Health Care System, Services and Development PDF

HEALTH CARE SYSTEM, SERVICES AND Provides direct health improving activities DEVELOPMENT whether in personal health care, public health services...

HEALTH CARE SYSTEM, SERVICES AND Provides direct health improving activities DEVELOPMENT whether in personal health care, public health services to achieve high health equity. Main Purpose: To provide equal and I. HEALTH SYSTEM accessible health care services for the public in order to promote personal health care and high health equity. Parts of the Health System 1. Community 2. Department of Health 3. Health Care Providers Maxicare Healthcare Corp. St. Luke’s Medical Center, Inc. UNILAB, Inc. 4. Health Service Organizations 5. Pharmaceutical Companies Generika Drugstore Mercury Drug Corporation Rose Pharmacy, Inc. 6. Health Financing Bodies and Organizations Philippine Health Insurance Corporation (PHIC, or PhilHealth) Manulife PRU Life U.K. A. GOALS AND FUNCTIONS OF A HEALTH SYSTEM Improving the Health of the Population Figure 1. Components of the Health System Primary Health System Objective ○ The overarching goal of a healthcare Roemer (1991): “Combination of resources, system is to improve the overall health organization, financing, and management that of the population by: culminate in the delivery of health services to assessing health status across the population.” different socioeconomic All the organizations, institutions, resources, groups and people whose primary purpose is to safeguarding against existing improve health. and emerging health risks 1  ○ Examples: their care. It also extends to responding to the DOH needs and expectations of various Fight Against Tuberculosis, stakeholders, including partners. Human Immunodeficiency ○ The basis of our responsiveness is how Virus (HIV), and COVID-19 proper and accurate the healthcare Pandemic services are given to our patients. ○ In the Philippines, the healthcare Responsiveness encompasses values such as system is a matter of privilege. respect, dignity, confidentiality, and quality, ○ A lot of immunocompromised people emphasizing the importance of addressing not are not treated efficiently because of only health-related but also non-health needs a lack of access to healthcare. and expectations of populations. Health Equity ○ Holistic Healthcare: physical, ○ Health systems should actively strive psychological (mental), emotional, and to minimize health disparities spiritual stemming from factors like income, A responsive health system empowers ethnicity, occupation, gender, location, individuals by promoting their autonomy and and sexual orientation. involvement in decision-making, ultimately ○ These disparities can vary widely on placing them at the center of the healthcare both a global and national scale and system. should be acknowledged and targeted ○ In a sense where the patient is always as a core national objective. catered to satisfactory and timely ○ In an ideal health system, these healthcare service with respect, disparities should be minimized or dignity, and quality. eradicated, even. Providing Fair Health Financing Organizational Impact ○ Variations in health outcomes are Adequate Funding influenced by the way healthcare ○ Health financing systems should be systems are structured and operated. sufficiently funded to ensure access to To effectively reduce these disparities, essential services for all citizens. it’s vital to recognize and make the ○ Health care providers, as well as reduction of disparities a central goal health care organizations should have in healthcare planning and adequate funding. implementation. ○ Examples: Department of Health (DOH) Public hospitals Improving the Responsiveness of the Health System Government institutions that cater to the health needs of all Responsiveness in healthcare involves citizens delivering satisfactory and timely health services while actively engaging individuals in 2  Fairness and Non-Deterrence ○ System has to perform a wide range ○ An ideal health system should provide of activities to cater to the various both social and financial risk demands. protection, ensuring that individuals Health Service Inputs are not discouraged from seeking ○ Includes managing and generating the necessary care due to upfront essential physical resources so that payments. there will be a delivery of health ○ It should also strive for equitable services, such as the supply of contributions, where individuals pay a medications, human resources similar percentage of their income for (trained doctors and medical staff), needed services. and medical equipment ○ Patients must not be deterred from ○ These resources often take time to be assessing quality healthcare, just produced so that is why the health because he/she cannot afford it. system policy makers have to respond Impact on Health Outcomes and use the available resources to ○ Health financing systems that deter address the short-term population people from seeking necessary care needs. or lead to impoverishment of Stewardship individuals and families can have ○ The main responsibility of the detrimental effects on overall health government outcomes. ○ Sets the direction and policy ○ Ensuring that these individuals are not framework for the overall health deterred from the necessary care system helps lessen the detrimental or ○ The core of the stewrdship’s function is negative effects on the overall to identify health priorities in order to outcomes. achieve effective decision-making and policy-making on health matters through: B. HEALTH SYSTEM FUNCTIONS Identifying the institutional framework Coordinating activities with Health Service Provision other systems related to our ○ The most visible product of the health external healthcare system. Analyzing priorities and ○ Health service is any service and is not resource generation trends limited to clinical service only, as long and their implications as it is aimed at improving the health Generating appropriate data of populations. Health Financing ○ Preventive measures and the ○ Racing and pulling resources as promotion of a healthy way of living to means to pay for health services avoid illnesses also form part of the ○ Examples include revenue collection, best systems. general payments from health care 3  services, taxation, direct household out structural flaws in its healthcare system, of pocket expenditures, strategic prompting recent health reform efforts. purchasing ○ Risk-pulling organizations use collected funds and pulled financial resources to finance health care services for the members. ○ Purchasers define the substantial part of the health provider’s external incentives to develop provider user interaction. Figure 2. Philippines Population (2021) II. PHILIPPINE HEALTH SYSTEM AND SERVICES Current population is estimated at around 110 million people and expected to peak in 2070 The Philippines, an archipelago in Southeast at 150 million. Asia, has a population of 104.9 million as of Considerable difference in male and female in 2017, making it the 13th most populous terms of life expectancy: country globally. ○ Male: 66.2 years The majority of Filipinos are Christian Malays ○ Female: 72.6 years (92.2%), with Roman Catholics comprising ○ Average: 69.3 years 87.4% of the Christian population, while Muslim minorities (5.6%) are concentrated in Mindanao. The country boasts a high adult literacy rate of 96.5% and is undergoing a transition from an agrarian economy to one centered around services and manufacturing, with a strong GDP growth of 6.7% in 2017. Life expectancy in the Philippines has risen from 62.2 years in 1980 to 69.1 years in 2016, primarily due to improved living conditions, although it faces health challenges like pneumonia, tuberculosis, heart diseases, Figure 3. Philippines Population (2020) malignant neoplasms, and diabetes. Increasingly important risk factors, typically The Philippines is highly exposed to disaster having more impact on men, include: risks, ranking 3rd globally, with frequent ○ Dietary Risks strong typhoons. ○ Tobacco Smoke The country’s most pressing health issues are ○ High Systolic Blood Pressure inequities in health status and access to ○ Alcohol Consumption healthcare services, stemming from 4  ○ Within Communicable Disease Category is Neonatal and Maternal health improving while some infectious diseases are growing (pre-Covid-19) Figure 4. Mortality and Health Indicators (1980-2016) A. BURDEN OF DISEASE Burden of Disease: impact of living with a specific illness, disease, or injury, as well as dying prematurely because of such disease Figure 6. Burden of Diseases Attributable to 15 Leading Risk Factors (2010) B. ORGANIZATION OF THE HEALTH CARE SYSTEM Characterized as a dual health system (public sector and private sector) Private sector mainly active in hospital care and maternities Government caters for primary care and first-line facilities Health facilities are regulated by DOH - Health Facilities & Services Regulatory Bureau (HFSRB) Figure 5. Philippines Burden of Disease Impact of main disease categories ○ Growing importance of Non- Communicable Diseases (NCD) ○ Within NCDs growing impact of cardiovascular diseases (e.g. IHD & Stroke), Diabetes, Cancers ○ Injuries is a growing category 5  In The Philippines, the health system is a complex, multi-layered system in which responsibilities in the health care sector are fragmented Responsibility is shared between the central government (DOH), and Local Government Units that have full autonomy to organize and finance their ‘own’ regional systems. Figure 7. Organization of the Health Care System Figure 9. Public Health Care System In a government sector, several national government agencies and LGUs are responsible for ensuring that health policies are implemented and health services and programs are delivered to the population Figure 8. Number of Health Facilities by Type DOH acts as the national lead agency in health, which consists of 18 bureaus and services responsible for policy development, Barangay Health Station, Rural Health Unit, program planning, standard setting and and City Health Office are exclusively public regulation, and related management support Most hospitals are private (67%) services The DOH structure reflects major organizational changes brought about by Public Health Care System strategic reviews, rationalization of government agencies and functions. Largely financed through tax-based budgeting system where health services are delivered by government facilities run by the national and local governments 6 Executive Order 366 health care is generally paid for through user Signed by President Gloria Arroyo (2004) fees at the point of service. The private health sector is regulated by the Effected by the DOH in 2013 with the final Government through a system of standards approval of its plan and guidelines implemented through the Penning an organizational change licensure procedures of the DOH and the standardized the nomenclature of bureaus, accreditation procedures of PhilHealth service and regional offices Private sector provides also medical tourism, Streamlined the functions, divisions and mostly for low cost aesthetic and dental staffing pattern of the entire agency procedures. It also emphasized the DOH’s leadership and Consists of profit and nonprofit health care policy setting role for the whole health sector providers It strengthened and rationalized the regulatory capacity of the old Bureau of Food and Drugs by also establishing adequate Formal Private Health Care System testing laboratories and field offices, upgrading their equipment, augmenting their The formal private sector consists of human resource, and of course, giving ○ clinics authority to retain its income and renaming it ○ infirmaries as the FDA in the Philippines. ○ laboratories ○ hospitals ○ drug manufacturers and distributors ○ drugstores ○ medical supply companies and distributors ○ health insurance companies ○ health research institutions and academic institutions offering medical, nursing, midwifery, and other allied professional health education 5 Hospitals hold Accreditation from the Joint Commission International ○ Asian Hospital and Medical Centre Figure 10. Organizational Structure Showing ○ Chong Hua Hospital the Health Offices Devolved to the LGUs ○ The Medical City ○ St. Luke’s Medical Centre and Makati Medical Centre Private Health Care System Non-Formal Private Health Care System The private sector consists of thousands of Non-formal health service providers include for-profit and non-profit health providers, traditional healers (herbolarios) and which are largely market-oriented and where traditional birth attendants (hilots), which are 7  not covered by any licensing or accreditation system by the Government. Other relevant private organizations and NGOs in the health system including professional groups are involved in the promotion of standards of practice and competence in the health professions. ○ The Philippine Medical Association ○ The Philippine Nurses Association ○ Philippine Dental Association Figure 11. Services that the National and Local ○ The Integrated Midwives Association Governments Provide and Pay For of the Philippines C. SERVICES THAT THE NATIONAL AND LOCAL GOVERNMENT PROVIDE AND PAY FOR Municipal facilities mainly provide primary care services in health centers Provinces provide primary-level care in Figure 12. Secondary Care - Hospital Bed Capacity is infirmaries and secondary-level care in district Unevenly Distributed hospitals (Level 1) and provincial hospitals (Level 2) Cities provide primary and secondary services; however, a few large cities may D. FINANCING HEALTH CARE operate tertiary-level hospitals (Level 3) The DOH operates tertiary-level hospitals in the NCR as well as in the various regions of the country There are other National Government agencies that run tertiary hospitals, including the military and the University of the Philippines Funds from the General Appropriations Act, which includes internal revenue allotment for local government Figure 13. Current Health Expenditure by Health Care Financing Scheme (2019) 8  The current health expenditure by health care system administration and financing (7.4%) financing scheme in 2018 had Out of Pocket accounted for EUR 1 billion. Payments (OOP) at 47.9% which means that the biggest bulk/portion of payments come from the citizens themselves and not government-funded programs and not from insurances. This severely limits financial access to health care and/or may push people into poverty in case of catastrophic health expenditures. ○ e.g. Medication to admit themselves into a hospital so people would have access to quality healthcare especially if they have communicable diseases such as COVID-19. A lot of people, through out-of-pocket payments, will be released after a long time and will be in debt because of financial risks Figure 14. Flow of Financing in Philippine Health Care and hospitalization. ○ If we look at it practically, if out-of-pocket payments are high it National Health Insurance Program (NHIP) means that the health care system is not doing its job. In order to address the issues about financial ○ Primary Goal of a Health System: to risks to the citizens, the government has deter people from poor health created the National Health Insurance outcomes because of financial risks Program (NHIP) and social risks. This is carried out by PhilHealth, which ○ If out-of-pocket payments are high, receives premiums from households, firms and the goal of the health system was not government. met. Premium: amount of money that an individual Health spending financed through or a business pays to the insurance provider government schemes and compulsory periodically. Those who work have salary contributory health care financing schemes deductions per month to pay for PhilHealth. came second at a 42.0% share (e.g. PhilHealth reimburses health care costs at PhilHealth). both public and private facilities. However, it Meanwhile, voluntary health care payment matches only part of the total health care schemes contributed 10.1% share. costs, ranging between 30-70% maximum. Among the health providers, the bulk of CHE They cannot cover the whole hospital cost. were spent on hospitals (43.6%), amounting to Although central in organized health care EUR 6 billion. It was followed by pharmacies financing, more than 90% of Philippines were (30.3%) while the providers of health care directly or indirectly covered before 2019, the role of PhilHealth is limited due to the skewed 9  distribution of health facilities, limitations in Top 4 Categories of Health Professionals type of care covered and limited ‘depth’ of Working in Health Institutions financing services, or the share of the health ○ Nurses (90,308) care costs reimbursed. ○ Doctors (40,775) Not all operations are covered by PhilHealth. ○ Midwives (43, 044) There are a lot of actual outpatient ○ Medical Technologists (13,413) procedures that are not covered by PhilHealth. Institution-based doctors are equally Also, there are aesthetic procedures that are affiliated in public and private institutions. not covered by PhilHealth (Plastic surgery, Nurses (61%), midwives (91%), and medical Outpatient Department (OPD) procedures, technologists (53%) tend to work more often etc.). in public institutions. A lot of Filipinos cannot actually experience Compensation is considered better in public the benefits of PhilHealth because of the facilities like a public hospital or government limitations and type of care covered. institution because pay is better than in private institutions. The distribution in terms of place of work of E. DISTRIBUTION OF HEALTH PROFESSIONALS institutional health workers is hospital-centric, thus curative in nature. Only 9% of doctors work outside the hospital in primary care settings. ○ Health workers are hospital-centric which means patients should be the one to go to hospitals. ○ Work of health workers is curative in nature. ○ Doctor to patient ratio is still skewed. ○ NCR: 10 doctors per 10,000 (1 doctor:1000 patients) ○ BARMM: 0.8 doctors per 10,000 population (1 doctor handles more than 10,000 patients). ○ A lot of people would prefer to go abroad because the health care system in the Philippines is not ideal not only to medical technologists but to doctors as well. Figure 15. Distribution of Health Professionals 10  F. MIGRATION OF HEALTH PROFESSIONALS Main Legislative Milestones in the Past 30 Years Primary Health Care for All (1970) Because of the workload being put on the ○ Based on strategy, one of the major shoulders of allied medical health milestones in the past 30 years is the professionals and doctors, the migration of primary Health Care for All in the health care professionals is something that is 1970’s. very much talked about right now. This should ○ The Philippines developed a largely be addressed by the government. centralized, government funded and Despite many different policy efforts to operated health care system. reduce the flow, in recent years, still an Milk Code (1986) average of 13,000 nurses migrate yearly ○ Prevention and nutrition became Many stay for substantial periods overseas visible in the push to promote before returning or try to naturalize/become breastfeeding through the Milk Code natural citizens (in particular in the USA). mandating breastfeeding. ○ Reasons include pay, better living Generics Law (Early 1990s) conditions, better health care system ○ The Philippines was at the forefront of Bilateral agreements between the Philippines pharmaceutical regulation when it and destination countries have proven difficult passed the Generics Law in the early to implement and are not considered effective 1990s in an attempt to lower in reducing outflow of health professionals expenditure on drugs by promoting Both push (e.g. wages, job positions) and pull and purchasing non-branded factors (e.g. wages and overseas experience) medicines. contribute to ongoing migration. ○ If you actually go to pharmacies, the In 2020, migration was put on hold due to the pharmacists would ask if you’d like to pandemic situation. buy the generic (which is considerably In 2021, policies expected to limit outflow to cheaper) or the brand which are 5,000 nurses manufactured by pharmaceutical If we look at it, instead of prioritizing the companies like Pfizer and UniLab. welfare of allied medical health professionals, ○ Branded medicines have generic what the government is doing instead is to alternatives so that it’s more limit them going abroad. accessible to the public. Local Government Code (1991) ○ The Local Government Code passed in 1991 and decentralized also the III. HEALTH SECTOR REFORMS governance and financing of the health system (devolution) 1992 In line with everything mentioned, the ○ In line with the decentralization efforts government will always have lapses which is hospitals under DOH were granted why there are a lot of health sector reforms. fiscal autonomy National Health Insurance Act (1995) 11  ○ Reducing the pressure on government Extra resources to health insurance finances, while harnessing earmarked to Special Fund exclusive for LGUs out-of-pocket payments through the for improvement of local health systems and introduction of the National Health health infrastructure Insurance Act in 1995. Stricter delineation in mandates between DOH ○ This is considered a major milestone and PhilHealth. for social health protection. ○ DOH to focus on population based ○ Example of National Health Insurance health services, e.g. health promotion, is PhilHealth disease surveillance and vector Health Facilities Enhancement Funds (2007) control ○ To counter low levels of government ○ PhilHealth to focus on individual financing for health care and a based health services, e.g. services dilapidated health care infrastructure, that can be accessed within a health the DOH introduced the Health facility (or remotely) and can be Facilities Enhancement Funds to traced to one recipient. support local governments in 2007. Good Governance Act (2008) ○ Improving quality and management in A. ISSUES IN HEALTH CARE REFORM health care was the goal of the Good Governance Act in 2008 2011 Oral Diseases ○ Mandatory ISO certifications for hospitals A serious public health problem, creating an Sin Taxes for Health (2013) epidemic and a heavy burden on school ○ Trying to catch two flies with one children (Department of Health, 2012). stone, the aim of the introduction of Dentists play a very limited role in education Sin Taxes for Health is to discourage and prevention of oral disease and generally harmful consumption of alcohol and see no role for themselves in this area. tobacco while generating extra Private sector dentists can only help through revenue for the DOH. dental missions in poor communities but ○ It is considered the start of Universal mostly focus on the extraction of teeth due Health Care financing. to dental caries. This is because there is a total lack of public Universal Health Care Law 2019 dentists to perform treatments. RA 11223 Also, not all health centers (or public health centers to be specific) have dentists. In March 2019, President Duterte signed the There is confusion regarding whether the Universal Health Care (UHC) Bill into law, Department of Education or Health has the Republic Act No. 11223. responsibility for the dental health of school Major step by enrolling all Filipino citizens children. automatically in the National Health Insurance Program administered by PhilHealth 12 Inequity in Health and Care E-Health A very important thing to address The Philippines has reportedly one of the Improvements in health status as a national slowest internet speeds among Asian average can mask inequality in countries. ○ Health Outcomes Still, it scores relatively well when it comes to ○ Socioeconomic Status the actual use (67 users out of 100 people). ○ Educational Attainment ○ We are the facebook capital of the ○ Regional Disparities world meaning, a lot of us have access Disparities across socioeconomic status are to the internet. However, this does not associated with guarantee that the internet speed in ○ Maternal Education the Philippines is indeed fast. ○ Regional Allocation The Philippines has had an eHealth Strategic ○ Access to Health Services Framework since 2014. The National Demographic and Health Crucial effort is the Philippine Health Survey (NDHS) found that the proportion of Information Exchange (PHIE) which is a women who receive prenatal care from a platform for secure electronic access and provider is associated with the mother’s level efficient exchange of health data and/or of education and economic status. information among health facilities, ○ This means that those who availed or health-care providers, health information those who actually received prenatal organizations and government agencies in care were ones who were at a higher accordance with set national standards. socioeconomic status as well as In the health sector, digitalization is taking attaining a better level of education. hold in different areas such as e-prescriptions, The highest prevalence of underweight, hospital management information systems, stunting, and wasting (FNRI, 2014) Integrated Clinic Information System ○ Among the Poorest Quintile (iClinicSys) for primary care facilities, Underweight (29.8%) electronic patients records. Stunting (44.8%) Especially during the COVID-19 pandemic, Wasting (9.5%) more focus was given to e-health and ○ Among those in Rural Areas telemedicine. Underweight (22.6%) The Department of Health (DOH) and Stunting (35.0%) Philhealth are currently collaborating on an Wasting (8.1%) integrated decision support and reporting ○ Those underweight, have stunted system to foster the evolution and growth, and wasted weights optimization of the DOH nationwide. Mostly those from lower socioeconomic statuses As well as in far places due to regional allocation 13 Telemedicine deaths to monitor health service delivery The use of electronic information to ○ R4Health is an application that was communications technologies to provide and developed and field tested in 246 support healthcare when distance separates isolated and disadvantaged the participants municipalities to support the campaign E-prescription services have come into use for Universal Health Care and the The rise of COVID-19 is speeding up the achievement of the Millenium application of Telemedicine Development Goals. Bayanihan Na! COVID-19 Operations Center ○ It collected point-of-care-specific data ○ University of the Philippines planning on services routinely provided at the COVID bed capacity across the rural health facilities, aggregated country. them, and presented them in a ○ 48 Electric beds were provided by St. dashboard for use by program Luke’s Medical Center. Other sectors managers and policymakers. also donated medical equipment and KonsultaMD cash to this program. ○ Subscription-based telehealth service ○ UP-PGH launched Bayanihan Na! which is available 24/7 and allows COVID-19 Operations Center to answer access to skilled & Licensed Filipino queries 24/7 regarding COVID-19- Doctors who can provide safe medical related matters. assessment and advice on basic National Telehealth Service Program (NTSP) healthcare & proper medication. ○ Managed by the DOH and University ○ KonsultaMD Doctors may provide of the Philippines (UP) in the National important medical documents such as Telehealth Center e-prescriptions, e-laboratory requests, ○ This program aims at expanding and e-medical certificates at the telemedicine in the 4th to 6th class doctor’s discretion which are all municipalities nationwide accessible through SMS or the ○ NTSP Facilitates consults between KonsultaMD app. primary care physicians and clinical New issues or the unintended consequences specialists in the University of the arising from the increasing spread of Philippines using mobile and telemedicine Internet-based interface and triaging ○ Billing & reimbursement issues system ○ Telemedicine makes health care delivery ‘impersonal’ ○ Resistance from doctors to protect physical practice Realtime Regular Reporting 4Health (R4Health) ○ Mobile system to collect routine health data of selected maternal & child 14  IV. STRENGTHS AND WEAKNESSES OF THE B. IMPORTANT GOVERNMENT ORGANIZATIONS PHILIPPINE HEALTH SYSTEM ORGANIZATION ACTIVITY A. STRENGTHS AND WEAKNESSES DOH The main body in healthcare in the (Department of Health) government PPP Center NEDA Facilitate the implementation of the (8) STRENGTHS (8) WEAKNESSES (Public Private country’s PPP Program and Projects Partnership Center - Adoption of Universal Health Fragmented healthcare system National Economic and Care Law (2019) due to decentralization Development Authority) Government reforms increasing Diversity of health systems, FDA Main Regulatory agency for registration of (Food & Drug drugs, medical equipment, supplies & insurance coverage varying from advanced to basic Administration) cosmetics Significant growth in health Slow and substantial expenditure governmental bureaucracy PhilHealth Single government health insurance (Philippine Health agency Stable pre-COVID economy, Quality of care below regional Insurance Corporation) projected growth standards (WHO) KMITS DOH unit in charge of digital health (Knowledge applications Large, young population with a Corruption issues affecting Management & skilled workforce business costs and uncertainty Information Technology Service) Continued financial support Poor condition of health from IFIs infrastructure, particularly in NAST Advises the President and the Cabinet on rural areas (National Academy of matters related to Science and Science and Technology) Technology Improving ease of doing Chronic understaffing due to business (ranked 95) health worker migration UP NIH Strengthen the research facility of UP (University of the Manila and serve as an institutional home Active private sector in Substantial inequality, with Philippines National of a network of researchers and research healthcare people paying substantial Institutes of Health) institutions amounts for health services, even in the public sector University of the Premier institution of higher learning Philippines Philippine General Leader in transforming the lives of the Hospital people through excellent health care, education, and research, accessible to all Development Bank of Pre-eminent development financial the Philippines institution, influencing sustainable economic growth Land Bank of the Universal bank with a focus on serving Philippines farmers and fishermen ECCP Foster close economic ties and business (European Chamber of relations between the Philippines and Commerce of the Europe Philippines) World Health UN Organization for Health 15  ORGANIZATION ACTIVITY Organization Western Pacific Regional Office USAID Partnering with the Philippines for inclusive (U.S. Agency for economic growth and stability International Development) UNDP Working in the Philippines for over 40 (United Nations years Development Programme) Asian Development Bank Committed to achieving a prosperous, inclusive, resilient, and sustainable Asia and the Pacific World Bank Multilateral development bank Asian Infrastructure Multilateral development bank focused on Investment Bank developing Asia 16