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 overheads alone, for example, are responsible for over 20 percent of the United States’ total healthcare expenditure. It is thought that private insurance can also be responsible for over-consumption of care by patients, and over-delivery of services by doctors, as neither group is incentivized to keep costs in check as long as insurance companies will pay. Private insurance companies are also seen as discriminating against people at risk in favor of healthy individuals and so creating problems of equity, a condition that Singapore works very hard to avoid in its society.
Ensure Good and Affordable Basic Medical Services for All Singaporeans
In the White Paper, the government stated the need to make a good, basic medical package available to all people, whatever their means. The package did not necessarily have to make available the latest medical technologies but should include proven, cost-effective treatments, benefiting the maximum number of people. The package excluded certain treatments deemed not basic, such as cosmetic procedures and in-vitro fertilization (IVF, which is now subsidized, by the way.)
The basic package had to be affordable and be provided by hospitals receiving government subsidies. The most highly-subsidized ward classes were to offer this basic level of care.26 The package should be reviewed frequently to reflect, among other things, the purchasing power of Singaporeans and productivity increases in medical science. In later years, means testing was initiated to ensure that government subsidies would be better targeted to help patients in greater financial need. Patients not meeting the criteria can still elect to go into the highly-subsidized wards, but they may not receive the maximum subsidy.
The White Paper foresaw that with the rising affluence of Singaporeans, the desire for sophisticated (and costly) medical services beyond the basic package would grow. It recommended that patients who were willing to spend more in order to obtain a different level of service be allowed to do so in the non-subsidized wards of public hospitals and in private hospitals.
In order to spur medical research, a plan was suggested under which the National University of Singapore (NUS) would focus on “academic research” that might provide valuable discoveries for the future. The subsidized hospitals were to focus on research that had “cost-effective” practical applications. The advancement of medical research in Singapore was furthered by the establishment in 1994 of the National Medical Research Council. It provides research funding to institutes and individuals, awards fellowships, and supports research that may one day be applied in medical practice, as well as clinical research.
Engage Competition and Market Forces to Improve Service and Raise Efficiency
The White Paper adopted the principle that resources available for healthcare were finite and must be put to efficient use. Market forces should be used to promote efficiency, improve quality of services, develop more choices for patients, and make sure patients are receiving good value for their money. It judged that healthcare providers were in a unique position to influence the demand for their services as patients rely on doctors for advice and are themselves generally unaware of better or competing alternatives. Yet, too much competition and too many providers might actually drive up the demand for medical services, since patients would naturally want to avail themselves to promising new treatments or technologies or popular doctors. Oversupply or overabundance of choices would in turn drive healthcare costs up rather than keep them in check and defeat the purpose of encouraging competition.
One step the Ministry of Health has taken to stoke competition is to provide price transparency by publishing the hospital bills for common illnesses on its website. One example of its effectiveness that I found striking is the drop in the price of LASIK surgery. In 2004, the price of the surgery for one eye was S
Intervene Directly in the Healthcare Sector, When Necessary, Where the Market Fails to Keep Healthcare Costs Down
I view Singapore's chosen approach to the healthcare market as a kind of
