Help not just with healthcare, but also health

As Singapore gets ready for Budget 2014, health issues may not be the most terribly interesting item on the agenda. Many of the major policy announcements have already occurred: MediShield Life in August last year, further details of the Pioneer Generation Package just last week and over the weekend, a new 1,800-bed integrated health facility in Woodlands.

What, then, should we hope for from the Budget?

While I am heartened by the Government’s vigorous efforts to meet what it perceives as the urgent needs of the people of Singapore, I am nonetheless haunted by the words attributed to the automobile pioneer Henry Ford: “If I had asked people what they wanted, they would have said faster horses.” So, what do Singaporeans really want?

I would argue that Singaporeans actually want good health first and affordable healthcare second, and only if they need it. However, healthcare is so complex that more beds, more doctors and more hospitals are an understandable but flawed surrogate for what Singaporeans really want.

At the same time, financial sustainability is uppermost on the minds of policymakers. Deputy Prime Minister and Finance Minister Tharman Shanmugaratnam in last year’s Budget speech laid out the dual objectives succinctly: To provide greater peace of mind for all Singaporeans while ensuring that the healthcare system remains sustainable.

With the Budget just around the corner, it is an appropriate starting point.

THE MEDICALISATION OF HEALTH

People want health, not healthcare. Healthcare is simply a means to the end. If one can maintain good heart health and avoid bypass surgery, who would want his chest opened up?

Thankfully, the Ministry of Health has made great strides in this respect. Today, breast and colon cancer screenings can be paid for through Medisave, as can select vaccines. Although some vaccines are conspicuously missing (such as herpes zoster vaccination), at least influenza and pneumococcal vaccinations are on the list of Medisave-eligible items.

But the criticism is not about what’s in and what’s out, but, rather, the degree of medicalisation of health.

This is not unique to Singapore and ministries of health the world over have been criticised for being “ministries of sickness”. In the United States, 75 cents out of every dollar are spent on combating chronic diseases, but only 5 per cent spent on preventing them.

As a means to an end though, healthcare is in actuality surprisingly limited. The World Health Organization and the US Centres for Disease Control and Prevention estimate that 80 per cent of heart disease and Type II diabetes, and 40 per cent of cancers, are preventable.

While the Pioneer Generation Package looks to be generous in providing for healthcare, one speaker at a panel discussion on the topic described the Package as “the ambulance waiting at the bottom of a cliff”. This may be harsh but it reflects the frustration that so much more can be done to keep Singaporeans healthy.

LEVEL THE FIELD

How can more Singaporeans mostly avoid the scourge of chronic diseases? By doing three things almost anyone can do: Exercising more, eating better and avoiding tobacco.

Can the Government play a proactive role? Yes, by levelling the playing field for health. Use direct subsidies, allow use of Medisave dollars or structure MediShield to enable coverage for health-enabling options, even if they are not traditional “healthcare expenses”.

Want to exercise but worried about breathing in smoke particles from the haze? Health insurers such as Kaiser Permanente in the US offer heavily discounted gym memberships for members.

What about committing to eating healthier food? Well, get ready for both a thinner you and a thinner wallet. Researchers from the Harvard School of Public Health released findings last year that eating a healthier diet would increase food costs for one person by about US$550 (S$690) per year.

What about smokers? Surely the government should not subsidise smoking cessation treatments? After all, they made the conscious decision to smoke and harm their health. But we are in all in this together, first emotionally as Singaporeans because we want our fellow citizens to enjoy good health and secondly, financially because MediShield Life binds us all together.

Call it what you want, MediShield Life is a tax on all Singaporeans to help pay for healthcare. The more that smoking, obese and sedentary Singaporeans use healthcare for the inevitable chronic diseases, the more all of us pay.

We need more healthcare infrastructure, no doubt about it. Singapore has under-invested for so many years that despite the developed world moving towards smaller and fewer hospitals, Singapore has to play “catch-up” first.

But let’s not forget that these are necessary but insufficient. The real gains for Singapore lie in helping Singaporeans to be the healthiest we can be, and perhaps health officials should account for not just how many hospitals and how many hospital beds are built, but also the proportion of Singaporeans who exercise regularly, do not smoke, eat healthily and have no major illnesses.

After all it is about health, not just healthcare.

ABOUT THE AUTHOR:

Dr Jeremy Lim is head of the Asia-Pacific health and life sciences practice in Oliver Wyman, the global consulting firm. He recently authored Myth or Magic: The Singapore Healthcare System, which describes the successes and challenges of the Singapore model.

Tomorrow, in part 2 of fiscally sustainable healthcare: Primary and community healthcare.