A comprehensive Report about one of the best healthcare system in the world. This report has taken a detailed view of the healthcare system in Singapore.

1. By
•Dr Satish Tajne
•Dr Geetesh Shelar
•Dr Rohit Nair
•Dr Shekhar Gaddam

3. Introduction
x Singapore is a small country with a total land area of 710 square
kilometres.
x Obtained independence from Malaysia on 9 August 1965.
x Singapore is a parliamentary republic.
x Singapore is characterized by a highly developed and successful free-market
economy.
x It has a very open and corruption-free business environment.
x The Singapore economy grew by 8% in 2009 and it is projected to
grow by 15% in 2010.
x Per capita gross domestic product amounted to US$ 39,951 in 2008.
x Literacy rate : 96.3%

4. THE HEALTH CARE SYSTEM IN SINGAPORE
x 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 down
3. Personal responsibility for one’s health.
Emphasis on – a)Health education
b)Immunization
c)Health screening for early detection of diseases.

5. Ministry of Health-
Overall responsibility for the provision and regulation of health care services in
Singapore.

6. HEALTHCARE DELIVERY SYSTEM
Singapore has a dual health care delivery system.
x Primary health care-x
80%provided by private practitioners
x 20% government polyclinics
Includes –
x curative out-patient medical treatment
x health screening
x preventive health programmes for school children,
x home nursing
x day care and rehabilitation for the elderly
x health education and promotion.
x Hospital Care-x
80% by public sector
x 20% by Private sector

8. PUBLIC HEALTH
EXPENDITURE

9. Health Indicators
x The crude birth rate
x
x
x
9.9
4.4
1.3
0
3
x
per 1000 resident population.
The crude death rate
per 1000 resident population.
The total fertility rate per resident female
MMR
Under 5mortality Rate

11. Demography
Population of Singapore = 4.9 millian (2009)
% of Total Population
Chinese 74.2%
Malaysian
13.4%
Indian
9.2%
Others
3.2%

12. Burden of disease

13. Principal Causes of Death

14. TOP 5 CONDITIONS OF HOSPITALISATION

16. PREVENTIVE HEALTH
SERVICES

17. NUMBER AND PERCENTAGE OF BEDS IN PUBLIC AND PRIVATE
HOSPITAL
NUMBER OF BEDS
PUBLIC HOSPITALS
PERCENTAGE(%)
9091
2185
80.6
PRIVATE HOSPITALS 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%

18. Human resources for health

19. x Singapore's only Western-style Medical School, established in
1905 trains 150 doc/yr
Reason for growth in specialization -
Push FOR growth by forming
x Committee for Postgraduate Medical Education in 1970
x Up-gradation of hospitals with sophisticated technology.
x Sending doctors to higher medical centers in world for training

23. Traditional medicine.
x 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.
x Registration with the self regulatory body.
x Establishment of a Chinese Proprietary Medicines as a
Listing Unit in the Ministry of Health.

24. Programmes
x Chronic Disease Management Programme (CDMP) and
vaccinations (Oct 2006)
x 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.
x National AIDS Control Programme (since 1985)
x National Childhood Immunization Programme (NCIP)
x Singapore Tuberculosis Elimination Programme (STEP) (1997)

25. Important Acts
x 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.
x 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.

26. 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 yrs
Objectives of the NHP were
x to secure a healthy, fit and productive population through active disease
prevention and promotion of healthy lifestyles
x to improve cost-efficiency in the health care system.
x meet the growing demand of a rapidly aging population for increased health
care.
x 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.

27. Singapore Health system
Financing
By-Dr.Gitesh H Shelar

28. HEALTH CARE FINANCING IN SINGAPORE
x 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.
x 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.

29. HEALTHCARE DELIVERY SYSTEM
x Singapore has a dual health care delivery system.
Financing
x Primary health care.
x Hospital care
x Long term care.
x Dental services.
x Pharmaceutical.

30. FINANCING HEALTH CARE SYSTEM
BASICALLY THE HEALTH CARE IS FINANCED BY FOUR PAYERS-x
The individual
x The employer
x The insurer
x The government
Financing of healthcare is mainly divided in to
x Public financing including Taxation and Medifund
x Private financing including the government-administered schemes,
Medisave and Medishield, private medical insurance and savings.

32. Public health financing-x
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.
x Medifund started with an initial endowment of S$200 million from
the government in 1993 which has increased to S$600 million in 1998.
x Since its inception 99% of the applicants were given financial
assistance.

33. Medisave
x 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.
x Under Medisave, between 6 and 8 per cent - according to age of every
member's CPF account, subject to a ceiling of Sin $16000.
x From 1 March 2010 Singapore residents can use the medisave account to
pay for overseas hospitalisations.
x Amount with drawn from Medisave accounts-
2008-SGD 590mn
2oo9-SGD 660mn.

34. x For the year 2006, the salary ceiling for the Central Provident Fund
contribution is S$4,500/month.
x Additional Medisave Contribution Scheme made by the employer as an
incentive to employee which is limited to S$1,500per employee/peryear.
x For all self-employed persons who earn more than s$6,000 are required to
contribute.
x Accumulated savings in a Medisave Account are subjected to a Medisave
Contribution Ceiling . The Medisave Contribution Ceiling for 2006 is
S$32,500.
x Medisave Account savings that exceeds S$27,500 can only be withdrawn.
x If the Medisave A/C Balance is lower than required amount (S$8,300)then
amount from other two sub-account is transfered

35. x 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.
x This scheme has been initiated with two providers-
1. Health Management International (HMI)
2. Parkway Holdings
x Boost to the Palliative care with the Health Ministry’s decision to liberalise
the use of Medisave for home palliative care in September 2009.
x Some SGD500mn (US$347mn) is to be spent on elderly care, with a focus
on home care, rehabilitation and palliative services.

36. Marriage and Parenthood Schemes
x Medisave Maternity Package provides for the delivery and
pre-delivery medical expenses of your first four children.
x For normal delivery withdrawal upto SGD 2,100 for Non-
Medisave Maternity Package while for Medisave Maternity
package SGD 450 more will be alloted.
x Claim only upto the mentioned amount will be provided for
maternity expenses.

37. Interim Disability Assistance Programme for
the Elderly(IDAPE)
x Provides financial help to needy and disabled elderly
Singaporeans, who are not eligible for ElderShield because
of their age or pre-existing disabilities.
x IDAPE provides with $100 or $150 a month, for a maximum
period of 72 months.
Eligibility-x
If one is unable to perform 3 or more of the 6 Activities of Daily Living
(ADLs; washing, feeding, dressing, toileting, mobility and
transferring).
x 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.
x If one’s per capita monthly household income is less than $1000.

38. Payment schedule for IDAPE
Per capita monthly household
income *
$700 and below
Monthly payout
$150
$701 - $1,000 $100
Above $1,000 Not eligible for IDAPE payout

39. Primary Care Partnership
x To provide convenient and affordable healthcare for needy
elderly and disabled Singaporeans, the Ministry of Health
(MOH) started the Primary Care Partnership Scheme (PCPS).
x In this scheme needy patients can receive subsidised treatment at
General Practitioners (GPs) and dental clinics near their homes.
x To provide common outpatient medical treatments and basic
dental services for this group of patients
x The scheme will also cover treatment for 3 chronic diseases:
Diabetes Mellitus (DM), Hypertension (High blood pressure)
and Lipid Disorders (e.g. High cholesterol).

40. INTERMEDIATE AND LONG-TERM
CARE (ILTC)
x 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 as
Community Hospitals
Chronic Sick Facilities
Nursing Homes
Hospices
Day Rehabilitation Centres
Home care services such as home nursing and home medical.
i.
ii.
iii.
iv.
v.
vi.
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.

42. Health insurance plans
x Health insurance plans approved by either the Central Provident Fund
Board or the government serve the function of pooling health care
resources which include-x
(a) Medisave-approved health insurance schemes; and
x (b) employer-sponsored schemes.
x Medisave approved insurance schemes consists of MediShield,
Integrated MediShield (which includes IncomeShield) and ElderShield

43. MEDISHIELD
x Is a voluntary low-cost catastrophic medical insurance scheme
launched in 1990.
x It covers hospitalization expenses for major or prolonged illness
according to the extent of limit chosen.
x Element deductible and co-insurance (20 per cent)present along with
upper age limit of 70 years for participation.
x 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
x In 2005, there were five health insurance companies in Singapore
providing 15 integrated MediShield insurance products

44. ELDERSHIELD
x Is a severe disability insurance scheme for those who need
long-term care, especially during old age.
x Provides a monthly cash payout to help pay out-of pocket
expenses for the care of a severely disabled person.
x Till 2007, the market was controlled by just two local
providers –
1)Great Eastern Life Assurance
2)NTUC Income Insurance Cooperative
Aviva now is also present.
x From September 2007, the disability insurance scheme was
introduced in two tiers – Basic ElderShield and ElderShield
Supplements

45. Employer-sponsored schemes
x 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).
x Employers are encouraged to provide employees with medical benefits by tax
incentives.
x This schemes include Portable Medical Benefits Scheme or the Transferable
Medical Insurance Scheme
x The Portable Medical Benefits Scheme is an institutionalized scheme.
x Involves Employers making monthly contributions to employees’ Medisave
Accounts which is limited to S$1,500 per employee per year.
x 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.

46. Patient safety and EMR
x 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.
x Accordingly, the government started making electronic medical records
(EMRs) compulsory.
x 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.
x The creation of the new electronic records system is supported by the
investment of around SGD200mn (US$139mn).

47. Health Promotion Board
x Established in 2001, the Health Promotion Board (HPB) has a
vision to build a nation of healthy and happy people.
x Main driver for national health promotion and disease prevention
programmes.
x Goal is to increase the quality and years of healthy life and
prevent illness, disability and premature death.
x 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

48. Health expenditure analysis
x 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 .
x GDP fluctuated at around 3% to 4% since 1960.
x Health care expenditure per person has increased more than two times between
1986 (S$524.8) and 1995 (S$1,181.7).

49. Health expenditure Pattern

50. Share of Financial responsibilty

54. Analysis
Dr Rohit Nair

55. x WHO Health System Rank 6th in the world
The story behind the scenes….

57. Political
x 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
x Strong foundation with regulation and guidelines
( Intellectual and property rights)
x Official promises have been made to eradicate Singapore’s
reputation as an overprotective nanny-state, with efforts to
enhance freedom of expression.
x Strong relationship between the public and the govt that help
overcome barrier in the process of building , maintaining and
developing the nation.

58. Economic
x Strong market foundations consistent growth
x Imports most of resources and largely export dependent
x Other weaknesses are the public feelings of insecurity and concern
xxx
x
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.

59. Social
x Ethnic diversity of Chinese, Malaysians and Indians.
x Worlds cleanest city and the least corrupt city
x HDI 27th rank in the world
x The worlds only slum free city
x 100% Urban population
x The social strengths of Singapore have been demonstrated by
an educational system that produces a well-educated
workforce .
x Not only developing its own pool of local talents, Singapore
also recruits foreign talents to work in both the public and
private sectors.

60. Technology
x Technologically, Singapore has a high-tech based economy.
x
x
x
x
x
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.

61. S.W.O.T

62. 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).
x Well-established research infrastructure backed by strong supporting
industries.
x Singapore is the least corrupt country in Asia,(Transparency International)
xxxxxxxxxxx
Strengths

63. Weakness
x Ageing Population “silver industry”
x Hospital based Health Care system
x Resource poor
x Shortage of health care professionals
x Small population size, which limits longer-term
market potential.
x 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

64. Opportunities
x Medical tourism
x Government focused on developing Singapore into a hub
x
x
x
x
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 Singapore's 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.

65. Threats
x Changing Disease Profiles
x Costs via high technology and high standards
x Rising AIDS,TB
x Lifestyle related Diseases
x 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

66. Challenges
x 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
x Healthier. In terms of mobility, about 87% of seniors are
ambulant and physically independent. They will also be living
longer
x 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.
x 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.

67. Challenges Cont.
x Cost containment vis-a-vis a rapidly ageing population: increasing
x
x
x
x
x
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.

68. x What Do the people of Singapore feel about their healthcare
system??

69. Public Perceptions of Healthcare in
Singapore: Case Study (August 2006)
x
x
x
x
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.
x There were 1783 respondents to the survey.

70. Result Of the Study

71. Result Continue..

72. x Conclusion: Singaporeans are confident in the Singapore healthcare system and sentiments appear to be
more positive when compared to other countries.

73. The future

74. The future

75. Comparative Analysis
Dr. Shekhar S. Gaddam

76. Key components of a well functioning health
system ----WHO
x Leadership and Governance
x Health financing
x Human resources for health
x Essential medical products and technologies
x Service delivery
x Health information systems

77. Leadership and Governance
x Ensuring that health authorities take responsibility for
steering the entire health system (including the private sector)
x Set clear direction through transparent and inclusive process of
--
-- planning and strategy
-- accountability
-- monitoring and evaluation

78. …Leadership and Governance ctd…
Responsibility
/ governance
Planning &
strategy
Monitoring &
evaluation
Accountability
France
Germany
UK
US
Singapore
No
…yes…
yes
…yes…
yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
…yes…
Yes

79. Health Financing
x A system to raise sufficient funds for health fairly
x A system to pool financial resources
x Ensure efficient use of funds

80. …Health Financing ctd…
Fairness
France
Germany
UK
US
Singapore
Pooling
…yes…
Yes
Yes
Yes
Yes / no
Efficient utilisation
Yes /no
Yes
Yes/ no
No
Yes
…yes…
Yes
Yes /no
No
Yes

81. Human Resources for Health
x Arrangements for achieving sufficient health professionals in
right mix
x Ensure system wide deployment and distribution according to
needs

82. …Human Resources for Health ctd…
Sufficient no. Right mix Efficient
deployment
?Yes
?Yes
France
Germany
Yes
Yes
Yes
Yes
UK
US
Singapore
No
Yes
No
Yes
Yes
Yes
Yes
No
No

83. Essential Medical Products and
Technology
x Medical products regulatory system (marketing, safety,
quality, etc)
x National list of essential medical products
x Availability and price monitoring system
x A national programme to promote rational prescribing

84. …Essential Medical Products and
Technology ctd…
Regulatory
system
List of
essential
medical
products
Yes
Yes
Yes
Yes
Yes
Monitoring of
availability
and price
Yes
Yes
Yes
Yes
Yes
Programme
for rational
prescription
Yes
Yes
Yes
Yes
Partly yes
France
Germany
UK
US
Singapore
Yes
Yes
Yes
Yes
Partly yes

85. Service Delivery
x Network of close-to-client primary care and back-up of
specialized care
x Standard norms and guidelines to ensure access, quality,
safety andpeople-centeredness
x Mechanisms to hold providers accountable for access and
quality, and to ensure consumer voice

86. …Service Delivery ctd…
Close-to-pt
primary care
Norms to
ensure
access/quality
/safety
Yes
Yes
Yes
Yes / no
Yes
People
centeredness
Accountability
of providers
France
Germany
UK
US
Singapore
Yes
Yes
Yes
Yes
Yes
Yes /no
Yes /no
Yes / no
…Yes…
Yes / recently ?
Yes
Yes
Yes
Yes / no
Yes

87. Health Information System
x Health information system
x Health management information system

88. …Health Information System ctd…
HMS
France
Germany
UK
Yes and developing
Yes and developing
Yes and developing
HMIS
Yes
Yes
Yes
US
Singapore
Yes
Yes and developing
Yes
Yes

89. Health Indicators
Country
France
Germany
UK
US
Life expectancy in yrs
(m/f/both)
78/85/81
77/83/80
78/82/80
76/81/78
HALE in yrs
(m/f/both)
71/76/73
71/75/73
71/73/72
68/72/70
Singapore 79/83/81 71/75/73

90. …Health Indicators ctd…
IMR / 1000
live births
France
Germany
3
4
Less than 5 yrs
MR / 1000
4
4
MMR / 1000
deliveries
8
6
Adult MR
(prb death 15-
49)/1000
87
78
UK
US
Singapore
5
7
2
6
8
3
7
13
8
78
107
64

91. …Health Indicators ctd…
Physicians /
10,000
France
Germany
UK
US
Specialists /
10,000
17
20.3
17.7
14.6
Nurses / 10,000 Hospital beds
/ 10,000
81
80
6
98
37
35
21
27
72
83
39
31
Singapore 17 7.8 54 32

92. Health Expenditure
Expenditure % Govt share in
of GDPexpenditure
(%)
France
Germany
UK
US
Singapore
11
10.4
8.4
15.7
3.1
79
76.9
81.7
45.5
32.6
Pvt share in
expentiture
(%)
21
23.1
18.3
54.5
67.4
Per capita
expenditre
using PPP (US$
3709
3588
2992
7285
1643

93. 1) Is AMD(Advance Medical Directive )
= EUTHANASIA
????????
2) Human Organ Transplant Act (Hota)
Can we have it in India ????????