What Chas expansion means for healthcare in Singapore

Healthcare enjoyed prominence in this year’s Budget as the Government reassured citizens that it would “make healthcare more affordable, accessible, and comprehensive”.

Whilst the S$6.1 billion allocation for the Merdeka Generation Package stole the headlines, what was also very interesting is the expansion of the Community Health Assist Scheme (Chas) and the major strategic shifts it signals.

Some 1.3 million Singaporeans are now part of the three-tiered Chas Scheme — depending on their age and household income — which provides them subsidised treatment for common illnesses, chronic health problems and specific dental issues.

Chas is being expanded in three ways. First, it will be extended to cover all Singaporeans for chronic conditions, as first announced by Prime Minister Lee Hsien Loong in the National Day Rally in August.

On Monday (Feb 18), Finance Minister Heng Swee Keat said that Chas Orange cardholders (with a per capita household income between S$1,101 and S$1,800) who currently receive subsidies for chronic conditions only will now get subsidies for common illnesses.

Third, the Government will increase subsidies for complex chronic conditions, said Mr Heng, adding that the increased Chas subsidies will cost more than S$200 million. The Minister for Health will provide more details in the Committee of Supply debate next month.

There are two paradigms that these announcements cement as tenets of our healthcare system design.

First, the private sector is a major and integral part of the primary health system. Second, market mechanisms will continue to be deployed with choice a central feature. What do I mean?

CENTRAL ROLE OF PRIVATE SECTOR

Initiated in 2012, Chas was originally intended to provide for lower- and middle-income Singaporeans and as a means to spread out the burgeoning workload faced by the then 18 polyclinics.

Seen in this light, the private General Practitioners (GPs) were supplemental to the Government’s efforts in primary care.

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For the longest time, the Ministry of Health focused its primary care plans on the public sector polyclinics and addressed the private sector mainly through a regulatory lens. However this position has evolved in the last decade.

And with the rise of chronic diseases in Singapore and the ambition to enable “more affordable healthcare, closer to home”, the expansion of Chas as announced by Mr Heng becomes necessary. It was striking that the Minister noted that currently, most Chas users have a clinic within 10 minutes of their home.

Policy-wise, this is long overdue recognition of the centrality of primary healthcare and the necessity of a fuller engagement with the private sector.

We have more than 2,000 GP clinics in Singapore and even with the new polyclinics to be built in the next decade as announced at last year’s Budget, there would only be 30-32 polyclinics nationwide.

Private GPs comprise 80 per cent of the primary care physician workforce and serve 80 per cent of the primary care attendances; they also tend to be older and more experienced.

These factors, coupled with the convenience of proximity and more time spent per consultation compared to the polyclinics, make GPs critical nodes in the network of care sites to realise the Government’s aim to move healthcare beyond the hospital to the community.

However, practical challenges remain. Take for example the recent case of Mrs Yeo Saw Hua who realised belatedly that her X-rays taken at a polyclinic — ordered by a GP she had consulted under the Chas scheme — did not enjoy subsidies.

Health Minister Gan Kim Yong explained that she was not assessed by polyclinic doctors and hence “our doctors are unable to determine whether the ordered tests or investigations are appropriate”.

Still, this would be cold comfort to patients like Mrs Yeo. As we scale up Chas to become a pillar of the healthcare delivery system, cases like this have to be systematically ferreted out and addressed decisively.

Especially on matters pertaining to professional judgment, the system should be designed to enable doctors across both the public and private sectors to liaise with each other and collectively determine the appropriate plan of action.

WHAT’S THE ROLE OF THE MARKET?

The second paradigm the Chas expansion highlights is the continued confidence in the market, the centrality of choice and the policy framing of patients as customers or consumers.

The market approach is congruent with Singapore’s overall philosophy of governance, but in healthcare some caution is merited.

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In a perfect market, buyers would have perfect or complete information about the products sold and their prices and buyers would be competent in selecting sellers based on their needs. However, these conditions do not always exist in healthcare.

Patients in most instances do not know and won’t ever know more than their doctors. Furthermore, final prices can oftentimes only be known after the consultation.

There are also black sheep in our midst as evidenced by recent suspension of Chas clinics for “severe non-compliance” and the Ministry of Health’s (MOH’s) warning that “in line with the Singapore Medical Council's Ethical Code and Ethical Guidelines, doctors cannot abuse the doctor-patient relationship for personal gain”.

Today, citizens enrolled into Chas don’t have much guidance on which clinics to turn to, other than a 62-page document containing basic information such as their location.

It is heartening that Mr Heng mentioned in the Budget speech that “measures to ensure that Chas clinics are delivering good outcomes” will be undertaken and MOH will track patients’ progress and outcomes.

I hope that even as MOH actively monitors Chas clinics’ performances, it will also think through what information to release to the public to allow citizens to better choose their Chas clinic providers.

The expansion of Chas is much-needed as Singapore reshapes her healthcare landscape and brings the private sector more fully on board in the war against diabetes and other related initiatives.

The laudable policy intent notwithstanding, there remain operational challenges which need to be addressed for smooth roll-out.

Choice remains important in the Singapore model of healthcare delivery and rightly so.

But adequate measures must be taken to ensure safeguards and the Government is ready to intervene when needed to uphold quality and appropriate prices.

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.