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.
