Affordable Healthcare for All
In 1983, almost two decades after independence, the first comprehensive National Health Plan was introduced. The plan presented the government's broad health development strategies including keeping care affordable, meeting the demands of a growing population, and managing the rising expectations of an increasingly affluent society. It set national objectives for empowering Singaporeans to lead healthy, fit, and productive lives made possible through active disease prevention and promotion of a healthy lifestyle. The plan aimed to improve cost-efficiency in the system. Interestingly, it foresaw the growing demand for increased care for the rapidly ageing population.19 The plan mentioned the need to restructure the healthcare delivery system to cope with the changing trends of diseases—mainly the shift from treating infectious disease to chronic disease.20 The plan reflected the success of the early measures taken by the government to contain infectious diseases, provide clean water, and promote childhood vaccinations, allowing the focus of efforts to shift to chronic diseases. In time, Singapore began focusing on disease prevention through a healthy lifestyle—including exercise, eating healthy, managing stress, stopping smoking—along with screening for and optimal treatment of disease.21 In this respect, Singapore was well in advance of other countries in the region that only started to shift their emphasis to chronic diseases around 2010 or so.
Restructuring
A sweeping reform started in the 1980s, when the government embarked upon the restructuring of its public hospitals, giving them greater autonomy to function more like private hospitals than public institutions under a central control. Speaking as an entrepreneur, I can imagine how liberating this move must have felt to hospital management. National University Hospital was incorporated in 1985, and Singapore General Hospital was incorporated in 1989. The majority of the hospitals were corporatized in the 1990s. The goal was to allow the public hospitals to compete against one another. The unsubsidized wards were meant to serve as a benchmark in terms of quality and price for the private sector. This action helped stabilize prices throughout the system.
The public hospitals were given a freer hand to implement management practices for improving effectiveness and efficiency, and much more freedom in their day-to-day decisions regarding staffing, compensation, deployment of resources, and some user fees. The reforms succeeded in providing consumers with more choices for their healthcare and also served to dampen rising costs. The public hospitals are still owned by the Ministry of Health through a holding company called the Health Corporation of Singapore set up in 1985. It later became MOH Holdings Private Limited. The government appoints the Board members, and the Chief Executive Officers and management of the hospitals are accountable to the Board, allowing the government to continue to exercise its authority in larger, strategic decision-making.22
Medisave
Perhaps most importantly, the Plan announced the creation of Medisave, Singapore's individual medical savings plan. Medisave is the expansion of the Central Provident Fund mentioned earlier in the chapter. Workers contribute a certain percentage (set by the government) to their individual accounts, as do their employers. The money can then be used to pay for health services as well as health insurance plans. I firmly believe that the program is one of the cornerstones of the current system. Medisave enables patients to pay their share of their healthcare bill. It has also had the effect of keeping national healthcare costs low by shifting a large portion of expenses to individuals and their employers. I discuss Medisave in depth in Chapter 3.
Blueprint for a Modern Healthcare System
By the early 1990s, it became clear that healthcare costs were growing at an alarming rate that would soon put an unacceptable strain on the nation's as well as family finances. It was also recognized that increasing life expectancy was creating another challenge: how to care for the growing elderly population in Singapore. A Ministerial Committee was set up to review the role the government could play in containing costs, controlling subsidies, and ensuring the continued quality of care. In 1993, the committee issued its report in a White Paper entitled “Affordable Health Care.”23
The White Paper became, in effect, the blueprint for developing and refining a healthcare system that would serve the population well into the 21st century. In outlining the government's philosophy and approach to healthcare, it set forth five fundamental objectives:
1 Become a healthy nation by promoting good health;
2 Promote individual responsibility for one's own health and avoid overreliance on state welfare or third-party medical insurance;
3 Ensure good and affordable basic medical services for all Singaporeans;
4 Engage competition and market forces to improve service and raise efficiency; and
5 Intervene directly in the healthcare sector when necessary, where the market fails to keep healthcare costs down.
Let us take a closer look at each of these objectives.
Promote Good Health
The White Paper set forth the need for health education, disease prevention, and motivating the population to adopt a healthy lifestyle and teaching the importance, for example, of leading an active life, not smoking, and eating the right foods in order to avoid obesity. To further these goals, the government created the Health Promotion Board (HPB). Its mission is to raise the level of health and health awareness through education, screening programs, dental services to children, nutrition programs, and more.
In effect, the government began to take the lead, working with agencies to reach out to groups within the population, developing an integrated and comprehensive approach. For example, the National Healthy Lifestyle campaign was given top political support.24
The National Healthy Lifestyle Campaign is an annual, month-long event that reaches into the community, workplace, schools, supermarkets, and restaurants. Healthy living themes are chosen—fighting obesity, for example—and activities such as mass workout sessions, weight loss reality television shows, school programs, and advertising are created around them. Some simple steps taken by the government to encourage healthy lifestyles include building exercise corners in all public housing, smooth pavements for people to walk and jog on, ensuring availability of healthier options at public food centers near public housing and transportation hubs, workplace health promotion programs, and the healthier choice symbol on foods.
The philosophy of healthy living is also evident today in nutrition counseling and nutrition support programs for patients in the hospitals, at outpatient clinics, and in the schools where the curriculum includes the basics of nutrition. Other programs are also available to the schools for promoting healthy eating habits among students.25
Promote Individual Responsibility for One's Own Health and Avoid Overreliance on State Welfare or Third-Party Medical Insurance
Singapore espouses the philosophy of individual responsibility: the population should be encouraged to cultivate a strong sense of personal responsibility toward health. The White Paper suggested that by making patients pay directly a part of their healthcare expenses, excessive demand for services could be mitigated and overreliance on state welfare or third-party medical insurance kept in check. It was asserted that the entitlement mentality—the notion that people are entitled to unlimited healthcare services at the expense of the state, employer, or an insurance company—should be prevented from gaining hold.
To avoid overreliance on comprehensive insurance programs that provided first-dollar coverage, the government incentivized the purchase of health insurance schemes with features such as deductible and co-payment components and guaranteed renewals by restricting the use of Medisave to only plans that met these requirements. Insurance plans that provided first-dollar coverage were viewed as playing a major role in raising costs in countries where they are readily available.
Administrative