Affordable Excellence. William A. Haseltine. Читать онлайн. Newlib. NEWLIB.NET

Автор: William A. Haseltine
Издательство: Ingram
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Жанр произведения: Медицина
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isbn: 9780815725268
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foundation for today's healthcare system.

      Singapore's transformation from a British colonial outpost to a First-World city-state is nothing short of remarkable. Since achieving independence in 1965 as a tiny, impoverished country with few assets and no natural resources, it has turned itself into a modern, prosperous, secure city-state. Singapore's founding father, Lee Kuan Yew, knew that without Britain's military and financial support, this new country would succeed and endure only if it could turn itself into a “First World oasis in a Third World region.”

      Many institutions had to be erected before Singapore was able to reach that goal. How it was all accomplished makes for a fascinating study in nation-building. However, the scope of this book allows me to focus my discussion on the underlying Singaporean philosophy and actions that drove the development of the public healthcare system. While providing for the health needs of his people, Lee also wanted his country to avoid the pitfalls of Western systems—such as those in the United Kingdom and the United States—that were already showing signs of strain caused by high costs.

      In the late 1940s, as a student at Cambridge, Lee witnessed the beginnings of the English welfare state:

      Looking back at those early years, I am amazed at my youthful innocence. I watched Britain at the beginning of its experiment with the welfare state; the Atlee government started to build a society that attempted to look after its citizens from cradle to grave. I was so impressed after the introduction of the National Health Service when I went to collect my pair of new glasses from my opticians in Cambridge to be told that no payment was due. All I had to do was to sign a form. What a civilised society, I thought to myself. The same thing happened at the dentist and the doctor.8

      Over time, though, Lee realized that a system that took care of all of its citizens’ needs would diminish the population's “desire to achieve and succeed.” It was obvious to him that Singapore, upon independence, was a poor, struggling country that needed a motivated population working hard in the interests of their country and their future. He could not begin to contemplate a system like Britain's. If anything may be identified as the guiding philosophy behind Singapore's success, it is Lee's conviction that the people's desire to achieve and succeed must never be compromised by an overgenerous state. The government made certain that Singaporeans developed and retained a sense of responsibility for all aspects of their lives—including the care and maintenance of their own physical and emotional well-being.

      Building the Foundation

      Bringing Care to the People

      I mentioned earlier that high-quality healthcare was not a high priority in the early days of independence. However the young government did take some significant steps to improve the health of Singaporeans. An early move was to bring primary care services closer to the people by developing a network of satellite outpatient dispensaries and maternal and child health clinics. They offered a one-stop center for immunization, health promotion, health screening, well-women programs, family planning services, nutritional advice, psychiatric counseling, dental care, pharmaceutical, x-ray, clinical laboratory, and even home-nursing and rehabilitative services for non-ambulatory patients.9 The move took the pressure off Singapore's General Hospitals to provide such care.

      Mr. Khaw Boon Wan characterized the movement to outpatient clinics as one of the low-hanging fruits in the transformation of the healthcare system, yielding a high return for a low investment, a necessary condition in the early days of the country.10 These outpatient clinics have since been consolidated into modern polyclinics, small, well-equipped medical centers providing a range of diagnostic and treatment capabilities that do not require overnight stays, and catering to all age groups. Although acute illnesses still represent the majority of the problems being seen at polyclinics, the clinics are increasingly focused on chronic disease management. Services such as home-nursing and rehabilitative care for non-ambulatory patients have since been moved from polyclinics to Voluntary Welfare Organizations, community hospitals, and private nursing homes.

      Introduction of User Fees at Public Clinics

      Services at the outpatient clinics had been free-of-charge—modeled after the practice of the British healthcare system. But the government quickly changed that.

      As Lee Kuan Yew recalled in his memoirs:

      The ideal of free medical services collided against the reality of human behaviour, certainly in Singapore. My first lesson came from government clinics and hospitals. When doctors prescribed free antibiotics, patients took their tablet or capsules for two days, did not feel better, and threw away the balance. They then consulted private doctors, paid for their antibiotics, completed the course, and recovered.

      Lee's government imposed a fee of 50 cents for each attendance at the clinics, doubled during public holidays.11 This bold move reminded Singaporeans that healthcare is not free, and that the nation would not be building a welfare system such as Britain's. People would be expected to a large degree to pay their own way.

      

      Early Human Resources/Manpower Planning

      Before 1960, there were fewer than 50 medical specialists in Singapore to serve Singapore's two million residents. To boost their numbers, the Committee for Postgraduate Medical Education was set up in 1970.12 Initially, there were few specializations offered in Singapore. The government began sending its brightest doctors in the public sector to the best medical institutions around the world for training.

      In the 1980s, the Healthcare Manpower Development Programme was launched giving specialists opportunities to work and train at world-renowned overseas institutes. HMDP at the outset was meant for specialist training, and subsequently subspecialty training was introduced in areas such as trauma, advanced cardiology techniques, gastro-pathology, breast reduction, and more.13 This action nurtured a new generation of highly-skilled specialists and set the stage for developing Singapore's current world-class capability in highly-specialized, advanced medicine.

      Over the years, Singapore has continued to forge strategic partnerships with healthcare organizations all around the world and continues to send doctors for training at world-class medical facilities. In 2009, 1,750 doctors practicing in Singapore were foreign-trained. Half of newly-recruited doctors are foreign-trained.14

      Healthcare Infrastructure Improvements

      Early on, the government began upgrading the infrastructure at public hospitals, all of which dated from before the Second World War. Gradually, one at a time, facilities were improved, investments were made in modern equipment, and sophisticated specialties were developed. Ambitious hospital construction and expansion programs have been undertaken since.15 To encourage community participation and initiative in providing healthcare to the elderly, chronically sick, terminally ill, and mentally ill, the government began providing subsidies to certain private institutes and Voluntary Welfare Organizations and continues to do so today.

      Housing

      Although not a part of the healthcare system per se, the country's early housing initiative has contributed immeasurably to the health of Singaporeans. I would be remiss in not mentioning it here.

      In the days before independence, according to the Housing and Development Board (HDB), many Singaporeans were living in “unhygienic slums and crowded squatter settlements.”16 At the time, only nine percent of Singaporeans lived in government flats. Set up in 1960, HDB began investing in good, clean affordable housing that greatly improved living conditions and health conditions. In less than three years, over 20,000 flats were built. By 1965, the number climbed to almost 55,000 flats, and within ten years, the housing problem was solved.17 Today almost 85 percent of Singaporeans live in HDB flats. I believe that this effort on behalf of the people remains one of the most successful examples of public housing in the world.

      For anyone interested in learning about living conditions before the improvements I have just discussed, I highly recommend a visit to the Chinatown Heritage Centre at 48 Pagoda Street. There visitors will find a fascinating recreation of housing from the 1950s, including reconstructed interiors.

      The government did not stop