by Max Dakara
Singapore has been successful in developing an effective healthcare system in the span of a slightly over 50 years and as a result, gained universal praise for their efficient system and legislation that has allowed for affordable healthcare. Despite this, the system isn’t perfect and it can be attributed to a number of issues. This article will look into the strengths, the weaknesses and the solutions being undertaken and proposed in order to overcome these issues.
Worldwide there is a disparity in how countries provide healthcare services to its people, countries like the United States where a majority of hospitals are privatised and as a result driving prices of healthcare to become exorbitantly high in order to maximise profit. On the other hand, how universal healthcare is facilitated varies and as a result it’s a case to case basis of whether or not it’s provided to the population for free. This includes completely relying on taxes to fund the system such as in Germany, a social health insurance where the system relies on contributions by individuals, enterprises and the government such as in Japan, and the Single-payer system where the government completely covers the cost of healthcare among others. These different systems vary in their strengths and weaknesses in being able to provide universal healthcare to its population and can encounter issues of inefficient provision of medical attention or an overconsumption of medical goods.
This understanding of different ways healthcare is provided around the globe allows us to understand how Singapore’s mixed financing system hinges on the idea of affordable healthcare yet integrates the need for personal responsibility. Affordable healthcare is brought about through subsidies, these are provided dependent on the income of the patient which can be seen through how wards in public hospitals are priced with the lowest level, C wards, having an 80% subsidy while the highest level, A wards, having no subsidy provided by the government. This allows each individual to get the adequate care they need and the difference in ward level doesn’t translate to a difference in the quality of care, rather it’s more of a choice based on comfort.
Along with this are the 3Ms for healthcare, this being MediSave, MediShield Life and MediFund which allows people from different income levels to be able to get access. MediSave is one of the three accounts provided by the Central Provident Fund board that gains a percentage of a citizen or PR’s salary and a fixed contribution from their employer which increases as their employee ages which is subject under a minimum, competitive interest rate. This provides residents to pay their small medical bills using this account as well as their spouse’s or family’s bills.
The second M stands for MediShield Life which is an affordable insurance plan for more serious medical issues provided by the government in which the annual cost of it increases as the individual grows older. This allows the more expensive bills to be covered and in addition some selected treatments such as dialysis and chemotherapy are covered under the plan and can be used once a certain amount has been paid out of pocket or through their MediSave. Premiums for these insurance plans are made to be affordable by subsidising plans for lower to middle income families and for elderly Singaporeans who fit the criteria regarding age and when they obtained citizenship. In addition, those who are interested in the benefits that private insurance may provide are able to gain an Integrated Shield Plans (IP) that contains both the base MediShield and additions provided by these firms which would cover care on the higher end of comfort such as A or B1 level wards.
Lastly, there is MediFund that aims to help those in lower income Singaporean families in affording healthcare services which they have difficulty in paying out of pocket, using MediSave and MediShield after subsidies are applied. These three can be considered the pillars as to why healthcare is accessible as well as affordable in Singapore and as such it allows for the many reasons why its system is efficient.
So how have the subsidies and the 3Ms affected Singapore healthcare positively? The major answer to this is that it has been able to provide equal access to healthcare for those who need it. Another effect of this is that it allows prices to be kept low as a good proportion of patients will have to pay for treatment using mostly their own money and as a result hospitals would have to make sure their costs remain low in order for it to be accessible. In addition, the requirement for prices of treatments to be stated publicly on the hospital’s websites means that each hospital is able to gauge each other’s prices and would set it accordingly to remain competitive while also allowing patients to make an informed choice about where to take their treatment. Moreover, by not providing healthcare for free and having stringent regulations when it comes to how a person uses their MediSave, MediShield and MediFund, it prevents the system from being completely overrun under normal conditions and as a result prevents situations where medical supplies are depleted with those who require medical attention getting it. These systems as well have facilitated Singapore to keep their funding of healthcare very low yet still keep the system as effective.
Another aspect of why Singapore has become well known for healthcare is it being a hub for medical tourism through both its private and public sector to treat international patients for diseases such as cancer. This could be attributed to its high quality of treatment rather than the relative cost of treatment and as a result a proportion of medical tourists are upper class individuals from abroad. Research in Singapore is heavily supported by the government and has become a lucrative option for foreign corporations to invest in research within the country due to its prowess in research while the government provides benefits for those that do invest into its research. Medicine still remains an attractive career choice for many in Singapore despite the length of the course and this can be attributed to a good salary and the idea that people are able to give back to society along with medical universities in Singapore ranked among the highest worldwide. This is apparent that Singapore doesn’t necessarily have a shortage of doctors but rather an unequal distribution between public and private as more are willing to work under private hospitals due to the better pay.
While Singapore has been able to pave a new way for providing its residents with universal healthcare, there are still apparent flaws within their system. One such issue has become apparent during the pandemic and that was a shortage of beds within the public hospital system and has been a long lasting issue. This was apparent during the height of the pandemic when Singapore converted places such as Expo being temporarily converted into a care facility for Covid-19 patients who suffered from mild symptoms. These shortages lead to long waiting times which is an issue seen in other countries that do implement universal health care. How it has been addressed is through making sure the load of patients are spread evenly among hospitals in times where one is particularly flooded with patients and the building of new hospitals have been on the agenda to improve the country’s ability to provide healthcare. The former however may not necessarily be effective if the entire system is overloaded with patients.
Internally, issues regarding the mental wellbeing of its workforce has become a topic of discussion in Singapore and calls to question what has been done in order to address these issues. At the height of Covid-19, it was commonplace to see stories regarding why medical personnel experienced psychological distress and burnout. While Singapore has implemented psychological service for medical personnel free of charge, the problem arises from a more cultural place where a social stigma around mental health is present. Furthermore, the possibility of medical personnel being reported as unfit for work due to their condition and it being stated on their record as a healthcare worker stirs them away from seeking help. A study conducted by National University Health System researchers showed that around 75% are at risk of suffering from burnout while prior to the pandemic roughly around 42% out of 97 doctors suffered from symptoms of anxiety.
Partially the reason for this can be attributed to the rise in the number of cases in which personnel have been harassed by patients. In response to this, MOH have established a Tripartite workgroup in order to tackle the issue through developing ways in order to respond to harassment caused by a patient and raising public awareness about it.
These issues are glaringly apparent in junior doctors in public healthcare who have to undergo a work culture that may not be conducive for growth as there is somewhat of an ideological disconnect between them and senior doctors. Surveys by TheHomegroundAsia have shown that junior doctors end up going through long and gruelling working hours with some instances being pressured to under-declare work hours, a negative relationship between the junior doctors and the senior doctors and a tendency for feedback to be disregarded or absent by junior doctors about the workflow. Other issues stem from how the ambition to specialise has dissipated among many due to the competitive nature resulting from a very limited number of seats. This causes a waiting time of five to six years where junior doctors don’t really see progress in their career and as such have to wait patiently at the chance of pursuing an area of interest.
However, progress may lie ahead as the formation of junior doctors’ wellness workgroups in order to address specific issues concerning them in order to develop a more positive environment. Reviewing of workflow models by the National Wellness Committee for Junior Doctors will aim to work with junior doctors themselves and other concerned parties and this could mean that there would be more feasible working hours and a reduction in the instances of psychological distress or burnout. Why this is important is that junior doctors do contribute a significant amount in making the healthcare system work and if a conducive space isn’t developed then dire mistakes may happen as a result. It’s necessary too from the perspective of public healthcare as many personnel either resign or shift to private for a better work-life balance as well as improved pay which causes an uneven distribution of doctors in the healthcare system.
Some issues are also present with the 3Ms specifically concerning MediSave however this issue stems from an external source that being a reduction in the fertility rate of Singapore, signalling a decline in the population. It poses a problem for those families who pool money to pay for the treatment of one family member, the ability to pay it off would reduce as family sizes end up decreasing. In this regard however, Singapore is most likely to adapt to such a change as they have done before with the implementation of MediShield in order to help residents pay off larger expenses.
Singapore has achieved what could be considered the impossible, having a healthcare system that ranks number two on the Bloomberg Health Efficiency Index, providing world class healthcare and paving the way for a new way to approach the business side of healthcare. Only being a country for the past 56 years, feats such as a high life expectancy of 83 years and a low infant mortality rate of 2.1 for every 1000 live births are impressive. While it does have its own set of flaws, it’s probable that said issues would be worked upon and positive results would be seen, eventually overcoming these hurdles in order to provide the best healthcare for all of its residents.
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