capitalism. Government intervention is sanctioned in certain circumstances to correct or redirect the market. This approach is seen in the fact that it funds public hospitals and other care facilities but also encourages the participation of private hospitals and clinics.
Situations that might demand government action included preventing an oversupply of healthcare services, moderating demand, and creating incentives to keep costs down. The White Paper also recommended that the government regulate specifics of the system. For example, over the years, intervention has included creating and adjusting medical savings programs, sponsoring insurance programs, providing subsidies to hospitals and polyclinics, determining the number of beds and their distribution in public hospitals, funding new medical schools, regulating the number and type of doctors who can practice in the country, and regulating and limiting the type and number of private insurance programs available to Singaporeans.
I will provide a closer look at a number of these practices for the development and maintenance of the system in subsequent chapters. But first, in the next chapter, I will walk you through the specific programs that make it possible for Singaporeans to pay for their care: Medisave and MediShield, as well as the safety net for those who cannot afford care: Medifund.
Chapter 1: KEY POINTS
Singapore has built and maintains a high-quality healthcare system at a lower cost than any other high-income country in the world
Four factors have enabled Singapore to achieve its remarkable health-care goals:Political unity, constancy of purpose, and a culture of cooperation within governmentAbility to recognize and establish national priorities, giving the economy time to grow before investing heavily in healthcareAn overwhelming desire for collective well-being and social harmonyAttention to the rights, education, and health needs of women
Singapore's then Prime Minister Lee Kuan Yew envisioned a system that would not be “free” to consumers and would not contribute to a welfare state mentality nor diminish the people's desire to achieve and succeed
Early actions to build the system included:Moving primary care to a network of outpatient clinicsCharging patients for visits to clinicsSending doctors abroad to train in specialtiesUpgrading and updating care facilitiesSolving the housing crisis
Singapore's National Health Care Plan, issued in 1983, set forth strategies for keeping care affordable and meeting the demands of a growing and increasingly affluent population. It also:Restructured the public hospital system, granting more autonomy to hospitals and promoting competition among themIntroduced Medisave, a medical savings account that enabled individuals to put away money to pay for their healthcare
The blueprint for Singapore's current healthcare system was published in 1993 as a White Paper entitled Affordable Health Care. It announced five objectives and set forth plans for implementing each:Become a healthy nation by promoting good healthPromote individual responsibility for one's own health and avoid overreliance on state welfare or third-party medical insuranceEnsure good and affordable basic medical services for all SingaporeansEngage competition and market forces to improve service and raise efficiencyIntervene directly in the healthcare sector when necessary, where the market fails to keep healthcare costs down
CHAPTER 2
High Quality, Low Cost
Lee Kuan Yew wanted Singapore to achieve excellence—“first world standards” as he put it in his memoirs. Only then, he believed, would his young country survive and thrive. There is no doubt in my mind that the standards he desired for his city-state have indeed been met, and healthcare is one good example. Singapore now has a First-World healthcare system, rated sixth in the world by the World Health Organization and ahead of most high-income economies.1 By most common measures, the nation has achieved noteworthy outcomes in all areas of healthcare. It has increased the life expectancy of its citizens; increased infant survival rates, and achieved one of the lowest under-five mortality rates in the world. Singapore's cancer survival rates are similar to Europe's, while its cardiovascular disease death rate is half that of the rest of the Asia Pacific region. As I will show throughout this chapter, Singapore produces world-class outcomes on par with the most-developed nations of the world, but it does so at a fraction of the cost usually associated with high-quality care.
A quick look at cost comparisons with other nations brings the point home. Countries like the United States and the United Kingdom struggle with the budget-busting, ever-rising cost increases of providing care. The United States, for example, spends almost 18 percent of GDP on healthcare. Singapore, on the other hand, spends slightly under four percent of GDP. The government's expenditure for healthcare has been slightly under one percent, far less than other most developed countries. It is, however, beginning to break the one percent barrier, coming in at just under 1.5 percent in 2010.2
I would like to begin our exploration of the Singapore healthcare system's achievements with a close-up look at some representative outcomes (see Table 2.1), how they have improved over the years, and how they compare with other nations in the region and around the world.
Table 2.1
Life Expectancy
The number of years we may be expected to live is of utmost interest to all of us, and is a key measure of the efficacy of a nation's healthcare system. A Singaporean woman can now expect to live until 84, versus 66 in 1960. Singaporean men also live longer—up to 79 years, versus 62 in 1960. This enhancement of life is a direct result of the quality of healthcare services, but the system must share some credit with the improved standard of living, improved sanitation, good quality water, and a cleaner environment. Such improvements were part of a well-thought-out effort to raise the quality of health of all Singaporeans.
Singaporeans now live two to three years longer than the citizens of the UK and the US. They also live longer than inhabitants of other high-income economies, with the exception of Japan and Hong Kong, where life expectancy is up to 83 years.
In the Asia Pacific region, there is a dramatic divide among nations. On one side are countries like Japan, Singapore, Hong Kong, and Australia where people live beyond 80 years, and on the other are lower-middle-income countries where citizens can only expect a lifespan of about 70 years. Then there is the case of India, where the numbers are even less promising, with men living until 63, women to 66 (see Table 2.2).
Newborn and Infant Mortality
Another key measure of the success of Singapore's healthcare initiatives is the vastly improved survival rate among newborns and infants. A number of factors affect infant mortality, such as health of the mother, maternal care, and birth weight.
The newborn mortality rate per 1,000 live births in Singapore declined from five in the 1990s to just one in 2009. The United Kingdom, Australia, and Canada had the same mortality rate of five in the 1990s, but by 2009 had declined to three in the United Kingdom and Australia, and four in Canada. In the United States, the rate stands at four. Singapore's infant mortality rate (the probability of dying in the first year per 1,000 live births) has fallen from 36 in 1960 to just over two in 2009; a decrease of almost 94 percent in just under 50 years. Aside from Japan among the high-income economies, Singapore has
