a community of singaporeans

Singapore’s healthcare system – uniquely Singapore? F1 or F9? (Part 3)

Posted by theonlinecitizen on June 8, 2007

This is part 3 of theonlinecitizen’s 3-part focus on healthcare, written by Leong Sze Hian.

Looking for the Substance of subsidies

The Ministry of Health’s website touts the fact that subsidies for subsidised patients have been rising from $560 million in 1997 to $1.39 billion in 2005. However, increases in subsidies should never be looked at in a vacuum: they need to be viewed in the context of rising healthcare costs. This is especially relevant in the context of the poor.

For example, if healthcare costs rise by 10 per cent, and subsidies also increase by the same amount, the net impact on the poor is zero.

Thus, notwithstanding rising subsidies, the poor were most affected as healthcare spending of the lowest 20 per cent of households by income, had the highest increase of 81 per cent among all items of expenditure from 1998 to 2004.

This increase is further compounded by the decline in average monthly household income of this group by 3.2 per cent a year from 1998 to 2003.

A slew of changes in healthcare policies in recent years may have contributed to rising healthcare costs for the poor, such as the 9 per cent increase in polyclinic fees to cover renovation work; no more free treatment for infectious diseases like dengue fever and chicken pox at the Communicable Disease Centre; increase in MediShield deductible and premiums; maximum waiver of only up to 60 per cent for non-air-conditioned 6-bedded ward under Medifund; means testing for disabled care; means testing for community hospitals elderly care, etc.

Means testing borders on the stingy: means testing since 2000 for community hospitals elderly care, starts at $301 per capita income. How can a family with a per capita monthly income of $301 be considered not poor?

According to the World Health Organisation’s (WHO) World Health Report 2004, Singapore‘s per capita government expenditure on health, at an average exchange rate, fell gradually from US$365 (S$577) in 1997 to US$274 in 2001.

The WHO Report 2005 showed that Singapore’s general government expenditure on health – as a percentage of total expenditure on health – declined gradually from 41.6 to 30.9 per cent from 1998 to 2002.

General government expenditure on health as a percentage of total government expenditure also dropped from 8.7 to 5.9 per cent for the same period.

With over three per cent of Gross Domestic Product (GDP) spent on healthcare, I understand that Singapore’s healthcare spending over GDP is one of the lowest in the world.

The poor are not interested in the debate or statistics on healthcare, but rather the issue of affordability and whether healthcare will continue to be a rising financial burden.

Healthcare expenditure: cutting spending, cutting corners?

The media has reported that there will be no fee and prescription subsidies for foreigners at polyclinics from next year, and that subsidies for permanent residents will also be cut by 50 per cent.

According to the Department of Statistics, foreigners number 753,400 out of the total population of 4,240,300.

If 10 per cent of the resident population are permanent residents, according to the Total Population by Residential Status, Census of Population 2000, the total number of foreigners and permanent residents should be 1,102,090.

Therefore, a cost-cutting policy change as in the case of the polyclinic fee subsidy may affect about one in four of the population.

From 1998 to 2003, about 97 per cent of total marriages were resident marriages, which refer to marriages where either or both the groom and bride are residents. I believe there are many Singaporeans with spouses or dependants who are not citizens.

Therefore, the removal and reduction in fee subsidies may add to the financial strain of these Singaporeans, too. The fact that attendances at polyclinics had increased by 14 per cent from 3,337,300 to 3,791,700 from 2003 to 2004 may indicate that more people have been turning to polyclinics because of the lower fees they charge.

Other recent cost-cutting measures like the closure of night polyclinics and the termination of free treatment for some infectious diseases at the Communicable Disease Centre, and the mandatory increase in deductibles for CPF Shield medical insurance plans, may also increase medical costs for the poor.

Consequently, poorer residents may become more inclined to delay or avoid seeking medical treatment, or resort more to self-medication.

Since Total Government Health Expenditure per person has already declined by 16 per cent from $584 to $491 from 2003 to 2004, do we really need to cut spending further, to the extent of increasing the burden on lower-income Singaporeans whom I believe have relatively more non-citizen dependants than those of higher income?

According to the Economist magazine (Nov 19), a Chinese ‘government survey published last year, said nearly 30 per cent of city residents recommended for hospitalisation refuse to be admitted with some 70 per cent citing the cost’.

This highlights how relentless cost-cutting in healthcare may affect the poor.

Medical costs will also go up for the few hundred thousand Singaporeans who employ domestic maids and foreign workers. It has been said that ‘with the subsidies removed, it makes sense for employers to buy medical insurance for their foreign workers’.

The cheapest medical insurance premium that I can find to cover my maid for outpatient treatment is quite high at $250 a year for a female below age 31, and there are also co-payments of $5 per outpatient visit, $15 per specialist care visit, and 10 per cent of the total eligible bill for B2 hospital care.

The annual premiums increase to $350 and $460 for those above age 30 and 40 respectively.

This change in fee subsidies may, therefore, actually affect more Singaporeans than foreigners, because in many cases, it is Singaporeans who will ultimately be footing the bill.

As the Health Ministry is also looking at withdrawing government subsidies on hospital care for foreign workers, medical costs may increase further in future, for Singaporean employers and Singaporeans with non-citizen dependants.

Waiting till the cows come home

It was reported that keeping medical records electronically saved the National Skin Centre $237,000 in labour costs at the end of the year, and cut patients’ waiting time. The media also reported that two hospitals here retrenched 108 workers, presumably to cut costs.

When you go to a hospital to seek treatment for a dental problem, you may be told that, as it is not something which warrants immediate attention, you may have to wait for up to nine months if you pay subsidised fees.

However, if you opt to pay the non-subsidised rate, you can be treated immediately.

The same goes for eye operations. As the question of whether an ailment is serious enough to require treatment sooner rather than later is sometimes subjective, patients who do not want to take a chance may opt to pay the full rate.

Those who cannot afford or do not wish to pay the full rate may risk a deterioration in their condition. As a matter of principle, should the priority of treatment not be based on one’s health condition, rather than ability to pay more?

Is this fair to the poor and less economically well-off?

What if the rest of the health-care system, such as specialists, polyclinics and general practitioners, follow the example of the dental and eye centres?

Hypothetically, if one’s health condition worsens and irreversible damage is done because of the delay in treatment, can the medical facility and medical practitioner be held liable?

The Health Ministry should examine the ways in which hospitals manage their financial objectives and resources.

Which is a bigger problem that should be given priority: cutting waiting time by 30 minutes, or letting those who cannot pay wait for months?

Summary to this 3-part essay

The Ministry of Health (MOH) responded (ST, June 2) to Straits Times HEALTH Correspondent Salma Khalik’s article “Demand for C-class beds at hospitals up sharply”, ST, June 1), with “(she) observed that Class C patients now formed 40 per cent of public-hospital admissions when it was 27 per cent five years ago.

Perhaps alarmed by this observation, she concluded that this has ‘put a strain on hospital finances’ and speculated that this was the reason for (a) hospitals raising fees, and (b) the Ministry of Health (MOH) contemplating means-testing in hospitals”.

The MOH’s letter ended with “We hope that ST can do its part to help educate, inform and reassure Singaporeans. It is not helpful to alarm the public unnecessarily”.

Singaporeans may like to give more feedback to the Government on the varous issues raised in this 3-Part article “The Healthcare System: Uniquely Singapore, F1 or F9?”.

As such issues are raised in the media practically every month over the last two years or so, it should not be like a school debate between two opposing parties – the proposition and the opposition – between the MOH and those who ask questions or give suggestions to improve our healthcare system.

We are all on the same side

As we are all Singaporeans.

You can view part 1 here, part 2 here.

About the author:

Sze Hian has 5 degrees and 13 professional qualifications. A Wharton Fellow, alumnus of Harvard University and the United Nations University International Leadership Academy, he has served as Honorary Consul of Jamaica, President of the Society of Financial Service Professionals, Representative of the Inter-American Economic Council, Chairman of the Institute of Administrative Management, and founding Advisor to the Financial Planning Association of Indonesia.

He has been invited to speak more than 100 times in over 15 countries on 5 continents, authored 3 books and quoted over 700 times in the media.


7 Responses to “Singapore’s healthcare system – uniquely Singapore? F1 or F9? (Part 3)”

  1. ganchau said

    My views on healthcare in a lighthearted manner in my blog article, “Cheers to Good Health!”

    Thursday, June 07, 2007
    Cheers to More Good Health!

    I had not been feeling well of late and attributed it to the extremely hot weather and the bug that had been going around. Since I am going to Kuching this Saturday, I thought I would make a trip to the polyclinic to have a check up. As a regular blood donor, I have free medical benefits.

    I chose to go in the late afternoon so that I could proceed to the AIA Building at Alexandra Road for my toastmasters’ meeting. It was a Dr. Ng Chung Sien who saw me. He is an affable, pleasant looking doctor who tries to cheer his patients up by being humorous. I asked the doc if my dizziness could be due to some new development eg. diabetes, etc. He smiled and said more likely it could be due to the hydrochlorothiazide tables. However it would be better if I reduce some weight.

    “So hard to lose weight doc…. more like genetic factor for me,” I volunteered.

    “By the way what work do you do?” asked Dr. Ng.

    “Real estate”.

    “Now market is good. When market is good, everyone’s weight goes up. When market is down, people’s weight also go down. Maybe you can try liposuction,” suggested Dr.Ng.

    “Yucks… scared of surgery … am not afraid of death…but it’s important how I die. Don’t mind dying in the mission fields…but due to liposuction? Don’t want to become famous in this way lah,” I smiled sheepishly. I assured Dr. Ng that whether market is down or up, I have always been overweight. Hence my nickname, Pooi Choo.

    “Then I’ll refer you to the weight management clinic at Alexandra Hospital.’

    “That’s a better idea. So they will have to take a before and after photo?”

    Dr. Ng smiled. “Not like that….to us it is weight loss for good health….not like those already slim ladies at Expressions who want to lose weight to look even slimmer for beauty”.

    “Ok. Sounds like a good idea so long as treatment is still free for me as a blood donor. I hate to spend money to lose weight when half the world is starving for want of food.”

    “Let me take your weight as I have to give you a referral letter.”

    I stepped onto the weighing machine.

    “Wow! What a nice number. 88.8kg. See I told you…you’re prosperous!”

    I laughed. What a coincidence.! Few believe my weight….for I am always 10 kg heavier than my appearance.

    I gave the doctor my name card. I told him to read my blog if he has time and that I may blog about our visit. I told him that he is one of the most friendly doctors as most physicians at polyclinics are serious and distant, with a look that seems to say, “Don’t ask too many questions… I’m very busy.”

    I smsed Vanessa Yong, my good friend and colleague. She replied, “I’m half of you, Choo. I’m 44.4kg! Hee Hee.” I had once jokingly suggested to Vanessa that I would love it if some surgery could be done to remove my excess flesh and implant them onto her. This way, we can both share the weight together!

    At the AIA Toastmasters’ Club, one of the speakers, Tan May Yan, who works with Singhealth, talked about the Government’s plan for means testing. Now the hospitals are struggling with insufficient beds for Class C and B wards, because more people want to enjoy the greater subsidies that come with these two classes of wards. What a coincidence.

    As I took the bus back after the toastmasters’ meeting, I reviewed the day’s happenings. Mm…. it is best for me to do something about my weight so that I do not have to worry about Class A, B or C. This is why the government is now advocating us to take greater care of our health by encouraging us to ask for less oil and salt when we patronise our favourite food stalls. Mm…I will also make an effort to cook more at home when I move to Chander Road. This time I will have less excuse not to cook as the Tekka Market is next to my apartment.!

    Cheers to a more healthy lifestyle! Health is wealth!

    Gan Chau

  2. jdtoh said

    They seem to be blaming patients for causing the problem of C ward bed shortages. Well, maybe its because more people really cannot afford anything better? Means testing might tackle the symptoms but shouldn’t we be looking at the cause as well?

  3. Anonymous said

    Politicians… always speaking out of both sides of their mouths…

    I like your ‘Recollection’
    “Means testing will not be implemented within the next two years as originally planned, said Health Minister Khaw Boon Wan .”
    2nd May 2006

    “Means testing may kick in within the next 12 months, says Health Minister Khaw Boon Wan. ” Channelnewsasia
    7th April 2007

    In fact, according to a Straits Times article, the esteemed Khaw Boon Wan made “Means-test a health priority for this year” in Jan 2005.

    Of course, when election time rolled around in May 2006, we all know what happened…. at least until they won the elections…

  4. Alex Har said

    Over the last 2 years, I have become care-giver to my 81 year old mum and 91 year old father and have been to hospitals and outpatient clinics many times. From my little knowledge and experience in work redesigned and business process optimization acquired over 25 years working with insurance companies…I can quite assuredly say that given the right management systems and management attitudes, minus the bureaucracy and politically inspired policies…operation costs can be reduced by at least 30%….while service levels and overall patient experience improve by the same quantum.

  5. raymondchua said

    Means testing is really mean. Why not even ask Minister’s father and mother, children to experience mean testing ?

    One test of poor leaders are that these leaders always come out policy that they themselves are exempted ! Because these leaders are so rich, they find themselves out of it !

    No wonder we lose respect of those leaders, and those leaders will just wayang on, because no matter what they do, they are just plain shit before the eyes of Singaporean.

  6. ssyap said

    TO put things in perspective, check this out

    Our healthcare as compare to some EU countries, we are much better off.

  7. RaymondChua said

    ssyap, we can do better. Let’s not be complacent. We should reduce health care cost and justify cost increment, and not doing senseless comparison which are plain meaningless. Ask yourself, just because we are cheaper in some ways, does that mean that we should also be expensive in the same way? What is cheaper in some way make up for other increasing expenses. Don’t be trapped into seeing the leave rather than the whole forest. One might found a few green leave among the bunch of many dead yellowish leave.

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