Lessons
from Singapore
Vanam
Jwala Narasimha Rao
Express
Healthcare magazine
(8th December 2015)
Contrary
to Indian situation, 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 in most of the states the
specialties and super specialties healthcare is available in private sector only
or mainly and the entire primary care is done by government. Another problem in
India in general and particularly to the middle class people is the huge costs
for diagnostic services which are provided mainly by private centers. For
instance a PET (Positron Emission Tomography) Scan costs anywhere around
Rs. 20, 000 and an MRI (Magnetic resonance imaging) costs around Rs. 10, 000 and many more like that.
These need to be provided by Government at affordable costs. It is also
desirable that the government establishes its own polyclinics and also takes the help of private
clinics enabling the patient 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 population the primary
healthcare, hospital care, long-term care and other integrated care. The City
State has a network of outpatient polyclinics and private medical
practitioner's 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. 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. The early primary health care in Singapore
commenced with a Government promoted National Health Plan in 1983. The plan is
being up-dated 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 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. 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% 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
introduced in April 1984 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. The vast majority of Singapore citizens have substantial savings in
this scheme.
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% of Singaporeans obtain their medical care within the public health
system.
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 centralized location.
SingHealth is Singapore's largest group of healthcare institutions.
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. 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 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. 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.
I had an opportunity to go round the
SGH while in Singapore with Dr Anantharaman an Indian origin senior doctor
working there 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.
Probably it would be a good idea if
the system in Singapore is applied to Indian Situation and conditions. End
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