The world’s best health care? How Singapore’s hybrid model is the envy of other countries

As governments across the world struggle to keep health care affordable in the face of runaway costs and ageing populations, Singapore, which is ranked as one of the best, offers some lessons worth considering.

Staff nurses attend to an elderly patient doing rehab excercises at the Ren Ci Community Hospital in downtown Singapore. Munshi Ahmed for The National

SINGAPORE // Two years since her husband’s death the pain remains fresh for Chen Mui Ing, who could only pray as she watched his health deteriorate during a seven-year battle with cancer.

One of the many things she worried about when she discovered her husband was seriously ill was how they were going to pay his medical bills.

“I told my children straight off, if the treatment costs us money, I will sell the house,” said the Singaporean mother of three, now 63.

As governments across the world, from Europe to America and even the UAE, struggle to keep health care affordable in the face of runaway costs and ageing populations, Singapore offers some lessons worth considering.

Unlike the private insurance-based model of the US, and far from the state-funded system of the UK, Singapore has adopted a hybrid model of health care that combines government subsidies with patient co-payments. The result is a system which ranks among the best in the world at relatively low cost to the government.

“In the immediate aftermath of the 2011 general election, I think it became very clear to the government through the electoral results ... that health care, or the affordability [of health care] was a pain point for many Singaporeans,” said Dr Jeremy Lim, a Singapore-based partner in the health and life sciences practice of global consulting firm Oliver Wyman.

“If we fast-forward from 2011 to the current day, things have improved tremendously,” he said.

Since 2012, the government has rolled out a series of healthcare financing options including a “pioneer generation” package to help the elderly meet increasing medical costs; the community health assist scheme which provides additional subsidies for lower to middle-income households; and expanded the coverage of Medishield Life, a national health insurance that provides lifelong protection for all Singaporeans and permanent residents, including those with pre-existing conditions and above 90 years old.

“There is a common saying that it is better to die than fall sick in Singapore,” said 59-year-old taxi driver Philip Choong.

“But better now – after the pioneer package and Medishield Life,” he said.

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Singapore’s healthcare system has won global accolades including from the World Health Organisation, which ranked the country sixth out of 191 others in terms of overall health system performance in 2000.

In Bloomberg’s annual healthcare efficiency index, Singapore has ranked either first or second among about 50 countries in the past four years, while the Economist Intelligence Unit placed the South-East Asian nation as number two for healthcare outcomes among 166 countries in 2014.

Life expectancy in Singapore is one of the highest in the world – 83 years in 2014, and infant mortality is among the lowest at 2 per 1,000 births in 2015, according to the World Bank.

Yet the country’s spending on health care is among the lowest for developed nations – just 4.9 per cent of GDP in 2016.

That same year, the OECD average was 12.4 per cent, and 17 per cent in the United States – the highest in the world.

“I don’t think there’s a single system in the world that spends as little as Singapore does [on health care] in terms of percentage of GDP and gets the outcomes that it gets,” said World Bank president Kim Jim-yong in 2014.

“We see a government that is extremely focused on execution, and actually delivering results for their population,” he said. “Every country in the world is trying to get there.”

In Singapore, paying for health care is the shared responsibility of the government and individuals. Public subsidies – up to 80 per cent for citizens – go hand-in-hand with co-payments by patients or their families.

Without subsidies, Mui Ing would have had to pay more than 40,000 Singaporean dollars (Dh103,400) for her husband’s cancer treatment. But with government subsidies of 65 per cent, she paid about 13,000 Singaporean dollars for the surgery and found costs to be “manageable” despite frequent follow-up visits to the hospital for tests and MRIs. In comparison, a friend who suffered from the same cancer of the nasal cavity paid hundreds of thousands of Singapore dollars for surgery in the US.

In the end, selling the house to fund her husband’s treatment was unnecessary.

“In Singapore, there’s the assurance that nobody will drop out, or will be deprived of health care when they absolutely need it,” said Loh Shu Ching, chief executive of Ren Ci Hospital, a charity hospital that provides intermediate and long-term care at three facilities around the island state.

“One of the things in Singapore’s healthcare financing is that we always believe in co-payment. That’s kind of what we call a sacred cow,” Ms Loh said. “This whole idea of co-payment goes back to the fact that you have to be responsible for your own health and making you pay a part of it makes you feel more responsible.”

However, "critics have noted that as patients have little control over their healthcare consumption, which is largely determined by their health condition and what doctors order, the co-payment can become a financial burden", according to Lau Wei Lin, an author who contributed to the book Singapore's Health Care System: What 50 Years Have Achieved.

A survey by HSBC last year showed that 78 per cent of Singaporeans found the costs of healthcare treatment, medication and rehabilitation a major concern, compared to the global average of 57 per cent. In 2012, a Mindshare survey found 72 per cent of Singaporeans believed they could not afford to fall sick due to high medical costs.

A former British colony, Singapore’s healthcare financing framework before self-rule was modelled after the UK’s National Health Service. Until 1959, Singaporeans received free health services from government hospitals and outpatient clinics. But the self-rule government was not convinced that the British system would work in Singapore.

“The ideal of free medical services collided against the reality of human behaviour, certainly in Singapore,” the country’s first prime minister Lee Kuan Yew said.

"My first lesson came from government clinics and hospitals," he wrote in his memoirs, From Third World to First: The Singapore Story. "When doctors prescribed free antibiotics, patients took their tablet or capsules for two days, did not feel better, and threw away the balance. They then consulted private doctors, paid for their antibiotics, completed the course, and recovered."

Dr Lim from Oliver Wyman said a big challenge of free health care is that “when the patient doesn’t pay anything, there is a concern that there will be overconsumption on the part of the patient, and there will be wastage or over-servicing on the part of the healthcare providers”.

To help citizens manage their healthcare finances, the government has introduced what is known as the 3Ms: Medisave, Medishield Life, Medifund.

Medisave is a mandatory savings account where individuals set aside part of their income to pay for certain healthcare services for themselves or their family members. Medishield Life is a basic health insurance plan protecting individuals from very large hospital bills, while Medifund is the safety net to help the needy who cannot afford their bills even after subsidies, Medisave, Medishield Life and private insurance.

The government – in its unique role as healthcare provider, payer and regulator – has pledged to keep costs affordable for every citizen.

But like most developed nations, Singapore faces the twin problems of a rapidly ageing population and a shrinking workforce, resulting in soaring medical costs and economic slowdown.

By 2030, the nation of 5.6 million is expected to have 900,000 people aged 65 and above – double the current number.

But Dr Lim is confident the country is well placed to meet these challenges.

“Singapore, thankfully, transforms from a position of great strength,” he said.

“We could double or even triple healthcare spending and we’ll only then look normal, like the rest of the developed world.”

And unlike many countries struggling with fiscal challenges, he said, Singapore has formidable reserves and the financial muscle to make tough decisions today and invest in health care.

“Overall I would say that Singapore should be optimistic that if any country is going to be successful, I think Singapore has the input factors that put it in a very favourable position.”