Understanding the changes in Singapore’s healthcare system in the last decade

The last decade has seen more change in Singapore healthcare than arguably the previous 40 years combined.

MediShield Life, Pioneer Generation Package, CareShield Life, Community Health Assist Scheme (Chas), Primary Care Networks, War on Diabetes... the list goes on and on. How should one make sense of the monumental reshaping of the system?  And what does it mean for healthcare here going forward?

Two broad themes can explain many of the reforms: Growing imperative for universalism and the focus on health promotion and better chronic disease management. Let’s examine these separately while acknowledging that they are closely related to each other.

The notion that Singaporeans should be largely responsible for our own health and healthcare needs has been advocated by the People’s Action Party Government since 1959. The traditional stance of the Government towards subsidies for healthcare and other social services has been to see them as a necessary evil, with no less than founding prime minister Lee Kuan Yew comparing them to opium or heroin.

Hence co-payments were introduced in 1960 and Medisave, the world’s first and thus far only national health savings accounts, was set up in the early 1980s to compel savings for health and also to reinforce that Singaporeans were spending our own money in consuming health services.

In fact, the 1993 White Paper on Affordable Healthcare described a key design principle of Singapore’s system as needing to “promote personal responsibility for one’s health and avoid over-reliance on state welfare and medical insurance”.

Singapore also embraced a utilitarian approach, with the “greatest good for the greatest number” philosophy leading to tough decisions made around which segments of the population got medical coverage.

Hence MediShield, the national health insurance scheme, had age limits for coverage (90 years prior to MediShield Life) and specifically excluded citizens with pre-existing conditions including congenital diseases.

However, over time, Singaporeans’ concerns about our ability to afford healthcare grew, as shown in post mortems of the 2011 General Election and the 2012 national engagement effort Our Singapore Conversations.

It was also jarring to the national psyche that MediShield covered only 92 per cent of the population, excluded children with congenital illnesses and dropped from coverage 90-year-old Singaporeans, in effect causing Singaporeans who lived long enough to lose their insurance coverage at a time they were most likely to need it.

Credit to the Government for its responsiveness to public sentiments in launching MediShield Life in 2015. The health insurance scheme protects all Singapore Citizens and Permanent Residents against large hospital bills for life.

In words illustrative of a new era, Health Minister Gan Kim Yong argued passionately in Parliament that year: “The idea of MediShield Life goes beyond healthcare and insurance. It is a reflection of the kind of society we want to build: A more inclusive society … and a more caring society.”

With CareShield Life, the national scheme for long-term disability care insurance, the Government decided that right from the onset, all citizens would be enrolled and it would de facto be a universal scheme much as MediShield Life was about “Better Protection. For All. For Life”.

No more of the MediShield of the 1990s with voluntary enrolment and downstream issues. 

The necessary corollary to universal coverage is higher health expenditure and to this end, the Government has had to mandate compulsory inclusion and frontload premium collections from an early age, with citizens paying premiums for CareShield Life from 30 years of age.

PROTECTING SENIORS

The Government’s engagement with seniors early in the decade also highlighted growing concern and even displeasure at rising healthcare costs.

This was understandable as some seniors who had started work in the 1970s and earlier simply did not have enough working years to accumulate sufficient Medisave monies to cater to their future healthcare needs.

Furthermore, healthcare inflation typically is almost 10 per cent year-on-year whilst Medisave at best offers a 4 per cent interest rate. A segment of seniors was worried and rightly so.

Enter then the Pioneer Generation Package in 2015 to offer in one fell swoop, a lifetime of improved healthcare benefits for every Singaporean born before December 1949.

This was so popular and reassuring to citizens that a subsequent Merdeka Generation Package was enacted for those born between 1950 and 1959.

The official rationale was that these cohorts of Singaporeans had “contributed greatly to Singapore during a time of struggle, hardship, and sacrifice” and this was due recognition.

I would suspect that policy planners had also worked the numbers and realised that the healthcare financing challenges afflicting the pioneers to some extent were shared with the Merdeka Generation.

Singapore has one of the fastest aging populations in the world. Increased longevity coupled with abysmal birth rates mean there is no choice but to, by all means possible, help citizens to be as healthy and active as possible.

Hence beyond a massively expanded budget for the Health Promotion Board and other wellness maintenance and disease prevention agencies, the Government has also become more paternalistic in public health, declaring a ‘War on Diabetes’, banning advertisements for high sugar drinks and adopting stronger smoking control measures.

Despite all these efforts, it will be hard to prevent Singaporeans from getting diseases of modern living, and the explosion in chronic conditions such as diabetes and high blood pressure will happen, albeit with smaller peaks. After all, no country has managed to reverse the worsening chronic disease situation. 

In Singapore, the National University of Singapore’s Saw Swee Hock School of Public Health has projected that there may be potentially one million Singaporean diabetics by the year 2050. 

Currently, 11 per cent of Singaporean adults aged 18 to 69 have diabetes, with the incidence rate higher among seniors. There are currently an estimated 450,000 adults with diabetes.

Citizens have to remain economically active despite living with these conditions. This coupled with acceptance that consequences of poor control of these ‘silent killers’ such as kidney failure, heart disease and so on would ultimately still be borne by the public purse has led to a profound mindset shift. 

Today, we have moved from a hardline “personal responsibility” to a softer “shared responsibility”, with the Government spending substantial monies to help Singaporeans manage these diseases better, avoid financially devastating outcomes such as lifelong dialysis or heart failure and preserve the nation’s economic vibrancy.

The number of polyclinics — the Government’s primary care facilities — grew modestly from 16 to 18 between 2000 and 2010. Two more were added recently to make it 20. Four more are scheduled to open in 2020 and another six to eight by 2030. Better funding has also permitted the polyclinics to adopt team-based models with superior outcomes for patients with chronic conditions.

At the same time, the Government has progressively expanded Chas, a scheme to enable private General Practitioners (GPs) to treat Singaporeans using government subsidies. 

GPs have also been organised into Primary Care Networks with improved supporting infrastructure such as nurse educators, dieticians and the like to improve chronic care.

Today, every Singaporean, regardless of personal or household wealth, is eligible for subsidies in both public and private primary care, and the entire primary care sector’s quality has been uplifted.

BEYOND HEALTHCARE TO HEALTH FOR ALL 

The next decade for Singapore health is set to be an exciting one.

The overarching policy pieces are in place and what is needed now is adroit implementation. This is not trivial and likely much harder than the last decade’s policy shifts. 

The health system needs to be transformed to emphasise health over healthcare as well as community- and team-based and shared care models. Financial and other incentives across payers, providers and patients also have to align to health promotion and maintenance rather than disease treatments.

In fact, healthcare reforms have been likened to fixing a plane’s engine in mid-flight and what more in Singapore where we also must address the drivers leading to poor health such as unhealthy food choices and sedentary lifestyles.

What’s even more challenging is that the path is uncharted anywhere in the world and policy makers and healthcare operators have to, as former Chinese leader Deng Xiaoping describes as “cross the river by feeling the stones”.

We are moving in the right overall direction but the road ahead will be bumpy and some tripping up inevitable. 

I do hope the Government has the courage and conviction to stay the course, and citizens the patience and understanding whilst Singapore finds her way.

ABOUT THE AUTHOR:

Dr Jeremy Lim is a partner with the health and life sciences practice in the Asia-Pacific at Oliver Wyman, the global consultancy.