Health Beyond Borders Healthcare Challenges in ASEAN and

Health Beyond Borders: Healthcare Challenges in ASEAN and Issues Concerning Health Professionals Dr Phua Kai Hong AB cum laude SM (Harv), Ph. D (LSE) National University of Singapore

Overview • Overview of ASEAN integration and its impact - Trade in Health Services - Rise of Medical Tourism and Health Industries - Health of Migrants/Migrant Health Workers • Health Systems Development in ASEAN - Universal Health Coverage - Delivery, Financing, Regulation, Information • Prospects and Challenges in the Health Sector - Demand Supply Conditions - ASEAN Health Governance

Asia in Transition • Socio-economic - Rapid industrialization/technological changes - Rising affluence and consumption - Increasing privatization and corporatization • Demographic - Rural-urban migration and travel - Fertility decline and family formation - Increasing longevity and ageing • Epidemiological - New and re-emerging infectious diseases - Rise of chronic non-communicable diseases - “Double burden” “Triple burden” of diseases

Lancet Series on Health in Southeast Asia: Overview on health and health-care, 2011

Improving Life Expectancies in South East Asia

Improving Health in Southeast Asia

Key Messages – Health in S. E. Asia • The diversity of geography and history, including social, cultural, and economic differences have contributed to highly divergent health status and health systems across and within countries. • Demographic transition is taking place at among the fastest rates compared with other regions of the world, whether in terms of fertility reductions, population ageing, and rural to-urban migration. Rapid epidemiological transition is also occurring with the disease burden shifting from infectious to chronic diseases. • Rapid urbanisation, population migration and high-density living raise concerns about newly emerging infectious diseases, but the outbreaks have stimulated regional cooperation in information exchange and improvement in disease surveillance systems. • The peculiar geology contributes to it being the most disasterprone region in the world, more susceptible to natural and manmade disasters affecting health, including earthquakes, typhoons, floods, and environmental pollution. Climate change along with rapid economic development could exacerbate the spread of emerging infectious diseases.

Key Messages - Health Systems in SE Asia • Regional health systems are a dynamic mix of public and private delivery and financing, with new organisational forms such as corporatised public hospitals, and innovative service delivery responding to competitive private health-care markets and growing medical tourism. • The health-care systems are highly diverse, ranging from dominant tax-based financing to social insurance and high out-of-pocket payments. There is a greater push for universal coverage of the population, but more needs to be done to ensure access to health services for the poor. • Private expenditure is increasing relative to government expenditure, where new forms of financing include user charges, improved targeting of subsidies and greater cost recovery. Health financing could be further restructured in response to future demographic shifts in age-dependency, as in medical savings and social insurance for long-term care. • There is potential for greater public-private participation with economic growth through regional integration and international health collaboration, despite the current division of the region under two WHO regional offices.

Comparative Health Systems in Asia Public-Private / Modern-Traditional / Formal-Informal - Pluralistic systems in most countries With Universal Coverage • Social Health Insurance (SHI) - Japan, Korea, Taiwan, Thailand • Tax-based National Health Service (NHS) - Hong Kong, Malaysia, Brunei, Sri Lanka Singapore (with mixed public-private, cost-sharing system and 3 M schemes - Medisave/Medishield/Medifund) Towards Universal Coverage • Social Health Insurance and Tax-based Public Healthcare - Philippines, Indonesia and other emerging economies • Social Health Insurance - China, Vietnam and transitional economies What is the optimum financing system?

The Iron Triangle of Health Care Quality (Effectiveness) Cost/Affordability (Efficiency) Universal Health Coverage Access (Equity) Means-testing

Comparative Health Systems: Impact of Medical Tourism Industry?

Comparative Health Studies in Asia and Europe

Comparative Health Systems: Regional Governance in EU vs ASEAN Comparative Studies of Health and Migration

Stakeholder Analysis for Healthcare Systems – Whose Costs and Whose Values? Regulators Minimize safety risk Control costs Payers Evaluate financing options Manage services & payment Evaluators Evaluate relative clinical and costeffectiveness Create guidelines Industry Providers Improve patient care & outcomes Increase efficiency Mitigate errors ? Shankar, Rethinking pharma strategy in light of global market trends • IMS Consulting

Future Global Health Policy Challenges – Goals for Research and Training • Produce information – conduct policy research, collect, analyze and synthesize evidence • Communicate evidence – dissemination or publication, media/PR, social marketing • Build capacity – train health policy researchers, broker knowledge transfer and partnerships • Promote/advocate policy and action - engage with stakeholders/policy-makers - monitor take-up by policy-makers - evaluate policy implementation

The Health and Social Policy Matrix (Whole of Society Approach) Policy Levels Governance/Regulation/Provision/Financing National/Societal Local/Community Individual/Family Public / Government Private/ People/ Markets Civil Society Sectors

Paradigm Shifts in Public Health Policy Global Health Democratization Governance Globalization Civil Society Health Policy Government Business Public Health Administration Healthcare Management Public-Private Participation

Towards Future Regional Collaboration – From Research to Policy to Action! ASEAN Summit on SARS Bangkok, April 29, 2003 ASEAN + 3 Health Ministers Meeting on Type A (H 1 N 1) Flu Bangkok, May 8, 2009 ASEAN Health Ministers and Senior Officials Meeting Singapore 2010, Phuket 2012, ? ? ? What Next?

ASEAN Cooperation in Health • Modus Operandi Technical Working Groups (TWG) Senior Officials Meeting (SOM) ASEAN Health Ministers Meeting (AHMM) • Turning Points SARS 2003 ASEAN Charter 2007: ASCC Blueprint ; ASEAN Health Division established • Engagement in Health Regional declarations and agreements on health • ASEAN within a Global Health Governance framework Limited cooperation with WHO (structural divisions in SEARO/WPRO) ASEAN + partners, APEC, TPP and other regional blocs Rising civil society and third sector

ASEAN 2015 Mutual Recognition Arrangement on Medical Practitioners • RECOGNISING the objectives of the ASEAN Framework Agreement on Services (AFAT), which are to enhance cooperation in services …. ASEAN Member States under the General Agreement on Trade in Services (GATS). . • RECOGNISING ASEAN Vision 2020 on Partnership in Dynamic Development, approved on 14 June 1997, which charted towards the year 2020 for ASEAN the creation of a stable, prosperous and competitive ASEAN Economic Region. . . • NOTING the decision of the Bali Concord II adopted at the 9 th ASEAN Summit held in 2003 calling for the completion of Mutual Recognition Arrangements (MRA) for qualifications in major professional services by 2008 to facilitate free movement of professionals/skilled labour/talents in ASEAN; and • PROVIDING an MRA for Medical Practitioners that would strengthen professional capabilities by promoting the flow of relevant information and exchange of expertise, experiences and best practices. . .

ASEAN 2015 MRA (contd) • ARTICLE I OBJECTIVES • ARTICLE II DEFINITIONS Professional Medical Regulatory Authority (PMRA) refers to a body vested with the authority by the government in each ASEAN Member State to regulate and control Medical Practitioners and their practice of medicine • ARTICLE III RECOGNITION AND ELIGIBILITY OF FOREIGN MEDICAL PRACTITIONERS • ARTICLE IV PROFESSIONAL MEDICAL REGULATORY AUTHORITY • ARTICLE V RIGHT TO REGULATE • ARTICLE VI ASEAN JOINT COORDINATING COMMITTEE ON MEDICAL PRACTITIONERS • ARTICLE VII MUTUAL EXEMPTION • ARTICLE VIII DISPUTE SETTLEMENT • ARTICLE IX AMENDMENTS • ARTICLE X FINAL PROVISIONS Signed by Ministers of Trade and Industry of all ASEAN Member States

Beyond ASEAN Community 2015 Proposals to support healthcare integration – ASEAN wide framework for portability of health insurance and payment mechanisms – Minimize visa requirements for patients – Balance region-wide demand supply of health care workers, materials, resources, etc – Harmonisation of professional standards – Region-wide quality standards for training, accreditation, licensing, monitoring, etc

Health Care Policy and Governance Challenges in Asia – Facing Diversity and Disparities!

Selected References • • • Nichols LM, Prescott N and Phua KH, Medical Savings Accounts for Developing Countries, in Innovations in Health Care Financing, GJ Schieber (ed), World Bank Discussion Paper No. 365, 1997 Phua KH, Medical Savings Accounts and Health Care Financing in Singapore, in Innovations in Health Care Financing, GJ Schieber (ed), World Bank Discussion Paper No. 365, 1997 Phua KH, Comparative Health Care Financing Systems, with Special Reference to East Asian Countries, Research in Healthcare Financial Management 5(1), 1999 Phua KH, Financing Health and Long Term Care for Ageing Populations in the Asia-Pacific Region, Ageing in the Asia-Pacific Region, Philips D (ed. ): 93 -112, Routledge, London, 2000 Phua KH, The Savings Approach to Financing Long Term Care in Singapore, Journal of Ageing and Social Policy 13(2/3): 169 -183, 2001 Phua KH, Towards a Comparative Analysis of Health Systems Reforms in the Asia -Pacific Region, Asia-Pacific Journal of Public Health 14(1): 9 -16, 2002 Phua KH, Health Care Financing in the Asia-Pacific Region, Public Administration and Policy 11(2): 13 -36, 2003 Phua KH, Attacking Hospital Reforms on Two Fronts: Network Corporatization and Health Care Financing, Innovations in the Delivery of Health Services, Preker A & Harding A (eds), Human Development Network, World Bank, 2003 Phua KH, Singapore, Chapter in Social Health Insurance: Selected Case Studies from Asia and the Pacific, WHO WPRO and SEARO, March 2005

Selected References • Virasakdi C, Phua KH, Yap MT et al, Health and Health-care Systems in Southeast Asia: Diversities and Transitions, Lancet, January 2011 • Phua KH and Pocock N, Medical Tourism and Implications for Health Systems Globalization and Health, 7: 12, 2011. • Lamy, Marie and Phua, Kai Hong (2012) Regional health governance: a comparative perspective on EU and ASEAN, EU Centre Policy Brief 4, June 2012 • Lamy M and Phua KH, Southeast Asian cooperation in health: a comparative perspective on regional health governance in ASEAN and the EU, Asia-Europe Journal, 10(4) Aug 2012 • Trummer U, Novak-Zezula S, Phua KH et al, Migrants and Healthcare: Social and Economic Approaches, Asia-Europe Foundation, 2014 • Phua KH and Wong MLL, Comparative Health Systems in Asia, in Routledge Handbook of Global Public Health in Asia , Griffiths S at al (eds), Routledge, 2014 • Smullen A and Phua KH, Comparative Analysis of Health Systems in Asian High. Performing Economies, Policy Brief, Journal of Asia & Pacific Policy Studies, Australian National University, 2015 • Phua KH et al, Public Health and Development in Middle Income Countries, The Oxford Textbook of Global Public Health (5 th edn), Oxford University Press, 2015 • Phua KH, Health and Health Systems in Southeast Asia, World Scientific, 2015 (forthcoming)