 You know, but a bunch of different products. So your development in India, your business? No, I have companies that are in different places. Yeah, in the U.S., in the U.S. And I work a lot in development. You should be here. You should be here. Healthcare program, China, India, Africa, Latin America. Everything is about making things affordable and accessible by being in control. Great. I'm at the end of all aspects. Maybe you can say your more information about your product. I think the China is... I did the same kind of thing in China. We produce all the medical equipment, CDMR, ultrasound, X-ray. And this moment... Welcome. Thanks for joining in this early afternoon. This session part of the public program on the health advantage. In a minute, our moderator, Lee Yat-sen, will present our guest. So I won't go there. And I would like to discuss the term advantage. Advantage. We know those numbers very well. USA, $8,000 in terms of annual cost per individual. 79-year-old life expectancy, 18% of GDP. China, 75-year-old. $275 per individual. Well, actually, in actual dollars because they were as in 1990 dollars, it's closer to 400. Still less than 500. 5% of GDP. Singapore, 4% of GDP, 83-year-old life expectancy. Does it matter? Does it matter? Well, from an employer standpoint, if you can't recruit the best talent, because you can't afford to offer the best insurance program, it matters. For a city, if you rank very low in the ranking of the best livable city of the world because your healthcare system is not the one people would expect when they migrate, it matters. For states, when your healthcare system is going to result in high level of absenteeism, disability, reduced output, productivity loss, it matters. We estimate the direct cost of healthcare expenses worldwide to be $7 trillion. And Norbert, we've worked on that before. We think the true cost of healthcare is $47 trillion. When you take into consideration the indirect costs of not providing healthcare at the right level and the elements I just mentioned, we estimate that in the US alone, the productivity loss due to the absenteeism is $250 billion. For a company of 1,000 employees in the US, the cost of obesity is $280,000 annually. Now, it is time to rethink the healthcare systems. It is time to find new ways of building them or rebuilding them. And my expectation from the session is that our panelists should cover, and I think they will, how can we integrate innovation seamlessly into existing healthcare systems? How can we work in multi-stakeholder ecosystems along the continuum of care? What about business model innovation? Innovative financing. And let's not forget regulatory systems that have to promote innovation as well as safety. We have no further due. I pass on to you. Thank you very much, Anna. And let you introduce our guest. Do I need the microphone? Not sure. Thank you very much, Anna. And welcome, ladies and gentlemen. Anna did a terrific job of introducing the topic. I think he's done the first part of my job for me. But let me start then by introducing the panel. We have a terrific panel here today. We're very fortunate to have with us the Health Minister of Malaysia, Dr. Subra with us. Welcome, Dr. Subra. We have David Green, who's the founder of Auralab Indra and the Swab Foundation fellow at David. We have Andrew Lee, who's the Vice President Northeast Region Aitner from the United States. We have Gordon Liu, who's the Director of the China Center for Health Economics Research at the National School of Development from Peking University. And welcome. And last but not least, we have Mr. Liu Tiren, who's the Chairman and Chief Executive Officer of New Soft Corporation from China. Welcome to you all. Just in terms of housekeeping, we're going to have a conversation here for about half an hour. And then we're going to throw it open to you guys to ask whatever questions of any one of the panelists or to all of us that you want as well so we can make this as interactive as possible. But let me kick off and ask you, Dr. Subra, the situation in Malaysia. What is the Malaysian government doing? What is your ministry doing in terms of implementing universal health care in Malaysia? What are some of the challenges that you are facing? Okay. Thank you, Jason. As you know, there's a third session on health and speaking in this forum. Each with different titles to it. The first one was entitled, Economy and Health. The second one was leapfrogging over health. And now we are meeting advantage in health. So essentially it's all the same. And the material is going to be the same. To start off with, Malaysia has sort of assured universal health coverage through the public health system. This has been done since independence. So we have in terms of principle, all Malaysians are entitled to free health care through the public service system. So when you look at that, then the three areas in which we're probably to look at it. One is, of course, access. Second is affordability and third is quality. If you talk about access, I think we are fortunate through a very extensive network of both the public health service and also an equally widespread availability of private health services. There is good access to health care for all Malaysians. We have got a primary health clinic for every 50,000 population with five feeder clinics which feed to these main clinics. So we have met access. We have met affordability because public health is 98% subsidized by the government. So anybody who has got no money has got access to public health service. But how affordable is it for the government? That's the other issue. That's what I'm coming to the third issue. The third part is the quality. So that is where, of course, when you provide a service which is so extensive, so widespread, then you have to meet qualities in expectation of the people, not as defined by the government. So when that comes, of course, that is, I think, it's our biggest challenge in terms of whether we can meet up to the expectations of the people in terms of waiting time, in terms of giving them the correct kind of technology. And, of course, making sure that all forms of ailments which they have can be treated according to the current knowledge of medicine and science. I think that probably is our biggest challenge and that's the challenge we are trying to meet with and that probably will answer your question. And I won't give you the answer now because we're in the process of transforming and finding an answer to that question. Okay. Very good. Thank you. China and Malaysia. You come from a university perspective. When I look at the Chinese health system now and my staff, for instance, will start queuing in the morning at five o'clock in the morning to attend a hospital because they have a cold. So there's emphasis on hospitals and tertiary care. That strikes me tremendously inefficient. From your perspective, what's happening in China and how can China sort of break through some of these challenges and some of these barriers? Well, the health care system in China has been long concentrated at the hospital at the center of the service system. In other words, in China, there is no gatekeeper for people to obtain the health care for their common conditions like cold conditions in the community settings. Instead, most people, if possible, would all go to tertiary hospitals for all conditions. That is because the way we allocate resources which are highly concentrated at tertiary hospitals, that's our problem. That's our challenge. That's why you would see the long queue in almost all hospitals for any conditions. So I think our goal is to change the way the services are delivered from the hospital-centered system to primary care-centered in community settings and only have the patients who need the inpatient care going to the hospitals. That's our challenge. That's our job. I want to come back to that a bit later and the challenges around that. But obviously, some of the things that enable what you're talking about, the community delivery of health care is obviously technology. I want to refer to Mr. Liu here now in terms of what your company is doing, your technology company, the software company, and you're very involved in health care technology. Is there a linkage here in terms of the technology solutions that you're putting into the market? I think that is the linkage between the hospital with the community or the health care services in the community. The reason is that most of why the people come to a big hospital is because all the best doctors are very much centralized. It's not only in big hospitals, but also in the best cities. The best doctors in China are living in Beijing, Shanghai, Guangzhou. The second tier, that means our quality of health care is at the second level. And the rural areas, we have a barefoot doctor. So many of the doctors are not very much educated. Like myself? So that means in China, you can say every people is a doctor. If they are very hard to access public health or hospital, they can buy the drugs. They can handle some kind of trouble by himself. So now as a technology company, our mission is we try to use digital technology to connect big hospitals with small community hospitals. We want to convert those kind of knowledge or very, very limited resources to be shared by everybody. So we use the Internet. We share all big data. We use cloud as a platform to connect each individual, each small hospital. We build a group. I gave a name called Coordinate Medicine. So that means not just one single hospital to face-to-face provide a kind of services. It can build a kind of community like a more doctor working together. And for that kind of purpose, just like Dr. Liu mentioned about that, we can like a different kind of condition. It comes to the right place. So right place means right cost. So that is technology can drive those kind of transformation of healthcare system of China. But technology can't solve everything, right? I mean, I think some of the things you've talked about are going to trust. People just don't trust the barefoot doctors like Gordon here. Thirty years ago. So technology in itself doesn't solve trust. I wanted to throw to David here now and to us. So you're a social entrepreneur now in India. You were in the commercial sector before you developed products. I wanted to ask you about the role of the civil society, the role of social entrepreneurs in this space. But particularly, I wanted to ask you about trust. How do you build trust in at the grassroots level? If somebody thinks the only way I think I can be confident I get good quality healthcare is to go to this enormous big hospital that's had millions of dollars put into it. How does somebody trust a local primary care facility? Well, my background is mainly in eye care. And so by providing a good outcome to surgery, principally cataract surgery, and providing that service where free is the lowest price, that's what creates the buzz in the marketplace. So if the farm are working on my land, if his mother gets a good result from cataract surgery, then yes, of course, I'm going to go to Aravind Eye Hospital also. But it has to do with quality, pricing, and access. So I've been working for many years developing both hospitals, primarily eye hospitals, but also technology companies and financing. And so I've helped develop maybe over 300 eye hospitals that have become self-financing and do over a million surgeries per year. By contrast, China only does about a million cataract surgeries a year. At Aravind Eye Hospital in South India, they do about 400,000 surgeries a year through their network in Tamil Nadu, South India, and they have a system where free is the lowest price. 50% pay well above cost, 25% are free, 25% pay two-thirds cost, and yet they're able to have a profit margin of 38%. So we've spread this model to different mentoring, training institutions. They have become living laboratories, which then help other eye care programs develop similarly. One of them is here in China, which I helped develop, the HER Eye system in Liaoning Province, which does between 40,000 and 50,000 cataract surgeries a year. So coupled with that service delivery model, we've focused on bringing down the cost of the products used in eye care. So in 1992, we set up AuraLab to make intraocular lenses and then suture, pharmaceuticals, surgical blades, other ophthalmic equipment. And so we dramatically lowered the cost of the consumables, and at the same time, we started creating training programs in the better surgical technique, going from cataract surgery without intraocular lens where the patient would be given thick cataract glasses, which 50% would lose or break within a year, to the surgically implanted lens restoring good vision. And what happened was that this combination of affordable products, creating training programs, not just surgical but clinical, managerial, outreach, business planning, pricing, we were able to bring about a revolution in India. So AuraLab, when it started in 1992, India was doing something like 800,000 cataract surgeries a year. A lot of other companies came in and started competing with AuraLab, and they actually drove AuraLab's price down from $10 a lens at a time when we started, it was $300 a lens. They drove our price down today to what it is, $2 a lens for the lowest price lens. But in the meantime, India's surgical volume went from 800,092 to over 5 million by the new century, and now it's leveled off at 6 million, very much due to this price competitive market. China, again, by contrast, only does a million surgeries. So when I think about what's to be exported to other countries, especially the United States, it's this idea of price competition. In the United States, there is no price competition, there's no price transparency, and that's why the health system costs so much. Okay, but is that going to work? So you've just talked about business model here, and it's a business model that seems to work for that type of company in an emerging market. I mean, I'm interested in the big company sort of view here. Can you guys do something like that? And how would you feel if these highly entrepreneurial companies from emerging markets came into developed markets with extremely price competitive technologies and product offerings? What's that going to do to the status quo? Well, in the United States, we're in a system that's in the midst of transformation right now. And frankly, I think that kind of innovation is exactly the prescription that the United States needs. One of the lessons I would say that emerging markets really ought to take from the United States experience is that don't replicate it. There's so many flaws in the United U.S. health care system that for emerging markets to look at the developed health care systems is probably a mistake. And so there are probably many more lessons to avoid than there are things to embrace. Now, I would say that because the U.S. health care system is in this period of transformation, we're actually starting to see the kind of innovation that you're talking about. And that's actually very exciting. And when I think about a high performance health care system, I really think about a couple of things. Number one is this sort of shift toward population health management. So instead of just managing the individual patient, you think about how to manage outcomes for an entire population. So that's, I think, a wonderful concept that emerging markets ought to be looking at. The second thing is really around health information technology. The United States, we have $800 billion of waste. I mean, it's an incredible amount. And I think some of the emerging economies, they have an opportunity to eliminate some of that waste. And a big role, a big driver of that is going to be through health information technology that essentially turns data, big data, into knowledge that can be used to drive out excess and inefficiency in the marketplace. And then the third thing I would touch on in terms of thinking about a high performance system is something that we haven't touched on, but I think weighs on all of our countries enormously, which is the rise of chronic disease. You know, 63% of all deaths around the world are due to chronic disease. And we need to open our eyes and think creatively about how does it design systems that address the problem of chronic disease. Because unless we tackle that and we continue to sort of treat patients in an acute setting, we're not treating chronic disease, we're all in for a big surprise. And I think very much that we need to think about how to design systems that are going to work for the people in the future. And it's things like transparency. It's things like having competitiveness at the right levels rather than at the wrong levels. It's about changing incentive systems. It's about dealing with medical professional shortages, which China and many other countries around the world are really grappling with. That's great. Let's see where this goes. Take it where you want to go. I want to comment on your first point. I can't agree more on a transition from what we call disease-based medical care system to a health management system. Because this is a really important key to solve many kinds of problems that healthcare system faces. For example, in China in October 2013, the State Council issued a very important policy call for such a transition from disease-based medical care system to health management system, which would expand the medical care services to two sites. On the one hand, to extend the services to serve not only the patients, but also people who are not sick yet. But we have a lot of things to do to maintain their health status. Also, we can extend the services to the right-hand side to provide services for those people who just finished their surgical treatment. But they don't have to stay in hospital for post-treatment services. But China does not have formal sectors to take over these people. So if we can make this transition from disease-based medical care system to health management system, I think that's going to be a very, very powerful policy transition for both healthcare system and for economic transition. Now, I just want to make one more point to our dollars leader. He mentioned that the worldwide spend too much money out of GDP on healthcare. For example, in the U.S., we spend about 18% of GDP on healthcare. To me, I would not worry too much about how much we spend in total out of GDP on healthcare. What I would worry is what we would spend these money for. So services are different. We really have to prioritize what kind of technology, what kind of services should be included with the first priority. So we would encourage people to use those services that are more cost-effective than others. As long as we hold the cost-effectiveness basis to prioritize medical services including technology drugs, I think I would not worry how much we spend. Even if we spend 30% of GDP on health, that's fine with me. But if we waste a lot of money on those unnecessary technologies, even if we spend less than 10%, I would worry much about it. Just to take up on this point, what you said, I think this is an issue I think we have repeatedly re-emphasized in this forum over the last two days, is I think health cannot be seen as an entity that just belongs to the confines of the Ministry of Health itself, but to be looked at as a broader perspective of the entire government to ensure the ecosystem of health. I mean, you talk about the ecosystem of health. It involves, of course, anything from environment to sanitation, to city planning, to laws and legislations on nutrition and food down to the provision of facilities. So I think that will take us to what you said just now, to prevent. And I think to prevent diseases, that's where our investment is to come, is to ensure that the proper ecosystem is provided so that it actually generates community based on principles of health in which disease is actually put far away. Certainly in the context of chronic disease, you need an ecosystem approach, because it's not just killing a bug, but it's a much more complex issue. Any other contributions on this line of thought? I just want to pick up on what Dr. Lucid. You know, we think about the continuum of care. And today we have a really fragmented system. I think that's more the rule than the exception around the globe. We tend to think of health care in very particular silos, right? So we think of physical health, mental health, behavioral health, emotional. You know, we think of things in silos. And I think, you know, as we look to the future, we need to very aggressively just destroy those silos and think about the continuum of care, everything from staying healthy and preventing disease to dealing with acute care when you do get sick, all the way to sort of end-of-life care. We need to think of it very holistically. Okay, so who's we, right? So everybody with self-interested actors, different people with different incentives, we talked about prevention. So if we have a preventative system, big-drunk companies are going to go out of business. So who drives this agenda? Well, one stakeholder that we haven't mentioned yet but I think plays an absolutely vital role in the high-performance health system is the consumer himself or herself. And that's where sort of technology can really take hold. You know, if you think about the rise of technology, more people have access to mobile phones than they have access to toilets today. And that's just a, you know, that's a shocking example, but it tells you that the future may lie in sort of personalized technology in making it easy for patients and consumers to get price information, to get quality information about either facilities or their doctors and make it very easy for them to keep themselves healthy so they can avoid going into the hospital for the acute care. So I think the consumer or the patient, the end-user plays an absolutely vital role in this. We really have to understand the statistical distribution of patient population and healthy population are not independent. They are correlated highly. In other words, if we can treat the patients through medical care system, in the meantime, we can also serve healthy population with health services so our customers are not only patients, but the entire population. We can keep the patient population as small as possible, as delayed as possible. Otherwise, you know, your patient population may become larger and larger, sooner and sooner. These two populations are not independent distributed. Most governments or insurance schemes don't pay for prevention. I mean, it's a really hard thing to get covered. My sense is, you know, if you look at a country's disease profile, it's the 80-20 rule. You know, where's 20% of the disease concentration? What 20% of diseases affect 80% of the population? A lot of it's cardiovascular, or like in my case, you know, in eye care, it's cataract and now increasingly becoming diabetic retinopathy or macular degeneration. And I think that the approach that I take, and I work in many different countries, including the United States, is to look at vertical integration. Like, if you take a procedure like a pacemaker for arrhythmias, I worked with Medtronic and India to look at how you broaden the reach to lower-income Indians that have arrhythmias in need of pacemakers. You have to create a whole community surveillance system to pick up the arrhythmias before they show up half-dead at the hospital. You have to figure out how you bring down the price of the pacemaker, the price of the procedure. We looked at how we do retail financing to make it affordable. And what I got out of that whole experience working with... It's possible to lower the cost. The real value of competition is creating players that force the industry to lower their price points. Medical device companies, pharmaceutical companies, doctors will not lower their price point unless you're competing with them. I have an example. Oralab beat out a major company, I won't mention its name, on a suture contract. It's a company that makes 90% of the world's suture. They sued us, they lost, they appealed, they won. And then we took it to the Indian Supreme Court and ultimately won that case. But in the meantime, they lowered their price point from $240 for a box of suture to $23 in order to beat us out on the next bid. So that's the power of competition. When I look at just about any medical device, when you demystify cost and then deconstruct supply chains and take out all the non-value-added margin and add it up, it's better than cocaine, it's better than heroin margins, it's better than marijuana margins. So this is a sort of demystification that somebody has to do and it's very difficult to get governments to get into it. I tried to get U.S. state governments looking at Medicaid paying out for durable medical equipment and supplies. I had their data, I analyzed it and I said, you're paying 10 times what it would cost in a competitive market. But they didn't want to upset the apple cart of special interest. We're talking about the cost, maybe the cost from very expensive check and medical treatment. But I think the people from a customer point, they don't care about payment, they care about our car, the quality of services. Now if we look at what is the reason people waste the money, the first point is the doctor like an artist, each of them is individual. So hospital to hospital, doctor to doctor, everything is isolate. They don't share in our knowledge, they don't share in our data. So many of our waste is because people recheck and they come to one hospital to another hospital. The people have just like you mentioned about this, not continual data to like doctor have a clear picture to say what is their condition from first day to today. They come to different hospital, the doctor ask the same kind of questions in China, take a very long line, given 40 minutes ask 20 minutes questions. And then second day you're coming repeat again. So because not any data can recording the, you know, that the conditions, the situation and changing everything. So I think that based on that point, we solve that problem, the firstly we must be sharing that data. That is a big challenge. Secondly, we must build for every people, everybody have their personal health care record. That should be integrated with a hospital. It's like a doctor can use daily data or lifestyle data or a lot of questions from their home, not just in the moment come to a hospital. So that is a big challenge because each hospital like an individual, you know, the company, they compete each other to don't want sharing each other. But today we can say it's a big challenge, it's driven by technology. The firstly we really, really can go out more and more personal health care information. Yesterday you say that Apple announced new technology about phone, they embedded a lot of lifestyle apps to the phone. That means if you carry your phone every day, you can go to all the, your lifestyle, your activity, everything is exactly very much valuable for diagnostic for the future. The secondly, Internet gives more and more opportunity like we call, coordinate the medicine. So that means diagnostic is not from an individual doctor. So if you really have problem, you can like many hundred doctor, you can, you can give those kind of data to the doctor in Beijing, maybe US. So maybe, you know, we call integrated medicine. Before you have a one-med problem, you'll find some doctors very much focus on each of the areas. But when you solve that problem, you got another problem. But now Internet make that possible. Let's go to that area if there's no other interventions. Just responding to what Liu said, I think it is true that we are transiting from a period in which medical data was considered a very private document where the medical doctor was held ownership to it to a situation where technology will probably dictate that it becomes the ownership of the individual. Because previously we never had the technology. And it's very interesting yesterday in the ideas lab under which you're sponsored by the National University of Singapore where we actually discussed a concept called individual patient's health concierge. And every individual patient will have his own data record of health including the risk factors, concomitant of the genetic makeup and the behavioral element of the individual from birth to death. And how at any point you actually can intervene and actually suggest what are the risk factors which are going to have a different stage and how to modify it. So I think it is not an impossibility as what we discussed yesterday. It was not an impossibility. Even we discussed the modalities which are to be put to cause the behavioral changes which reduce the risk factor. I think these are things which will come by virtue of technology. I think I foresee a day where medical profession as such has to recognize that records are no more sacred to them but it's something which will own to the patient. And the patient will have a right to contain it and that will probably dictate the changes which is required upon them to make the changes. Very good. Let's some. I propose we open it up a little bit now if people are happy. So we're taking questions from the floor. If you have a question please raise your hand and I think the helpers will put a mic in your hand over here and then here. Let's start with those two. Okay. Norbert Hildenschmidt. Yeah, we're off. Let's work. Norbert Hildenschmidt from Bain. I have a little bit of a provocative question actually because you haven't touched on it. And the key question would be if I'm a consumer and again I'm not a patient, would I trust the doctor that the doctor really has a good understanding of what health means to me? Would I really believe, you know, that the medical profession doesn't need to change as well and would I actually go to a hospital which still has a little bit of a stigma of disease? So I think this is one of the key barriers that I would at least see in terms of transitioning from paradigm shift from disease to health. What is your view on this? Why don't I start and ask others to join in. So I think quality has, at least in the context of the United States, quality has been largely shielded from the consumer. So it's very difficult to know hospital outcomes, doctor quality, you know, and at the same time what you see happening is variation from clinical guidelines. And I think big data can play a key role in starting to eliminate that because as you have these terabytes of data about clinical pathways, you can start to create best practices and I think consumers ought to be holding their providers or their healthcare professionals accountable to maintaining and adhering to those clinical best practices or guidelines. But I think it really begins with this question of transparency where if you can introduce transparency into the system, suddenly people start paying attention because today in the United States it's very difficult to have any idea about the quality of the institution or the individual practitioner. I think the trust between doctors and a general population, not necessarily a patient, must be based on mutual understanding of modern medicine. See what is the role of modern medicine, how much medicine can really do for the health, how much medicine cannot do for our health. In a medical literature it is very well known that medical technology, medical intervention itself can only contribute at most somewhere 10 to 15 percent of health determination. Individual behavior contributes at least 50 or 60 percent. So as long as we both understand that knowledge, then the trust can be built. As long as we the healthcare sector, the government sector can transform, promote that information to a general population, I think trust has a basis to be developed. Any other tight groups? There was a question back here. My question is for David Green, but I appreciate the inputs from the others. I'm overwhelmed by the successes of Oralab and the Aravind model and the deconstruction of the pricing chain. I'm wondering if you could speculate on almost your wildest imagination. What would be other targets of the top two or three enormously inefficient but very important devices or practices where that kind of treatment could be impactful? Pacemakers, stents, and knees and hips, hip joints. If you look at any medical device realm, there's anywhere from two to five players they have bought up other companies and there's unspoken price fixing and that's how they maintain very high pricing. That's where competition is needed. I would say those are the main ones. I have another company that's making an affordable hearing aid. We figured out how to demedicalize the fitting of hearing aids. We have an app on a smartphone or a computer that you can download and wirelessly test your hearing in just a few minutes and then it automatically programs the device and we're selling this and I'm actually wearing them for like $80 and the technology is on par with hearing aids that cost between $2,000 and $3,000 a piece. Again, it's because of unspoken price fixing there's only five players serving the 95% of the market and they keep prices high artificially. Hearing is a really important arena to address from a public health point of view. Frank Lynn at Hopkins shows that hearing loss is directly related to cognitive decline. As your decibels go down so does your cognition and so this is a major public health problem. There's only 7 million hearing aids sold each year and yet 600 million people could benefit from a hearing aid that's 1.2 billion years since most people have bilateral hearing loss. So these are just... If you look at any medical device and I think it's probably the same with pharmaceuticals and you see that it really doesn't cost that much to make then you can make it affordably. Yeah, I would have a question David. I would like to play a David's Attocate on this one for a little while because you know what the argument is, you can do so at your own risk. And we'll continue the dialogue afterwards. Now it's just to take also the perspective of some of the medical players that are going to tell you well the reason why the cost of healthcare system in the US is 18% is because the healthcare system in the US has been funding innovation and where Indian players can develop a stand for less than 50 bucks today it's because for many years they've invested in R&D and they made those losses in the innovation and the cost of bringing a new drug to market is well in excess of 50 billion. If you look at Medtronic pacemakers it's 20 year old technology. I know, the IP has gone. There's only three players and by my estimation as your forensic cost accountant here it doesn't cost them more than $80 to make a pacemaker but yet I think the lowest price is $2,000. I agree. My point is because you were mentioning 38% gross margin I think with 38% gross margin you are not going to fund innovation in the long run. I've developed many products on a very low budget that have novel IP and that don't have the same R&D cost that the industry claims is derigor so I think a lot of it is hyper inflated and hyped. I think that there was some major review done on how much does it cost to really develop a pharmaceutical the industry says it's a billion dollars when in fact it's really about 250 million and most of those drugs are gleaned from NIH supported research where industry buys it for very little and then so the US taxpayer gets to pay twice both to develop the drug and then to purchase it. There's probably a whole lot of low cost innovation that can happen along the drug discovery like clinical trials for instance and using mobile technology to lower the cost of clinical trials there's probably a whole lot of innovation that can lower the cost of development as well. So there's a question here and then here and then here. Okay. Pay Amazon from Sweden a country well known for its welfare system I think we spent about 10% of GDP on healthcare. We've gone through a very dramatic change during the last 30 years in moving from a system where a new one had the right to choose a doctor or hospital to a system where you have personal choice within the framework of a system which is paid for by taxes probably 95% is taxes. Now there is an interesting debate what happens when people like to spend more on healthcare do something extra that is not allowed in Sweden basically. So my question to you is what trends do you see long term in the development in various parts of the world are we moving to a system where more private money will go into healthcare or are we preserving universal healthcare system where it's being paid for by taxpayers. What trends do you see? Well I can share one research evidence with you and two economists in the United States conducted very solid research for the prediction of healthcare in the United States as a percentage of GDP by 2050. Now guess what? You think 18% of GDP on healthcare is too much today and these two economists named Robert Hall and Charles Jones both at Stanford showed that by 2050 at least 30% of GDP will be spent optimally on population health. Now they give a very important argument for such a prediction they believe as the world becomes more and more wealthy with more resources people cannot keep spending too much on many other things like how much we can eat, how much clothes we can have how much cars we can drive. So the diminishing return to the use of almost everything except health was our age, our life expectancy reached 90. Do we reduce our effort to make things possible to survive for one more year? We may not reduce our efforts. As a result the whole world will spend more and more on health. Now I think to ask you a question then who should pay private sector individuals or government according to our research, the research we conducted we find if government spent public finance for health care that would create more job positions create more higher employment in the macroeconomy so if that's something we care about so we may want to promote more public finance but I want to just make one last point since we're talking about the course of care everybody saying well we spend too much I think we have to think about the value of investment in health first of all health care is part of the economy it's a zero sum game, it's an economy let's put that aside but in addition we find that if we spend every 10% in health care market in the long run based on 21 APEC country data for the past 40 years we find for every 10% increase in health care per capita that would lead to about 5% in GDP per capita that means as long as health care does not account for more than 50% of GDP we gain in economic performance so if we really want to know the relationship between health and economy and you said you participated in that session earlier I wish I was in that session I can share that data with them I just report that data to the APEC meeting two weeks ago in other words for every 10% increase in health care spending per capita that would lead to about 5% in GDP per capita so as long as health care does not account for more than 50% of GDP we gain economically that's a pretty amazing algorithm you can create an app around that one any other comments to that question? one quick comment on this in both the United States and in China the consumer pays quite a bit of the health care cost and one of the interesting things we're seeing a trend that we're seeing in the United States where the employer also pays a substantial portion of health care costs is the employers are thinking about sort of defined contributions so let's take colonoscopies for example in New York City where the price variation is unbelievable it is lowest $740 at the low end for a colonoscopy all the way up to $8,500 for a routine and arguably commoditized service where there is no real variation in quality so what explains that difference? and so a growing number of employers are saying well let's look at the market and figure out an average and hand those dollars over to their employee and say if you want to have a colonoscopy that costs over $8,000 we'll only reimburse you at this level and you eat the rest and if you want to do it for less than the average then you get to keep some of the savings and so we're seeing some interesting things around defined contributions I think for most of the emerging country you ask the question who pays but like a country like China we ask pay to who so the reason is there's very limited kind of services for healthcare of course we know the government pays something like a hospital but you really want to use your personal money to buy it's very hard to buy so I think that's another kind of the thing I fully agree with Dr. Liu's comments is we must be leveraging the government funding and private funding to work together to solve healthcare problems it's coming from the government I think the government has got multiple responsibilities and health is not the only area in which the government funding has to be given too so I think it's a difficult issue I mean how high, like the Swedish example the Malaysian example is also the public service is paid through general taxation how high are we going to increase general taxes to meet up to the increasing needs and what is that, the impact of that is going to be the consumption ability of the population at large so these are balances which we have to make I think eventually what governments have probably to decide is what are the essential components of the healthcare which should be provided by the state and which are the components which probably has to be met by the individual and drawing this line will be an inevitable line by virtue of the economics of that time and what is public and what is private what are public goods and what are private goods in that equation I think we had a comment here a question here following on the comment that we have to take care of the patients but also of the non-patients the population that doesn't use healthcare what should you take on the role of insurance or particularly private insurance or fund pooling in controlling healthcare costs around the world I can only speak for the Chinese situation according to the official documentation issued by Chinese state council when we start offering health services including medical care but also other non-medical care services like for health maintenance, health management the state council documentation says we should encourage or promote the role of commercial insurance programs first for some years and then perhaps the state-led insurance programs will kick in to pay more and more later so the current policy design is to have private insurance to play a greater role in the beginning that's the situation in China based on the official documentation to just look at another perspective whether private insurance in itself can assist in the element of prevention as it does for the management of disease I think there are very few insurance companies which actually fund preventive programs as part of the insurance mechanism a lot of them don't even put screening normal screening into the scheme but I think one which has been coming off is dis-incentives given to high-risk behavior in terms of premium that might be one component which might actually promote we are trying to trigger the behavioral change towards health whether that can be one component which can be contributory as an insurance representative I can assure you that we think long and hard about the role of prevention our own employees we take metabolic syndrome tests and get refunds on our premiums if we pass the metabolic syndrome test and we roll out disease management programs across the country and increasingly across the world and also investing heavily in health information technology because we see the promise both in eliminating waste and encouraging this transformation from a system that's primarily based on treatment of disease to one that can facilitate and promote wellness and so we very much as we think about our future role around the world and certainly in the United States we're transforming ourselves to have that very orientation around wellness very good I think we have time for one more question before we wrap up Hi, my name is Kumar we just heard about the conversation on continuum of health and breaking silos talked about the monopolies and how people are charging what they want and of course the investments being made behind those research and that's the reason why it's so expensive and we also heard about the fact that the consumer at the end of the day can make choices about what they have to do but the information is not always available to consumers what choices they can make what is generic what is and of course providers and of course hospitals and doctors always want to make sure patients come to hospital otherwise how will they make money but the role of government the question therefore is probably to and I don't know how what is a policy or what is this thinking of governments today to give more information out there all the information is already there also may be not available to a patient or a customer when they want it to know specifically something about health how to prevent something from happening so what is the role that governments and agencies who support you know not for profit others coming together to do something really to prevent and manage wellness instead of going to hospitals and also informing people about where you can and they're paying more money for colonoscopy as opposed to you can pay less why don't we put all the information out there for people to make choices and become aware of what is be done today care of themselves much more than what's being done today and what's the governments doing about it I think in a situation where there is reimbursement to such payment from the state there are systems in which this information is available because at the end of the day the state reimburses the cost of going to whichever doctor which is there but unfortunately in our system we don't have these reimbursement so those who come into the public service are taken completely care by the public service and the private sector is a market driven entity where the individuals make the choice like in Malaysia I have started a triggering of the creation of very strong consumer health groups while you have consumer groups which take care of products for example or food prices or other things there are very few active consumer health groups which actually fight for optimal market of health care like what we are saying so as a result of which the health market has been completely unregulated both by the policy makers and also by the consumers themselves by virtue of pressure so I think there is a need for consumers to organize themselves into pressure groups which will actually cause this change and they can create this empowerment within society to make sure people can make the right choices so the government could be the trigger force to create such a fire and that will be the strongest entity I think the government can really make a first call to create the environment conditions government can make a first call to issue policies to encourage market to respond but I think the central driving force for such a healthy product for the health population have to come from market forces so everyone over here if you are interested in health product market now you are most welcome to China to do the business so don't just focus on medical care but health products that's what most needed in China which has a huge business very good other than it was a terrific place to finish the government, the market thank you all very very much for your contributions great panel, I've certainly learnt a lot and thank you to the audience as well for all of your contributions thank you