Wednesday 19 February 2014

Help not just with healthcare, but also health

By Jeremy Lim, Published TODAY, 17 Feb 2014

As Singapore gets ready for Budget 2014, health issues may not be the most terribly interesting item on the agenda. Many of the major policy announcements have already occurred: MediShield Life in August last year, further details of the Pioneer Generation Package just last week and over the weekend, a new 1,800-bed integrated health facility in Woodlands.

What, then, should we hope for from the Budget?

While I am heartened by the Government’s vigorous efforts to meet what it perceives as the urgent needs of the people of Singapore, I am nonetheless haunted by the words attributed to the automobile pioneer Henry Ford: “If I had asked people what they wanted, they would have said faster horses.” So, what do Singaporeans really want?

I would argue that Singaporeans actually want good health first and affordable healthcare second, and only if they need it. However, healthcare is so complex that more beds, more doctors and more hospitals are an understandable but flawed surrogate for what Singaporeans really want.

At the same time, financial sustainability is uppermost on the minds of policymakers. Deputy Prime Minister and Finance Minister Tharman Shanmugaratnam in last year’s Budget speech laid out the dual objectives succinctly: To provide greater peace of mind for all Singaporeans while ensuring that the healthcare system remains sustainable.

With the Budget just around the corner, it is an appropriate starting point.


People want health, not healthcare. Healthcare is simply a means to the end. If one can maintain good heart health and avoid bypass surgery, who would want his chest opened up?

Thankfully, the Ministry of Health has made great strides in this respect. Today, breast and colon cancer screenings can be paid for through Medisave, as can select vaccines. Although some vaccines are conspicuously missing (such as herpes zoster vaccination), at least influenza and pneumococcal vaccinations are on the list of Medisave-eligible items.

But the criticism is not about what’s in and what’s out, but, rather, the degree of medicalisation of health.

This is not unique to Singapore and ministries of health the world over have been criticised for being “ministries of sickness”. In the United States, 75 cents out of every dollar are spent on combating chronic diseases, but only 5 per cent spent on preventing them.

As a means to an end though, healthcare is in actuality surprisingly limited. The World Health Organization and the US Centres for Disease Control and Prevention estimate that 80 per cent of heart disease and Type II diabetes, and 40 per cent of cancers, are preventable.

While the Pioneer Generation Package looks to be generous in providing for healthcare, one speaker at a panel discussion on the topic described the Package as “the ambulance waiting at the bottom of a cliff”. This may be harsh but it reflects the frustration that so much more can be done to keep Singaporeans healthy.


How can more Singaporeans mostly avoid the scourge of chronic diseases? By doing three things almost anyone can do: Exercising more, eating better and avoiding tobacco.

Can the Government play a proactive role? Yes, by levelling the playing field for health. Use direct subsidies, allow use of Medisave dollars or structure MediShield to enable coverage for health-enabling options, even if they are not traditional “healthcare expenses”.

Want to exercise but worried about breathing in smoke particles from the haze? Health insurers such as Kaiser Permanente in the US offer heavily discounted gym memberships for members.

What about committing to eating healthier food? Well, get ready for both a thinner you and a thinner wallet. Researchers from the Harvard School of Public Health released findings last year that eating a healthier diet would increase food costs for one person by about US$550 (S$690) per year.

What about smokers? Surely the government should not subsidise smoking cessation treatments? After all, they made the conscious decision to smoke and harm their health. But we are in all in this together, first emotionally as Singaporeans because we want our fellow citizens to enjoy good health and secondly, financially because MediShield Life binds us all together.

Call it what you want, MediShield Life is a tax on all Singaporeans to help pay for healthcare. The more that smoking, obese and sedentary Singaporeans use healthcare for the inevitable chronic diseases, the more all of us pay.

We need more healthcare infrastructure, no doubt about it. Singapore has under-invested for so many years that despite the developed world moving towards smaller and fewer hospitals, Singapore has to play “catch-up” first.

But let’s not forget that these are necessary but insufficient. The real gains for Singapore lie in helping Singaporeans to be the healthiest we can be, and perhaps health officials should account for not just how many hospitals and how many hospital beds are built, but also the proportion of Singaporeans who exercise regularly, do not smoke, eat healthily and have no major illnesses.

After all it is about health, not just healthcare.

Invest in excellent primary healthcare too
By Jeremy Lim, Published TODAY, 18 Feb 2014

Deputy Prime Minister and Finance Minister Tharman Shanmugaratnam cautioned in last year’s Budget that while the Government does more and more in healthcare, there is a need to ensure the system remains sustainable.

What does this mean? Are we in danger of charging ahead on an unsustainable path with the many new hospitals announced? After all, hospitals are by far the most costly part of the health system.

I was in Jakarta last week speaking to policymakers about health reforms. One chart I shared caught their attention (see graph). It showed simply that in Indonesia, as in most countries around the world, healthcare spending far outstrips general inflation. In Singapore, medical inflation has been a persistent 10 per cent per annum.

This is worrying, as it means that most healthcare systems are unsustainable in their current form. Regardless of how low the starting point is, as long as the rate of healthcare spending grows faster than general inflation or wages, at some point, a fiscal crisis is inevitable.

Another graphic sheds light on where the money is being spent. Using data from the United States, we estimated that 5 per cent of the population account for 45 per cent of total healthcare costs. Speaking at a conference in Sydney last year, I was taken aback when an Australian insurer shared similar data — except that the top 1 per cent of healthcare utilisers accounted for 50 per cent of costs!

Thankfully, the solution lies in the same graphic, at the bottom of the population breakdown. The more Singaporeans there are at the bottom of the distribution and the fewer at the top, the better our financial position.


Singapore’s life expectancy of 81.7 years is higher than the average of Organisation for Economic Co-operation and Development (OECD) countries’ 79.7 years in 2010, and this is to be celebrated. However, a closer inspection reveals a fly in the ointment — the years of healthy life lost due to disability has increased by roughly two years from two decades ago. The average man spends 10.7 years while the average woman spends 13.3 years of their lives suffering from poor health. This comes at substantial costs to society.

What Singapore needs to do is to reduce the years of life spent in disability. This compression of morbidity, as health policy wonks term it, is attained not by hospitals and expensive specialists. Hospitals only extend life for the chronic sick; it is family physicians, community nurses and health coaches, counselling and cajoling their charges to eat the right foods, exercise regularly and avoid smoking and binge drinking, who are the real heroes in reducing disease.

Let’s take diabetes as an example. While diabetes affects less than 10 per cent of the population, it is the seventh leading cause of death directly and probably contributory to others such as heart disease and stroke.

The National Healthcare Group Diabetes Registry reports increasing trends of diabetes-related complications. Sixty per cent of kidney dialysis cases result from poorly controlled diabetes. Imagine the avoidance in human suffering and the savings in dollars if we could rein in the scourge of diabetes alone.

If Singapore wants to enjoy fiscally sustainable healthcare, we need not only “okay” primary and community healthcare. We will need excellent primary and community healthcare. Prime Minister Lee Hsien Loong noted at last year’s World Health Summit: “It is better and cheaper to keep Singaporeans healthy and manage diseases at the primary or community level instead of in hospitals.”

I recognise the need for more hospitals, but I fear unbalanced development of our health system. The allure of specialty medicine may “suck” doctors, nurses and other healthcare professionals out of even more needed areas in primary and community care.

This will lead to our inability to enhance standards in those sub-sectors of the health system that, in the larger scheme of things, are even more important than world-class hospitals.

It is a zero sum reality to some extent. The doctors and nurses in the Jurong, Sengkang and Woodlands hospitals cannot also be in family physician clinics and community health centres.

The personal incentives today are heavily skewed towards speciality medicine and hospitals and, if left unchanged, will give us more of the same: Bigger and better hospitals, but depleted primary and community care. If we cannot reverse this, Singapore will be doomed to the spiral of escalating costs and eventual fiscal crisis.

Dr Jeremy Lim is head of the Asia-Pacific health and life sciences practice in Oliver Wyman, the global consulting firm. He recently authored Myth Or Magic: The Singapore Healthcare System, which describes the successes and challenges of the Singapore model.

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