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 The accumulated money could be withdrawn at age 55.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 planning that created the 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
