Health Beyond Borders: Healthcare Challenges in ASEAN and Issues Concerning Health Professionals

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Health Beyond BordersHealthcare Challenges in
ASEAN and Issues Concerning Health Professionals
Dr Phua Kai Hong AB cum laude SM (Harv), PhD
(LSE) National University of Singapore


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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 and Supply Conditions   
• - ASEAN Health Governance

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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

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Lancet Series on Health in Southeast Asia
Overview on health and health-care, 2011
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Improving Life Expectancies in South East Asia
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Improving Health in Southeast Asia
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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 disaster-prone region in the world, more
  susceptible to natural and man-made 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.

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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.

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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 3M schemes - Medisave/Medishield/Medif
  und)
• 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?

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The Iron Triangle of Health Care
Universal Health Coverage
Quality (Effectiveness)
Cost/Affordability (Efficiency)








Access (Equity)
Means-testing
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Comparative Health SystemsImpact of Medical
Tourism Industry?
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Comparative Health Studies in Asia and Europe
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Comparative Health SystemsRegional Governance
in EU vs ASEAN
Comparative Studies of Health and Migration
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Stakeholder Analysis for Healthcare Systems
Whose Costs and Whose Values?
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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

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the Health and Social Policy Matrix(Whole of
Society Approach)
Policy Levels
Governance/Regulation/Provision/Financing
National/Societal
Local/Community
Individual/Family
Private/ Markets
Public / Government
People/ Civil Society
Sectors
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Paradigm Shifts in Public Health Policy
Globalization
Democratization
Civil Society
Health Policy
Government
Business
Public-Private Participation
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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 (H1N1) Flu Bangkok,
  May 8, 2009
• ASEAN Health Ministers and Senior Officials
  Meeting
• Singapore 2010, Phuket 2012, ???

What Next?
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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

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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 9th 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 .....

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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

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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 and supply of health
  care workers, materials, resources, etc
• Harmonisation of professional standards
• Region-wide quality standards for training,
  accreditation, licensing, monitoring, etc

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Health Care Policy and Governance Challenges in
Asia Facing Diversity and Disparities!
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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
  Policy11(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

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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, 712, 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 (5th edn), Oxford University
  Press, 2015
• Phua KH, Health and Health Systems in Southeast
  Asia, World Scientific, 2015 (forthcoming)