Jeremy Lim MBBS, MPH, MRCS (Edin), MMed (Surg), FAMS Principal Consultant, Insights Health Associates www.insightshealthassociates.

com Oct 2013

MYTH OR MAGIC: THE SINGAPORE HEALTHCARE SYSTEM

Disclaimer: The views expressed in this paper/presentation do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. Terminology used may not necessarily be consistent with ADB official terms.

Copyright 2013 Insights Health Associates Not to be reproduced or transmitted without permission

UNMASKING THE HIDDEN

The real voyage of discovery consists not in seeking new landscapes but in having new eyes.

~Marcel Proust

SINGAPORE HEALTHCARE SYSTEM

Singapore 710 sq km 5.2 million inhabitants, 3.3 million citizens GDP per capita S$50,123 , 11th in the world

Health Outcomes

Singapore is ranked 6th , the only Asian country apart from Japan in the top 10 countries.

Singapore Rank: 1st

Health Grade: 89.45%

Total Health Score: 92.52% Health Risk Penalty: 3.07%

Total health-score factors, e.g. Life expectancy at birth and infant mortality, Causes of death: Communicative and non-communicative diseases, excluding war-related injuries, Death rates, Survival to 65 and life expectancy at 65, Risk-score factors, e.g. % of population age 15+ who smoke, Total per-capita consumption of alcohol,% population ages 20+ overweight ,% of population physically inactive

Myth or Magic is a wonderful account of how Singapores health system has evolved, and provides important insights about where the future is likely to take it. There are valuable lessons in the evolving Singapore story for all of us.
Alfred Sommer, MD, MHS. Dean Emeritus, Johns Hopkins Bloomberg School of Public Health, Professor of Ophthalmology, Epidemiology, & International Health, The Wilmer Eye Institute, The Johns Hopkins School of Medicine

OVERVIEW
Political Philosophy Healthcare Financing Healthcare Delivery

PRODUCTIVIST WELFARE CAPITALISM

Social policy is strictly subordinate to the overriding policy objective of economic growth. Everything else flows from this: minimal social rights with extensions linked to productive activity, reinforcement of the position of productive elements in society, and state-marketfamily relationships directed towards growth. Ian Holliday (Political Studies, 2000)

We owe it to ourselves individually to keep fit and healthy. The healthcare system needs to be structured to strengthen this sense of personal responsibility. It must give the individual maximum incentive to stay healthy, save for his medical expenses and avoid using more medical services than he absolutely needs.

Thou shall co-pay

MK Lim, 1998

Opium or Heroin
Subsidies on consumption are wrong and ruinous ... for however wealthy a nation, it cannot carry health, unemployment and pension benets without massive taxation and overloading the system, reducing the incentives to work and to save and care for ones family when all can look to the state for welfare. Social and health benefits are like opium or heroin. People get addicted and the withdrawal of welfare benefits is very painful. Lee Kuan Yew, 1981

COST-CONTAINMENT: WHITE PAPER ON AFFORDABLE HEALTHCARE 1993

THE SINGAPORE STORY AND IMPACT ON HEALTHCARE

1819 Sir Thomas Stamford Raffles comes to Singapore 1826 Straits Settlement- Singapore, Malacca, Penang 1942-45 Japanese Occupation 1959 Self-government 1963 Merger with Federation of Malaya, Sabah, and Sarawak to form Malaysia 1965 Independence

Implications: 1. British legacy of National Health Service type healthcare structure 2. Very poor at independence 3. Fight for survival- economic pragmatism 4. Market model of the world

Singapore in the early years

When my government first assumed office on June 3rd 1959..businessmen and industrialists, far from hailing this event as a happy augury for the future, felt for the most part that the end of the world was around the corner. The stock market collapsed and there was a flight of capital out of Singapore. Several people fled the country. [But] In a short space of ten years, we brought about a transformation of the business climate.- Dr. Goh Keng Swee (former Deputy Prime Minister and Finance Minister)

When Singapore became selfgoverning in 1959, we faced serious problems of over-crowding and poor public sanitation. The top causes of death were infectious diseases like tuberculosis and pneumonia.

Our first priority was to get our basics right. We focused on developing our primary and preventive services. We invested in public sanitation and cleaned up the Singapore River relocating pollutive industries, dredging the riverbed to remove rubbish, and bringing wholesome leisure activities to the River (e.g. dragonboating, kayaking). We built a wide network of outpatient dispensaries and primary health clinics, especially for maternal and child health.

We introduced Nutrition Supplement programmes to help malnourished children. We vaccinated children against infectious diseases such as measles, diphtheria and polio. Our small size helped us to reach our whole population quickly and efficiently, although back then doctors and nurses had to travel along dirt trails to rural villages or endure choppy boat rides to offshore islands!

As we made progress on these basic public health challenges, we consolidated our outpatient dispensaries and maternal and child health clinics into polyclinics. Polyclinics acted as one-stop centers for general curative treatment, screening, immunization and dental services. We sited them in our public housing estates, so we could deliver primary healthcare to Singaporeans doorsteps.

Hospital made do with what they had. Patients stayed in open barrack-style wards, about 40 to a room. We really had to make do. In those days, syringes and needles were recycled. We didnt have the luxury of disposables. And every time a needle was blunt, can you imagine it, it was also sharpened. We cleaned it up and we sterilized But thats how we lived. And we lived. In operating theaters, doctors economized on sutures to stitch up wounds, making sure to maximize every inch.- Dr. Andrew Chew former Head Civil Service

Subsequently, we built up hospitals and specialty centers to deal with more complex medical challenges. We corporatized our public healthcare institutions to make them operate more efficiently and be more responsive to patients needs. If our healthcare institutions had continued to run as government departments, it would have been much harder for them to improve, and upgrade themselves.

CORPORATIZATION AND ESTABLISHMENT OF HCS

From Ministry of Health, 2009

When we underestimate demand, the result is overcrowding at hospitals as we now experience at the Tan Tock Seng Hospital. If we overestimate demand and oversupply, we end up with under-utilized assets, a costly outcome. Between the two, I prefer to

undersupply than to oversupply as this will put pressure

on ourselves to intensify usage and minimize over-consumption. A built bed tends to be a filled bed. Khaw Boon Wan, 2007

COMPARATIVE SPENDING
Public Spending as % GDP National Healthcare Expenditure as % GDP 9 9 4 10 10 18 13 Government Spending on Healthcare as % of Total Healthcare Spending 68 75 36 81 84 53 65

Australia Finland Singapore Sweden United Kingdom United States of America High-income OECD Countries (Aggregated)
Data source: World Bank (2010 statistics)

27 40 13 33 46 27 30

Number of Hospital Beds per 1000 population

Total Number of Hospital Acute Care and Extended Care beds in Singapore and Total Number of Hospital Beds in OECD Countries per 1000 population

Extended Care Beds in Singapore per 1000 population

Acute Care Beds in Singapore per 1000 population

2 Total Number of Beds in OECD countries (average) per 1000 population

0 1994 1995 1996 1997 1998 1999 2000 2001 2002 Year 2003 2004 2005 2006 2007 2008 2009 2010

In May 2011, Singapores ruling party, the Peoples Action Party saw an unprecedented vote swing, leading Prime Minister Lee HL to apologize to Singaporeans and pledge to do better.

The opposition tapped a vein of resentment towards the PAP. Despite its success in making Singapore a rich, clean, law-abiding and pleasant city, the PAP has alienated many voters.

A common perception is that it has lost touch with the concerns of the less well-offabout rising prices, especially of housing, and about the rapid influx of immigrants, notably from China. Of the population of just over 5m about a quarter are immigrants. ~The Economist, 8 May 2011

The first lesson in economics is scarcity. There is never enough of anything to satisfy all those who want it. The first lesson in politics is to disregard the first lesson of economics.
Thomas Sowell American writer and economist

However, our approach to healthcare financing has to evolve. As our society gets older, we will see higher demand for quality care, longer life expectancy and the rising incidence of chronic diseases. Families will also get smaller over time and we will have more singles without family support when they are in their silver years. We have hence embarked on a thorough review of our healthcare financing system, as the Minister for Health has earlier indicated. This should seek to provide greater peace

of mind for all Singaporeans while ensuring that the healthcare system remains sustainable. The review will look at
all components of our healthcare financing framework.
DPM and Finance Minister Tharman Shanmugaratnam

First, although overall healthcare expenditure will go up, we want to see Singaporeans outof-pocket share of medical costs fall, and the Government take on a larger share. We will target help at those who need it the most. But we will also want to ensure that the needs of the middle-income group are met. Second, we want to broaden insurance coverage by expanding risk-pooling so that as a society, we support those who require more help. We must however be careful about how this affects premiums. Third, we must study how to increase the role of Medisave so it can be used to meet more healthcare needs whilst ensuring sustainability of savings. Fourth, we will do more for those who need help with their medical expenses by expanding the usage of Medifund.
Finally, we will help Singaporeans stay healthy by increasing our investments healthy.

in

health promotion and preventive care, so all individuals are encouraged to stay

And going forward, the middle income group will be a major beneficiary of the healthcare financing review. The lower income group is in fact already heavily subsidised, although we can improve things for them by providing greater assurance upfront on whether they qualify for Medifund. But the middle income group

is a major beneficiary of the healthcare financing review.

Transforming Care: From Silos to Systems

Prevention and Early Diagnosis Primary Care
Secondary/ Tertiary Care (OutpatientSOC and ED) Secondary/ Tertiary Care (Inpatient) Acute & Intermediate Care Long Step Down/Comm unity Care -

End-ofLife Care

Primary Care

Term Care

Rehab Centres

Polyclinic
Screening & Prevention

Nursing Home Patient Palliative Care Community Hospital Acute Hospital

Family Physician

Patient education & empowerment IT Infrastructure Manpower capability and capacity Well Frail elderly

GEOGRAPHIC CONCEPT OF REGIONAL HEALTH SYSTEMS

CH
Polyclinics
Screening & Prevention

NH RH
Palliative Care Home Care Rehab & support services

FPs

CH
Polyclinics
Screening & Prevention

CH NH
Polyclinics
Palliative Care Home Care Screening & Prevention

CH NH
Polyclinics
Palliative Care Home Care Screening & Prevention

NH RH
Palliative Care Home Care Rehab & support services

RH
FPs
Rehab & support services

RH
FPs
Rehab & support services

FPs

CH
Polyclinics

CH
Polyclinics
Screening & Prevention

NH
Palliative Care Home Care Rehab & support services

NH
Palliative Care Home Care Rehab & support services

Screening & Prevention

RH SINGHEALTH
FPs

RH NUHS
FPs

- Linked through IT systems (EHR) - 4 RHS (including KTPH/ JGH), 2 AMCs - Coordinated care across 39 regions (AIC)

REGIONAL HEALTH SYSTEMS AS THE NEW PARADIGM

Hospitals are not only for the sick. Hospitals are most successful if they can help the residents avoid falling sick. We have been progressively making this strategic shift in healthcare policy and delivery: going beyond sickness to health; beyond treatment to prevention, beyond the hospitals to the community. In this new model of healthcare delivery, hospitals are without walls. Their responsibility does not

begin only when a patient walks into the hospital or ends when the patient departs. Their responsibility extends far beyond the hospital walls, going deep into the community at large. They will interact with more healthy people than sickly ones, trying to get them to stay healthy
and manage their chronic illnesses, avoiding complications and unnecessary hospitalisation.
Hospitals cannot do this alone. They need to build a strong network of trusted relationships

with GPs, grassroots organisations, schools, factories, polytechnics, universities, VWOs and the people. They need to leverage on these relationships to help spread the health messages,
conduct regular screenings, and persuade people to change lifestyle.

Khaw Boon Wan, Blog Post 26 April 2010

COMPARATIVE SPENDING
Public Spending as % GDP National Healthcare Expenditure as % GDP 9 9 4 10 10 18 13 Government Spending on Healthcare as % of Total Healthcare Spending 68 75 36 81 84 53 65

Australia Finland Singapore Sweden United Kingdom United States of America High-income OECD Countries (Aggregated)
Data source: World Bank (2010 statistics)

27 40 13 33 46 27 30

($60 billion)

Conclusion
Unprecedented time in Singapores healthcare history; most significant transformation since Medisave and individual responsibility Singapore transforms from a position of financial strength Continuing tension between individual responsibility, productivist welfare capitalism, system financial sustainability AND peace of mind

DISCUSSION