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4.health systems financing.asia by Prof. Pua
 

4.health systems financing.asia by Prof. Pua

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Prof Phua Kai Hong holds a tenured appointment at the Lee Kuan Yew School of Public Policy and was previously Associate Professor and Head, Division of Health Care, Department of Community, Occupational & Family Medicine at the Faculty of Medicine, National University of Singapore, where he teaches health policy, health care management and health economics in the various graduate programs in public policy, public health and business administration. He was also an Adjunct Senior Fellow at the Institute of Policy Studies, Singapore. He graduated with honours cum laude from Harvard University and received graduate degrees from the Harvard School of Public Health (Master’s in Health Services Administration & Population Sciences) and the London School of Economics & Political Science (PhD in Health Economics). He was the recipient of a Harvard College Scholarship, the Sigma Scholarship from the Faculty of Arts & Sciences, Harvard University and a NUS Overseas Graduate Scholarship

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    4.health systems financing.asia by Prof. Pua 4.health systems financing.asia by Prof. Pua Presentation Transcript

    • Health Systems Financing in Asia Dr Phua Kai Hong, AB cum laude SM (Harvard), PhD (LSE) Lee Kuan Yew School of Public Policy National University of Singapore
    • Current Trends and Issues in Health Care Financing in Asia
      • Predominantly out-of-pocket expenditure in WHO SEARO and WPRO (Asia-Pacific)
      • Growth in social insurance and less taxation in WPRO region (eg Korea, China, Vietnam)
      • Increasing catastrophic expenditure and impoverishment due to healthcare spending (China and transitional economies)
      • High expenditures for drugs and diagnostics (50-60 % of total health budget in China)
      • Strong fundamentals and driving forces for increasing demand and consumption
    • Comparative Health and Expenditure in Selected Asian Countries ( WHO Report 2000)
      • $/capita (Int $) Public/Total %GNP %Pop>60 DALE
      • Japan 2373 (1759) 80.2 7.1 22.6 74.5
      • Korea 700 (862) 37.8 6.7 10.2 65.0
      • China 20 (74) 24.9 2.7 10.0 62.3
      • India 23 (84) 13.0 5.2 7.5 53.2
      • Singapore 843 (750) 35.8 3.1 10.3 69.3
      • Brunei - (857) 40.6 5.4 5.0 64.4
      • Malaysia 110 (202) 57.6 2.4 6.5 61.4
      • Thailand 133 (327) 33.0 5.7 8.5 60.2
      • Philippines 40 (100) 48.5 3.4 5.6 58.9
      • Indonesia 18 (56) 36.8 1.7 7.3 59.7
      • Vietnam 17 (65) 20.0 4.8 7.5 58.2
      • Myanmar 100 (78) 12.6 2.6 7.4 51.6
      • Cambodia 21 (73) 9.4 7.2 4.8 45.7
      • Laos 13 (53) 62.7 3.6 5.2 46.1
      • Health Expenditure
      • % GDP Per capita
      • France 9.8% $2,369
      • Italy 9.3% $1,855
      • San Marino 7.5% $2,257
      • Andorra 7.5% $1,368
      • Malta 6.3% $551
      • Singapore 3.1% $876
      • Spain 8.0% $1,071
      • Oman 3.9% $370
      • Austria 9.0% $2,277
      • Japan 7.1% $2,373
      Health Systems Performance WHO Rankings 2000
    • WHO Health Systems Performance Assessment
      • Health Attainment (Effectiveness)
      • Responsiveness (Efficiency)
      • - basic amenities, social support, respect,
      • confidentiality, autonomy, choice,
      • communications
      • Fairness in Financing (Equity)
      • - distribution of risks, social protection
    • Effects of Health Care Financing and Payment Systems
      • EQUITY Who pays? Who benefits?
      • - Distribution
      • - Access
      • EFFICIENCY Supply & Demand
      • - Allocation
      • - Production
      • EFFECTIVENESS Outcomes
      • - Quality of Care
      • - Health Status
    • Comparative Health Expenditure in Selected Developed Countries U.S. Germany Canada Japan U.K. Singapore Year
    • Some Reasons for Singapore’s High Ranking and Low Expenditure
      • Relatively high GNP growth in denominator
      • Lower consumption due to age structure (age-adjusted projection up to 6-8% of GNP)
      • Strong budgetary controls on public spending
      • Absence of comprehensive health insurance
      • Government subsidies for public health and differential pricing for personal consumption
      • ? Cost-sharing and co-payment system
    • Health Expenditures as % of GDP in East Asian Economies (2000)
      • National Health Insurance Systems
      • Japan 7.1
      • Korea 6.7
      • Taiwan 5.0
      • National Health Service Systems
      • Hong Kong 4.7
      • Malaysia 2.4
      • Singapore 3.1
    • Healthcare Expenditure in East Asia % GNP Public:Private 36 : 64 3.1 Singapore 58 : 43 2.4 Malaysia 80 : 20 7.1 Japan 38 : 62 6.7 Korea 54 : 46 4.7 Hong Kong 66 : 34 5.0 Taiwan
    •  
    • Asian Health Care Financing Systems
      • With Universal Coverage
      • Social Health Insurance
      • - Japan, Republic of Korea, Taiwan, Thailand
      • National Health Service
        • - Singapore, Hong Kong, Malaysia, Sri Lanka
      • Without Universal Coverage
      • Social Health Insurance
        • - China, Vietnam and transitional economies
      • National Health Service
        • - India, Indonesia and other developing countries
    • Selected Health Care Financing - Social Health Insurance Models
      • JAPAN
      • Universal health insurance (1922/1939)
      • NHI Law amended (1984/1990)
      • Trial DRG/PPS in 10 Hospitals (1/11/1998)
      • Long term care insurance (1997/2000)
      • KOREA
      • Universal health insurance (1976/1989)
      • Health Care Reform Committee (1994/1997)
      • K-RDRG Pilot Program (1997-1998)
      • TAIWAN
      • Universal health insurance (1995)
      • Partial DRG system (from 1998)
      • Cost-containment measures (from 2000)
    • Selected Health Care Financing – National Health Service Models
      • SINGAPORE
      • National Health Plan (1983)
      • Medisave/Medishield/Medifund (1984/1990/1993)
      • Review Committee on National Health Policies (1992)
      • White Paper on Affordable Health Care (1993)
      • Casemix Funding (1999)
      • Eldercare Fund/Eldershield (2000/2002)
      • Enhanced Medishield/Private Insurance (2005)
      • HONG KONG
      • Scott Report (1985)
      • Consultation Paper - Towards Better Health (1993)
      • Harvard Consultant’s Report (1999)
      • Consultative Paper - Lifelong Investments in Health Care(2000)
      • Proposal for Supplementary Private Insurance (2010)
    • Changing Features of the Singapore Health Care System
      • Mixed Public-Private Health Care Market
      • Choice of private and public systems
      • Competition and integration between public, private and voluntary sectors
      • Appropriate mix of financing methods
      • Co-payment at the point of consumption
      • Selective insurance to avoid moral hazard
      • Targeted public subsidies to address inequity
      • Government benchmarks for prices & quality
    • Public-Private Health Expenditure in Singapore (1965-2000)
    • Singapore Health Statistics – Past and Present
      • 1980 2005
      • Life expectancy 70 years 80 years
      • Infant mortality 12/’000 2.5/’000
      • Aged/total population 5 % 9 %
      • Public hospital mix 85 % 80 %
      • Health expenditure/GDP 3 % 4 %
      • Health expenditure/ 6 % 7 % government budget
      • User fees recovered / 3 % 60% public expenditure
    • Singapore’s Hybrid Health Care Financing Seeks to avoid either extremes -
      • Welfare State
      • Tax-funded/
      • Social insurance
      • - ‘Free’ services
      • Low quality
      • Inefficiency
      Free Market Fee for service Private insurance - Moral hazard - Adverse selection - Inequity
    • Healthcare Financing Strategies Instill personal and family responsibility (Cost-sharing) + Ensure future sustainability with ageing and avoid inter-generational problems (Savings) + Enhance risk-pooling and social protection (Insurance) + Target subsidy and equitable distribution (Taxation)
    • Medisave Medishield Medifund PRIMARY CARE ACUTE CARE CATASTROPHIC (LONG TERM CARE) Financing Method Private Payment Compulsory Savings Social/Private Insurance PUBLIC SUBSIDIES Source: Dr. Phua Kai Hong Taxes PUBLIC HEALTH SERVICES (Eldershield) (Eldercare fund) Health Care Financing in Singapore
    • Public Hospitals: Bed Distribution
    • Health Care Financing Reforms - The Unfinished Agenda
      • Blue Paper – National Health Plan
      • 1984 Medisave
      • 1990 Medishield
      • 1993 Medifund
      • 1993 White Paper - Affordable Health Care
      • 2000 Eldercare Fund
      • Eldershield
      • 2005 Enhanced Medishield/Private Insurance
      • Means Test (Targeted Public Subsidies)
      • ?
    • The Singapore Health Care Model
      • Singapore’s health system ranked extremely high
      • Reputation for high quality, choice and efficiency
      • Equity risks covered by subsidies and safety nets
      • Fully funded medical savings with social insurance to finance increasing needs of ageing population
      • Balance between health care supply and demand with pricing and subsidy, while containing costs
      • Goals of efficiency, equity, quality and sustainability to be maintained by appropriate public-private mix in provision, financing, regulation and education
    • Similar Approaches to Old Age Security and Health Care Financing
      • World Bank’s 3 Pillars for Old Age Security
      • Redistribution (Taxation)
      • Savings
      • Insurance
      • Singapore’s 3M for Health Care Financing
      • Medisave (avoids inter-generational transfers)
      • Medishield (pools risks for catastrophic care)
      • Medifund (subsidizes the poor and indigent)
    • 4 8 12 16 20 24 28 0 2 4 6 8 10 12 14 France Switzerland Russia Germany Italy Finland Norway Sweden Belgium United Kingdom Denmark Spain Portugal Greece Japan Ireland New Zealand Australia Canada United States Hong Kong Taiwan Korea Malaysia Singapore Health Expenditure as % of GDP Aged Dependency Ratio (>65/Aged 15-64) Health Expenditures and Ageing
    • Population Ageing: Impact on Health Expenditure
      • Health expenditure will increase with growing proportion of the aged
      • Health expenditure will increase with longer survival of the aged population
      • Health expenditure will increase with widening periods of morbidity and disability before death
    • Population Ageing Trends by 2030
    • Health and Long Term Care Financing in Japan
      • Universal health insurance 1922-1939
      • National Health Insurance (1961)
      • Health Service Law for the Aged (1982/1986)
      • National Health Insurance amendments 1984-1990
      • The Golden Plan / New Golden Plan (1990) -
      • 10 -Year Gold Plan for the Development of Health and Welfare Services for the Elderly
      • Public Long Term Care Insurance Act (1997) - implemented in 2000
      • - 50% insurance (40 years and above)
      • - 50% general taxation
    • Health and Long Term Care Financing in Singapore
      • FINANCING METHOD
      • Personal savings
      • Compulsory savings
      • Catastrophic insurance
      • Disability insurance
      • Endowment
      • Taxation
      • 3-M SYSTEM + 2E
      • MEDISAVE (1984)
      • MEDISHIELD (1990)
      • + ELDERSHIELD(2002)
      • MEDIFUND (1992)
      • + ELDERCARE FUND (2000)
    • Special Conditions in Asia
      • Fastest pace of economic transition
      • Highest rates of population ageing and population growth
      • Great propensity for savings
      • Strong traditional family support systems
      • Old age security and health care financing
      • must contend with such considerations