Providing equitable access to healthcare
services and addressing funding problems is the main focus
of healthcare policies in the 10 countries covered by the IMS
Market Prognosis Asia report. None of the
10 countries spends more than 6% of its gross domestic
product on healthcare, well below the OECD average of 8.1%,
with the proportion varying from just 2.4% in Indonesia
to 6% in South Korea.
Limited
access will remain a problem for large sections of the
region’s population during
the prognosis period (through 2007), largely because of
a lack of adequate resources and insufficient healthcare
infrastructure. China’s reform policy for the introduction
of basic healthcare insurance for urban employees and a
restructuring of the hospital system is focused on urban
areas, leaving limited access a problem for the rural population
- more than 800 million people. India’s approach
to decentralisation has proved overly bureaucratic, and
the lack of infrastructure will thwart implementation of
the new National Health Policy, one aim of which is the
provision of modern healthcare to the two-thirds of the
population in rural areas who are currently denied access.
For
the Philippines and Indonesia, overcoming the geographical
obstacles and widespread poverty, which
deny access to healthcare for at least one third of their
populations, represents a major challenge. The speed with
which Thailand implemented its new low-cost healthcare
programme - the so-called ‘30 baht’ scheme
- in 2002 took many observers by surprise, but future viability
of the scheme will depend on addressing the funding crisis,
which is also undermining progress with Thailand’s
reform of the public hospital sector.
Longer
term structural reforms…
Approaches to tackling the increasing demands
on healthcare provision while limiting the increase in
costs are under discussion in most countries in the region.
Reform of health insurance schemes has become a priority
as income is failing to meet expenditure, contributing
to growing budget deficits.
Having
achieved radical reforms to South Korea’s healthcare system, government policy is now
focused on addressing the funding deficit of the National
Health Insurance system, which covers 97% of the population.
South Korea is increasing patients’ premiums and
co-payments for health services and drugs in an attempt
to address its budget crisis, which has been exacerbated
by recent healthcare
reforms that have added to costs.
The
issue is also preoccupying the government of Taiwan,
where universal healthcare coverage has largely
been achieved through the National Health Insurance scheme,
which is now in deficit and a priority for reform. In 2002,
Taiwan introduced the first increase in insurance premiums
since 1995 to address the NHI scheme’s deficit. The
implementation of global budgets for the general practitioner
clinics sector in 2001 and the hospital sector in 2002
includes ceilings for all expenditures.
Broad
reform of healthcare delivery to contain costs of the
heavily subsidised public system is a short-term
goal in Hong Kong, while healthcare financing reform will
be a long-term objective. Hong Kong is grouping hospitals
into regional clusters to increase specialisation and avoid
duplication of services, which will see primary care playing
an increased role as the clusters step up the momentum
to develop a fully integrated healthcare system. Longer
term, a medical savings scheme is envisaged in Hong Kong,
along the lines of Singapore’s compulsory savings
scheme, Medisave.
While
Singapore’s government subsidises
up to 80% of basic medical services, the increase in the
number of patients opting for more heavily subsidised wards
as a result of economic slowdown has prompted the government
to look at introducing selective means testing. Singapore’s
efforts to restructure its healthcare system have had mixed
success, as some hospitals have encountered financial difficulties
with higher operating costs and low fees, despite savings
achieved through bulk purchasing arrangements. As Hong
Kong embarks on a similar programme, cost savings will
be sought from standard formularies and centralised purchasing.
The threat of a funding crisis in Malaysia
is adding impetus to proposals for an NHI scheme based
on compulsory contributions, although implementation is
some years away. Similarly, plans for a new NHI programme
in Thailand, merging the 30 baht scheme with existing public
insurance schemes, are unlikely to come to fruition in
the short term. Plans for a new health insurance scheme
in Indonesia have so far failed to get off the ground and
under-funding will remain a problem. The insurance scheme
in the Philippines accounts for just 7% of healthcare expenditure,
underlining the limited benefits of such a scheme.
Concerted attempts are being made in a number
of countries to shift more care from the hospital sector
to the primary sector, and to place more emphasis on disease
prevention and health promotion:
-
Taiwan is attempting to shift more
of the care into the primary sector by offering incentives
to GPs, especially for chronic disease care
-
Hong Kong is planning to shift more
care to the primary sector through family medicine
centres, outsourcing chronic disease treatment from
hospitals and shared protocols with private sector
GPs, while shifting more costs to patients, who have
hitherto made little contribution
-
Malaysia’s
moves to implement a GP gatekeeper system in its
largely hospital-led
system have been hampered by a shortage of doctors,
and financing reform of the government-funded public
system has now become a priority.
Healthcare
reforms have also focused on improving the efficiency
of the hospital sector. China’s plans
to reorganise enterprise-affiliated hospitals by 2005 will
contribute to the major restructuring of the hospital system,
which seeks to engender cost-efficiencies and introduce
competition. While Indonesia has focused on developing
its primary care sector, the financial and administrative
autonomy being given to government hospitals is being undermined
by the decentralisation process.
… versus
short-term pharmaceutical cost-containment measures
Pharmaceutical
expenditure varies as a proportion of total healthcare
spending across the region, accounting
for up to 60% of costs in China’s hospitals and as
little as 6% of the Hospital Authority’s costs in
Hong Kong. With limitations to the extent to which more
of the burden can be shifted on to patients, controlling
drug costs and making treatment more accessible by providing
cheap drugs have become key components of governments’ cost-containment
policies.
Pharmaceutical cost-containment measures
in the region are a mix of demand and supply controls.
Where drug reimbursement is available, reimbursement limitations,
ranging from more difficult access reimbursement lists
and delistings to tighter controls on reimbursement and
reimbursement prices, are the major focus of cost-containment.
Measures are also aimed at drug purchasing, and in many
countries volume drug purchases are attracting wider uptake
of tenders or group purchasing arrangements. Hospital purchasing
practices and patient purchasing power tend to exert powerful
influences on prescribing but direct prescribing controls
are being stepped up in a number of countries.
In addition, mechanisms to improve rational
use of drugs are being developed. There is also a trend
towards more restricted formularies in public hospitals,
and price is increasingly the main factor for inclusion
on formularies in a number of countries. The introduction
or extension of diagnosis-related group or case payment
systems is increasing cost-awareness among prescribers
and encouraging the use of low-cost medicines. Furthermore,
patient co-payments are gradually stepped up, heightening
cost awareness among patients.
This article was written by Andrea Streit,
a Project Manager for IMS Market Prognosis. For more information
on IMS' Forecasting portfolio, please contact Cristina
Cucinotta or call +44 207 393 5254.
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