Some have suggested that Singapore is a thinly-disguised dictatorship, and that political stability is attained at the cost of democratic freedom. That is simply not the case. Although one party, the PAP, has been in power since independence, it is elected and does not hold power through force, and could not have maintained its rule without being highly responsive to the concerns of the electorate.
The government is responsive to the concerns of the electorate. In the 2011 elections, healthcare was one of the issues raised. There were concerns that the government was not doing enough for the elderly and that families were experiencing severe financial strain and even bankruptcy as they tried to pay for older family members’ care. Opposition parties organized themselves around issues of healthcare affordability and eldercare costs.
Early the following year, the government responded with a new program of increased spending—doubling the Ministry of Health's budget over the next five years—to address citizens’ concerns. It announced increased subsidies for long-term care, even for patients being cared for in the home, and expanded eligibilities for subsidies, giving middle-income families some financial relief. Subsidies were increased for nursing homes (including eligible patients in private nursing homes), day care, rehabilitation care, and home-based care. These actions by the government seem to me to be a direct response to the issues raised in the elections.
Establishing Priorities
The health of the populace was not a top priority for the government at the start of independence. As Lee Kuan Yew observed in his memoirs, he had three immediate concerns to deal with: international recognition for Singapore's independence; a strong defense program that would “defend this piece of real estate”; and finally the economy—“how to make a living for our people.”2 Yong Nyuk Lin, the Minister for Health at the time, stated the situation bluntly: “health would rank, at the most, fifth in order of priority” for public funds. National security, job creation, housing, and education were in the queue ahead of health, in that order.3 With the exception of the basics of public health, healthcare planning and development would have to wait until the nation achieved a level of military and economic stability.
It seems to me that this ordering of priorities was apt for the time, as it was vitally important first to set up the defense of this small nation, and then to attract investors to set in motion economic growth, and tackle glaring issues of unemployment, housing, and education. After these critical problems had been dealt with, others, including healthcare, could be taken on. Exactly where health comes in the priorities of an emerging economy may vary. In countries where HIV/AIDS is highly prevalent, or if another epidemic or disease threatens a broad segment of the population, health may become the first or second national priority.
Wisely, the initial focus in Singapore was on public health: putting proper sanitation procedures in place, controlling infectious diseases, all successful efforts. Early initiatives were launched to provide clean water, develop a vaccination program, and guarantee access to basic medications, clean food, and more.
In time, the priorities set by the government proved to be effective. The security situation stabilized and the economy grew to the benefit of all. The creation of the healthcare system was aided immeasurably by the outstanding growth. One important indicator to consider: GDP grew from just under S
Promoting a Sense of Collective Well-Being and Social Harmony
One of the most important tenets of Singaporean governance is that a strong society requires social harmony. If tensions between social groups and races are to be avoided, all groups should be included in the life of the country and should benefit, to some degree, from its successes. The government's actions on behalf of this belief have undergirded the building of modern Singapore. As part of the social fabric, the government built a system that promotes a sense of fairness and well-being through both economic opportunity and delivery of social services. I find these words of Lee key to understanding Singapore's approach:
A competitive, winner-takes-all society, like colonial Hong Kong in the 1960s, would not be acceptable in Singapore…To even out the extreme results of free-market competition, we had to redistribute the national income through subsidies on things that improved the earning power of citizens, such as education. Housing and public health were also obviously desirable. But finding the correct solutions for personal medical care, pensions, or retirement benefits was not easy.5
One important solution Lee and his ministers found was the Central Provident Fund (CPF). It was set up during British colonial rule as a compulsory savings program for workers to build a nest egg for retirement. Individuals put five percent of their wages into the fund and their employers matched it. The accumulated money could be withdrawn at age 55. Lee's government expanded the program, upping the contribution levels, and allowing funds to be used for home-buying (widespread home ownership was seen as vital for political and social stability).6
The CPF has become one of the key pillars supporting social stability. The government had a long-range vision to increase the use of the Fund over time and broaden it to allow individuals to save for and pay for education and healthcare as well as retirement and home-buying. Mandatory contribution rates have risen over the years and now stand at 16 percent of wage for employers and 20 percent for employees. After age 50, the rates decrease.
The Central Provident Fund's contribution to the viability of the healthcare system cannot be overstated: it helps control costs by instilling in patients a sense of responsibility about their spending—after all, it is their money to save or spend; and it helps make care available and affordable to all. Eventually, however, the government recognized that the health savings program would not be enough to support care, and other systems were put in place, including a medical insurance program and a social safety net.
Respect and Education for Women
Singapore has been a pioneer in the area of women's equality beginning with The Women's Charter of 1961 that improved the rights and protections of women under law. Singapore established early on the importance of respect and education for women, as well as seeing to their health needs. The government accomplished a great deal well before the women's movement established itself in many countries.
Specifically, women's health education was deemed essential to the future of the country. The Education Ministry took the lead in educating young women about important health topics. The then Health Minister Mr. Khaw Boon Wan credited that effort with creating a vitally important advance in healthcare: educated women were now able to look after their own health, their health during pregnancy, their babies, and their families.7
In the coming chapters, I will take you through these and other elements that have made healthcare in Singapore such an enviable achievement: the high quality of care, more on the critical role of the CPF, financing the system, controlling costs, infrastructure, investing in medical research, and the new challenges of long-term care and eldercare. But first, in the remainder of this chapter, I will walk you through the ideas and the history of social