I was lucky to work there and have fond memories. The Singapore model of healthcare has a lot to be spoken about, and inordinate funding to “spur innovation”. Healthcare delivery isn’t just about a patient meeting a doctor, but a complex synchronization of processes, financial incentives, and a clear approach to “preventive-healthcare”. The American system, as mentioned, is wasteful – but only because, barring a small co-pay and employer covered costs, the risk-modeling has specific assumptions around delivery costs. However, those models are clearly untenable (and given the excessive focus on marketing/patient-support groups pushed by pharma companies) and a polarized environment around which “experts” thrive. The combined effect is that the trust in those systems has been dwindling. It has become a socio-political problem, rather than a healthcare delivery issue. I won’t get into more specifics, as the blog is not focused on those issues, and there are other considerably better resources to dissect them out.
Book Review: From Third World to First, by Lee Kuan Yew [PART ONE] : TheMotte
Speaking of blithe self-assurance and scornful dismissal, he dismisses the British National Health Service as idealistic but impractical and destined to cause ballooning costs, then takes a shot at the American system with its “wasteful and extravagant diagnostic tests paid for out of insurance.” He reports that at least in Singapore, the ideal of free health care clashes with human behavior. Doctors prescribe free antibiotics, patients take them for a few days, don’t feel better, and toss them out. Then they go to private doctors, pay, and take the medicine properly. (100)
The first solution was a token 50-cent fee to attend outpatient dispensaries. The full solution, and part of the reason Singapore’s per capita health care costs are half the UK’s and less than a quarter of the US’s, once again went through the CPF pensions: 1% set aside into “Medisave” for health care costs at first, gradually increasing to 6%, capped at S$15,000. “To reinforce family solidarity and responsibility”, LKY reports, accounts could be used for immediate family members as well. (101)emphasis mine
The healthcare behavior and financial modeling to shape “human-experiences” with it are fascinating. Singapore created a compulsory savings system (CPF) and then allocates a specific percentage to “Medisave”. Those falling below a specific threshold have other means of healthcare support. Eventually, some proportion (in varying degrees) is always subsidized, which then helps to provide “healthcare-for-all”.
The point here is – can this be replicated elsewhere? It requires two major levers to operate-political will and a bureaucratic system to administer it. To me, it is appealing because users have a strong incentive to save, matched by the state. There is a strong sense of ownership through universal housing and compulsory savings. Accessibility is defined by risk modeling and creating a system for preventive healthcare. It appears like a “socialist+capitalist” hybrid, but with unique Singaporean characteristics. Surprisingly, it hasn’t been successful elsewhere (there were some attempts to have this in mainland China) and its failure can be surmised to a degree of control.
This successful implementation is also due to formalization of healthcare roles. Singapore, mercifully, is without the usual titular roles, and their bureaucracy understands limitations on when NOT to expand on itself. A careful feedback loop on implementation, actual results, and then fine-tuning the policy yields greater dividends. I mean, you don’t need a “director of patient-experience” while pushing paper from “central-leadership” to underlings. There are better ways to involve nursing administrators for the same role, for example. These formalized structures also require considerable inputs from human resources (especially to address issues related to diverse teams) and clear focused outlines on patient transition from out-patient to pharmacy or admission and post-discharge followups.
It will then be instructive to establish clear processes on “research-and-development”, rather than a system to construct infrastructure based on quarterly “profit-and-loss”. Most of the private sector, elsewhere, thrives on inefficient mechanisms without clear elucidation of physician roles and continued investments in patient journeys. Healthcare policies are dynamic in approach, and the Singapore model provides clear templates.
I’d be looking into it in the future.