaviors of people. If we can do that, we can help people to reduce their exposure to risk factors, reduce the presence of risk factors in our communities, and thereby start reducing the increasing prevalence of NCDs, and also open the way for better management and compliance with the treatment regimens for NCDs.

In the case of NCDs, many people are unaware that they have an NCD, including people with diabetes and hypertension. Unfortunately, even the people who know that they are diabetic or hypertensive are not on regular treatment and their conditions are not adequately controlled.

Work towards strengthening UHC and finding innovative solutions necessarily includes new technologies, because a “business as usual” approach will not work with some NCDs. 

One of the most important challenges is to examine how best to engage communities: how best to harness new technologies, utilize digital spaces and social media to get better compliance, and encourage better awareness among patients. 

Another area of critical importance within the NCD space is the challenge of mental health, which has an impact on productivity and economic return. 

For all of the above measures, the WHO has developed what are termed “best buys” interventions for NCDs. WHO has recently implemented an investment case study in Malaysia using recent data from Malaysia's health system. It was announced in a report issued last year that NCDs cost the Malaysian economy 4.5% of its GDP annually, and this is in a combination of healthcare costs and lost productivity. 

It is therefore imperative that Malaysia and other countries invest in health systems and capacities to address the challenge of NCDs if they want to continue with economic development and strengthening prosperity. To do this effectively it is important to address not only issues of health equity, but also recognize the important role played by social determinants of health and also importantly the fundamental challenge posed by the commercial determinants of health. The UN SDGs play an important role in tackling NCDs as they seek to bring all sectors and stakeholders together. This cross-sectoral approach to addressing the risk factors to address the determinants with their social or commercial is fundamentally as important as working towards strengthening healthcare systems, both at primary care level and at secondary and tertiary care.

Importantly, the WHO is also working with the Malaysian government to strengthen its primary care approach. A significant proportion of investment is currently going into managing hospitals and curative services, which does not leave enough money for promotive preventative activities. Therein is a challenge because that then leaves room for a continuing increase of NCDs, thereby challenging the capacity of any health system to deliver services to address the challenges posed by these diseases. 

The WHO is particularly concerned about the increasing prevalence of cancers, which are caused by known risk factors that are preventable with tools that are already available. However, access to these tools is not universal because there is no universal access to healthcare in some countries. In the case of Malaysia, a very high proportion of colorectal cancers or lung cancers are detected late at T3 or T4 stage, when there is very little opportunity for good treatment outcomes. This is a challenge that the WHO is working with the Malaysian government on and indeed with the private sector and non-governmental entities to advance access to screening and better management of cancers.

The question of health equity and universal healthcare is one that has a long history that dates back to the Alma-Ata Declaration, as introduced by Dr. Nozaki. Today there are still about two billion people who lack access to essential health services and about 930 million who are facing catastrophic health expenditures. There is an urgency on how to ensure health equity and how to promote UHC. 

However, to be effective, it is essential to revisit the concept of UHC and what it actually means. This is because UHC should ideally cover the range of promotive, preventative, curative and restorative services. To date, however, little attention has been paid to expanding the promotive preventative and primary care aspects. 

The problem of UHC has traditionally been described as a problem between urban and rural, but that is not necessarily correct. In today's context, we see that there are pockets of even urban populations who are being left behind and who do not have access to services. That is why it is necessary to address these factors so that irrespective of what people are doing, what race they are, what nationality they are, or what religion they follow, they are all guaranteed access to the services.

The UHC Partnership for 2030 is a huge coalition of donors that have come together to support the WHO to advance UHC. Through this partnership WHO is working with countries, including Malaysia, to help in the refinancing and redistribution of human resources for health, looking at health insurance policies and how to work with countries to strengthen their universal healthcare. The WHO seeks to work with global partners to ensure that it is possible to advance the health situation in all countries. 

Finally, in terms of the need for health security, it is important to strengthen capacity to detect early potential outbreaks and pandemics. The revised international health regulations following the endorsement at the World Health Assembly have now come into force from 19 September 2025. The World Health Assembly also endorsed the Pandemic Treaty at its meeting in May this year, which has created new momentum to work together, not just in countries, but across countries and regionally, so that countries can be made safer for populations and hopefully make them more resilient and capable of dealing early with outbreaks and pandemics.

There is a great deal of interest in how the WHO can help Malaysia and other countries in their battle to advance UHC and in their battle against NCDs. This is clearly an area where we need a lot of innovation, because the traditional approaches will not be sufficient. We need new systems and partnerships and also encourage academia and the private sector. It is important to encourage civil society to partner with ministries of health and with global players like WHO to find new and innovative solutions. 

It is important for students think about potential innovative solutions to address the burdens that our countries are facing and to advance the UHC concept and protect people's health. 

Discussion 

Dr. Kawahara noted that the Asia Cancer Forum (ACF) has been working closely with partners in Malaysia and while there has been tremendous progress in many areas, one challenge that remains is how to raise people’s health awareness and promote health-seeking behavior. She asked what are the most important factors required to truly change people’s mindsets on health, and what kind of approaches could make a real difference. 

Dr. Abeyasinghe responded that in Malaysia there is a perception that the health of people is the responsibility of the government, and within people’s minds there is a belief that they have no responsibility for their own health. This is a concept that needs to be changed, moving to a concept of “co-ownership,” with individuals being encouraged to take responsibility for their own health. Subsidized healthcare cannot be sustained if people continue to abuse their health. The WHO has helped the Malaysian government to create a health literacy policy and recently the National Behavioral Health Blueprint was launched. The WHO is therefore creating a framework that seeks to gradually shift the focus from state responsibility to a shared responsibility for health.

Dr. Nozaki agreed with the importance of governments working to encourage behavioral change. The question of how to effect such change is extremely challenging and sometimes change is down to serendipity or luck, rather than any specific policy. 

A student asked about the pros and cons of a free healthcare system like in UK compared to co-pay systems like in Japan. 

Dr. Nozaki responded that from his own personal perspective it is difficult to compare the two different kinds of system – totally free, or co-pay. It has been suggested that the Japanese co-pay system is more sustainable than the UK system that is free. In the case of Thailand, there is a mixed system, where 25% of people use a health insurance system, and 75% of the population use the government’s taxpayer funded system. There are a variety of future policy options available to different countries, depending on their specific situation. One of the WHO’s mandates is to demonstrate the variety of policy options available. 

Dr. Abeyasinghe responded that there is no “one-size-fits-all” solution. It is important for the WHO to provide various options that have the potential to sustain UHC. 

A student  noted that global health increasingly intersects with climate change, and asked in what ways UHC can be reimagined to operate within planetary boundaries rather than independently of them. 

Dr. Abeyasinghe responded that fundamentally health systems are owned by national governments, but we have seen that adopting a regional approach can be successful, such as in the European Union, for example, where there is broad policy agreement on service provision. However, in ASEAN there is no reciprocal access to health services. Given not just climate change, but also the transboundary impact of health today, it is very important to have a regional-focused approach to ensure UHC, and so moves to greater collaboration and interoperability are important. 

Dr. Nozaki added that global health in the 2020s has become increasingly complicated, due to various related issues, such as climate change, among others. A case-by-case approach should be considered that is tailored to national or local realities. Even in the Western Pacific region, there is great diversity in national situations, with the Pacific islands facing different challenges to countries in Asia. 

Dr. Kawahara noted that many of the students in the class are interested in working for international organizations in the future. She asked the two speakers for advice to young people who aspire to make their careers in global health, and what kind of mindset, skills, or experience are most important. 

Dr. Abeyasinghe responded that fundamentally the WHO encourages people to consider a career in global health, but the challenge is that global health requires some degree of specialization. To join international organizations like WHO it is therefore desirable to have at least a master's level degree and working experience in developing countries. The situation more recently is more complex because WHO, due to the withdrawal of the US, is facing funding difficulties and is no longer actively recruiting. It would therefore be interesting to encourage private entities and philanthropic organizations to step into the role formerly played by the WHO, which would ensure new opportunities to serve the global community. He recommended students to keep acquiring qualifications and experience. 

Dr. Nozaki encouraged students to not hesitate in joining international organizations, which provide ways for employees and officials to make an international contribution.