Chronic diseases are rising rapidly across Southeast Asia and look set to continue, given ageing societies, growing affluence, increased urbanisation and changing nutritional patterns. Public and private healthcare need new, improved ways of working together to tackle this silent epidemic.
Introduction
Chronic diseases account for over 75 per cent of all deaths in Southeast Asia , with the most prevalent being cardiovascular disease, cancer, diabetes, and chronic respiratory conditions. In 2017 alone, direct and indirect costs from chronic diseases, which include health, economic and social impacts, amounted to 8 per cent of GDP in Malaysia, 9.7 per cent in Thailand, and 5 per cent in the Philippines. As of 2019, cardiovascular diseases are the leading cause of death across Southeast Asia, followed by other non-communicable diseases (NCDs) such as diabetes and lung cancer. This places a significant burden on public health systems which could benefit from partnerships with the private sector to effectively meet patients' needs.
Private spending makes up about half of total healthcare expenditure in Southeast Asia. Yet the private sector is often left out of policy, programs, and financing. Given that chronic diseases are long-lasting and persistent and will increase due to growing affluence and ageing societies, the private sector has a vital role to play in chronic disease control efforts. We need to think of improved and reformed public-private partnerships (PPPs) - ones that go beyond acute care to prioritise proactive and holistic models of care.
What challenges do PPPs currently face?
Governments responded to COVID-19 by rapidly involving the private sector, reflecting the scale and severity of the worst global pandemic since 1918. But this has not translated to other sectors, including chronic disease management. Some common challenges include
Unaligned goals. Without unified vision, PPPs tend to face rudderless leadership, poorly defined management roles and a lack of accountability to their stakeholders.
Inadequate risk and financial mitigation. Rigid contracts, inadequate incentives and financing frameworks can impede success given that the private sector needs sufficient risk mitigation to implement projects.
Limited scalability. The scope and scale of PPPs may not translate to a population-wide program, especially if the project has not been adequately resourced or designed as above. This is further complicated by the geographical and development challenges that Southeast Asian countries face, including remote mountainous areas, far flung islands, and poor transport and communications infrastructure.
How to build better PPPs
Several frameworks have been proposed. Harvard’s Health Policy Innovation Lab suggests that “strategic PPPs” are needed: long-term, sustainable public-private relationships that adopt an “inclusive and agile” approach, underpinned by five principles: trust, integrity, interdependence, learning and iterative improvement. Harvard’s framework is useful to identify the ‘spirit’ (and not merely the letter) of how partnerships should be structured. Highlighting that “collaborative governance” in healthcare service delivery should be led by the public sector, the Asian Development Bank (ADB) advocates four processes: analysis of need, costs and benefits; assignment of responsibility; design of roles, responsibilities, incentives and accountability, and regular performance assessments. Lastly, the World Economic Forum (WEF) - while largely echoing the Harvard and ADB frameworks - adds that good public engagement and communication is essential.
Align interests, goals while building in flexibility.
While the private sector has a greater focus on profit maximisation, both public and private providers are aligned in a social mission to deliver high quality care to all patients. Stakeholders' ability to respond to changing circumstances - whether new health security threats or chronic disease management - will allow the private sector to be a responsive player in health systems.
In India, the CoWin portal (set up by industry, providers and the government) is being repurposed from a COVID-19 vaccination program to delivering polio and hepatitis vaccinations, thanks to stakeholder alignment and flexible contractual arrangements. Private providers in Thailand were able to be reimbursed for services in 15 days, after the National Health Security Office reduced the timeline from one month to ease cashflows. This change was maintained even after the pandemic subsided and continues to apply to all services covered under universal health coverage.
Engage relevant stakeholders early and consistently.
As highlighted by the WEF, early, consistent, and active engagement of public and key stakeholders is integral to secure buy-in for PPPs. In Malaysia, ProtectHealth Corporation, a non-profit under the Malaysian MOH, works with private providers to conduct NCD health screening. ProtectHealth was proactive in organising engagement sessions with NGOs and the public, to adequately understand their needs and solicit input. This enabled ProtectHealth to provide over 545,000 health screenings through the program since 2019.
Leverage public sector convening power while tapping on private sector capacity.
Southeast Asian governments have greater access to public healthcare infrastructure, capacity building, manpower deployment, and research technology. The success of healthcare PPPs depends on the government’s ability to tap on these resources to ensure a population-wide impact of the PPPs’ programs, to engage behavioural change on a large scale. Governments can also establish dedicated PPP taskforces within their organisation to lead PPP negotiations, communications, and stakeholder engagement with the private sector.
The PPP can tap the private sector’s innovation, technology expertise, and leadership to create targeted and future-oriented models of healthcare management. Private general practitioners (GPs) in Singapore provide 80 per cent of all primary care services. Under the Primary Care Networks (PCN) scheme, the Ministry of Health has provided financing to incentivise GPs to organise informal networks that access ancillary services for people with diabetes, nurse counsellors and care coordinators. Data collection and analysis via a Chronic Disease Registry (CDR) was also established to ensure continuity of care and regular monitoring and evaluation. The CDR has enabled private GPs to record process and outcome indicators, improving the team-based care model of Singapore’s chronic disease management.
The future of PPPs
The COVID-19 pandemic exposed the limitations of the public health sector to cope with national health threats, where many healthcare services were over-stretched. To create more resilient health systems, improved ways of working together are needed. We are already witnessing health systems in countries such as Malaysia, Indonesia, and Singapore, transforming to focus on multi-stakeholder solutions and PPPs.
Looking ahead, using PPPs in chronic disease management will allow governments to transition to an overarching role in healthcare monitoring, regulation, and evaluation while leveraging private sector expertise, financing, and leadership to spearhead efforts towards lowering the regional chronic disease burden.
References
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