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 at providing housing. Over the years, other investments were made in clean water, proper sanitation services, clean environment, good nutrition, and health education. All these actions played a crucial role in improving the health status of Singaporeans.18
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;
