Lessons from Singapore

Vanam Jwala Narasimha Rao, Chief PRO, Telangana government, who was on a recent visit to Singapore, talks about the healthcare situation in Singapore and weighs the options of replicating the same model back in India

Contrary to the Indian situation, in Singapore, 80 per cent of primary healthcare services are offered by 2000 private medical clinics; whereas the remaining is delivered by 18 government polyclinics. In India, in most of the states, specialities and super specialities in healthcare are available in private sector only while most of the primary care is done by the government. Another problem in India in general, and particularly for the middle class people is the huge costs for diagnostic services which are provided mainly by private centres.

For instance a positron emission tomography (PET) scan costs anywhere around Rs 20,000 and an magnetic resonance imaging (MRI) costs around Rs 10,000. These need to be provided by the government at affordable costs. It is also desirable that the government establishes its own polyclinics and also takes the help of private clinics to enabe the patients to get treatment at affordable costs. It is high time that we study systems elsewhere and adopt them here. For example, Singapore’s healthcare delivery system provides its populace with primary healthcare, hospital care, long-term care and other integrated care. The city state has a network of outpatient polyclinics and private medical practitioners’ clinics to provide primary medical treatments, preventive healthcare as well as health education. In Singapore, hospital care consists of inpatient, outpatient, diagnostic and emergency services. In contrast to primary healthcare, public hospitals provide 80 per cent of hospital care including speciality treatment. Even in the bed strength, government hospitals account for 80 per cent, whereas private hospitals the remaining 20 per cent. The percentage of registered doctors (excluding specialists) and in the public institutions is about 80 and that of private sector is a mere 20. The early primary healthcare in Singapore commenced with a government promoted National Health Plan in 1983. The plan is being updated from time to time to suit the needs of people.

There are three main regulators in the system, Minister of Health (MOH), Central Provident Fund (CPF) and Monetary Authority of Singapore (MAS). MOH oversees the provision and regulation of healthcare services. CPF is a comprehensive and compulsory social security savings plan. It ensures working Singaporeans and permanent residents (PRs) to support themselves in the old age. MAS, as Singapore’s central bank, regulate the financial aspect of insurance sector. Insurance department of MAS administers the Insurance Act, which protects the interests of policyholders.

The well-established healthcare system in Singapore consists of 13 private hospitals, 10 government hospitals and a number of specialist clinics, each one specialising in catering to the needs of different patients at varying costs. Patients are free to choose the providers within the government or private healthcare delivery system and can walk in for a consultation at any private clinic or any government polyclinic. Both the private and public hospitals of Singapore are equipped with state-of-the-art medical equipment in order to maintain the highest standards of medical services.

The government’s healthcare system is based upon the ‘3M’ framework. This has three components: Medifund, which provides a safety net for those not able to otherwise afford healthcare, Medisave, a compulsory health savings scheme covering about 85 per cent of the population, and Medishield, a government-funded health insurance scheme. Singapore government ensures affordability of healthcare within the public health system, largely through a system of compulsory savings, subsidies and price controls. Singapore’s system uses a combination of compulsory savings from payroll deductions to provide subsidies within a nationalised health insurance plan known as Medisave. Medisave was introduced in April 1984 which allows Singaporeans to put aside part of their income into a Medisave account to meet future personal or immediate family’s hospitalisation, day surgery and for certain outpatient expenses. Under this system, Singaporean employees contribute 6.5 to nine per cent (depending on age group) of their monthly salaries to a personal Medisave account. The savings can be withdrawn to pay the hospital bills of the account holder and immediate family members.

A key principle of Singapore’s National Health Scheme is that no medical service is provided free of charge, regardless of the level of subsidy, even within the public healthcare system. At the same time no one is refused treatment on the pretext that payment has not been made. Normally, the charges are collected at the time of discharge and irrespective of bill paid or not the patient is discharged first. There is a mechanism to chase the defaulters. Approximately 70-80 per cent of Singaporeans obtain their medical care within the public health.

The Singapore General Hospital (SGH) is the largest and oldest public hospital in Singapore, of which the foundation of its first building was laid in 1821. The Tan Tock Seng Hospital is the second largest hospital, but, its accident and emergency department is the busiest in the country largely due to its geographically centralised location. SingHealth is Singapore’s largest group of healthcare institutions. At SGH, patients have access to over 600 doctors from 29 clinical specialities. Its dedicated team of healthcare professionals is committed to give each patient the quality of care that would best address the clinical problem. Except for emergency cases, patients are admitted to SGH only on recommendation from their medical specialists from the Specialist Outpatient Clinic. Once a date for admission is confirmed, patients are encouraged to visit the hospital’s pre admission testing (PAT) centre to seek information on ward accommodation and register themselves for their desired accommodation class. The PAT Centre will also schedule appointments for patients to undergo compulsory pre admission investigations such as blood tests, chest X-ray, electrocardiogram, which are conducted one week before admission.

The Emergency Department at SGH is one of the busiest in the country. There is a senior emergency physician on duty on every shift. Patient will be assigned a specific priority level according to the severity of his or her medical condition. Emergency Ambulance Service (EAS) is operated by the Singapore Civil Defense Force (SCDF) and it can be reached by dialling 995. The service is designed to provide an immediate response to patients with life-threatening situations. EAS is meant for calling during medical emergencies only. One may dial 1777 instead, if an ambulance is required, for non-emergency condition. The SCDF operates a 24-hour emergency ambulance service (EAS), which is ready to answer to any emergency at any part of Singapore. Qualified medical personnel, who are equipped to handle emergencies, man all the ambulances. However, if a case attended to by the SCDF is deemed to be a non-emergency by its paramedics, the patient will have to pay an ambulance fee of $180. Probably, it would be a good idea if the system in Singapore is applied to Indian situation and conditions.