Dr PHUA Kai Hong AB cum laude SM (Harv), PhD (LSE)

Lee Kuan Yew School of Public Policy

National University of Singapore

UNIVERSAL HEALTH COVERAGE AND PUBLIC-PRIVATE PARTICIPATION

Presented at the World Health Organization

Department of Health Systems Governance & Financing

March 27, 2017

Overview

• Introduction

• The Public-Private-People Sectors

• PPP Innovations in Health Financing

• Role of the Third Sector – Governance Issues

• The Asia-Pacific Region

• Conclusion

Introduction

• Presented at 2015 Singapore Conference on UHC – Achieving the Post-2015 Development Agenda

• Subsequent UHC Conferences in Japan and elsewhere

• UHC Conference 2015 had participation of WHO, WB, and Gates Foundation in private sector collaboration (Bill Gates supported UHC health systems approach)

• Trends – Public-Private Partnerships/People Sector

- Civil Society, Voluntary/Third Sector, NGOs, etc

- Public-Private Mix Optimal Balance (Optimization)

- New Public Administration New Public Governance

The Challenges of Universal Health Coverage

• Achieving UHC Post-2015 Development Agenda

• But how do we deliver on this goal?

– no silver bullet or one-size-fits-all formula

– path to UHC is complex and contingent on conditions

• Developing/developed contexts to address policies

– What? Maximum/Minimum – basic health coverage

Where? When? How? (Efficiency – Costs)

– Who pays? Who benefits? (Equity – Access)

– How much? What standards? (Effectiveness – Quality)

Optimum public-private mix/trade-offs? (The Iron Triangle)

Complex Issues in Providing Universal Health Coverage

• Illusion of “free” healthcare is populist – Governments jump on bandwagon without

undertaking holistic health systems reform

• Capacity problems may become exacerbated – National UHC programmes can unleash unexpected

demand and supply (moral hazard)

• More money in risk-pool but not managing its proper utilisation with poor governance – Will lead to greater inefficiency as well as inequity

– Needs total system approaches with effective reforms on the supply side and other checks & balances

Social Goals of the Optimum Mix

Seeks to balance between extremes

State Monopoly Total tax-funded

Social insurance

- ‘Free’ services

- Low quality

- Inefficiency

Free Market Pure profit-making

Private insurance

- Moral hazard

- Adverse selection

- Inequity

Effective delivery of UHC requires public-private-people participation

• Government and public sector – Investments in public health measures and PHC

e.g. sanitation, vaccination and MCH services

– Focus limited resources on supplying essential targeted services to the poor and vulnerable

• Participation of private and voluntary sectors – Ensures that everyone’s choices are best served

– Allows room for competition and innovation

– Mobilises additional resources to meet needs

– Utilizes local elements and enhances “buy-in”

– Involves altruistic and charitable values

Third sector has important role for Universal Health Coverage

• Role of non-profit/voluntary sector under-estimated - when states and markets fail the public interest (bureaucracy, lack of incentives, corruption, etc) - disasters and crisis situations (breakdown of government or poor governance) - cross-border conflicts / “no-man’s land”

• Duplication of private/non-profit services - Government should ensure that third sector serves the interest of the poor through effective collaboration - “Win-win” positions to enhance synergy

• Appropriate regulation of third sector required - Checks and balances of stakeholders’ interests - Level playing field and common deliverables

Role of non-profit providers is important…

• Non-profit providers include voluntary welfare organisations and faith-based organisations

-- track record for resource mobilization

-- humanitarian and philanthropic funds

• Driven by humanitarian objectives

– Help mobilise scarce resources towards the poor, vulnerable and marginalized

– Identify new needs and may close gaps that public and for-profit providers cannot address

– Provide checks against excessive profit-seeking

– Moral compass for both public and private goals

Some Public-Private Partnerships

PPP Models

Corporate social responsibility

Social enterprises

Negotiated service contracts

Co-sponsorships/joint projects/co-funding

Philanthropy/charities/tax-exempt trusts

Common Issues

Conditionality (terms & conditions - “strings”)

Ownership and control (sovereignty in global health)

Top-down vs bottom-up (community-based approaches)

Pilot and demonstration projects

Replication and scaling-up

Long-term sustainability and integration

Changing Public-Private Allocation - What is Public and What is Private?

26

% of population

$ per personX

H1

T1

X1

Private Public

Total (x)

OOP Expenses

Health Expenditure Density Functions

2

Catastrophic Care

Primary Care

Acute Care

Chronic Care

Medisave

Medishield Life

Medifund

PRIMARY

CARE

ACUTE

CARE

CATASTROPHIC

(LONG TERM CARE)

Financing

Private

Payment Compulsory

Savings

Social

Insurance

PUBLIC SUBSIDIES

Source: Dr. Phua Kai Hong

Taxes PUBLIC HEALTH SERVICES

(Eldershield)

Singapore’s Optimal Health Financing

for Universal Health Coverage

FOR-PROFIT NON-PROFIT

Private

Payment

Taxes

Public Policies to Cost-Share

Tax Financing with Savings and Insurance

Provider/

Organization

Social

Insurance

Private

Insurance

Patients/

HouseholdsSavings Premiums

Prepaid

Premiums

Government

Pricing?Subsidy?

Towards an Optimal Public-Private Balance in Health Care Systems?

• Universal coverage of defined health care

• Choice of public, private or voluntary systems

• Competition and integration between public, private and voluntary (non-profit) sectors

• Appropriate mix of provision and financing

• Targeted public subsidies to address inequity

• Co-payment at the point of consumption

• Selective risk-pooling to avoid moral hazard

• Government benchmarks for prices & quality

Paradigm Shifts in New Public Governance for Universal Health Coverage

Universal Health Coverage

Government

Civil Society Business

Democratization Globalization

Public-Private-People Participation

National/Societal

Provision/Financing/Regulation/Information

Local/Community

Individual/Family

Public /

Government

People/

Civil Society

Private/

Business

Policy Levels

Sectors

Integrated Health Governance – The Whole of Society Approach

Governance in Health Financing

What is Good Governance?

Rule of Law and Predictability – legal frameworks are fair and enforced impartially

Transparency – Free flow of information guaranteed; processes and institutions are directly accessible

Participation – Differing interest are mediated and broad consensus is reached on political, social and economic priorities

Accountability – decision-makers in public, private and civil society organizations are answerable to public and institutional stakeholders

Efficiency, Effectiveness and Equity – processes and institutions that will produce outcomes fairly to meet specific needs using optimal resources

Asian Values in Health and Social Care?

• Traditional family values such as filial piety

• Balance in life & health - “yin-yang” philosophy

• Public-Private-People – relationships between state, individual and family responsibilities

• Centrally planned/socialist Mixed economies

? Traditional civil society/clan associations

• Tri-sectoral approaches from empirical evidence – 1) infectious diseases 2) environmental pollution 3) migration (tripartite state/employer/employee)

Asian Health Systems Routledge Handbook of Global Public Health in Asia 2015

Lancet Series, 2011

Towards Evidence-Based Policies

LKYSPP Projects in Regional Health • Towards Greater Regional Health Governance in ASEAN, 2012 • Migration and Health in the Development Agenda: Towards

evidence-based policies for migrants’ health, ASEF, 2013 • Social Science & Medicine: Asian Health Systems, 2013 • Prospects for the Future: Towards Regional Governance in Health,

Urban Poverty and Health in Asia, 2014 • Comparative Health & Social Care Systems in Ageing Asia, 2015 • Asian Trends Monitoring: Diversity and Disparities in Development,

Rockefeller Foundation and Centre for Futures, Singapore, 2016 • Social Science and Health: Training for Governance (forthcoming) Case Studies (Lessons and Best Practices) • Healthcare for Foreign Workers - Social and Economic Approaches • Environmental Health and Economic Development • Disaster Management and Responses

Possible Roles for WHO in UHC Financing?

• Innovative health policies and programmes

- validation and dissemination

• Benchmarking PPP standards and impact

• Monitoring and evaluation reports

• Role of regional knowledge networks

- documentation of innovative approaches

- lessons and best practices for governance