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