Who should be subsidised?

“Who shall live?” is the dramatic title of Victor Fuchs’ classic text on health economics. The melodrama is unfortunately not over-stated.

Healthcare is marked by finite resources and infinite demand.

There can never be enough doctors, nurses, hospital beds and medicine to fulfil the wants and needsof society.

Even the richest country in the world, America, struggles with burgeoning healthcare costs which, at 17 per cent of gross domestic product, is four times what Singapore spends.

Incredibly emotive and wrenching decisions have to be made, not only in clinics and at bedsides, but also in government offices.

Why government offices? Because governments decide which services and drugs should and should not be subsidised. And like it or not, health officials play god.

How does Singapore do it?

Former Health Minister Khaw Boon Wan had explained previously that the Singapore government subsidises drugs based on three principles: Used in the treatment of medical conditions that are important causes of morbidity and mortality, more efficacious and effective when compared to existing standard drugs, and sufficient evidence of long-term safety and cost-benefit.

These positions are not controversial, but it is unfortunate that there is little public information about the mechanisms used to determine what constitutes “cost-benefit”, “important causes of morbidity and mortality” or “long-term safety”.

In fact, what is subsidised was, until recently, not even known by the public as the Health Ministry was reluctant to make the list of drugs included in the Standard Drug Lists public for fear of lobbying by pharmaceutical companies.

INVOLVE THE PUBLIC

There are a number of issues to contemplate.

First, let’s look at the very process of decision-making. In Singapore, bureaucrats determine subsidy decisions in a largely top-down, opaque fashion, adopting a “Trust us, we know best” approach. This is in stark contrast to the approach taken by other countries.

Take Australia and Canada for example. Both countries devote entire websites to informing the public of the process of decision-making, the composition of the committees that advises on reimbursement decisions and even the rationale for decisions.

And the Canadians, in not recommending listing Gefitinib (Iressa),provided a two-page report concluding that “it was the Committee’s opinion that although Gefitinib holds promise, its degree of effectiveness is not known in patients with locally advanced or metastatic non-small cell lung cancer”.

There are even layman descriptions of the coverage decisions to supplement the often technical judgments to enhance public understanding.

Transparency is so valued that the manufacturer’s comments are often reflected verbatim in the final publicly released report.

The Australian decision to recommend against listing Cervarix in July 2007 also captured the manufacturer’s comments in its report: “GSK (GlaxoSmithKline) is extremely disappointed by the PBAC’s (Pharmaceutical Benefits Advisory Committee) decision. We believe the PBAC has significantly undervalued the evidence of some cross-protection by Cervarix against infection caused by HPV-31 and HPV-4 …”

Public involvement is also increasingly important internationally.

Sixty-seven per cent of countries surveyed by HTAi — the international society for health technology assessment — reported that citizen participation was built into their processes, with an additional 21 per cent stating they already had plans to engage their citizens.

THE LUCKLESS MINORITY

Secondly, defining the scope of “important causes of morbidity and mortality” should be a matter of public dialogue.

While the “greatest good for the greatest number” is the often pragmatic articulated position of the Government, should Singaporeans with rare diseases be disadvantaged?

Multiple sclerosis affects an estimated 100 Singaporeans. Should drugs needed in their care such as beta interferons be subsidised? Do Singaporeans want public monies to be used to subsidise these 100 citizens?

And is this consistent with what President Tony Tan called for when he wrote: “As a society, we must judge ourselves by how we care for those in need … Together, we should ensure that the last are not left behind, the lost have a guiding hand?”

The decision to emphasise long-term safety is controversial.

If we were to wait until procedures or drugs are “proven”, it means that in the interim, subsidised patients will be deprived of the latest and potentially hugely beneficial therapies.

Of course, waiting allows better control of healthcare costs as prices typically plummet after patent expiry or introduction of rival devices or drugs, but Singapore needs to balance between cost control and access to innovative treatments.

This dilemma is starkest with the new and very expensive biologics. Gleevac (imatinib), approved by the FDA in May 2001, has revolutionised care and survival in Chronic Myelogenous Leukemia but is still not on the Ministry of Health’s list of drugs “subsidised at our public healthcare institutions for eligible patients”.

‘Who shall live?’ is a difficult question under any circumstances. It is timely to engage society in an informed, mature debate and find common ground between State and citizens on what to subsidise, who to subsidise and how much to subsidise.

Economics and rationality help in the decision-making around optimising “value” but cannot decide.

This is a question as much of “values” as it is of “value”. It is something Singaporeans collectively as a society should decide.

Dr Jeremy Lim has held senior executive positions in the public and private healthcare sectors. He is writing a book on the Singapore health system, the second in a series on health policies in Singapore.