Time to measure equity in health, too

Since its independence in 1965, Singapore has made incredible strides in improving the health of its citizens. Life expectancy has jumped an impressive 18.2 years, propelling Singapore to having the world’s third-highest life expectancy, while infant mortality has improved more than tenfold.

The averages, unfortunately, may not convey a complete picture when one considers equity in health. It is timely to ask whether all Singaporeans have benefited health-wise from the remarkable improvements.

Health equity has been defined as the “attainment of the highest level of health for all people” and has long been a global concern. This is more so in today’s world where, as the charity Oxfam reports, “62 people own the same as half the world”.

Marked economic inequalities should not lead to stark differences in health outcomes. Most of us would believe that everyone deserves a fair chance to lead a healthy life and no one should be denied this because of socio-economic status.

Health equity is especially pertinent in Singapore, as our health system is by design a two-tiered one: Those who opt for private medical care and non-subsidised care in government hospitals and those who rely on what the health ministry describes as “quality and affordable basic medical services” that are subsidised. Does this lead to different health outcomes? We don’t know.

Two tiers are inevitable in countries with market approaches to healthcare and what matters is recognising this reality and tracking for any inequities.

Three decades ago, the United States openly recognised disparities among its people and set ambitious targets via the Health People initiative in a bid to improve health equity. In Healthy People 2000, the ambition was to reduce health disparities among Americans. In Healthy People 2010, it was even loftier: To eliminate, not just reduce, health disparities. In Healthy People 2020, that goal was expanded further: To achieve health equity, eliminate disparities and improve the health of all groups. To this end, the US has systematically sought to measure disparities and intervened to close these gaps.

In the United Kingdom, the famous Whitehall studies that began in 1967 have highlighted the concept of a “social gradient”. Studying British civil servants, Professor Michael Marmot, one of the giants of social medicine, concluded that “the lower you were in the hierarchy, the higher the risk”.

He further identified that it was not simply that the most senior civil servants were better off than the lowest in the hierarchy, but that it was graded. And, thirdly, this social gradient applied to all the major causes of death.

Globally, the World Health Organization has stressed the importance of health equity and raised the alarm over growing inequities. The report by the Commission on Social Determinants of Health in 2008, aptly titled Closing the Gap, is filled with research on health disparities the world over. The analysis of under-5 mortality rates by household wealth particularly struck a chord: There were profound inequities not just across countries by wealth but also within countries. Just as in the UK, social gradients are evident and even more pronounced.

The social gradient does exist in Singapore, as it does in every other country in the world. One small example comes from the latest National Health Survey. In it, the Ministry of Health reported that households earning less than S$2,000 per month had the highest prevalence of obese individuals (14.3 per cent). Those households earning more than S$6,000 a month? A much smaller 8.8 per cent.

Unfortunately, other examples are sparse and the near-absence of data is perhaps telling of our lack of appreciation or unawareness of the social gradient and its impact on health outcomes.

Singapore is nonetheless not barren when it comes to equity evaluation. In many other fields, equity and equality are carefully studied, and the government intervenes to minimise inequalities and inequities. In last year’s Budget debates, Deputy Prime Minister Tharman Shanmugaratnam reported that “Singapore saw 14 per cent of those from parents in the bottom 20 per cent (by income), move up to the top 20 per cent among their peers”. He further highlighted that the Government was making “significant moves to temper inequality” and even described social mobility as the “defining challenge of every advanced country”.

In recent years, some of the most experienced and highly-regarded principals have been deployed to heartland schools, a move described by then Education Minister Heng Swee Keat as “yet another tangible way for us to make every school a good school”.

US President Franklin Roosevelt famously said: “The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little.”

Health has been said to be the ultimate wealth. We care about income inequalities, we care about social mobility and we care about education equity. Let us care too about health equity.

ABOUT THE AUTHOR:

Dr Jeremy Lim is head of the health and life sciences consulting practice, Asia in Oliver Wyman, the global consultancy. He is the only Singaporean appointed as an inaugural fellow of the Equity Initiative, a global programme focused on health equity. This is the first of a two-part series. Look out for Part 2 this week on how Singapore can measure health equity.