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Public-private mixed system
Social health insurance and tax-based systems offer viable routes to UHC. However there is
evidence that a few health systems with modest levels of government spending and that use
approaches that do not fit the classic tax-based model have been able to progress
substantially towards UHC. These cases include Sri Lanka, Malaysia, Hong Kong, Ireland,
and Australia. These health systems combine public financing and delivery with a substantial
reliance on private financing and delivery. They have been described as dual-track, parallel,
and hybrid systems to denote their mixed public-private funding and provision approach.
These systems, which span the globe and levels of economic development, may be
characterised by notable performance on health outcomes, low levels of government
spending, and a significant out-of-pocket spending share in total financing.
2.2.2 INTERNATIONAL COMPARATIVE ANALYSIS:
STRATEGIC PURCHASING FOR CHRONIC DISEASE
SCREENING AND MANAGEMENT
Each system has its own merits and limitations and challenges which may be aggravated by
escalating healthcare demand driven by population ageing and the associated increasing
prevalence of chronic diseases. Rather than reforming the entire foundation of healthcare
financing schemes, strategic purchasing allows mobilisation of finite resources to optimise
provider systems, hence increasing capacity and enabling long-term sustainability.
To better explore how strategic purchasing works in chronic disease prevention and
management which is one of the biggest challenges in Hong Kong and globally, we used a
qualitative case study approach to review the purchasing programmes against a strategic
purchasing framework. Different jurisdictions were chosen for diverse geographical locations
and health system types (tax-based system, social health insurance system, private health
insurance dominated system, and public-private mixed system). The resulting sample was of
eight jurisdictions: the United Kingdom (UK), Canada, China, Japan, the United States (US),
Australia, Malaysia, and Singapore. An overview of economic and health spending indicators
of the jurisdictions is presented in Table 2.1.
For each jurisdiction, one existing purchasing programme or policy for chronic disease
prevention and management was reviewed. As presented in the Section 2.1, purchasing
involves mainly three sets of decisions: (a) what to purchase: identifying the interventions or
services to be purchased, taking into account population needs, national health priorities,
cost-effectiveness and other factors; (b) from whom to purchase: choosing service providers,
giving consideration to service quality, efficiency and equity and (c) how to purchase:
determining how services will be purchased, including contractual arrangements and
provider payment mechanisms. The purchasing programme/policy for chronic disease
screening and management in each jurisdiction was reviewed from those three perspectives
in Table 2.2.
The key goal of this section is to evaluate to what extent these purchasing programmes fulfil
the definition of strategic purchasing. Several theoretical models exist that define strategic
purchasing. We used the synthesised framework of strategic purchasing constructed by
Klasa et al., which was derived from systematically reviewing the existing definitions and
components of strategic purchasing (Klasa et al., 2018). We benchmarked the characteristics
of those purchasing programmes in Table 2.2 against the synthesised strategic purchasing
framework.
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