As healthcare costs for patients with non-communicable diseases such as diabetes have risen, governments and healthcare providers have sought creative measures to align financial incentives with better patient outcomes. One incentive payment system known as “pay-for-performance” (P4P), in which providers are beholden to metric-driven outcomes, represents a potential path forward for healthcare providers to improve healthcare processes, resulting in higher quality and better patient health outcomes. The evidence on the effectiveness of P4P programs, however, is mixed.

To address this uncertainty, a new study, published in The European Journal of Healthcare Economics, assesses the effectiveness, in monetary terms, of a P4P program for patients with diabetes at a hospital system in Taiwan. 

The study coauthors, including APARC’s Asia Health Policy Program Director and FSI Senior Fellow Karen Eggleston, employed new patient-level data on clinical indicators, utilization, and expenditures, combined with data from the national death registry, to better understand the costs and benefits of the P4P program. Their results show that Taiwan’s implementation of the P4P program for diabetic care yielded positive results in terms of net value, defined as the value of life years gained minus the cost of care.

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Assessing Net Value of Taiwan’s P4P

Taiwan’s Bureau of National Health Insurance (now National Health Insurance Administration) introduced P4P in 2001 and enhanced the program in 2006 with an incentive for pay-for-reporting of outcomes. Financial incentives were used to encourage continuity of care with metrics such as new patient enrollment, follow-up visits, and annual reports, each tied to a specific monetary value. The program’s features are common across P4P, so the study’s findings have implications in other settings that incorporate similar designs in their P4P programs.

The study compares two different groups of patients at a large regional hospital in Taiwan, one consisting of newly enrolled P4P patients and another using P4P patients who have been enrolled since the beginning of the program. The researchers leverage detailed clinical data not used in previous assessments of the P4P program to better identify both costs and longer-term clinical outcomes based on measured biomarkers and predicted mortality.

Using an economic cost-benefit analysis conducted from a budgetary perspective, the study is the first analysis of any P4P program that estimates changes in the quality-adjusted price index relative to usual care. The authors consider health benefits in terms of survival and predicted survival and convert them into monetary terms. This net value approach is especially useful for policymakers and healthcare administrators who implement value-based purchasing and monitor outcomes for any service delivery innovation over time.

The study finds that Taiwan’s P4P program provided a positive net value for payers and patients, ranging from $40,084 USD to $348,717 USD. These positive net value results are primarily derived from health outcomes as measured by lower mortality rates in the P4P versus non-P4P cohorts, across both newly enrolled and continuously enrolled groups of patients. According to the authors, “these encouraging findings of the positive value of quality improvement net of expenditures adds evidence to the literature that has found mixed results of P4P programs.” 

 This study develops a new model for assessing the net value of service delivery innovations like P4P programs that can be applied in other contexts globally, providing healthcare systems researchers with new tools to better understand an emergent option for incentivized care. With a more economically-translatable understanding of P4P programs, this research helps build the bridge between the oft-disparate worlds of healthcare and policy.

As populations age, societies must take into account the nuanced needs of different groups. This is the research domain of Cynthia Chen, who joined the Walter H. Shorenstein Asia-Pacific Research Center as visiting scholar with the Asia Health Policy Program during the 2022 winter and spring quarters. An Assistant Professor at the National University of Singapore (NUS), Chen’s current research focuses on the well-being of older adults, healthcare financing, and the economics of aging. 

Drawing on support from Singapore’s Ministry of Health, Ministry of Education, the U.S. National Institutes of Aging, and the Thai Health Promotion Foundation among others, Chen explores how demographic, economic and social changes affect the burden of care, financing needs, and optimal resource allocation in the future. 

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In a recent talk at APARC, Chen presented findings on gender and socioeconomic differences in aging, exploring the ways in which such society-level characteristics can have major positive and negative effects on the health and well-being of older persons. 

According to Chen, these effects are interconnected with factors including access to effective health care, support systems that enhance function and restrict dependency, and programs assuring financial security and opportunities for older persons to effectively engage in society. “We must move beyond the archaic old-age dependency ratios and metrics, such as GDP, which neglect many of the critical factors that influence societal function,” Chen argued.

Finding Better Metrics for Aging

Gender and socioeconomic differences affect a country's ability to support its older adult population. Specifically, the longevity risk associated with females' longer life expectancy entails different needs between genders in old age. Chen aims to quantify gender differences in the aging experience of Organization for Economic Co-operation and Development (OECD) countries and compare differences in projections of disability and chronic diseases among future cohorts of older adults, including disparities by educational attainment.

In order to gain a more nuanced perspective on aging data, Chen drew data from The Aging Society Index, composed of established and available social and economic measures. The Index provides a quantitative estimate of the degree to which a society is successfully adapting to demographic transformation.

Much of Chen’s time is spent focusing on how to address gender-specific needs when developing policies and programs for aging societies. Chen cites The Network on an Aging Society, which defines a successfully aging society as “one which provides for the general well-being of older adults, is cohesive with minimal tension between generations and major subgroups, productive with opportunities for engagement both within and outside the workforce, and is equitable and secure.” Such society-level characteristics are necessary to understand the difference between successful and unsuccessful policies. 

Chen identifies systemic gender differences across critical domains of successful social aging that favor males. Thus, Chen argues, for many wealth or income-based measures, such as security, equity and productivity, males experience an advantage, which suggests room for improving women’s standing in paid work, job opportunities, and retirement income. One aspect where women do have an advantage is life expectancy. However, they tend to live longer in poorer health, reflected in a lower well-being score. 

Likewise, the gender disparity in cohesion is significantly driven by differences in co-residence rates, which is attributable to women outliving their spouses. These findings suggest that gender-specific needs should be considered when engineering policies and programs for aging societies. 

Varying Rates of Functional Disabilities 

Gender is not the only society-level characteristic that Chen investigates in her resarch on aging. In a recent study, published in Asian Development Review, Chen and her co-authors, including AHPP Director and FSI Senior Fellow Karen Eggleston, shed light on the dynamic evolution of the health and functional disparities of the future elderly.

In order to understand the differences in aging and its relationship with functional disabilities across multiple societies, Chen looked at data from Korea and Singapore. While the two nations have a similar pace of aging, they differ in the rate of increase in functional disability and chronic diseases. This may be due to many factors, including diet, lifestyle, and cultural differences, Chen suggests. Most notably, older adults with high educational attainment are projected to have a lower prevalence of functional disability and chronic diseases, and consistent across gender in both Korea and Singapore. 

The study employs a new model to compare projections of functional status and disability among future cohorts of older adults, including disparities in disability prevalence by educational attainment. These changes will have important implications for social protection systems, including the financing and delivery of long-term care and health care. The study highlights potential differences in the aging experience by gender and education in each country to inform social and healthcare policy and provides a common platform for international comparison to identify and compare challenges across countries.

Studying aging and effective medical care in late adulthood, especially with an eye for society-level characteristics, is an urgent task. Chen’s research complements the existing literature on life-protection activities, further underscoring the importance of investment in healthy aging and control of chronic disease so that the future elderly may receive appropriate care.

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A Shifting Civil Conflict

Nyantha described the evolution of the anti-coup movement in Myanmar from its beginnings with protests and civil disobedience campaigns by government workers and civil servants to its current state of armed resistance movement aimed at bringing down the military regime. Ethnic Armed Organizations (EAOs) have played a pivotal role in this shift. These non-state actors have fought the Myanmar military for decades in the borderlands and hold parts of the country under de facto control, sheltering and training tens of thousands of young people.

These resistance groups now present a powerful front of grassroots-level insurgency that is hampering operations by the coup regime. In this collection of self-organized groups, some are working with the National Unity Government (NUG) shadow administration, others with more decentralized networks, but all share the conviction that armed struggle is the only option for dealing with the military regime.

The power dynamic between the military and anti-regime resistance forces is now existential for both sides. “We are looking at what will most likely be a protracted civil conflict in Myanmar,” says Nyantha.

What are the paths toward a better future for Myanmar? One possibility is a shift in the military’s calculus, though it would necessitate a leadership change. Another possibility, according to Nyantha, is that the array of opposition actors can come together and use multilateral platforms to facilitate unprecedented forms of cooperation beyond resistance against the military to establish areas of territorial control and self-governance. “If they can emerge from this process with a new political vision and a roadmap for a more tolerant and inclusive Myanmar, then there is a chance the balance may tip against the military.”

These platforms include the National Unity Consultative Council (NUCC), which includes representatives from multiple opposition groups. Depending on how dialogues within the NUCC continue, it could generate a new political dynamic in the country and lay the groundwork for a future federal democratic union, notes Nyantha.

Historical Grievances, Future Visions

But there remains a lot of work to do to build trust among Myanmar’s traditionally fractious ethnic groups, Ambassador Marciel stresses. This mistrust has historical roots in decades of political disunity among Myanmar’s ethnic minorities amidst struggles for autonomy and self-determination, and in their longstanding grievances toward the state that has privileged the majority Burmans (also known as Bamar). Thus, possibly the biggest weakness of the resistance movement is the lack of a unified vision for establishing civilian rule. “I do think that it is hugely important to bring about more unity to the movement that is resisting the military regime,” says Marciel.

The international community should better understand the complexity of the civil conflict in Myanmar and recognize that the spontaneous revolt underway is not only a resistance front against the military but also a movement demanding dramatic social and political change, Marciel emphasizes.

He, therefore, cautions that the traditional tools of conventional diplomatic thinking – ceasefire, peaceful negotiations, and dialogue — do not currently apply to Myanmar. “At this point, there is no realistic scenario of dialogue leading to some compromise deal. As long as the military is in power, Myanmar is not going to enjoy peace or stability.” The people of Myanmar have suffered for far too long at the hands of the military, and the resistance forces are not interested in a compromise deal that would allow the military to maintain substantial political power, Marciel says. At the same time, the military is also not interested in negotiating.

According to Marciel, the international community should focus on supporting the resistance movement efforts. He also expressed this point in a recent interview with The Irrawaddy. “[T]he best possible scenario is for the military to face so much pressure that they then begin to look for a way out […] I think that maximum pressure on the military, both internally and externally, whether it’s by sanctions or other means, is the best chance of achieving progress, though it won’t be easy.”

A Deadly Syndemic

Even before the coup, Myanmar had one of the world’s weakest health systems and one of the least prepared for addressing epidemics and pandemics, according to the 2019 Global Heath Security Index. The devastating effects of the coup have coincided with the COVID-19 pandemic, combining into a perfect storm that has brought the country’s already-fragile health system to collapse.

The coup and the post-coup conflicts interact with the pandemic and Myanmar’s fragmented health system in ways that resemble a syndemic, says Phyu Phyu Thin Zaw, a medical doctor, epidemiologist, and health systems researcher now based at the University of Hong Kong’s School of Public Health. The term syndemic refers to the synergistic nature of health and social problems affecting vulnerable communities and contributing to an excess disease burden. It helps explain the dire crises gripping Myanmar’s health system, explains Dr. Thin Zaw.

Thin Zaw, a former visiting scholar at APARC, spoke at a webinar hosted by the Asia Health Policy Program about the impacts of the devastation caused by the coup and the COVID-19 pandemic on Myanmar’s health system and the current opportunities and challenges for response and recovery. She was joined by Nay-Lin Tun, a medical doctor who manages programs that help vulnerable communities in remote and conflict-affected areas of Myanmar to get access to health services.

Since the coup, hundreds of medical personnel and health care workers have been dismissed and subject to violent attacks. Many have escaped to areas under the control of anti-junta forces, leading to a severe “brain drain” or rather “brain hemorrhage” in the health system, Thin Zaw notes. When the third wave of the coronavirus struck Myanmar in July 2021, it hit like a tsunami. Immunization plans were severely interrupted, no quarantine or contact tracing measures were taken, and with shortages of health workers, medicine, and equipment, the health system was soon overwhelmed, with thousands of infections and rising deaths.

“To fight a pandemic, collective action is needed. Instead, Myanmar has faced a collective trauma,” says Thin Zaw. “The coup destroyed the reciprocal trust both horizontally among people and vertically between people and the government.”

Challenges for Humanitarian Response

Myanmar needs humanitarian assistance in every area, but grueling challenges hamper humanitarian relief delivery. International aid groups grapple with shuttered access, high-cost and high-risk operations, and ethical and political dilemmas: Should they stay or exit? Through which channels should they deliver aid? How can they advocate and work with the military junta? How should their money be spent under the military regime?

Dr. Tun, providing a grassroots medical humanitarian perspective on what is happening in Myanmar, described the multiple problems facing providers and patients on the ground. These include a severe shortage of health workers on the frontline, difficulties getting patients to hospitals, lack of essential medical supplies and equipment, COVID-19 infections, and overall increased mortality and morbidity among IDPs. He presented the results of a mixed-methods survey of health care workers conducted in non-military-controlled areas and conveyed their urgent requests for help. 

A Way Forward

With Myanmar’s health system in collapse, this is a time to focus on strengthening primary health care and leveraging the silver lining of the post-coup softening of ethnic tensions to build a federal health education system for inclusiveness, said Thin Zaw. She pointed to the collaboration between the NUG and EAOs-controlled healthcare groups as an encouraging step towards creating a federal health system.

She urged international actors to be realistic about the limits of their influence over the military junta and to create flexible and politically sensitive aid programs with contingency plans. Yet international organizations must continue all efforts to support the delivery of critical services to the people of Myanmar, especially in areas such as food security, emergency health, and COVID-19 response, she said. “Please don’t forget the people of my country,” she pleaded.