Myth or Magic - The Singapore Healthcare System

By Jeremy Lim

This book provides a comprehensive look at the political philosophy that has shaped Singapore's healthcare system over the last five decades, and the financing and delivery of healthcare in Singapore. It delves into different aspects of the Singapore healthcare landscape, including pharmaceutical cost management, medical tourism, doctors' remuneration, medical education, rules and regulations, workforce panning and health promotion. It suggests lessons that the Singapore healthcare story holds for healthcare policy makers and reformers and the challenges that the future holds.

• Language: English
• Publisher: We Green Solutions
• Release date: Sep 20, 2013
• ISBN: 9789810778941

Book preview

PREFACE

My love affair with health systems began in the last century. I was a young doctor then, spending about a month every year volunteering in rural areas around the region. It was at that time that I began asking why some health systems worked while others so painfully failed.

I was privileged to go to the Bloomberg School of Public Health at Johns Hopkins University for graduate studies. This allowed me to further my interest and, more importantly, my academic understanding of health systems, what they are, why they are the way they are and where the leverage points for change are.

A decade later, having experienced the local health landscape in different capacities, I finally felt ready to take on the challenge of researching and articulating the story of the Singapore health system. This book is the result of that journey, one that has been incredibly intellectually enriching for me. I owe a profound debt of gratitude to many people, too numerous to name, who have, over the years, educated me immensely through their teaching, writing and example. Mr Khaw Boon Wan, who was Health Minister during the time I was in public service, may not know this, but I gained tremendous insights from interacting with him and listening to his mini-sermons drawn from his decades of experience in healthcare. I may not share his views all of the time, or even some of the time, but his logical, methodological approach to the health system and his political acumen are qualities well worth emulating.

I had wonderful research support from Mr Eo Siang Ee and Mr Clarence Tan from Tembusu College, Mrs Wan Chen K Graham from Duke-NUS, as well as Ms Lee Puay Ling from Hwa Chong Institution, who interned with me. I owe them a debt of gratitude for their help. I am grateful too to the Institute of Policy Studies and its staff for supporting the closed door discussions that were very helpful in sharpening the ideas and writings captured in this book. As a novice author, I will always be grateful to Dan Feng and the team from Select Books who have been wonderful to work with, patiently teaching me the ropes of book publishing.

Most of all, I am grateful to my dear family for their patience and tolerance. For this book, I had to spend much time away from home researching and interviewing. Even at home, I invariably had to work late into the night. This book is a labour of love, for it represents my hope for a better Singapore health system for my children, a. system that retains many of the strengths of the current model but with reforms to the obsolescent parts to better meet the needs of today’s and tomorrow’s Singaporeans. I hope that this book will, in some modest way, contribute to the evolution and advancement of health in Singapore.

Jeremy Lim

Singapore, August 2013

P.S. While this book should ideally be read sequentially, I have attempted to keep each chapter relatively self-contained to help readers who may want to refer only to specific areas.

FOREWORD

There is perhaps no more contentious and confusing topic than that of healthcare: what it means, how to measure it, what it should cost, and what one gets for all the bother. Because of this, fewer topics have received more scrutiny or public exposure, nor as many conflicted and conflicting opinions, most of which are strongly held! It is often said that where one stands on an issue depends upon where one sits. This is certainly true of healthcare, where economists, physicians, politicians and patients all seem to be sitting in mutually exclusive places.

There are certain truisms in healthcare. No country anywhere in the world is entirely happy with its healthcare system; some populations are happier with theirs (think Canada and the U.K.) than others (think the U.S.). But no population thinks theirs is ideal. Healthcare costs money, increasingly, a lot of it, and more money does not translate into better care for more people! In the U.S., with the most costly and arguably most dysfunctional system among OECD nations, expenditures on healthcare are rapidly approaching one-fifth of GDP, while huge segments of society receive little or no care at all.

Just as there are truths in healthcare, there are also many myths which need unmasking. Johns Hopkins medical students, when asked, believe that America has the best medical system in the world. They see the proof every day, when wealthy sheikhs and industrial titans fly in for complicated and expensive care. What the students fail to recognise is that the healthcare services they witness daily are not available to every American; indeed, to very few Americans. And, America is far from being the healthiest country.

Healthcare is thus ripe for reform: Difficult choices have to be made, and made now. Where the healthcare programmes of the past focused on acute, intermittent care, usually to treat an infectious disease of short duration (like pneumonia), or definitive, relatively inexpensive surgical intervention (think cataract removal), today’s healthcare system addresses very different pathologies related to ageing and chronic conditions. Few if any healthcare systems were designed to meet today’s challenges and all responsible governments, Singapore’s included, are racing to re-jig their traditional systems to meet these new challenges as cost-effectively as possible.

Jeremy has provided healthcare wonks and interested people everywhere with this timely history and analysis of Singapore’s healthcare system, and the manner in which it has evolved. There is no doubt there is much to envy about the health of Singaporeans, and the low cost at which this has seemingly been achieved. But, as Dr Lim explains, simple metrics belie a complex situation. Low per capita expenditure (4% in Singapore, 5% recommended by WHO, 17% in the U.S.) reflects, in part, a high GDP, and a more equitable distribution of wealth than that of many other countries. As he describes, the good health of Singapore’s population has more to do with its life style than with its health care system. Health is more a product of behavioural and cultural preferences, and preventive services (immunisations, sanitation), than it is of caring for disease.

One can be envious of the rational manner in which Singapore’s leaders have designed its system. Indeed, Hillary Clinton and Barack Obama must be insanely jealous. As Jeremy describes it, I can envision a group of economists and behavioural scientists sitting around a table, designing (what their theories suggest to them) an ideal system of incentives and disincentives, which, titrated just right, would maximise health while minimising costs.

Myth or Magic is a wonderful account of how Singapore’s health system has evolved, and provides important insights about where the future is likely to take it. There are valuable lessons in the evolving Singapore story for all of us.

Alfred Sommer M.D. M.H.S.

Dean Emeritus, Bloomberg School of Public Health

Gilman Scholar, and Professor of Epidemiology, Ophthalmology and International Health

Johns Hopkins University

INTRODUCTION

Colleagues were stunned when I announced last year that I was writing a book on the Singapore health system. Who would be interested? and Is there enough material to write an entire book? were the two most common refrains (Would you be arrested? was thankfully voiced by only one person). I am therefore glad for the minority who agreed with me that the Singapore story was worth telling and encouraged me to forge ahead. I am also deeply indebted to the many thoughtful critics and advocates who so freely shared with me their perspectives, insights and hopes for the Singapore model.

In truth, the Singapore model of healthcare has been a remarkable one thus far. Professor William Haseltine, in his book on the Singapore health system, waxes purple over Singapore’s achievements and titles his treatise Affordable Excellence: The Singapore Healthcare Story – How to Create and Manage Sustainable Health Care Systems. In the book, he notes that Achieving and maintaining the good health of the populace at reasonable cost seems like an unattainable dream in many nations, yet Singapore has done it and has much to teach the rest of us.

The reality is unfortunately more nuanced. I will attempt to present an honest account of the Singapore healthcare story in this book and dispassionately discuss both the good and the not-so-good. My hope is that despite my biases, the reader can gain a deeper understanding of the unique Singapore model and place in context five decades of this great experiment.

Why does Singapore capture the imaginations of many health policy observers the world over? There are perhaps three main reasons that pique their interest:

Firstly, Singapore has won numerous health accolades despite spending just 4% of its GDP on healthcare. These include being named by Bloomberg as the world’s healthiest country and being ranked sixth in the World Health Organisation’s (WHO) review of health systems in 2000. To provide perspective, 4% is lower than the 5% recommended by the WHO as minimum spending on healthcare, and a quarter by GDP of what the United States of America, the richest country in the world, spends. Incidentally, America, despite this largesse, ranked only 37th in the 2000 WHO assessment. Global interest in the apparent ability of Singapore to deliver excellent health outcomes on a shoestring budget has surged in recent years as countries around the world struggle to provide healthcare to their citizens in an age of austerity.

Secondly, modern Singapore, which had its beginnings as a British colony, was still a British possession in 1948, when the English National Health Service (NHS) was born. How did Singapore shake off its colonial legacy and move its philosophy of healthcare from state obligation to individual responsibility? To fiscal hawks, the more compelling related question would be this: How did Singapore, in the span of one generation, reverse the ratio of healthcare financing from 70% government-funded in 1980 to barely 30% in 2012?

Finally, Medisave, Singapore’s national health savings account system, has drawn much interest globally for it is the only such implemented scheme in the world. It has been lauded as the linchpin of our healthcare financing model but this deceptively simplifies the Singapore system.

At the same time, critics of the Singapore model decry that it is better to die than to fall sick in Singapore and bitterly criticise the co-payment and explicit rationing that are central pillars of the ideology of the Singapore system. Is the Singapore system the magic the world is seeking to address the challenge of providing affordable healthcare or is it just a myth? Where does the truth lie between myth and magic?

This book seeks to provide a balanced analysis of the Singapore health system and will be of interest to two groups of readers in particular.

The first would be non-Singaporeans who wish to acquire a deeper understanding of the Singapore health system and the lessons, both positive and negative, we may hold for their countries. A former Permanent Secretary of the Ministry of Health once related how a visiting counterpart praised the impressive design of the Singapore system but immediately went on to woefully bemoan that such a system could never be implemented in his own country. Of course, it would be impossible for the Singapore model to be imported or transplanted wholesale onto foreign soil. However, are there aspects of conceptualisation or implementation that can provide insights or that can be adapted? These are the areas that I hope this book can help shed some light on.

The second group would be Singaporeans who care passionately about the country’s future and who want to contribute in an informed manner to the debate on the future direction of Singapore’s healthcare system.

This book begins with a discussion of Singapore’s political philosophy and how this has shaped decisions in the design of its healthcare system. With these insights, we move on to how the healthcare financing model of Singapore evolved, moving from the colonial vestige of the state as the dominant payer to today’s unique multi-layered model of subsidies, health savings accounts (Medisave), national catastrophic insurance (MediShield) and indigent funding (Medifund). In healthcare delivery, we examine the journey from a national, almost socialised medicine model to one premised on choice and competition at all levels, amalgamating public and private systems and also overseas providers. After this detailed study of the Singapore model, warts and all, we discuss what and how much of the Singapore story holds lessons for healthcare reformers, given the unique circumstances under which the nation and its health system were formed. Finally, with the Singapore story continuing to be re-shaped and re-told by each new generation, each coming with its own life experiences and expectations of nationhood, we explore the challenges faced and what the future may hold.

THE SINGAPORE HEALTH SYSTEM TODAY

– AN OVERVIEW

Singapore’s reputation as an economic miracle needs little introduction. Despite the trauma of its ejection from Malaysia in 1965 and the consequent sudden loss of a hinterland, Singapore rapidly advanced up the economic league tables. Its GDP has grown more than 300-fold, from a modest US$704 million in 1960 to an impressive US$247.7 billion in 2012.¹ Today, Singapore holds the distinction of having the world’s highest number of millionaires per capita, a title it has held for two years running. The Boston Consulting Group estimates that just over 17% of households in Singapore, or 188,000 in absolute numbers, can be classified as millionaire households².

Wealth aside, Singapore prides itself as a country where things work. Writing in Brown University’s Global Conversation, Loh Kai Herng, a young Singaporean scholar, observes, The streets are now sparkling clean, and the city runs like clockwork. Singapore is a leading financial centre, and boasts an impressive skyline that is easily recognisable. Among other things, Singapore’s public transportation and education systems are consistently rated highly in international rankings. Singapore is also known as a clean and green city.³

The economic formula that allowed Singapore’s transition from Third World to First is well-known – eradicate corruption, abandon the import-substitution strategy after its separation from Malaysia in 1965, industrialise instead through an export-oriented strategy, drawing foreign investors to Singapore to develop the manufacturing and financial sectors. In parallel, Singapore strengthened the labour and investment milieu and also invested in key infrastructure.⁴ Between 1965 and 1978, growth averaged 10.2% per annum and unemployment fell from 13.5% in 1960 to less than 3.6% in 1978.⁵

Less well-known is Singapore’s healthcare story and even less well-known and understood is Singapore’s approach to health policy. Even today, Singapore’s health system defies easy categorisation. The late Professor Lim Meng Kin, one of the earliest chroniclers of the Singapore health system, describes the approach as a unique combination of free market principles with careful government control⁶. I recall a number of years ago a foreign academic sending me a table and asking me to classify Singapore’s health system as either Public or Private in financing and delivery. I entered Mixed in all the boxes!

To enable the unfamiliar to navigate the ensuing chapters more easily, I will provide a brief overview of the Singapore model of healthcare as it stands today.

Healthcare Delivery: Singapore’s health system is a hybrid of public and private elements in delivery with 80% of primary care delivered by over 2,000 private general practitioners largely operating as solo or small group practices. The Singapore government offers primary care in only 18 polyclinics (primary care centres) dispersed throughout the island. Despite the sheer imbalance in magnitude, the public sector manages almost half of all patients with chronic diseases while the private sector has a larger share of acute minor ailments and wellness health consultations. In hospital services, the ratio is reversed, with the public hospitals accounting for almost 85% of inpatient beds. Within the public system, Singapore has introduced different types of ward accommodation ranging from the unsubsidised A class wards (single rooms with air-conditioning and other amenities) to the heavily subsidised class B2 and C wards, where patients share a common dormitory type set-up with shared toilet facilities. 81% of beds are B2 or C class while the remaining 19% are class B1 (four patients to a room with air-conditioning) or higher. In the intermediate and long-term care (ILTC) sector, there exists a plethora of Voluntary Welfare Organisations (VWOs are the local equivalent of Non-Governmental Organisations) and private agencies providing home, ambulatory and residential care.

Healthcare Financing: Despite the Singapore government contributing directly only thirty cents out of every dollar spent in healthcare, the Ministry of Health maintains that Singapore offers universal healthcare coverage to our citizens⁷. This is through a mixed financing system which emphasises shared responsibility. Other payers include employers, insurers and individuals. Singapore’s healthcare financing model is described as comprising four layers, or tiers, of protection. The first is provided by government subsidies, which can be up to 80% for inpatient C class wards. The second tier is Medisave, a compulsory individual health savings account scheme. Working Singaporeans and their employers contribute a part of the monthly wages (7% to 9.5% at time of writing) to the account. Medisave is the world’s only national health savings account scheme and enables Singaporeans to save up for their future medical needs as well as pay premiums for MediShield. Medisave is personal to the holder and hence portable across jobs. It can be used to pay the medical expenses of immediate family members. The third layer of protection is provided by MediShield, a low-cost catastrophic medical insurance scheme. While this allows for risk-pooling and mitigation of the financial risks of major illnesses, MediShield premiums are not community-rated but are instead risk-rated by age cohorts. What this means is that premiums increase with age; the premium for a 5-year-old is S$50 while that of an 85-year-old is S$1,190 per annum. By design, to encourage individual responsibility for one’s healthcare needs, MediShield has high deductibles (currently at S$2,000 for those 80 years and below and S$3,000 for those above 80 years admitted to subsidised class wards) and a co-payment component that is computed on a decreasing sliding scale from 20 to 10% of the total claimable amount (Central Provident Fund 2013)⁸. Finally, Medifund is the ultimate safety net for needy Singaporean patients who cannot afford to pay their medical bills despite subsidies, Medisave and MediShield. Medifund is structured as an endowment fund, that is, the principal cannot be withdrawn and it is the investment returns which can be deployed to finance care for needy Singaporeans. It stands at S$3 billion principal sum currently and disbursed S$84.3 million in 2011.⁹

It should be noted that Singaporeans have the option to supplement MediShield, which is meant for basic coverage (that is, subsidised healthcare), with integrated private insurance policies (Integrated Shield Plans). To preserve the risk pool and prevent cherry picking by private insurers, all Integrated Shield Plans can only be procured by Singaporeans enrolled in the MediShield scheme.

With this brief introduction to the health system today, we can begin our journey of understanding how Singapore evolved from a National Health Service-type starting point to the mixed payer, mixed provider model it has today, which, while enjoying international acclamation, scores poorly domestically, with a significant majority of Singaporeans concerned about the affordability of healthcare.

WHAT MAKES A GOOD HEALTH SYSTEM?

Singapore has been lauded for having the sixth best health system in the world.¹⁰ It is a major regional medical hub, drawing patients from all over Southeast Asia and the Middle East to its sunny shores. At the same time, 72% of Singaporeans believe that they cannot afford to get sick these days due to high medical costs.¹¹ In the same World Health Organisation ranking in 2000, America came in a modest 37th; today, the United States is excoriated for having as many as 47 million of her people uninsured. Yet America is also home to world-famous institutions such as the Mayo Clinic, Memorial Sloan Kettering, etc. In fact, Singapore’s current Prime Minister, Mr Lee Hsien Loong, when diagnosed with lymphoma in 1992, flew to the United States to confer with physicians there. What then makes a good health system?

The importance of health systems has long been recognised. Writing in the 2000 World Health Report, Dr Gro Harlem Brundtland, then-Director General of the World Health Organisation, commented, The way health systems are designed, managed and financed affects people’s lives and livelihoods. The difference between a well-performing health system and one that is failing can be measured in death, disability, impoverishment, humiliation and despair.

This chapter addresses what the components of health systems are and the system objectives. The answers may appear blindingly obvious but there are nuances that are often not fully appreciated. The health system is not just about enabling good health; the means of achieving this are also important as is the avoidance of impoverishment, humiliation and despair.

The World Health Organisation defines a health system as comprising all organisations, institutions and resources devoted to producing actions whose primary intent is to improve health¹². It goes on further to describe four essential functions – service provision, resource generation, financing and stewardship – and their inter-relationships with regard to health. This is illustrated in the figure below.

Figure 1: Functions and Objectives of Health Systems

There are four points that are worth noting. First, health creation is not confined to healthcare providers; it includes public health services and public works such as sanitation, food security and housing. Second, health system objectives also encompass responsiveness to non-medical expectations and fairness of financial contributions. Objectives are not narrowly defined though health parameters such as life expectancy, infant mortality, survival following major illnesses, etc. Third, health service offerings are influenced not just by the resources created but also by the system governance and how healthcare is financed. The concept of an eco-system is a crucial one and ideally, health systems should be studied and analysed in their totality. The organisation of this book into discrete sections on political philosophy, healthcare financing and healthcare delivery is admittedly an artificial construct for academic convenience. Finally, a health system’s primary objective is not to create and deliver healthcare services but rather to produce good health in individuals and the population at large.

WHO CREATES HEALTH?

Despite doctors’ pretensions that we are the linchpin of the health system, the truth is somewhat more humbling. To celebrate the arrival of the new millennium, the Centers for Diseases Control and Prevention (CDC) published a series of reports highlighting the advances in health in America from 1900 to the year 2000. One statistic is especially insightful in placing healthcare in the proper context of health creation: The average lifespan of individuals in the US increased by more than 30 years over the century; however, 25 years of this gain could be attributed not to healthcare but rather to advances in public health. What were some of these advancements? Prominent on the list of achievements listed by the CDC were motor vehicle safety, safer and healthier foods, fluoridation of drinking water and vaccinations.¹³ Should we be surprised that radiotherapy, cancer drugs and heart stents did not make it onto the list?

The old adage that an ounce of prevention is worth a pound of cure still rings true today. Much of the gains in population health have come from preventive measures. Because these tend to intervene early on in life, they have a much greater impact on life expectancy. For example, routine vaccines which are largely administered in childhood are estimated by the World Health Organisation to save two to three million lives a year.¹⁴

In contrast, many modern medical technologies can be conceptualised as mainly palliative in nature. Stents do not cure coronary artery disease; they merely keep the affected vessel patent but do nothing for disease progression systemically. Cancer drugs do not cure cancer in the sense that they eradicate all malignant cells. Modern thinking is that the drugs reduce the tumour burden to a level that the body’s immune system can overcome the remnant cancer. And again, we cannot be sure that there are no tumour cells lying dormant waiting to rear their ugly heads when the body’s immunity wanes with age or disease. Stents and oncology drugs are very effective and life-prolonging palliation, but ultimately, still palliation.

FULFILLING BOTH MEDICAL AND NON-MEDICAL EXPECTATIONS

What use is medicine if I cannot put food on the table for my family? and Doctor, you say this treatment can cure me but to afford the treatment, I have to sell my home! are not implausible refrains. Modern medicine can be very expensive and no country is spared. Healthcare has improved by leaps and bounds and is becoming more accessible to the man in the street. However, this has come at a price, and a price that the average citizen is increasingly hard-pressed to bear. This is the case in all countries. Even in America, the richest country in the world, David Himmelstein of Harvard Medical School has noted: Unless you’re Warren Buffett, your family is just one serious illness away from bankruptcy.¹⁵

In Singapore, even the wealthy are waking up to the realities of spiralling healthcare costs. In the last interview he gave before his untimely demise, Senior Minister of State Balaji Sadasivan, a neurosurgeon by training, shared his concerns: Cancer treatment can be very, very expensive. This is something our health system will have to deal with. It is not surprising if some patients have to sell their house [sic].¹⁶

Countries such as the United Kingdom emphasise equity, where the same treatments are offered by public healthcare without charge to rich and poor alike. Personal wealth is inconsequential and medical bankruptcies are virtually unheard of. However, this has led to a different challenge, namely that waiting times for medical procedures can be onerous. The National Health Service (NHS) Constitution provides for patients to wait no longer than 18 weeks from GP referral to start treatment in a tertiary institution, but policy makers concede that it is a struggle to meet this standard.

THE IRON TRIANGLE OF HEALTHCARE – COST, ACCESS AND QUALITY

In 1994, Dr William Kissick of Yale University introduced the concept of the Iron Triangle of Healthcare.¹⁷ The Iron Triangle depicts the relationship between cost, access and quality, generally to indicate trade-offs in the healthcare system. Conceptually, one can think of cost, quality and access as positioned at the three corners of a triangle. As two corners move closer together, the third, by the laws of geometry, must move further apart. This analogy illustrates richly how difficult it is in practice to achieve the health planners’ nirvana – a health system that is low cost, high quality and with universal access. Some countries have very high quality public hospitals funded almost entirely by taxation with minimal user fees. However, the hospitals are largely located in major cities. Rural populations, in theory, have access to free high quality healthcare, but, in practice, struggle to have anything beyond basic healthcare services in their locale. Similarly, some countries may spend little on healthcare as a percentage of GDP and proudly proclaim all public healthcare services are free. However, pharmacy shelves are sparse and patients and their families have to offer informal payments to healthcare workers for both their services and necessary medicines.

THE FOURTH FACTOR – RESILIENCE

So while cost, quality and access have long been the staples of health systems discussions, attention has turned also to one other critical attribute in recent years – resilience. This resilience can be considered in two dimensions: resilience to massive surges in public health needs such as the outbreak of infectious diseases and resilience to fluctuating public expenditure on health. The last decade has amply highlighted the importance of this attribute. The SARS epidemic in 2003 was a painful reminder of how woefully unprepared most countries were for combating an infectious disease epidemic, with shortages of N95 masks, insufficient ventilators, isolation rooms and the like. Singapore learnt her lesson and the Ministry of Health earlier this year announced the setting up of a dedicated infectious diseases hospital.¹⁸

The ability to continue to provide essential healthcare services in the face of deep public spending cuts is a key marker of financial resilience and not some mere theoretical consideration. In 2012, at the height of concerns over Greece’s continued support from funders, pharmacists were warning of a dire healthcare crisis. Warning of utter chaos, Dimitris Karageorgiou, secretary general of the Panhellenic Pharmaceutical Association, told British newspaper The Guardian, that The situation will become dramatic. Already we have cancer sufferers going from hospital to hospital to try and find drugs because no one can afford to stock them. If the shortages get worse, God knows what we will see.¹⁹

Interestingly, in the Singapore parliamentary debates when Medisave was proposed, the vagaries of a country’s fiscal health were highlighted as one of the reasons why individual savings had to be encouraged. Then-Health Minister Mr Goh Chok Tong challenged former Health Minister Dr Toh Chin Chye (who had argued that provision of healthcare should be mainly tax-financed) with two rhetorical questions, Can he guarantee continuous economic growth at 8% per annum? Can he guarantee that Singapore will never face unemployment again?²⁰

POLITICAL PHILOSOPHY OF THE

SINGAPORE HEALTH SYSTEM

The ideas of economists and political philosophers, both when they are right and when they are wrong, are more powerful than is commonly understood. Indeed the world is ruled by little else. Practical men who believe themselves to be quite exempt from any intellectual influence are usually the slaves of some defunct economist.

John Maynard Keynes

We believed in socialism, in fair shares for all. Later we learnt that personal motivation and personal rewards were essential for a productive economy. However, because people are unequal in their abilities, if performance and rewards are determined by the marketplace, there will be a few big winners, many medium winners, and a considerable number of losers. That would make for social tensions because a society’s sense of fairness is offended.

A competitive, winner-takes-all society...would not be acceptable in Singapore... To even out the extreme results of free-market competition, we had to redistribute the national income through subsidies on things that improved the earning power of citizens, such as education. Housing and public health were also obviously desirable. But finding the correct solutions for personal medical care, pensions or retirement benefits was not easy. We decided each matter in a pragmatic way, always mindful of possible abuse and waste. If we over-redistributed by higher taxation, the high performers would cease to strive. Our difficulty was to strike the right balance.

Lee Kuan Yew

From Third World to First: The Singapore Story 1965 to 2000

Discussions on health systems are typically based on characteristics related to financing and delivery. However, the design of a health system, as with other essential public services, reflects first and foremost the ruling elite’s political philosophy. In a sense, financing and delivery are thus second-order decisions, which flow in a coherent fashion from the underlying logic of a country’s political philosophy. The analogy in organisations would be the Hierarchy of Choices described by MIT don Daniel Kim, where Kim defines fundamental choice as one that addresses the big question ‘WHY?’ and serves to clarify one’s purpose in life.²¹ Kim goes on to explain that understanding core values (the organisational equivalent of a country’s political philosophy) and purpose

Reviews for Myth or Magic - The Singapore Healthcare System

[Ivan Tham · Rating: 5 out of 5 stars]

Excellent and insightful review of this complex topic. Essential reading for anyone interested in healthcare management.