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Affordable Excellence: the Singapore Healthcare Story

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Affordable Excellence: the Singapore Healthcare Story HASE LTIN This is the story of the Singapore healthcare system: how it works, how it is financed, its history, where it is going, and E what lessons it may hold for national health systems around the world. Singapore ranks sixth in the world in healthcare out- AFFORDABLE comes, yet spends proportionally less on healthcare than any other high-income country. This is the first book to set out a comprehensive system-level description of healthcare in Singapore, with a view to understanding what can be learned from its unique system design and development path. EXC ELLE The lessons from Singapore will be of interest to those currently Affordable planning the future of healthcare in emerging economies, as NC E: THE SINGAPORE HEA E: THE SINGAPORE Excellence well as those engaged in the urgent debates on healthcare in The Singapore Healthcare Story the wealthier countries faced with serious long-term challenges in healthcare financing. Policymakers, legislators, public health by William A. Haseltine officials responsible for healthcare systems planning, finance and operations, as well as those working on healthcare issues in universities and think tanks should understand how the Singa- pore system works to achieve affordable excellence. WILLIAM A. HASELTINE is President and Founder of LT HCARE S ACCESS Health International dedicated to promoting access to high-quality affordable healthcare worldwide, and is President of the William A. Haseltine Foundation for Medical Sciences TORY and the Arts. He was a Professor at Harvard Medical School and was the Founder and CEO of Human Genome Sciences. BROOKINGS Brookings Institution Press Washington, D.C. www.brookings.edu/press Cover image by Tay Kay Chin Cover CS5_.339 spine.indd 1 3/28/13 2:57 PM Affordable Excellence: The Singapore Healthcare Story Affordable Excellence combined t1 1 3/21/2013 7:12:48 PM Affordable Excellence combined t2 2 3/21/2013 7:12:48 PM Affordable Excellence: The Singapore Healthcare Story How to Create and Manage Sustainable Healthcare Systems William A. Haseltine Ridge Books Singapore Brookings Institution Press Washington, D.C. ABOUT BROOKINGS The Brookings Institution is a private nonprofit organization devoted to research, education, and publication on important issues of domestic and foreign policy. Its principal purpose is to bring the highest quality independent research and analysis to bear on current and emerging policy problems. Interpretations or conclusions in Brookings publications should be understood to be solely those of the authors. Copyright © 2013 William A. Haseltine All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without permission in writing from the Brookings Institution Press, except in the case of brief quotations embodied in news articles, critical articles, or reviews. Copublished by Ridge Books, an imprint of National University of Singapore Press, and by Brookings Institution Press Affordable Excellence: The Singapore Healthcare Story may be ordered from: Brookings Institution Press 1775 Massachusetts Avenue, N.W. Washington, D.C. 20036 Telephone: 1-800/537-5487 or 410/516-6956 E-mail: [email protected]; www.brookings.edu/press Library of Congress Cataloging-in-Publication data is available ISBN: 978-0-8157-2416-2 (pbk. : alk. paper) 9 8 7 6 5 4 3 2 1 Printed on acid-free paper Composition by Forum Kuala Lumpur, Malaysia Printed by Versa Press East Peoria, Illinois Contents List of Illustrations vi Acknowledgements ix Introduction xii Chapter 1 e Singapore Healthcare System: An Overview 1 Chapter 2 High Quality, Low Cost 16 Chapter 3 Helping Patients Pay 38 Chapter 4 Controlling Costs 64 Chapter 5 Financing 83 Chapter 6 Design and Infrastructure 93 Chapter 7 Investing in the Future through Medical Education 106 and Research Chapter 8 Facing the Future 128 Appendix 143 Notes 148 Bibliography 162 Index 174 Affordable Excellence combined t5 5 3/21/2013 7:12:49 PM List of Illustrations Tables Chapter 2 Table 2.1 Health Indicators, Singapore 17 Table 2.2 Life Expectancy at Birth (years) 19 Table 2.3 Infant Mortality Rate (probability of dying by 20 age 1 per 1,000 live births) Table 2.4 Under-Five Mortality Rate (probability of dying by 22 age 5 per 1,000 live births) Table 2.5 Adult Mortality Rate (probability of dying between 23 15 and 60 years per 1,000 population) Table 2.6 Physician Density 2000–2010 (per 10,000 population) 25 and Hospital Beds 2000–2009 (per 10,000 population) Table 2.6a Cost Comparisons of Some Major Procedures between 32 the United States and 3 Medical Travel Destination Countries Table 2.7 Healthcare Costs, Singapore 34 Table 2.8 Expenditures, 2000 and 2008 35 Table 2.8a Expenditures, 2000 and 2008 36 Chapter 3 Table 3.1 CPF Contribution and Allocation Rates for the 40 Various Types of Employees Table 3.1a CPF Contribution and Allocation Rates for the 41 Various Types of Employees Table 3.2 Medisave Withdrawal Limits 46 Table 3.3 Top Up for CPF Medisave Account 49 i Affordable Excellence combined t6 6 3/21/2013 7:12:49 PM List of Illustrations ii Table 3.4 Tax Benefits for Voluntary Contributions by 50 Companies to Self-Employed Persons’ Medisave Account Table 3.5 MediShield Yearly Premiums 54 Table 3.6 Deductible and Co-Insurance 55 Table 3.7 Premiums for ElderShield400 60 Chapter 4 Table 4.1 Annual Premiums for Basic Health Insurance 66 around the World Table 4.2 Appendix Surgery (Appendicectomy) 72 Table 4.3 Public Hospitals: Medical Specialties 73 Chapter 5 Table 5.1 Subsidies at Public Hospitals 85 Chapter 6 Table 6.1 Fee Scheme at Ang Mo Kio Polyclinic 95 Table 6.2 Intermediate and Long-Term Care (ILTC) 102 Services Chapter 7 Table 7.1 Statistics, Biomedical Industry 123 Figures Chapter 2 Figure 2.1 In-Hospital Case-Fatality Rates within 30 Days 27 after Admission for Acute Myocardial Infarction, 2007 Figure 2.2 In-Hospital Case-Fatality Rates within 30 Days 28 after Admission for Ischemic Stroke, 2007 Figure 2.3 In-Hospital Case-Fatality Rates within 30 Days 29 after Admission for Hemorrhagic Stroke, 2007 Affordable Excellence combined t7 7 3/21/2013 7:12:49 PM iii List of Illustrations Chapter 3 Figure 3.1 How MediShield is Utilized to Pay for 56 One’s Healthcare Bill: Case 1 Figure 3.1a How MediShield is Utilized to Pay for 57 One’s Healthcare Bill: Case 2 Chapter 7 Figure 7.1 NUS Yong Loo Lin School of Medicine, 109 NUS Faculty of Dentistry, and NUS Alice Lee Centre for Nursing Studies Charts Chapter 2 Chart 2.1 Overall Satisfaction of Public Healthcare Institutions 31 and Willingness to Recommend Public Healthcare Institutions Chapter 3 Chart 3.1 Distribution of Medisave Withdrawal 48 e author has resolved all copyright issues related to material in this publication. Affordable Excellence combined t8 8 3/21/2013 7:12:49 PM Acknowledgments is book was inspired by a speech given in 2010 by then Minister for Health of Singapore, Khaw Boon Wan, to an international group of health specialists. I had the good fortune to attend the meeting of NIHA (the Initiative to Improve Health in Asia), a Pan-Asian Policy Program sponsored by the National University of Singapore and the Global Asia Institute. e Minister’s speech outlined the history and more importantly, the thinking, behind the creation of the Singapore healthcare system. e system he described is both effective and unique. I asked if a book existed describing the Singapore approach to healthcare and was surprised to learn that none did. A few weeks later, I had a follow-up conversation over dinner with the NUS President, Tan Chorh Chuan, Director of the Global Asia Institute, Seetharam Kallidaikurichi Easwaran, and Paul Kratoska, then Director of NUS Press who encouraged me to write this volume. Seetharam Kallidaikurichi kindly provided support for a researcher for a year and the book was on its way. I mentioned that I was writing a volume on the Singapore healthcare system that might provide lessons in the creation of sustainable healthcare system to others in both developing and developed countries to Strobe Talbott of the Brookings Institution, and he and his colleagues kindly offered to jointly publish the book with NUS Press. I am grateful to Robert Faherty, Director of the Brookings Press for his encouragement. I thank Peter Schoppert, now Director of NUS Press, for his enthusiasm and assistance. I owe special thanks to Claudia Olsson, Managing Director of ACCESS Health International, Singapore for her valuable assistance throughout. She organized interviews for me, conducted others herself, did much of the research for the final chapter of the book and worked closely with our researcher, Eti Bhaskar. Eti was tireless in preparing ix Affordable Excellence combined t9 9 3/21/2013 7:12:49 PM x Acknowledgments background material for each chapter and tracking down the necessary information. I owe her a deep debt of gratitude. Both the Ministry of Health and the Singapore Economic Develop- ment Board were very helpful. The current Minister Gan Kim Yong graciously allowed us to interview him and his colleagues at the Ministry. Both helped to arrange the numerous interviews with key players in the healthcare system, both public and private, as well as past and present. Special thanks go to Lee Chien Earn, former Head of the Department of Public Health and Deputy Chief Medical Officer of the Ministry of Health and Lim Eng Kok, Deputy Director (Service Management) of the Ministry of Health, for their continued assistance and help in identifying people and documents important for this story. Representatives from the Ministry of Health graciously responded to my long series of written questions.
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