Colleagues were stunned when I announced last year that I was writing a book on the Singapore health system. “Who would be interested?” and “Is there enough material to write an entire book?” were the two most common refrains (“Would you be arrested?” was thankfully voiced by only one person). I am therefore glad for the minority who agreed with me that the Singapore story was worth telling and encouraged me to forge ahead. I am also deeply indebted to the many thoughtful critics and advocates who so freely shared with me their perspectives, insights and hopes for the Singapore model.
In truth, the Singapore model of healthcare has been a remarkable one thus far. Professor William Haseltine, in his book on the Singapore health system, waxes purple over Singapore’s achievements and titles his treatise Affordable Excellence: The Singapore Healthcare Story – How to Create and Manage Sustainable Health Care Systems. In the book, he notes that “Achieving and maintaining the good health of the populace at reasonable cost seems like an unattainable dream in many nations, yet Singapore has done it and has much to teach the rest of us.”
The reality is unfortunately more nuanced. I will attempt to present an honest account of the Singapore healthcare story in this book and dispassionately discuss both the good and the not-so-good. My hope is that despite my biases, the reader can gain a deeper understanding of the unique Singapore model and place in context five decades of this great experiment.
Why does Singapore capture the imaginations of many health policy observers the world over? There are perhaps three main reasons that pique their interest:
Firstly, Singapore has won numerous health accolades despite spending just 4% of its GDP on healthcare. These include being named by Bloomberg as the world’s healthiest country and being ranked sixth in the World Health Organisation’s (WHO) review of health systems in 2000. To provide perspective, 4% is lower than the 5% recommended by the WHO as minimum spending on healthcare, and a quarter by GDP of what the United States of America, the richest country in the world, spends. Incidentally, America, despite this largesse, ranked only 37th in the 2000 WHO assessment. Global interest in the apparent ability of Singapore to deliver excellent health outcomes on a shoestring budget has surged in recent years as countries around the world struggle to provide healthcare to their citizens in an age of austerity.
Secondly, modern Singapore, which had its beginnings as a British colony, was still a British possession in 1948, when the English National Health Service (NHS) was born. How did Singapore shake off its colonial legacy and move its philosophy of healthcare from state obligation to individual responsibility? To fiscal hawks, the more compelling related question would be this: How did Singapore, in the span of one generation, reverse the ratio of healthcare financing from 70% government-funded in 1980 to barely 30% in 2012?
Finally, Medisave, Singapore’s national health savings account system, has drawn much interest globally for it is the only such implemented scheme in the world. It has been lauded as the linchpin of our healthcare financing model but this deceptively simplifies the Singapore system.
At the same time, critics of the Singapore model decry that “it is better to die than to fall sick in Singapore” and bitterly criticise the co-payment and explicit rationing that are central pillars of the ideology of the Singapore system. Is the Singapore system the “magic” the world is seeking to address the challenge of providing affordable healthcare or is it just a “myth”? Where does the truth lie between myth and magic?
