By•Dr Satish Tajne•Dr Geetesh Shelar•Dr Rohit Nair•Dr Shekhar Gaddam

Introduction Singapore is a small country with a total land area of 710 square

kilometres.

Obtained independence from Malaysia on 9 August 1965.

Singapore is a parliamentary republic.

Singapore is characterized by a highly developed and successful free-

market economy.

It has a very open and corruption-free business environment.

The Singapore economy grew by 8% in 2009 and it is projected to

grow by 15% in 2010.

Per capita gross domestic product amounted to US$ 39,951 in 2008.

Literacy rate : 96.3%

THE HEALTH CARE SYSTEM IN SINGAPORE

Health Care Philosophy-

1. Aims to build up a healthy population through preventive health care programmes andthe promotion of healthy living.(Healthy family, healthy nation report 1991)

2. Responsibility to intervene in the health care sector where the market fails to keep healthcare costs down

3. Personal responsibility for one’s health.

Emphasis on – a)Health education

b)Immunization

c)Health screening for early detection of diseases.

Ministry of Health-Overall responsibility for the provision and regulation of health care services inSingapore.

HEALTHCARE DELIVERY SYSTEM

Singapore has a dual health care delivery system.

Primary health care-

80%provided by private practitioners

20% government polyclinics

Includes –

curative out-patient medical treatment

health screening

preventive health programmes for school children,

home nursing

day care and rehabilitation for the elderly

health education and promotion.

Hospital Care- 80% by public sector

20% by Private sector

PUBLIC HEALTH EXPENDITURE

Health Indicators The crude birth rate

9.9

4.4

1.30 3

per 1000 resident population.The crude death rateper 1000 resident population.The total fertility rate per resident femaleMMRUnder 5mortality Rate

DemographyPopulation of Singapore = 4.9 millian (2009)

% of Total Population

Chinese 74.2%

Malaysian

Indian

Others

13.4%

9.2%

3.2%

Burden of disease

Principal Causes of Death

TOP 5 CONDITIONS OF HOSPITALISATION

PREVENTIVE HEALTH SERVICES

NUMBER AND PERCENTAGE OF BEDS IN PUBLIC AND PRIVATE HOSPITAL

NUMBER OF BEDS

PUBLIC HOSPITALS

PERCENTAGE(%)

9091

2185

80.6

19.4PRIVATE HOSPITALS

TOTAL 11276 100

3 beds per thousand population ratio.Average length of stay is about 5.5 days in general hospital.

Occupancy rates - Public Hospital 84 % Private hospital 65%

Human resources for health

Singapore's only Western-style Medical School, established in

1905 trains 150 doc/yr

Reason for growth in specialization -Push FOR growth by forming Committee for Postgraduate Medical Education in 1970 Up-gradation of hospitals with sophisticated technology. Sending doctors to higher medical centers in world for training

Traditional medicine.

Traditional medicine (Chinese)- attends 12% of OPD

patients hence government appointed a committee in 1994 to review the practice of traditional Chinese medicine (TCM) which came out with recommendation of accreditation of TCM training programme. Registration with the self regulatory body. Establishment of a Chinese Proprietary Medicines as a Listing Unit in the Ministry of Health.

Programmes Chronic Disease Management Programme (CDMP) and

vaccinations (Oct 2006)

Health Promotion Programmes:

BreastScreen Singapore, Cervical Screening Singapore, ChildhoodInjury Prevention Programme, Community Health Screening, MentalHealth Education Programme, National Myopia PreventionProgramme, Physical Activity programme, Mental Health EducationProgramme, National Smoking Control Programme, NutritionProgramme, Osteoporosis Education Programme, Workplace HealthPromotion Programme.

National AIDS Control Programme (since 1985)

National Childhood Immunization Programme (NCIP)

Singapore Tuberculosis Elimination Programme (STEP) (1997)

Important Acts Human Organ Transplant Act (Hota)

On 6 January 2004, the Human Organ Transplant (Amendment)Bill was passed by Parliament which extending HOTA beyondkidney to include liver, heart and cornea.

Advance Medical Directive (AMD)- It’s a legal document that one sign in advance to inform thedoctor to not to use any life sustaining treatment to prolong thelife in case of an event of one becoming terminally ill andunconscious or imminent death.To ensure that terminal patients die with dignity and to cater tothe medical demands of its ageing population the ministry isplanning to increase the number of hospice beds by about 20%over the next five to seven years.

National Health Plan ‘83’

Government was prompt enough to think about solving the problem before it arrived which lead to National Health Plan 1983, detailing health infrastructure planned for the next 20 yrs

Objectives of the NHP were

to secure a healthy, fit and productive population through active disease

prevention and promotion of healthy lifestyles

to improve cost-efficiency in the health care system.

meet the growing demand of a rapidly aging population for increased health

care.

Under this plan, the Medisave scheme was introduced in 1984 to meet

rising medical expenditure. The Medisave account allows members towithdraw funds from their accounts in the Central Provident Fund (CPF) topay for hospital services, within certain limits, of themselves and theirimmediate family members.

Singapore Health system Financing

By-Dr.Gitesh H Shelar

HEALTH CARE FINANCING IN SINGAPORE

Prior to the reform in the 1980s medical services generally wereprovided free or at a nominal charge through public facilities whichwere financed through general taxation.

In 1981 Ministry of Health announced ‘a cradle to grave healthsystem’ like those of British NHS.

Included two major changes such as

a)shifting of financial burden of health care from government to individual and employer.b)Corporatization of Government Hospital.

HEALTHCARE DELIVERY SYSTEM

Singapore has a dual health care delivery system.

Financing

Primary health care.

Hospital care

Long term care.

Dental services.

Pharmaceutical.

FINANCING HEALTH CARE SYSTEMBASICALLY THE HEALTH CARE IS FINANCED BY FOUR PAYERS-

The individual

The employer

The insurer

The government

Financing of healthcare is mainly divided in to

Public financing including Taxation and Medifund

Private financing including the government-administered schemes,Medisave and Medishield, private medical insurance and savings.

Public health financing-

Taxation-Personal income tax ranging from2% to 28% is levied onresidents of Singapore at progressive rates on the previous year’s income.Companies are taxed on adjusted net profits less capital allowances. Thecorporate income tax rate is 26%. In 1995, tax revenue amounted to S$19.6billion.Provides fund for subsidising and promoting health care services.

MediFund-It’s a endowment fund set up by the government in April 1993.

Medifund started with an initial endowment of S$200 million from

Since its inception 99% of the applicants were given financial

the government in 1993 which has increased to S$600 million in 1998.

assistance.

Medisave Introduced in 1984 as an extension of CPF(1955) Medisave allows

Singaporeans to put aside part of their income into an account to meet future personal or immediate family’s hospitalisation, day surgery or certain outpatient expenses. Under Medisave, between 6 and 8 per cent - according to age of every member's CPF account, subject to a ceiling of Sin $16000.

From 1 March 2010 Singapore residents can use the medisave account to

pay for overseas hospitalisations.

Amount with drawn from Medisave accounts-

2008-SGD 590mn

2oo9-SGD 660mn.

For the year 2006, the salary ceiling for the Central Provident Fundcontribution is

S$4,500/month. Additional Medisave Contribution Scheme made by the employer as anincentive to employee which is limited to S$1,500per

employee/peryear. For all self-employed persons who earn more than s$6,000 are required tocontribute.

Accumulated savings in a Medisave Account are subjected to a MedisaveContribution Ceiling . The Medisave Contribution Ceiling for

2006 isS$32,500.

Medisave Account savings that exceeds S$27,500 can only be withdrawn. If the Medisave A/C Balance is lower than required amount (S$8,300)thenamount from other two sub-account is

transfered

Starting from 1 March 2010 the Ministry Of Health announced that the

Singapore residents will be allowed to utilise National Medical savingscheme or Medisave for overseas hospitalisation and day surgeries athospital in Malaysia.

This scheme has been initiated with two providers-

1. Health Management International (HMI)

2. Parkway Holdings

Boost to the Palliative care with the Health Ministry’s decision to liberalise

the use of Medisave for home palliative care in September 2009.

Some SGD500mn (US$347mn) is to be spent on elderly care, with a focus

on home care, rehabilitation and palliative services.

Marriage and Parenthood Schemes

Medisave Maternity Package provides for the delivery and

pre-delivery medical expenses of your first four children.

For normal delivery withdrawal upto SGD 2,100 for Non-

Medisave Maternity Package while for Medisave Maternitypackage SGD 450 more will be alloted.

Claim only upto the mentioned amount will be provided for

maternity expenses.

Interim Disability Assistance Programme forthe Elderly(IDAPE)

Provides financial help to needy and disabled elderly Singaporeans, who are not eligible for ElderShield because of their age or pre-existing disabilities. IDAPE provides with $100 or $150 a month, for a maximum period of 72 months.Eligibility- If one is unable to perform 3 or more of the 6 Activities of Daily Living (ADLs; washing, feeding, dressing, toileting, mobility and transferring). If one is aged 70 and above as at 30 September 2002. If you are aged 40 to 69 years as at 30 September 2002, your disability must occur before 30 September 2002. If one’s per capita monthly household income is less than $1000.

Payment schedule for IDAPE

Per capita monthly household income *

$700 and below

Monthly payout

$150

$701 - $1,000 $100

Above $1,000 Not eligible for IDAPE payout

Primary Care Partnership To provide convenient and affordable healthcare for needy

elderly and disabled Singaporeans, the Ministry of Health(MOH) started the Primary Care Partnership Scheme (PCPS).

In this scheme needy patients can receive subsidised treatment atGeneral Practitioners (GPs) and dental clinics near their homes.

To provide common outpatient medical treatments and basicdental services for this group of patients

The scheme will also cover treatment for 3 chronic diseases:Diabetes Mellitus (DM), Hypertension (High blood pressure)and Lipid Disorders (e.g. High cholesterol).

INTERMEDIATE AND LONG-TERMCARE (ILTC) After the patients are well enough to be discharged from the hospital but due to theirmedical condition may require further care and treatment at centres.

Such care isprovided through ILTC.

Refers to services such as Community Hospitals Chronic Sick Facilities Nursing Homes Hospices Day Rehabilitation Centres Home care services such as home nursing and home medical.

i.

ii.

iii.

iv.

v.

vi.

Realizing the fact that the cost of such care will be higher as they require care forlonger period of time hence the government subsidizes such care to those who needit.

Health insurance plans Health insurance plans approved by either the Central Provident Fund

Board or the government serve the function of pooling health careresources which include-

(a) Medisave-approved health insurance schemes; and

(b) employer-sponsored schemes.

Medisave approved insurance schemes consists of MediShield,

Integrated MediShield (which includes IncomeShield) and ElderShield

MEDISHIELD Is a voluntary low-cost catastrophic medical insurance scheme launched in 1990. It covers hospitalization expenses for major or prolonged illness according to the extent of limit chosen. Element deductible and co-insurance (20 per cent)present along with upper age limit of 70 years for participation. At the end of 1995, Medishield covered 1.5 million lives or 87 per cent of eligible CPF members as well as a quarter million of their dependants.In an Integrated Medishield Scheme additional benefits are coupled with the benefits by charging an additional fee paid to the insurance company by the consumer In 2005, there were five health insurance companies in Singapore providing 15 integrated MediShield insurance products

ELDERSHIELD Is a severe disability insurance scheme for those who need long-term care, especially during old age. Provides a monthly cash payout to help pay out-of pocket expenses for the care of a severely disabled person. Till 2007, the market was controlled by just two local providers – 1)Great Eastern Life Assurance 2)NTUC Income Insurance CooperativeAviva now is also present. From September 2007, the disability insurance scheme was introduced in two tiers – Basic ElderShield and ElderShield Supplements

Employer-sponsored schemes The Manpower Ministry announced in September 2007 that from early

2008 employers must provide insurance for all those on a work permit oran S pass (i.e. overseas employees).

Employers are encouraged to provide employees with medical benefits by tax incentives. This schemes include Portable Medical Benefits Scheme or the Transferable Medical Insurance Scheme

The Portable Medical Benefits Scheme is an institutionalized scheme. Involves Employers making monthly contributions to employees’ Medisave Accounts which is limited to S$1,500 per employee per year. The Transferable Medical Insurance Scheme is an employer-sponsored group insurance plan. At present, 19 health insurance companies provide transferable medical insurance products. Provides coverage for 12 months even if the employee leaves the job for whatever reason.

Patient safety and EMR

Being committed to patient safety Singapore introduced a project to

document the prevalence of medical errors in 2003 which documented 1000death annually due to inappropriate use of pharmaceuticals and medicaldevices.

Accordingly, the government started making electronic medical records

(EMRs) compulsory.

Nine polyclinics affiliated with the National Healthcare Group (NHG)

started to use the scheme in October 2009 and now is slated out for theremainder.

The creation of the new electronic records system is supported by the

investment of around SGD200mn (US$139mn).

Health Promotion Board Established in 2001, the Health Promotion Board (HPB) has a

vision to build a nation of healthy and happy people.

Main driver for national health promotion and disease preventionprogrammes.

Goal is to increase the quality and years of healthy life and prevent illness, disability and premature death. About 36 programmes are listed in HPB-A few of them worth mentioning are-

Adult Oral Health Promotion Programme , AIDS Education Programme,BreastScreen Singapore, Healthy Eating in Schools Programme, National BriskWalking Programme, Nurture Your Mind For Older Persons (NYMOP), PhysicalActivity Programmes Schedule, RESPECT and STI/AIDS Prevention Programmesfor Youths

Health expenditure analysis Total health care expenditure in Singapore in 1995 reached S$3,545

million in 1995. It represented nearly 42 times(S$85million) that in

1960 and 2.7(S$1312) times that in 1986 .

GDP fluctuated at around 3% to 4% since 1960.

Health care expenditure per person has increased more than two times between1986 (S$524.8) and 1995

(S$1,181.7).

Health expenditure Pattern

Share of Financial responsibilty

Analysis

Dr Rohit Nair

WHO Health System Rank 6th in the world

The story behind the scenes….

Political Political Stability since 1965( PAP)Effectiveness of policy of delivery mechanism of public services and no disruption of policy implementation. Singapore enjoys a very stable political system Strong foundation with regulation and guidelines ( Intellectual and property rights) Official promises have been made to eradicate Singapore’s reputation as an overprotective nanny-state, with efforts to enhance freedom of expression. Strong relationship between the public and the govt that help overcome barrier in the process of building , maintaining and developing the nation.

Economic

Strong market foundations consistent growth Imports most of resources and largely export dependent Other weaknesses are the public feelings of insecurity and concern

about making mistakes and being finedThe SARS outbreak in 2003The war in Iraq in 2002long-term economic problems. Competition from low-costneighbouring countries is on the increase and its population is ageingrapidly.In the face of regional competition for both exports and investment, thegovernment is encouraging economic diversification to boostcompetitiveness. New areas being promoted include biomedicalsciences, medical and financial services, and tourism.

Social Ethnic diversity of Chinese, Malaysians and Indians. Worlds cleanest city and the least corrupt city HDI 27th rank in the world The worlds only slum free city 100% Urban population The social strengths of Singapore have been demonstrated by an educational system that produces a well-educated workforce . Not only developing its own pool of local talents, Singapore also recruits foreign talents to work in both the public and private sectors.

Technology Technologically, Singapore has a high-tech based economy.

Well-prepared infrastructure and the latest technologycontribute to the rapid development.IT literate and English ProficientNationwide electronic Citizen (e-Citizen) programme.The Ministry of Health websiteOpening up of the market.Personal Health Records and Electronic Medical Records.

S.W.O.T

Individual Responsibility Political will 3 M Medical Savings Account stable government and economy. availability of skilled medical professional latest medical technology. E Health In terms of accessibility, location and air links Strengths Strong intellectual property (IP) protection laws. Favourable tax climate for foreign investment. World-class capabilities across the entire value chain, (research to support services). Well-established research infrastructure backed by strong supporting industries. Singapore is the least corrupt country in Asia,(Transparency International)

Strengths

Weakness

Ageing Population “silver industry”

Hospital based Health Care system

Resource poor

Shortage of health care professionals

Small population size, which limits longer-term market potential. The Singapore government censors the media and limits the distribution of foreign publications. The judiciary’s record of siding with prominent politicians calls into question the true extent of its neutrality in any contract dispute involving a politically sensitive issue

Opportunities

Medical tourism

Government focused on developing Singapore into a hub

for pharmaceuticalsMedical devices, clinical trials and biotechnology,attracting both foreign investment and patients.There is currently a government-inspired push to 'goregional', strengthening Singapore's position as a hub ofmedical excellence in SE Asia.ASEAN Countries Trade policiesAlso planned is the creation of a multi million-dollarmedical services park, to be co-located with a tertiaryhospital.

Threats Changing Disease Profiles Costs via high technology and high standards Rising AIDS,TB

Lifestyle related Diseases There are fears that Singapore’s foreign policy alignmentwith the US will cause the city-state to become a

target forterror attacks launched by Muslim extremists. Terorism

Challenges

The number of seniors will increase from 8.4% in 2005 to

18.7% in 2030. In absolute terms, seniors will increase from about 296,900 in June 2005 to 873,300 in 2030 Healthier. In terms of mobility, about 87% of seniors are ambulant and physically independent. They will also be living longer Better educated. The proportion of seniors aged 65 – 74 with at least a secondary education is projected to increase from 13.9% in 2005 to 28% by 2010 and to 63% by 2030. Richer. Each successive cohort of older people will be increasingly affluent and wield greater economic power. As consumers, they represent a potentially large and untapped market sector.

Challenges Cont.

Cost containment vis-a-vis a rapidly ageing population: increasing

health care costs due to advances in medical specialisation as well asthe use of expensive medical technologies.Quality of care, while medical audit and quality assurance arecurrently still relatively underdevelopedMedical manpower planning: especially in nursing home nursing andancillary health personnel. Harnessing information technology: Singapore is working towards aNational Health Information System that will allow the seamless flowof information, such as electronic medical records, across all healthcare establishments; Increased demand and expectations from the more affluent andeducated population.Diseases that are 'lifestyle-related'. 'Westerners'. HIV-infected peopleare very often considered as isolated cases who have been 'exposed‘to foreigners.

What Do the people of Singapore feel about their healthcaresystem??

Public Perceptions of Healthcare inSingapore: Case Study (August 2006)

Jeremy FY Lim, Veena Dhanajay Joshi, conducted a survey of Singapore residents todetermine perceptions of the affordability and quality of healthcare in Singapore.

A sampling frame comprising 6146 random telephone numbers from the 2005/2006 ofthe Singapore telephone directory was generated.

Trained interviewers then conducted the survey via telephone using a questionnaire thatwas purpose designed for this survey.

Respondents were asked to rank their agreement with statements pertaining tohealthcare cost and quality on a 5-point Likert scale.

There were 1783 respondents to the survey.

Result Of the Study

Result Continue..

Conclusion: Singaporeans are confident in the Singapore healthcare system and sentiments appear to bemore positive when compared to other countries.

The future

The future

Comparative Analysis

Dr. Shekhar S. Gaddam

Key components of a well functioning health system ----WHO Leadership and Governance Health financing

Human resources for health Essential medical products and technologies Service delivery

Health information systems

Leadership and Governance Ensuring that health authorities take responsibility for steering the entire health system (including the private sector) Set clear direction through transparent and inclusive process of -- -- planning and strategy -- accountability -- monitoring and evaluation

…Leadership and Governance ctd…

Responsibility/ governance

Planning &strategy

Monitoring &evaluation

Accountability

France

Germany

UK

US

Singapore

No

…yes…

yes

…yes…

yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

…yes…

Yes

Health Financing A system to raise sufficient funds for health fairly A system to pool financial resources Ensure efficient use of funds

…Health Financing ctd…

Fairness

France

Germany

UK

US

Singapore

Pooling

…yes…

Yes

Yes

Yes

Yes / no

Efficient utilisation

Yes /no

Yes

Yes/ no

No

Yes

…yes…

Yes

Yes /no

No

Yes

Human Resources for Health Arrangements for achieving sufficient health professionals in right mix Ensure system wide deployment and distribution according to needs

…Human Resources for Health ctd…

Sufficient no. Right mix Efficientdeployment

?Yes

?Yes

France

Germany

Yes

Yes

Yes

Yes

UK

US

Singapore

No

Yes

No

Yes

Yes

Yes

Yes

No

No

Essential Medical Products andTechnology

Medical products regulatory system (marketing, safety, quality, etc) National list of essential medical products Availability and price monitoring system A national programme to promote rational prescribing

…Essential Medical Products andTechnology ctd…

Regulatorysystem

List ofessentialmedicalproducts

Yes

Yes

Yes

Yes

Yes

Monitoring ofavailabilityand price

Yes

Yes

Yes

Yes

Yes

Programmefor rationalprescription

Yes

Yes

Yes

Yes

Partly yes

France

Germany

UK

US

Singapore

Yes

Yes

Yes

Yes

Partly yes

Service Delivery Network of close-to-client primary care and back-up of specialized care Standard norms and guidelines to ensure access, quality, safety andpeople-centeredness Mechanisms to hold providers accountable for access and quality, and to ensure consumer voice

…Service Delivery ctd…

Close-to-ptprimary care

Norms toensureaccess/quality/safety

Yes

Yes

Yes

Yes / no

Yes

Peoplecenteredness

Accountabilityof providers

France

Germany

UK

US

Singapore

Yes

Yes

Yes

Yes

Yes

Yes /no

Yes /no

Yes / no

…Yes…

Yes / recently ?

Yes

Yes

Yes

Yes / no

Yes

Health Information System Health information system Health management information system

…Health Information System ctd…

HMS

France

Germany

UK

Yes and developing

Yes and developing

Yes and developing

HMIS

Yes

Yes

Yes

US

Singapore

Yes

Yes and developing

Yes

Yes

Health Indicators

Country

France

Germany

UK

US

Life expectancy in yrs(m/f/both)

78/85/81

77/83/80

78/82/80

76/81/78

HALE in yrs(m/f/both)

71/76/73

71/75/73

71/73/72

68/72/70

Singapore 79/83/81 71/75/73

…Health Indicators ctd…

IMR / 1000live births

France

Germany

3

4

Less than 5 yrsMR / 1000

4

4

MMR / 1000deliveries

8

6

Adult MR(prb death 15-49)/1000

87

78

UK

US

Singapore

5

7

2

6

8

3

7

13

8

78

107

64

…Health Indicators ctd…

Physicians /10,000

France

Germany

UK

US

Specialists /10,000

17

20.3

17.7

14.6

Nurses / 10,000 Hospital beds / 10,000

81

80

6

98

37

35

21

27

72

83

39

31

Singapore 17 7.8 54 32

Health ExpenditureExpenditure % Govt share inof GDPexpenditure (%)

France

Germany

UK

US

Singapore

11

10.4

8.4

15.7

3.1

79

76.9

81.7

45.5

32.6

Pvt share inexpentiture(%)

21

23.1

18.3

54.5

67.4

Per capitaexpenditreusing PPP (US$

3709

3588

2992

7285

1643

1) Is AMD(Advance Medical Directive ) = EUTHANASIA

????????

2) Human Organ Transplant Act (Hota) Can we have it in India ????????