Singapore's Health Care System: Some Lessons to Be Learnt

Singapore’s health care system is today considered to be one of the best, if not the best in the world. Business Week magazine rated it as the healthiest country on the planet. How did Singapore achieve this spectacular feat at less than half the cost in comparable countries? A chapter titled “The Remarkable Healthcare Performance in Singapore” in the book “Great Policy Successes,” edited by Mallory E. Compton and Paul ‘T Hart, helps us to gain some insights into this extraordinary phenomenon.

The People’s Action Party (PAP), which formed the island city’s first independent government in 1959, inherited from its British colonial rulers a system of free inpatient care through public hospitals. The PAP retained and incrementally increased the arrangements while introducing modest reforms. In 1965, public expenditure on healthcare formed 50% of total spending on health. The 1960s and 1970s witnessed the expansion of public health clinics entirely owned and operated by the government, which provided basic outpatient services. A pivotal point to note is that side-by-side, the government worked in a meticulous and concerted way on the overall improvement of sanitation, housing, and education, which, in tandem with expanded public health measures, were pivotal in improving the population’s health.

Educational attainment, home ownership, and public amenities such as clean drinking water, solid waste disposal, and housing policies gradually saw the households that earlier lived in slums and tenements in the 1950s transition to public housing with access to electricity, gas, potable water, and toilets have greatly ameliorated Singapore’s health outcomes.

In addition to insurance schemes, like Medisave, Medishield, and Medifund, there are other schemes financed from the government’s general budget. The Community Health Assistant Scheme offers additional grants to low-income households for outpatient treatment. The Pioneer Generation and Merdeka subsidies reduce insurance premiums and co-payments for select groups of elderly Singaporeans. Medifund was introduced in 1993 for those citizens who could not afford to pay their medical bills. However, very stringent tests are required to qualify for the benefits of this scheme.

Since 2003, public hospitals (and some years later private hospitals also), have been required to publish their average bill sizes (expenditure), and the distribution along the mean, which includes charges for room, treatment, surgery, laboratory tests, etc. for various common conditions and procedures. This data is published on the Ministry of Health’s webpage.

This resulted in the Ministry of Health (MOH) introducing benchmarks for medical fees, jointly developed by doctors, hospitals, and other stakeholders in 2018. Such benchmarks are expected to give doctors a yardstick against which to measure their prices while giving patients a better idea of comparative costs.

Providers must now contribute data regarding admission, visit history, hospital discharge, laboratory tests, radiology results, history of medication, surgeries, and procedures, allergies, adverse drug reactions, immunisations, etc. to the National Electronic Health Records (NEHR) platform established in 2011.

One could argue that all these reforms and helpful policies are easy to implement in a country the size of Singapore—a country like India with a much larger geographical and demographic size brings along with this, complex problems and outcomes. Also, Singapore is run by a government that is very different from India’s. The range of data that providers have to contribute to the NEHR in Singapore will, in India, be opposed, citing a violation of many individuals’ privacy as far as their personal medical information is concerned. There is no question of any opposition to such exercises in Singapore. The government has taken many unpopular steps, especially regarding healthcare, unopposed. Lastly, the out-of-pocket healthcare expenditure is very high in Singapore—that need not be emulated, especially for the poorer sections of our population.

Looking at the systematic and effective way Singapore has implemented key measures, it's clear there are lessons for India. Improvements in sanitation, housing, and education, along with expanded public health efforts, have rapidly improved the population’s health. Similar steps could benefit India's people as well.

Additionally, for patients, having data that facilitates the comparison of medical costs in a country like India where medical prices seem to be increasing at an alarming rate (mostly for the economically deprived sections of the population) is extremely helpful.

India still considers itself a welfare state, despite all the liberalisation that commenced in the early 1990s. Singapore’s achievements will help to serve as a beacon to our government. Again, not all the measures practiced will suit us, but we could selectively attempt to implement those that do.

(The author is an independent researcher based in Mumbai. Views personal.)