Chart 2.1
Table 2.6a
Figures on government-only expenditure for the world's healthcare systems also show Singapore as the leader in keeping costs under control. Per capita studies reveal that in 2008, the government spent over
Private expenditure in Singapore amounted to around 65 percent of the total national expense (2008). Note that this includes payments out of the government-run MediShield scheme and related insurance schemes, Medisave accounts, and other private insurance schemes or employer-provided medical benefits. The figure for the United States is 52 percent, 17 percent for the United Kingdom, and 18 percent Japan. Singapore's relatively high private expenditure is a direct result of the government's efforts to shift more of the cost burden to consumers than do most other countries. The approach is a fundamental strategy for keeping public expenditures down and curbing unnecessary usage. I would have to say that the approach is working. Later in the book, I will take a much closer look at this strategy, as well as the system's guiding principle of encouraging individuals’ responsibility for their own care.
I find it interesting that the figures for private healthcare expenditure in lower-middle-income countries are also substantial, but for a different reason. The underdeveloped public healthcare infrastructure in these countries and a general lack of faith in the system cause citizens to gravitate toward private healthcare services and to pay for their own care. In India, private expenditure was as high as 67 percent in 2008; in the Philippines it amounted to around 65 percent.
Singapore's Advantages
Along with its excellent system of medical care, Singapore has developed an infrastructure that helps support healthy living and general wellness: an inexpensive and affordable mass transit system, neighborhood wet markets (fresh food markets) and supermarkets that carry affordable fresh fruit and vegetables, islandwide park connectors and HDB exercise stations, Ministry-funded community centers in every neighborhood, and close proximity to family and other support systems.
Table 2.7
Table 2.8
Table 2.8a
In addition, Singapore's economy and environment have played a role in its healthcare achievement. The country's wealth, high employment rate, compactness and lack of rural areas, and relatively low number of immigrants give it some advantages in its continuing efforts to nurture and sustain the excellence of its system.
Singapore's government leaders, ministers, and care professionals have developed a healthcare system with some of the best outcomes in the world, and as I have explained, with far less cost to the economy than might reasonably be expected. In the following chapters, I will explore how exactly they accomplished this extraordinary feat.
Chapter 2: KEY POINTS
Singapore's healthcare system has achieved First World standards at a lower cost than any high-income country in the world
The system has achieved excellent outcomes by most common measures:Increased life expectancy of its citizensIncreased infant survival ratesOne of the lowest under-five mortality rates in the worldAn adult mortality rate lower than any nation'sHospital beds ratios similar to the United States’Cancer survival rates similar to Europe'sCardiovascular disease death rates half of most countries in the region
Singapore's quality of care is excellent:Most consumers of its services report a high level of satisfactionIt is ranked sixth in the world by the World Health Organization
Cost of care has been kept low while achieving very high quality:It spends less per capita than any other high-income nationThe government outlays per capita for the system are a fraction of what developed nations spendPrivate expenditure is relatively high compared to many countries, in keeping with the government philosophy that people must be responsible for their own care
CHAPTER 3
Helping Patients Pay
The success of healthcare in Singapore today is largely due to the government's creative use of the Central Provident Fund. The CPF's medical savings component, called Medisave, makes it possible for Singaporeans to pay for much of their own medical care. Medisave is, in essence, a compulsory savings account. The government sets contribution rates for workers and their employers as a percentage of wages. Once in their accounts, the money may be used to pay for personal and family healthcare—always along carefully-established guidelines.
As mentioned in Chapter 1, the Central Provident Fund was first introduced under British colonial rule and functioned as a simple, mandatory retirement savings plan. Workers contributed five percent of their wages into the Fund, and their employers matched the amount.1 The nest eggs grew through these combined contributions plus interest paid on the balances. When participants reached 55, people could begin withdrawing the money to help pay for retirement.
Soon after independence, the government expanded the scope of the CPF and turned it into a vital factor in improving the lives, living conditions, and health of Singaporeans. It was determined early on that compelling health savings would play an increasingly larger role in the lives of the people, and it became a central part of long-term planning. Changes to the Fund were to be introduced in small doses over the years, so as not to cause concern and confusion among the population and to make them more acceptable. As wages rose, so too did the percentage of the salary contribution to the CPF. However, the increases were carefully calibrated so that an increase in wages always meant a net increase in take-home pay.2
The first significant step was taken in 1968 when, for the first time, in addition to retirement expenses, workers were allowed to use a portion of their CPF to help purchase apartments built by the Housing and Development Board. Since then, the rules governing the Fund have been changed to allow workers to use their savings to also pay for healthcare, approved insurance schemes, and education.
When employed Singaporeans and their employers make their monthly contributions, the money is dispersed into three accounts: Ordinary Account: to be used to buy a home, pay for CPF insurance against death and disability, investment and education;