In the third part of the series, we will be exploring the topic of ‘health infrastructure’ as part of the ‘Accessibility to healthcare’ agenda. As outlined in the previous series, whilst Universal Health Coverage (UHC) provides the fundamental economic scheme, without the necessary health infrastructure in place, healthcare services cannot be accessed by those in need at the right time and in the right place.
As part of global health practice, it is important that each nation has equitable standards of health infrastructure to allow health services to be accessed by all those in need. Unfortunately, there is a vast gap between the Global North and Global South in this agenda, and something must be done to mitigate this gap. This essay will explore the differences in health infrastructures across the Global North and Global South, in hopes of identifying potential solutions for the Global South, including ways in which Japan can take a leading role.
Of note, whilst this essay dives into case studies across countries, there are times when a complete apple-to-apple comparison of figures cannot be made due to the lack of accessible data. As such, please treat some of the figures as a reference and as ‘one perspective’ that allows us to explore this important topic of health infrastructure. Whilst not explored in this essay, this, in fact, also highlights the importance of capturing accurate data that can be compared across countries to support policy-making activities that should be revisited.
1. What is health infrastructure?
In this series, we have defined ‘health infrastructure’ as covering the following three aspects (Diagram 1).
These three aspects are critical to delivering healthcare services to patients in need. In other words, any issues faced in one of these aspects may directly impact the provision of healthcare services. Moreover, the three aspects are interconnected, and the impact on one can influence the others.
2. Case studies across the Global North & Global South
This section will explore the differences in the three aspects of health infrastructure through the lends of Global North and Global South case studies. Whilst it is expected that the Global North will have a more mature infrastructure compared to the Global South, understanding the specific differences is necessary to aid the Global South.
2-1. Human resources
First, we will focus on human resources related to the quality of healthcare services, patient safety and the efficiency of care. The challenges associated with healthcare human resources are common issues worldwide. Specifically, in Germany as part of the Global North and India as part of the Global South, there are different contexts and challenges. We will explain the current situations in both countries and the solutions being proposed to address them.
<Global South: India>
The challenges related to human resources in healthcare provision in India have become increasingly important due to the country’s rapid economic growth and population increase. The main issues include a chronic shortage of healthcare professionals and disparities in the quality of healthcare professionals and medical education between different regions. First, there is a significant shortage of both physicians and nurses. In India, the number of physicians is approximately 0.7 per 1,000 people*1, which is significantly lower than the OECD member countries’ average of 3.4 per 1,000 people (due to limited data on the global average, OECD data is used as a reference for human resources). Similarly, the number of nurses in India stands at only 1.7 per 1,000 people*2, which is a significant gap compared to the OECD member countries’ average of 9.4 per 1,000 people. Moreover, there are substantial disparities in the quality of healthcare professionals between urban and rural areas. In urban areas, well-educated physicians and nurses work in healthcare facilities, whilst in rural areas, the lack of adequate medical education leads to variability in the quality of healthcare professionals. This regional disparity is also a significant challenge in healthcare provision in India.
Although there are economic disparities and differences in policies between the Global South and the Global North, the challenges related to healthcare professionals are common worldwide. We will explore whether there are insights to be gained from the situations and initiatives in the Global North.
<Global North: Germany>
In Germany, the number of physicians is 4.5 per 1,000 people*1 (OECD average of 3.4), and the number of nurses is 12 per 1,000 people*2 (OECD average of 9.4), both exceeding the OECD averages. However, with the acceleration of an ageing society, the demand for healthcare professionals is increasing, and the supply is not keeping pace. As one solution to this challenge, Germany is strengthening its policies on the acceptance of foreign healthcare professionals. In 2003, 6 to 7% of all physicians in Germany were foreign physicians*3, whereas by 2023, this figure had risen to 12%*4, and further increases are expected in the future. Additionally, the issue of healthcare personnel shortages cannot be resolved simply by increasing numbers; therefore, Germany is also focusing on the digitisation of healthcare settings. For example, the introduction of telehealth and AI-powered documentation management and diagnostic tools is helping to reduce the burden on healthcare professionals and improve service delivery to patients.
Thus, the issue of healthcare professional shortages is a challenge even in the Global North, but it has become a more serious issue in the Global South. Additionally, it can be inferred that there is a structure whereby outstanding physicians from the South may help address human resource shortages in the North, as seen in Germany’s initiatives. To improve this situation, it is necessary to strengthen medical education in the Global South and to implement digital strategies that have proven effective in the Global North.
2-2. Health facilities
Next, let’s examine the aspect of health facilities—the foundation for providing medical services. Healthcare facilities are essential for patients to receive appropriate care, but in many regions, geographical constraints and limited resources leave challenges to fulfil this role. The disparity in healthcare facilities between the Global North and Global South is particularly pronounced, posing a major barrier to achieving UHC
<Global South: The Philippines>
In the Philippines, the number of hospital beds is reported to be approximately 0.9 per 1,000 people*5, which is significantly lower than the OECD average of 4.4 beds per 1,000 people*6. Similarly, the number of ICU beds is also low, with only 2.7 beds per 100,000 adults*7, far below the OECD average of 14.1*6. Alarmingly, about half of the population is unable to access hospitals or health centres within 30 minutes, and in island regions such as Visayas and Mindanao, the number of beds drops to less than 0.5 per 1,000 people*8. Meanwhile, in the capital city of Manila, where the population density exceeds 20,000 people per square kilometre, the number of hospital beds exceeds 2 per 1,000 people, indicating a concentration of healthcare facilities in urban areas. However, even this remains far below the OECD average of 4.4 beds, and across the Philippines as a whole, the absolute shortage of healthcare facilities and regional disparities have emerged as significant challenges.
For countries like the Philippines, which consist of many islands and lack robust infrastructure such as roads and communication networks, it becomes particularly important to strategically allocate limited resources and build an efficient healthcare delivery system. Let’s look at how the Global North is effectively utilising its limited resources by comparison.
<Global North: Denmark>
In Denmark, there are approximately 2.5 hospital beds per 1,000 people*6, which is below the OECD average. However, by streamlining healthcare delivery through hospital integration and digitalisation, Denmark has built a sustainable healthcare system whilst maintaining high quality of care. In the 2007 administrative reform known as the ‘Super Hospital’ project, Denmark reorganised 13 regional healthcare authorities into 5, strengthening the collaboration between large hub hospitals and local clinics. As a result, the number of emergency hospitals was reduced from over 40 to 21*9. Nationwide healthcare data is centrally managed through an integrated system, enabling the electronic communication of medical records, test results, prescriptions and more, whilst also promoting telemedicine. For example, in chronic disease management, Denmark has expanded remote monitoring and online consultations, allowing patients to receive care without the need for travel. Patients with chronic obstructive pulmonary disease (COPD) can now share real-time data measured at home with healthcare providers and receive timely advice from physicians*10.
As explored above, whilst healthcare facility shortages are severe in the Global South, urban-rural disparities are common across both the Global South and Global North. However, the scale of the issue and the approaches taken are quite different. In the Global North, countries are developing sustainable healthcare systems by networking facilities using digital technologies and streamlining the division of roles between advanced and chronic care services. In contrast, in the Global South, investment is heavily concentrated in urban areas, and the rural-urban gap is often much wider than that of the North. Facilities capable of providing advanced care, such as ICUs, are concentrated in cities, and even there, there is a shortage in both the capacity and quality of medical services. Therefore, it is important not only to increase the number of facilities but also to consider how to allocate limited resources effectively.
2-3. Logistics
Finally, we will cover the last aspect of health infrastructure: logistics. Ultimately, without well-functioning logistics, necessary supplies, including medicines, cannot reach healthcare facilities, making it impossible to provide high-quality healthcare services to those in need. This was particularly evident during the COVID-19 pandemic, which highlighted the critical role of logistics. In this section, we will explore the differences in medical supply logistics between countries in the Global South and Global North, focusing on African nations and Singapore, respectively.
<Global South: African nations>
COVID-19 vaccines require strict temperature control, and as expected, many challenges arose in distributing them across African nations. These challenges stem from underdeveloped logistics infrastructure, encompassing vaccine storage facilities, cold chain logistics (including ultra-low temperature storage) and monitoring networks for vaccine distribution*11. The causes include unstable power supply and frequent blackouts, limited cold chain equipment and facilities, and inadequate road networks that hinder vaccine delivery to target destinations*11. For example, in Nigeria, the most populous country in Africa and one of its major economies, six out of ten hospital wards lack cold chain equipment, and 58% of vaccination centres do not have electricity*12. The inability to distribute vaccines and other essential medical supplies not only leads to healthcare disparities but also results in significant drug wastage and increased costs*12. In fact, it is reported that globally, approximately 25% of vaccines are discarded due to cold chain failures, and in Africa, this rate is believed to be even higher.
As illustrated above, to provide high-quality healthcare services, it is crucial to improve logistics in addition to human resources and healthcare facilities. Let’s examine if there are any insights to be drawn from Global North practices to address these challenges faced in the Global South.
<Global North: Singapore>
WWithin the two and a half years between 23 January 2020, when the first COVID-19 case was reported in Singapore, and 27 August 2022, Singapore achieved a remarkable vaccination rate of 92%, far exceeding the global average of 68%*13. Behind this achievement were Singapore’s swift decision-making, effective public communication and advanced logistics infrastructure, which had been developed through experiences with SARS and COVID-19. Singapore’s logistics are ranked highly among the most resilient countries, due to the establishment of a robust vaccination supplying system supported by the National Centre for Infectious Diseases following the SARS outbreak in 2003. This enabled the rapid deployment of cold chain systems during the COVID-19 pandemic in comparison to other countries*14. For example, Singapore Changi Airport is now equipped with an 8,000-square-metre temperature-controlled warehouse, truck docks and containers*14. Consequently, Singapore not only ensured its domestic supplies but also played a pivotal role as a logistics hub to support Southeast Asia, Australia and New Zealand by transporting and storing vaccines, and managing the cold chain and distribution, through the use of their established system*13. Moreover, the pandemic accelerated the development of digital transactions, enabling improvements in supply chain inventory management, order tracking, delivery verification and the integration of vaccination registries with national health records. This ensured adequate vaccine stockpiles and facilitated rapid and widespread vaccination*13*15.
Whilst digitalisation alone cannot universally resolve logistics challenges*15, recognising the current status and desired goals in each country/organisation and implementing appropriate systems and infrastructure, as Singapore has done, can enable proper inventory management and rapid vaccination programmes, ultimately contributing to reducing drug losses.
As apparent from these case studies, mature logistics play a key role in improving access to medical supplies. Furthermore, well-functioning logistics can reduce drug losses, ensuring that essential medicines reach those in need and contributing to the broader goal of reducing healthcare costs faced by other nations.
3. So what can be done to support the Global South?
As outlined in the previous section, there are significant differences between the Global South and Global North in the three aspects of health infrastructure. It is essential that nations work together to minimise this gap in a collaborative manner, to embody the ethos of global health.
To eliminate the disparities, the first steps for the Global South include analysing the three aspects of health infrastructure by studying successful cases from the Global North and creating a plan that incorporates the success factors. When creating these plans, it is crucial not to simply jump into expanding the health infrastructure, but to optimally allocate human resources, health facilities and logistics through thorough analysis of the population structure and distribution, in order to avoid issues such as the uneven distribution of physicians—an issue that Japan is currently facing. Furthermore, it is essential to simultaneously consider education and health communication systems to disseminate the desired policies, in addition to securing the necessary budget for implementation. Without these considerations, even if medical access is enhanced, there are risks of quality not being maintained, which may potentially devalue what is established.
When devising the plans mentioned above, it is anticipated that each country will encounter its own limits. For example, even if measures to increase and correctly allocate the number of facilities are considered, there may be physical limitations in terms of land and resources to actually construct these facilities. Additionally, if a future pandemic similar to COVID-19 occurs, there will be limited time to address these measures (e.g. it takes about eight years to train physicians and two to five years to build a facility). One way to overcome these limits is through the use of technology. By effectively utilising the rapidly advancing technology, as seen in examples like Singapore, it is possible to overcome physical and time constraints. Furthermore, it is important not to forget that combining health infrastructure with technology will further emphasise the interconnectivity of the three health infrastructure factors. Therefore, rather than examining the three factors separately, it is crucial to consider how they influence each other.
So what can Japan, as a leader in the Global North, do? Japan possesses a wealth of advanced digital technologies and companies with strong partnerships. By effectively deploying these technologies to the Global South, we can contribute to improving the quality of medical care. In fact, several examples of Japanese companies promoting initiatives for the Global South can be cited. Additionally, PwC has mentioned the impact of technology in ophthalmology as part of the PwC Healthcare Hub for HCPs.
- Fujifilm Group: Developing a portable X-ray device that is small, lightweight, easy to carry and simple to operate. By utilising this device, they aim to provide opportunities for tuberculosis screenings to people living in rural areas of emerging countries, particularly in mountainous regions and isolated islands*16.
- Shionogi & Co., Ltd.: Promoting efforts to supply medicines to low- and middle-income countries by collaborating with international partners such as GARDP (Global Antibiotic Research and Development Partnership) and CHAI (Clinton Health Access Initiative) to address the global health issue of antimicrobial resistance (AMR)*17.
- Eisai Co., Ltd.: In collaboration with the WHO, Eisai has begun providing diethylcarbamazine tablets, a treatment for lymphatic filariasis, free of charge to endemic countries, including Zimbabwe. This initiative is part of efforts to achieve the WHO’s 2030 goal and realise a world free of neglected tropical diseases (NTDs). Eisai has also signed the Kigali Declaration to take part in this initiative*18.
A pandemic occurs once every decade. During such times, the maturity of healthcare access will inevitably be questioned. Accordingly, countries are required to prepare for such eventualities. Along with the establishment of the Universal Health Coverage (UHC) , as discussed in the second essay of this series, it is crucial to test the limits by strengthening health infrastructure.
Reference
*1: World Bank. (2025). Physicians (per 1,000 people). https://data.worldbank.org/indicator/SH.MED.PHYS.ZS
*2: World Bank. (2025). Nursing and midwifery personnel (per 1,000 people). https://databank.worldbank.org/source/health-nutrition-and-population-statistics/Series/SH.MED.NUMW.P3
*3: National Institute of Population and Social Security Research. (2010). Future Population Projections for Japan.
https://www.ipss.go.jp/syoushika/bunken/data/pdf/19176304.pdf
*4: Schengen Visa News. (2023). Germany’s Healthcare Staff Shortage Crisis to Further Deepen Without Foreign Doctors.
https://schengen.news/germanys-healthcare-staff-shortage-crisis-to-further-deepen-without-foreign-doctors/
*5: Ministry of Economy, Trade and Industry (Japan). (2021). Country Report: Philippines. https://www.meti.go.jp/policy/mono_info_service/healthcare/iryou/downloadfiles/pdf/countryreport_Philippines.pdf
*6: OECD. (2021). Health at a Glance 2021. https://www.oecd.org/content/dam/oecd/en/publications/reports/2021/11/health-at-a-glance-2021_cc38aa56/ae3016b9-en.pdf
*7: PubMed Central. (2024). ICU Capacity and Infrastructure in the Philippines. https://pmc.ncbi.nlm.nih.gov/articles/PMC10733690/
*8: The LawPhil Project. (2023). Executive Memorandum MC_26_2023. https://lawphil.net/executive/mc/mc2023/pdf/mc_26_2023.pdf
*9: Danish Ministry of Health. (2021). The Danish Super Hospital Programme. https://www.ism.dk/Media/0/2/TheDanishSuperHospitalProgramme2021.pdf
*10: Danish Health Data Authority. (2018). Digital Health Strategy 2018–2022. https://english.sundhedsdatastyrelsen.dk/Media/638657841521943752/Digital_Health_Strategy_2018_2022.pdf
*11: PubMed Central. (2021). Cold Chain Systems in Africa. https://pmc.ncbi.nlm.nih.gov/articles/PMC8548036/
*12: ScienceDirect. (2022). Cold Chain Logistics in Developing Countries. https://www.sciencedirect.com/science/article/pii/S2590136222000948
*13: Singapore Medical Journal. (2022). Singapore’s Vaccine Rollout Strategy. https://doi.org/10.4103/singaporemedj.SMJ-2021-405
*14: Duke-NUS Medical School. (2023). Cold Chain Facilities in Southeast Asia: Challenges and Opportunities.
https://www.duke-nus.edu.sg/sdghi/learn-with-us/cold-chain-facilities-in-southeast-asia-challenges-and-opportunities
*15: JTC Corporation. (2023). 4 Things to Know About Supply Chain Management Post-COVID.
https://www.jtc.gov.sg/about-jtc/news-and-stories/feature-stories/4-things-to-know-about-supply-chain-management-post-covid
*16: Fujifilm Holdings. (2025). Tuberculosis Initiatives in Developing Countries. https://holdings.fujifilm.com/en/sustainability/activity/health/tuberculosis
*17: Global Antibiotic Research & Development Partnership (GARDP). (2023). Combating AMR through International Partnerships.
https://gardp.org/amr%E3%82%81%E3%81%90%E3%82%8B%E8%AA%B2%E9%A1%8C%E3%80%81%E3%83%91%E3%83%BC%E3%83%88%E3%83%8A%E3%83%BC%E3%82%B7%E3%83%83%E3%83%97%E3%81%A7%E5%8F%96%E3%82%8A%E7%B5%84%E3%81%BF%E2%80%95%E5%A1%A9/
*18: Eisai Co., Ltd. (2012, 2022)
https://www.eisai.co.jp/news/news201360.html
https://www.eisai.co.jp/news/2022/news202250.html
