Dr Kai Hong PHUA Visiting Professor Nazarbayev University Lee Kuan Yew School of Public Policy

1. HEALTH FINANCING REFORMS FOR Universal Health CoverAGE:Public-Private PartNERSHIP FRAMEWORK Dr Kai Hong PHUA Visiting Professor Nazarbayev University Lee Kuan Yew School of Public Policy National University of Singapore

2. Overview • Introduction • UHC for the Public-Private-People Sectors • PPP Innovations in Health Financing • Role of PPP in Health – Governance Issues • Implications for Kazakhstan and Central Asia • Conclusion

3. Introduction • Presentation at 2015 Singapore Conference on UHC – Achieving the Post-2015 Development Agenda • Presentation at World Health Organization, Apr 2017 Dept of Health Systems Financing & Governance • Definitions of Public-Private Partnerships (PPPs) Public-Private Participation involving the People Sector - Civil Society, Voluntary or Third Sector, NGOs, etc - Public-Private Mix  Optimal Balance (Optimization) - New Public Administration New Public Governance - Asian Models of PPPs in Health and Social Care

4. 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 or trade-offs? The Iron Triangle

5. 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

6. Social Goals of the Optimum Mix Seeks to balance between extremes • State Monopoly • Total tax-funded • Social insurance • - ‘Free’ services • Low quality • Inefficiency Free MarketPure profit-making Private insurance - Moral hazard - Adverse selection - Inequity

7. Effective delivery of UHC requires public-private-people participation • Government and public sector • Investments in public health and primary care e.g. sanitation, vaccination and MCH services • Focus limited resources on supplying essential services targeted 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 integrity, idealism, altruistic and charitable values (professional, academic, moral and faith-based organizations)

8. 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 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

9. Role of non-profit providers is important… • Non-profit providers include voluntary welfare organisations and faith-based organisations -- track record for resource mobilization -- humanitarian funds (eg RC’s Human Impact Bonds) • 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

10. 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

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

12. Towards an Optimal Public-PrivateBalance 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

14. Paradigm Shifts in New Public Governancefor Universal Health Coverage Government Universal Health Coverage Civil Society Business Democratization Globalization Public-Private-People Participation

15. Integrated Health Governance –The Whole of Society Approach Policy Levels Provision/Financing/Regulation/Information National/Societal Local/Community Individual/Family Private/ Business Public / Government People/ Civil Society Sectors

16. Governance in Health Financing

17. 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  market economies ?Traditional civil society/family and clan support • Inter-generational social support mechanisms • Tripartite approaches – state-employer- employee relations to modern corporate structure

18. Policy Implications for UHC Financing in Kazakhstan and Central Asia? • Contexts of Central Asia – a confluence of history and geography - mix of social, cultural and religious values • Recent historical, economic and political developments • Innovative health and related policies and programs - require validation and dissemination - benchmarking quality standards and impact • Comparative policy and systems research • Role of regional knowledge networks - documentation of innovative policies with evidence - lessons and best practices for governance

19. Lancet Series, 2011

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

21. Towards Evidence-Based Policies in Asia National University of Singapore Projects in Regional Health • NUS Initiative to Improve Health in Asia (NIHA) – 2010-2020 • Towards Greater Regional Health Governance in ASEAN, 2012 • Migration and Health: Towards evidence-based policies for migrants’ health, Asia-Europe Foundation, 2013 • Social Science & Medicine: Asian Health Systems, 2013 • Prospects for the Future Regional Governance in Health, 2014 • Comparative Health & Social Care Systems in Ageing Asia, 2015 • Asian Trends Monitoring: Diversity and Disparities in Development, Rockefeller Foundation, Lee Kuan Yew School of Public Policy and Centre for Futures, Prime Minister’s Office, Singapore, 2016 • Ageing Asia: Contemporary Trends and Policy Issues, 2018 Case Studies (Lessons and Best Practices) • Migrants and Healthcare - Social and Economic Approaches • Environmental Health and Economic Development (The Haze) • Disaster Management and Responses