Lessons From Netherlands On Public-Private Partnerships For Health ‘Moonshot’

The Netherlands, whose population is about half of Malaysia, has over 600 public-private partnerships in its life sciences and health sector. The European country aims to add five years of healthy living to the Dutch and cut health inequalities by 30%.

ROTTERDAM, Jan 19 – By 2040, the Netherlands aims to add five healthy years to every resident and to reduce health inequalities between the poorest and richest by 30 per cent.

The World of Health Care (WoHC) and Health-Holland Visitors Programme 2022 held in Rotterdam, the Netherlands, last September showed how the Dutch prioritise public-private partnerships (PPPs), science, and innovation in their aim to improve healthy living, access to health care outside of institutions, and quality of life for people with non-communicable disease (NCD), including dementia.

Laura Duran, director of international relations at Top Sector Life Sciences & Health, described the central mission of five extra years in good health for everyone living in the Netherlands and reducing health inequalities between the lowest and highest socioeconomic groups by 30 per cent as a “moonshot” to be achieved by 2040.

The four missions underpinning the Netherlands’ central mission are:

1) Lifestyle and living environment
By 2040, the burden of disease resulting from an unhealthy lifestyle and living environment will have decreased by 30 per cent.

2) Care in the right place
By 2030, the extent of care will be organised and provided to people 50 per cent more (or more often) than present in one’s own living environment (instead of in health care institutions), together with the network around people.

3) People with chronic diseases
By 2030, the proportion of people with a chronic disease or lifelong disability who can participate in society according to their wishes and capabilities will have increased by 25 per cent.

4) People with dementia
By 2030, quality of life of people with dementia will have improved by 25 per cent.

“We really focus on a multi-disciplinary approach and combining citizens, researchers, and entrepreneurs, including the government, in these different projects and strategic partnerships that we have. So we make sure we have a quadruple helix approach,” Duran told participants of the Health-Holland Visitors Programme in Rotterdam last September 28.

The Dutch Life Sciences & Health (LSH) sector is one of ten “top sectors” in the Netherlands that works with public and private parties to support the societal theme, Health & Care, of the Dutch cabinet’s Mission-driven Top Sectors and Innovation Policy.

A PPP is a national multi-year, thematic and programmatic collaboration between quadruple helix organisations that contribute to at least one of the five missions from the societal theme Health & Care.

There are currently more than 600 PPPs in the Dutch LSH sector of varying shapes and sizes. Most of them have a project-based approach to make a significant contribution to research and development (R&D).

There are also some strategic, thematic, long-term collaborations that strive for innovative moonshots within large, national consortia. These consortia are referred to as “strategic public-private partnerships” by the Top Sector LSH. Currently, the Top Sector LSH is supporting about 30 of these strategic PPPs.

“Still then, we’re not doing this alone. We have knowledge and innovation coalitions that, together, contribute to over €1 billion a year towards achieving the central mission and the goals that we have,” Duran said.

“In short, plus five years and minus 30 per cent in inequality.”

Laura Duran, director of international relations at the Netherlands’ Top Sector Life Sciences & Health, speaks in Rotterdam, the Netherlands, on September 28, 2022. Picture by Boo Su-Lyn.

The Dutch government also offers support for startups and small and medium enterprises (SMEs) in the LSH sector, such as business development, courses and events, networking opportunities, PPPs, and funding.

“The Netherlands doesn’t give tax incentives or grants to companies to invest here. They come for our climate,” said Ellen Smit, director of Rotterdam Square, an organisation that connects researchers to entrepreneurs and companies in the LSH sector.

The Netherlands’ life sciences and health sector has a huge number of partnerships with the private sector, even though the European country’s population is only 17.8 million people, just over half of Malaysia’s 32.7 million population.

Malaysia still retains a dual health care system, separated between the public and private sectors. The Ministry of Health (MOH) provides the bulk of care in the public sector that also comprises university and military hospitals, while the private sector comprises private general practitioners (GPs), private hospitals, and community pharmacies.

There is also little institutionalised collaboration between MOH and the Ministry of Science, Technology and Innovation (Mosti) on innovations in health or the life sciences.

Malaysia saw unprecedented PPP in health care during the Covid-19 pandemic, when private medical practitioners and health care non-governmental organisations administered nearly half of jabs under the National Covid-19 Immunisation Programme (PICK) and public hospitals decanted non-Covid cases to private hospitals.

However, after the acute phase of the pandemic, it appears that government bureaucracy has set in again, with the usual silos between public and private health care providers back up, even as advocates have called for a reform of Malaysia’s entire health care system to shift from curative care to wellness.

In ‘Solidarity’, Everyone Pays For Care In The Netherlands

The five laws governing Dutch health care from the Quick Guide to Dutch Healthcare, published in 2021.

All health care facilities and entities in the Netherlands are private. Health care financing, however, is semi-public as purchasing basic health insurance is mandatory under the law for everyone living in the Netherlands.

The government’s role is to set rules and regulations for health care providers to ensure quality of care and to limit health care expenses.

“In order to guarantee solidarity, the government determines that everyone, by paying taxes, pays their share of curative and long-term care, irrespective of how many people use this care themselves,” states the Quick Guide to Dutch Healthcare.

“In order to keep the increase in health care expenses in check, the government enters into what are known as ‘outline agreements’ with the sector; these agreements contain terms on the maximum increase in health care expenses.

“Within these agreements, the main players determine the price, quality and service of the care, based on supply and demand; these players are health care purchasers, health care providers, and the general public.”

Five laws govern Dutch health care: Public Health Act, Social Support Act, Youth Act, Health Insurance Act, and Long-Term Care Act. The Public Health Act regulates infectious disease control.

The Social Support Act holds local governments responsible for social support, such as providing domestic help, day centres, support, and short-term stays at health facilities, as well as sheltered accommodation for people with psychosocial problems.

The Youth Act regulates municipal responsibility for assistance provided to children, adolescents, and their parents. It also covers developmental and parenting support for families, psychosocial and psychiatric problems.

“Note that both of these laws do not entitle people to specific forms of health care, but rather oblige the government to provide an appropriate form of support,” states the Quick Guide to Dutch Healthcare.

The Health Insurance Act requires that individuals purchase basic health insurance and stipulates that health care providers may not exclude anyone from basic health insurance. It also provides for basic entitlements to health care and for the funding of basic health insurance.

The Long-Term Care Act regulates health care for people who require 24-hour care and permanent supervision. It provides that people who have received a special-needs assessment are entitled to care. The Long-Term Care Act also provides that individuals are entitled to either home or institutional care, besides requiring that health care administrative offices procure sufficient care or provide personal budgets.

The principles of Dutch health care from the Quick Guide to Dutch Healthcare, published in 2021.

There are key differences between the Dutch and Malaysian health care systems. Public care in MOH health care facilities is mostly funded by government allocations from the federal budget.

University hospitals receive budgets from the federal government budget, but are also funded by much higher patient fees compared to MOH facilities, where patients pay a nominal RM1 outpatient fee or RM5 specialist fee respectively. Private care is funded either by out-of-pocket payments or private health insurance.

Notably, Malaysia lacks social and long-term or aged care. The care provided by MOH is mostly institutionalised medical care in hospitals or clinics.

Unlike the Netherlands that regulates the quality of care by all health care providers, Malaysia does not have a law that governs public health care. MOH plays a conflicting role as both a health care provider and regulator of (private) care under the Private Healthcare Facilities and Services Act (PHFSA) 1998. Standards set in the PHFSA do not legally apply to MOH facilities.

Galen Centre: Dutch Health Care System Comes Closest To Malaysia’s Health White Paper Reform Suggestions

Galen Centre for Health and Social Policy chief executive Azrul Mohd Khalib. Picture by the Galen Centre for Health and Social Policy.

One of the things that emerged from the Health-Holland Visitors Programme was the Dutch focus on the patient or rather, the “citizen”, as the centre of care.

Galen Centre for Health and Social Policy chief executive Azrul Mohd Khalib – who visited Erasmus Medical Center and Maasstad Hospital in the city of Rotterdam in South Holland during the programme – said he found that the Netherlands’ health care system comes closest to the health care reforms proposed for Malaysia, including in the upcoming Health White Paper.

“There has been a lot of discussion of reform and transformation of the Malaysian health care system. A key concern has been what the end product of the proposed reforms, including the introduction of mandated basic health insurance, would look like,” Azrul told CodeBlue.

“It is strategic to take some of the components of the Netherlands health system for adoption.”

He noted that the Dutch health care system is firmly grounded in the primacy of primary care, as family doctors are the point of entry and source of continuing care for most of the population. Outpatient services generally are provided by general practitioners (GPs), with referrals to hospital and specialist care being provided as necessary.

“It has been recognised as a high performing system from the perspective of the patient, with low levels of health disparities and high equity,” Azrul said.

“Building more hospitals is not the answer to meeting the growing demand for accessible and affordable care.”

Azrul pointed out that government hospitals are likely to continue to be insufficiently staffed to keep pace with the rising demand for care, especially when more and more cases of chronic conditions such as diabetes, heart disease, and cancer continue to increase in the population.

“There will continue to be disproportionately high numbers of emergency department visits and potentially avoidable hospitalisations as long as the status quo remains unchanged,” he said.

Azrul urged Putrajaya to look at the Netherlands’ model of “distributed care” as the future of the Malaysian health care system.

“It involves a decentralised network of ambulatory clinics, home-based monitoring, and on-site treatment. It has been proven that expanding out-of-hospital care can improve patient outcomes, reduce costs and offer more convenience for patients.

“Most hospitals will no longer need to provide all services under a single roof. They could focus on delivering a focused set of specialised services and acute care.

“The care continuum, which comprises prevention, diagnosis, treatment and recovery, will be better supported when care is able to be provided channelled accordingly to need.

“In order for health care to remain affordable and sustainable, it needs to move into lower-cost settings whenever possible to address people’s health issues at a much earlier stage and ideally prevent them.”

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