Healthcare Delivery System in Singapore: Vanam Jwala Narasimha Rao

Healthcare Delivery System in Singapore

Vanam Jwala Narasimha Rao

Singapore’s healthcare delivery system provides population the primary healthcare, hospital care, long-term care and other integrated care according to Dr. V. Anantharaman, Professor-Senior Consultant at Singapore General Hospital working in the area of emergency medicine. Having known Dr. Anantharaman as a visiting professor to Emergency Management and Research Institute (EMRI-108) when I was working there, I thought of meeting him, while I am in Singapore. I had a two hour interaction with him on the healthcare delivery system in Singapore. According to Dr Anantharaman, Singapore has a network of outpatient polyclinics and private medical practitioner's clinics to provide primary medical treatments, preventive healthcare as well as health education. Dr Anantharaman explained in detail on the overall healthcare delivery system.

Contrary to Indian situation in general and Andhra Pradesh in particular, in Singapore, eighty percent of primary healthcare services are offered by 2000 private medical clinics; whereas the remaining is delivered by 18 government polyclinics. In India and AP it is otherwise, where most of the specialties’ and super specialties’ healthcare is available in private sector and the entire primary care is done by government. In Singapore, Hospital care consists of inpatient, outpatient and emergency services. By contrast to primary healthcare, public hospitals provide 80% of hospital care including specialty treatment. Even in the bed strength, government hospitals account for 80%, where as private hospitals remaining 20%. The percentage of registered doctors (excluding specialists) and in the public institutions is about 80 and that of private sector is a mere 20.  

 Dr. V. Anantharaman, Professor-Senior Consultant 

at Singapore General Hospital

Singapore is an island country with population of 5.2 million, 704 kilometers squared, making it one of the very few remaining city-states around the world. It has one of the highest medical standards across Asia. It is well-known for its efficient and widely covered healthcare system. The early primary health care, after Singapore’s independence in 1965, started with a mass-immunization program against severe tropical epidemic diseases.  To foresee and avoid the future problems, Government promoted a National Health Plan in 1983. It detailed the infrastructural plan for the next 20 years together with the idea of Medisave. The plan is being up-dated from time to time to suit the needs.

            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 is composed of thirteen private hospitals, ten government hospitals and a number of specialist clinics, each one specializing 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. For emergency services, patients can go at any time to the 24-hour Accident and Emergency Departments located in the government hospitals. 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. Singapore was ranked 6th in the World Health Organization's ranking of the world's health systems as early as in the year 2000 itself. Singapore currently has the lowest infant mortality rate in the world and among the highest life expectancies from birth, according to the World Health Organization.

Singapore General Hospital

 

            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% 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 nationalized health insurance plan known as Medisave. 

Medisave was introduced in April 1984 as a national medical savings account system for Singaporeans. The system allows Singaporeans to put aside part of their income into a Medisave account to meet future personal or immediate family's hospitalization, day surgery and for certain outpatient expenses. Under this system, Singaporean employees contribute 6.5-9.0% (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. Incidentally, the unemployment rate in Singapore is as low as less than 2 percent. In other words almost all the citizens can afford savings from their earnings. Within Medisave, each citizen accumulates funds that are individually tracked, and such funds can be pooled within and across an entire extended family. The vast majority of Singapore citizens have substantial savings in this scheme. One of three levels of subsidy is chosen by the patient at the time of the healthcare episode.

            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 says Dr Anantharaman. 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. When asked as to what is the percentage of defaulters Dr Anantharaman replied that less than one and majority of them are foreigners. According to him, this mechanism is intended to reduce the overutilization of healthcare services, a phenomenon often seen in fully subsidized universal health insurance systems. Out-of-pocket charges vary considerably for each service and level of subsidy. At the highest level of subsidy, although each out-of-pocket expense is typically small, costs can accumulate and become substantial for patients and families. At the lowest level, the subsidy is in effect nonexistent, and patients are treated like private patients, even within the public system. The increasingly large private sector provides care to those who are privately insured, foreign patients, or public patients who are able to afford what often amount to very large out-of-pocket payments above the levels provided by government subsidies. Approximately 70-80% of Singaporeans obtain their medical care within the public health system.

            The Singapore General Hospital (SGH) is the largest and oldest 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 centralized location. SingHealth is Singapore's largest group of healthcare institutions. The group was formed in 2000 and consists of two public hospitals across the island, five specialist centers and a network of nine polyclinics. The group operates Singapore General Hospital and KK Women's and Children's Hospital. The group runs five specialist centers which include National Cancer Centre Singapore, National Heart Centre Singapore, Singapore National Eye Centre, National Dental Centre of Singapore and the National Neuroscience Institute.

At SGH, patients have access to over 600 doctors from 29 clinical specialties. 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 Singapore General Hospital 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. Patients will also be advised on estimated bill size, average length of stay, various modes of payment accepted, documents to bring on day of admission and assistance available for those in financial difficulties. 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. 

A unique feature of Singapore healthcare is that, patients who seek medical treatment at any Public Health-Care Institution, from hospitals to specialist centers and polyclinics need not recount their medical history to the doctors. This information is captured in a centralized database known as National Electronic Health Records System. With all public healthcare institutions using this system, medical details of patients who shuttle between these centers are polled in to one document for healthcare workers to access. With this set-up, patients can look forward to fewer duplicate tests and repeat treatments saving them time and money.

In the Emergency Department, priority is to attend to patients with serious illnesses and injuries. 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. Hospital staff will advise the patient appropriate area to go to for consultation and treatment. There are separate waiting areas for patients with different priority levels. The four different levels of priority are: Resuscitation and Critically-ill Patients, Major Emergencies, Minor Emergencies and Non-Emergency. Patients with fever will be managed in a separate area in the Emergency Department. This is to reduce the risk of infection to the other patients in the Emergency Department.

         In Singapore, the Emergency Ambulance Service (EAS) is operated by the Singapore Civil Defense Force (SCDF) and it can be reached by dialing 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. An emergency ambulance service is required when an illness or injury could end in death or serious complication if it is not treated immediately. 995 ambulance services are free only if it is a true emergency.  However, if a case attended to by the SCDF is deemed to be a non-emergency by its paramedics, or the doctor at the Emergency Department of the receiving hospital, the patient will have to pay an ambulance fee of $180. SCDF emergency ambulances will only convey patients to the nearest designated restructured hospitals so that the patients can receive immediate medical attention.  This will also enable the ambulance to be available earlier for the next emergency call. In all there are 40 ambulances parked in 14 ambulance stations providing this service. 

            I went round the SGH with Dr Anantharaman and found every part of it being maintained with highest standards. Outpatient wards, either in the look or in the management is hundred times better than even the best of the maintained private hospital in India. Emergency admissions are round the clock though the outpatient admissions are time bound.