MYTH OR MAGIC: THE SINGAPORE HEALTHCARE

SYSTEM

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

Jeremy Lim MBBS, MPH, MRCS (Edin), MMed (Surg), FAMS Principal Consultant, Insights Health Associates www.insightshealthassociates.com Oct 2013

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.

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

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

Health Outcomes

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 Singapore’s 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-market-family 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 benefits without massive taxation and overloading the system, reducing the incentives to work and to save and care for one’s 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 self-governing 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 didn’t 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 that’s 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.”

From Ministry of Health, 2009

CORPORATIZATION AND ESTABLISHMENT OF HCS

“When we underestimate demand, the result is over-crowding 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 under-supply than to over-supply 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

Government

Spending on

Healthcare as % of

Total Healthcare

Spending

Australia 27 9 68

Finland 40 9 75

Singapore 13 4 36

Sweden 33 10 81

United Kingdom 46 10 84

United States of America 27 18 53

High-income OECD

Countries (Aggregated)

30 13 65

Data source: World Bank (2010 statistics)

0

1

2

3

4

5

6

7

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

Nu

mb

er

of

Ho

spit

al B

ed

s p

er

10

00

po

pu

lati

on

Year

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 CareBeds in Singaporeper 1000population

Acute Care Beds inSingapore per1000 population

Total Number ofBeds in OECDcountries(average) per1000 population

the mrbrown show getting to the bottom of things.avi

In May 2011, Singapore’s ruling party, the People’s 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-off—about 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’ out-of-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 in health promotion and preventive care, so all individuals are encouraged to stay

healthy.”

“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.”

Frail elderly Well

Primary Care Acute & Intermediate

Care

Long - Term Care

Patient education & empowerment

IT Infrastructure

Manpower capability and capacity

Transforming Care: From Silos to Systems

Prevention and Early Diagnosis

Primary Care

Secondary/ Tertiary Care (Outpatient- SOC and ED)

Secondary/ Tertiary Care (Inpatient)

Step Down/Comm

unity Care

End-of-Life Care

Rehab Centres

Family Physician

Polyclinic

Palliative Care Screening

&

Prevention

Acute Hospital

Nursing Home

Patient

Community Hospital

39

RH

CH

NHPolyclinics

FPsHome

Care

Rehab &

support

services

Screening &

PreventionPalliative

Care

RH

CH

NHPolyclinics

FPsHome

Care

Rehab &

support

services

Screening &

PreventionPalliative

Care

RH

CH

NHPolyclinics

FPsHome

Care

Rehab &

support

services

Screening &

PreventionPalliative

Care

RH

CH

NHPolyclinics

FPsHome

Care

Rehab &

support

services

Screening &

PreventionPalliative

Care

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

RH

CH

NHPolyclinics

FPsHome

Care

Rehab &

support

services

Screening &

PreventionPalliative

Care NUHS

RH

CH

NHPolyclinics

FPsHome

Care

Rehab &

support

services

Screening &

PreventionPalliative

Care SINGHEALTH

GEOGRAPHIC CONCEPT OF REGIONAL HEALTH SYSTEMS

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

Government

Spending on

Healthcare as % of

Total Healthcare

Spending

Australia 27 9 68

Finland 40 9 75

Singapore 13 4 36

Sweden 33 10 81

United Kingdom 46 10 84

United States of America 27 18 53

High-income OECD

Countries (Aggregated)

30 13 65

Data source: World Bank (2010 statistics)

($60 billion)

Conclusion

• Unprecedented time in Singapore’s 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