Introduction Singapore is a small country with a total land area of 710 square kilometres. Obtained independence from Malaysia on 9 August 1965. Singapore is a parliamentary republic. Singapore is characterized by a highly developed and successful free- market economy. It has a very open and corruption-free business environment. The Singapore economy grew by 8% in 2009 and it is projected to grow by 15% in 2010. Per capita gross domestic product amounted to US$ 39,951 in 2008. Literacy rate : 96.3%
THE HEALTH CARE SYSTEM IN SINGAPORE Health Care Philosophy-1. Aims to build up a healthy population through preventive health care programmes and the promotion of healthy living.(Healthy family, healthy nation report 1991)2. Responsibility to intervene in the health care sector where the market fails to keep health care costs down3. Personal responsibility for one’s health.Emphasis on – a)Health education b)Immunization c)Health screening for early detection of diseases.
Ministry of Health-Overall responsibility for the provision and regulation of health care services inSingapore.
HEALTHCARE DELIVERY SYSTEMSingapore has a dual health care delivery system. Primary health care- 80%provided by private practitioners 20% government polyclinicsIncludes – curative out-patient medical treatment health screening preventive health programmes for school children, home nursing day care and rehabilitation for the elderly health education and promotion. Hospital Care- 80% by public sector 20% by Private sector
Health Indicators The crude birth rate 9.9 per 1000 resident population. The crude death rate 4.4 per 1000 resident population. The total fertility rate per resident female 1.3 MMR 0 Under 5mortality Rate 3
Demography Population of Singapore = 4.9 millian (2009) % of Total PopulationChinese 74.2%Malaysian 13.4%Indian 9.2%Others 3.2%
NUMBER AND PERCENTAGE OF BEDS IN PUBLIC AND PRIVATE HOSPITAL NUMBER OF BEDS PERCENTAGE(%) PUBLIC HOSPITALS 9091 80.6 PRIVATE HOSPITALS 2185 19.4 TOTAL 11276 100 3 beds per thousand population ratio.Average length of stay is about 5.5 days in general hospital.Occupancy rates - Public Hospital 84 % Private hospital 65%
Singapores only Western-style Medical School, established in1905 trains 150 doc/yrReason for growth in specialization -Push FOR growth by forming Committee for Postgraduate Medical Education in 1970 Up-gradation of hospitals with sophisticated technology. Sending doctors to higher medical centers in world for training
Traditional medicine. Traditional medicine (Chinese)- attends 12% of OPD patients hence government appointed a committee in 1994 to review the practice of traditional Chinese medicine (TCM) which came out with recommendation of accreditation of TCM training programme. Registration with the self regulatory body. Establishment of a Chinese Proprietary Medicines as a Listing Unit in the Ministry of Health.
Programmes Chronic Disease Management Programme (CDMP) and vaccinations (Oct 2006) Health Promotion Programmes: BreastScreen Singapore, Cervical Screening Singapore, Childhood Injury Prevention Programme, Community Health Screening, Mental Health Education Programme, National Myopia Prevention Programme, Physical Activity programme, Mental Health Education Programme, National Smoking Control Programme, Nutrition Programme, Osteoporosis Education Programme, Workplace Health Promotion Programme. National AIDS Control Programme (since 1985) National Childhood Immunization Programme (NCIP) Singapore Tuberculosis Elimination Programme (STEP) (1997)
Important Acts Human Organ Transplant Act (Hota) On 6 January 2004, the Human Organ Transplant (Amendment) Bill was passed by Parliament which extending HOTA beyond kidney to include liver, heart and cornea. Advance Medical Directive (AMD)- It’s a legal document that one sign in advance to inform the doctor to not to use any life sustaining treatment to prolong the life in case of an event of one becoming terminally ill and unconscious or imminent death. To ensure that terminal patients die with dignity and to cater to the medical demands of its ageing population the ministry is planning to increase the number of hospice beds by about 20% over the next five to seven years.
National Health Plan ‘83’Government was prompt enough to think about solving the problem before it arrived which lead to National Health Plan 1983, detailing health infrastructure planned for the next 20 yrsObjectives of the NHP were to secure a healthy, fit and productive population through active disease prevention and promotion of healthy lifestyles to improve cost-efficiency in the health care system. meet the growing demand of a rapidly aging population for increased health care. Under this plan, the Medisave scheme was introduced in 1984 to meet rising medical expenditure. The Medisave account allows members to withdraw funds from their accounts in the Central Provident Fund (CPF) to pay for hospital services, within certain limits, of themselves and their immediate family members.
Singapore Health system Financing By-Dr.Gitesh H Shelar
HEALTH CARE FINANCING IN SINGAPORE Prior to the reform in the 1980s medical services generally were provided free or at a nominal charge through public facilities which were financed through general taxation. In 1981 Ministry of Health announced ‘a cradle to grave health system’ like those of British NHS. Included two major changes such as a)shifting of financial burden of health care from government to individual and employer. b)Corporatization of Government Hospital.
HEALTHCARE DELIVERY SYSTEM Singapore has a dual health care delivery system. Financing Primary health care. Hospital care Long term care. Dental services. Pharmaceutical.
FINANCING HEALTH CARE SYSTEMBASICALLY THE HEALTH CARE IS FINANCED BY FOUR PAYERS- The individual The employer The insurer The governmentFinancing of healthcare is mainly divided in to Public financing including Taxation and Medifund Private financing including the government-administered schemes, Medisave and Medishield, private medical insurance and savings.
Public health financing- Taxation-Personal income tax ranging from2% to 28% is levied on residents of Singapore at progressive rates on the previous year’s income. Companies are taxed on adjusted net profits less capital allowances. The corporate income tax rate is 26%. In 1995, tax revenue amounted to S$19.6 billion. Provides fund for subsidising and promoting health care services.MediFund-It’s a endowment fund set up by the government in April 1993. Medifund started with an initial endowment of S$200 million from the government in 1993 which has increased to S$600 million in 1998. Since its inception 99% of the applicants were given financial assistance.
Medisave Introduced in 1984 as an extension of CPF(1955) Medisave allows Singaporeans to put aside part of their income into an account to meet future personal or immediate family’s hospitalisation, day surgery or certain outpatient expenses. Under Medisave, between 6 and 8 per cent - according to age of every members CPF account, subject to a ceiling of Sin $16000. From 1 March 2010 Singapore residents can use the medisave account to pay for overseas hospitalisations. Amount with drawn from Medisave accounts- 2008-SGD 590mn 2oo9-SGD 660mn.
For the year 2006, the salary ceiling for the Central Provident Fund contribution is S$4,500/month. Additional Medisave Contribution Scheme made by the employer as an incentive to employee which is limited to S$1,500per employee/peryear. For all self-employed persons who earn more than s$6,000 are required to contribute. Accumulated savings in a Medisave Account are subjected to a Medisave Contribution Ceiling . The Medisave Contribution Ceiling for 2006 is S$32,500. Medisave Account savings that exceeds S$27,500 can only be withdrawn. If the Medisave A/C Balance is lower than required amount (S$8,300)then amount from other two sub-account is transfered
Starting from 1 March 2010 the Ministry Of Health announced that the Singapore residents will be allowed to utilise National Medical saving scheme or Medisave for overseas hospitalisation and day surgeries at hospital in Malaysia. This scheme has been initiated with two providers-1. Health Management International (HMI)2. Parkway Holdings Boost to the Palliative care with the Health Ministry’s decision to liberalise the use of Medisave for home palliative care in September 2009. Some SGD500mn (US$347mn) is to be spent on elderly care, with a focus on home care, rehabilitation and palliative services.
Marriage and Parenthood Schemes Medisave Maternity Package provides for the delivery and pre-delivery medical expenses of your first four children. For normal delivery withdrawal upto SGD 2,100 for Non- Medisave Maternity Package while for Medisave Maternity package SGD 450 more will be alloted. Claim only upto the mentioned amount will be provided for maternity expenses.
Interim Disability Assistance Programme forthe Elderly(IDAPE) Provides financial help to needy and disabled elderly Singaporeans, who are not eligible for ElderShield because of their age or pre-existing disabilities. IDAPE provides with $100 or $150 a month, for a maximum period of 72 months.Eligibility- If one is unable to perform 3 or more of the 6 Activities of Daily Living (ADLs; washing, feeding, dressing, toileting, mobility and transferring). If one is aged 70 and above as at 30 September 2002. If you are aged 40 to 69 years as at 30 September 2002, your disability must occur before 30 September 2002. If one’s per capita monthly household income is less than $1000.
Payment schedule for IDAPEPer capita monthly household Monthly payout income * $700 and below $150 $701 - $1,000 $100 Above $1,000 Not eligible for IDAPE payout
Primary Care Partnership To provide convenient and affordable healthcare for needy elderly and disabled Singaporeans, the Ministry of Health (MOH) started the Primary Care Partnership Scheme (PCPS). In this scheme needy patients can receive subsidised treatment at General Practitioners (GPs) and dental clinics near their homes. To provide common outpatient medical treatments and basic dental services for this group of patients The scheme will also cover treatment for 3 chronic diseases: Diabetes Mellitus (DM), Hypertension (High blood pressure) and Lipid Disorders (e.g. High cholesterol).
INTERMEDIATE AND LONG-TERMCARE (ILTC) After the patients are well enough to be discharged from the hospital but due to their medical condition may require further care and treatment at centres. Such care is provided through ILTC. Refers to services such asi. Community Hospitalsii. Chronic Sick Facilitiesiii. Nursing Homesiv. Hospicesv. Day Rehabilitation Centresvi. Home care services such as home nursing and home medical. Realizing the fact that the cost of such care will be higher as they require care for longer period of time hence the government subsidizes such care to those who need it.
Health insurance plans Health insurance plans approved by either the Central Provident Fund Board or the government serve the function of pooling health care resources which include- (a) Medisave-approved health insurance schemes; and (b) employer-sponsored schemes. Medisave approved insurance schemes consists of MediShield, Integrated MediShield (which includes IncomeShield) and ElderShield
MEDISHIELD Is a voluntary low-cost catastrophic medical insurance scheme launched in 1990. It covers hospitalization expenses for major or prolonged illness according to the extent of limit chosen. Element deductible and co-insurance (20 per cent)present along with upper age limit of 70 years for participation. At the end of 1995, Medishield covered 1.5 million lives or 87 per cent of eligible CPF members as well as a quarter million of their dependants.In an Integrated Medishield Scheme additional benefits are coupled with the benefits by charging an additional fee paid to the insurance company by the consumer In 2005, there were five health insurance companies in Singapore providing 15 integrated MediShield insurance products
ELDERSHIELD Is a severe disability insurance scheme for those who need long-term care, especially during old age. Provides a monthly cash payout to help pay out-of pocket expenses for the care of a severely disabled person. Till 2007, the market was controlled by just two local providers – 1)Great Eastern Life Assurance 2)NTUC Income Insurance CooperativeAviva now is also present. From September 2007, the disability insurance scheme was introduced in two tiers – Basic ElderShield and ElderShield Supplements
Employer-sponsored schemes The Manpower Ministry announced in September 2007 that from early 2008 employers must provide insurance for all those on a work permit or an S pass (i.e. overseas employees). Employers are encouraged to provide employees with medical benefits by tax incentives. This schemes include Portable Medical Benefits Scheme or the Transferable Medical Insurance Scheme The Portable Medical Benefits Scheme is an institutionalized scheme. Involves Employers making monthly contributions to employees’ Medisave Accounts which is limited to S$1,500 per employee per year. The Transferable Medical Insurance Scheme is an employer-sponsored group insurance plan. At present, 19 health insurance companies provide transferable medical insurance products. Provides coverage for 12 months even if the employee leaves the job for whatever reason.
Patient safety and EMR Being committed to patient safety Singapore introduced a project to document the prevalence of medical errors in 2003 which documented 1000 death annually due to inappropriate use of pharmaceuticals and medical devices. Accordingly, the government started making electronic medical records (EMRs) compulsory. Nine polyclinics affiliated with the National Healthcare Group (NHG) started to use the scheme in October 2009 and now is slated out for the remainder. The creation of the new electronic records system is supported by the investment of around SGD200mn (US$139mn).
Health Promotion Board Established in 2001, the Health Promotion Board (HPB) has a vision to build a nation of healthy and happy people. Main driver for national health promotion and disease prevention programmes. Goal is to increase the quality and years of healthy life and prevent illness, disability and premature death. About 36 programmes are listed in HPB-A few of them worth mentioning are- Adult Oral Health Promotion Programme , AIDS Education Programme, BreastScreen Singapore, Healthy Eating in Schools Programme, National Brisk Walking Programme, Nurture Your Mind For Older Persons (NYMOP), Physical Activity Programmes Schedule, RESPECT and STI/AIDS Prevention Programmes for Youths
Health expenditure analysis Total health care expenditure in Singapore in 1995 reached S$3,545 million in 1995. It represented nearly 42 times(S$85million) that in 1960 and 2.7(S$1312) times that in 1986 . GDP fluctuated at around 3% to 4% since 1960. Health care expenditure per person has increased more than two times between 1986 (S$524.8) and 1995 (S$1,181.7).
WHO Health System Rank 6th in the world The story behind the scenes….
Political Political Stability since 1965( PAP)Effectiveness of policy of delivery mechanism of public services and no disruption of policy implementation. Singapore enjoys a very stable political system Strong foundation with regulation and guidelines ( Intellectual and property rights) Official promises have been made to eradicate Singapore’s reputation as an overprotective nanny-state, with efforts to enhance freedom of expression. Strong relationship between the public and the govt that help overcome barrier in the process of building , maintaining and developing the nation.
Economic Strong market foundations consistent growth Imports most of resources and largely export dependent Other weaknesses are the public feelings of insecurity and concern about making mistakes and being fined The SARS outbreak in 2003 The war in Iraq in 2002 long-term economic problems. Competition from low-cost neighbouring countries is on the increase and its population is ageing rapidly. In the face of regional competition for both exports and investment, the government is encouraging economic diversification to boost competitiveness. New areas being promoted include biomedical sciences, medical and financial services, and tourism.
Social Ethnic diversity of Chinese, Malaysians and Indians. Worlds cleanest city and the least corrupt city HDI 27th rank in the world The worlds only slum free city 100% Urban population The social strengths of Singapore have been demonstrated by an educational system that produces a well-educated workforce . Not only developing its own pool of local talents, Singapore also recruits foreign talents to work in both the public and private sectors.
Technology Technologically, Singapore has a high-tech based economy. Well-prepared infrastructure and the latest technology contribute to the rapid development. IT literate and English Proficient Nationwide electronic Citizen (e-Citizen) programme. The Ministry of Health website Opening up of the market. Personal Health Records and Electronic Medical Records.
Strengths Individual Responsibility Political will 3 M Medical Savings Account stable government and economy. availability of skilled medical professional latest medical technology. E Health In terms of accessibility, location and air links Strengths Strong intellectual property (IP) protection laws. Favourable tax climate for foreign investment. World-class capabilities across the entire value chain, (research to support services). Well-established research infrastructure backed by strong supporting industries. Singapore is the least corrupt country in Asia,(Transparency International)
Weakness Ageing Population “silver industry” Hospital based Health Care system Resource poor Shortage of health care professionals Small population size, which limits longer-term market potential. The Singapore government censors the media and limits the distribution of foreign publications. The judiciary’s record of siding with prominent politicians calls into question the true extent of its neutrality in any contract dispute involving a politically sensitive issue
Opportunities Medical tourism Government focused on developing Singapore into a hub for pharmaceuticals Medical devices, clinical trials and biotechnology, attracting both foreign investment and patients. There is currently a government-inspired push to go regional, strengthening Singapores position as a hub of medical excellence in SE Asia. ASEAN Countries Trade policies Also planned is the creation of a multi million-dollar medical services park, to be co-located with a tertiary hospital.
Threats Changing Disease Profiles Costs via high technology and high standards Rising AIDS,TB Lifestyle related Diseases There are fears that Singapore’s foreign policy alignment with the US will cause the city-state to become a target for terror attacks launched by Muslim extremists. Terorism
Challenges The number of seniors will increase from 8.4% in 2005 to 18.7% in 2030. In absolute terms, seniors will increase from about 296,900 in June 2005 to 873,300 in 2030 Healthier. In terms of mobility, about 87% of seniors are ambulant and physically independent. They will also be living longer Better educated. The proportion of seniors aged 65 – 74 with at least a secondary education is projected to increase from 13.9% in 2005 to 28% by 2010 and to 63% by 2030. Richer. Each successive cohort of older people will be increasingly affluent and wield greater economic power. As consumers, they represent a potentially large and untapped market sector.
Challenges Cont. Cost containment vis-a-vis a rapidly ageing population: increasing health care costs due to advances in medical specialisation as well as the use of expensive medical technologies. Quality of care, while medical audit and quality assurance are currently still relatively underdeveloped Medical manpower planning: especially in nursing home nursing and ancillary health personnel. Harnessing information technology: Singapore is working towards a National Health Information System that will allow the seamless flow of information, such as electronic medical records, across all health care establishments; Increased demand and expectations from the more affluent and educated population. Diseases that are lifestyle-related. Westerners. HIV-infected people are very often considered as isolated cases who have been exposed ‘to foreigners.
What Do the people of Singapore feel about their healthcare system??
Public Perceptions of Healthcare inSingapore: Case Study (August 2006) Jeremy FY Lim, Veena Dhanajay Joshi, conducted a survey of Singapore residents to determine perceptions of the affordability and quality of healthcare in Singapore. A sampling frame comprising 6146 random telephone numbers from the 2005/2006 of the Singapore telephone directory was generated. Trained interviewers then conducted the survey via telephone using a questionnaire that was purpose designed for this survey. Respondents were asked to rank their agreement with statements pertaining to healthcare cost and quality on a 5-point Likert scale. There were 1783 respondents to the survey.
Key components of a well functioning health system ----WHO Leadership and Governance Health financing Human resources for health Essential medical products and technologies Service delivery Health information systems
Leadership and Governance Ensuring that health authorities take responsibility for steering the entire health system (including the private sector) Set clear direction through transparent and inclusive process of -- -- planning and strategy -- accountability -- monitoring and evaluation
Health Financing A system to raise sufficient funds for health fairly A system to pool financial resources Ensure efficient use of funds
…Health Financing ctd… Fairness Pooling Efficient utilisationFrance …yes… …yes… Yes /noGermany Yes Yes YesUK Yes /no Yes Yes/ noUS No Yes NoSingapore Yes Yes / no Yes
Human Resources for Health Arrangements for achieving sufficient health professionals in right mix Ensure system wide deployment and distribution according to needs
…Human Resources for Health ctd… Sufficient no. Right mix Efficient deploymentFrance Yes Yes ?YesGermany Yes Yes ?YesUK No Yes YesUS Yes Yes NoSingapore No Yes No
Essential Medical Products andTechnology Medical products regulatory system (marketing, safety, quality, etc) National list of essential medical products Availability and price monitoring system A national programme to promote rational prescribing
…Essential Medical Products and Technology ctd… Regulatory List of Monitoring of Programme system essential availability for rational medical and price prescription productsFrance Yes Yes Yes YesGermany Yes Yes Yes YesUK Yes Yes Yes YesUS Yes Yes Yes YesSingapore Partly yes Yes Yes Partly yes
Service Delivery Network of close-to-client primary care and back-up of specialized care Standard norms and guidelines to ensure access, quality, safety and people-centeredness Mechanisms to hold providers accountable for access and quality, and to ensure consumer voice
…Service Delivery ctd… Close-to-pt Norms to People Accountability primary care ensure centeredness of providers access/quality /safetyFrance Yes Yes Yes /no YesGermany Yes Yes Yes /no YesUK Yes Yes Yes / no YesUS Yes Yes / no …Yes… Yes / noSingapore Yes Yes Yes / recently ? Yes
Health Information System Health information system Health management information system
…Health Information System ctd… HMS HMISFrance Yes and developing YesGermany Yes and developing YesUK Yes and developing YesUS Yes YesSingapore Yes and developing Yes
Health IndicatorsCountry Life expectancy in yrs HALE in yrs (m/f/both) (m/f/both)France 78/85/81 71/76/73Germany 77/83/80 71/75/73UK 78/82/80 71/73/72US 76/81/78 68/72/70Singapore 79/83/81 71/75/73