The National Healthcare Plan in Singapore
In the late 1970s, Singapore was undergoing rapid modernisation and development, which brought with it a rapid increase in healthcare expenditure. Fears were raised that the city-state's legacy healthcare model, which was free at the point of use, was insufficient to meet future demand without significantly increasing expenditure, particularly given Singapore's ageing population.
The government therefore launched the National Healthcare Plan (NHP), which introduced radical new initiatives and policies to meet these challenges, including corporatisation of hospitals and an emphasis on individuals saving for and paying their own medical bills. Whether rightly attributable to the NHP or not, Singapore's healthcare system today produces some of the best healthcare metrics globally, with one of the lowest healthcare expenditures as a percentage of GDP.
The NHP was the Singaporean government's strategy to maintain a high standard of healthcare despite Singapore's limited resources, in the face of rising healthcare costs as a proportion of GDP. The MOH undertook extensive research to produce the NHP, with Goh Chok Tong (the then minister of health, and future prime minister) overseeing the plan. On 3 February 1983, it published the NHP Blue Paper, which opened a six-month public consultation inviting the public to contribute their views on the paper's proposals. The final NHP and its Medisave scheme was approved by parliament on 31 August that same year without changes to the Blue Paper proposals, and the Medisave programme began operations in April 1984.
The NHP outlined an approach to Singapore's healthcare and its development that would apply until the end of the century. The NHP's mantra was that “prevention is better than cure”, and its aim was “to build a healthy, vigorous, active and physically fit population”, while also fostering the belief in personal responsibility for one's own health and that of one's family.
The NHP sought to encourage Singaporeans to remain well and to reward those who did. To that end, the plan emphasised preventative medicine from the start. Alongside this philosophy, there were two major proposals. Firstly, that the financial burden of healthcare be shifted from the government to individuals and employers through a system of individual Medical Savings Accounts (MSAs) called Medisave, and secondly, the corporatisation of government hospitals. “Medisave was intended to ensure that when Singaporeans enter the medical marketplace, they are able to pay the costs of their own care without relying on the charity of others or the subsidies from the state.”
The system imposed a mandatory monthly saving on workers that was equivalent to 6 percent of their salary (half paid by employers and half deducted directly from wages). The savings were to be held by the Central Provident Fund (CPF) in individual MSAs for each contributor; it was not a communal pot. This 6 percent figure was calculated to cover the average hospital bills if a worker or member of their family were admitted to a subsidised, Class C hospital ward. Contributions were subject to a cap of SGD180 per month (equivalent to a cut-off monthly salary of SGD3,000 in 1984 when the NHP was implemented, and with a wage ceiling of SGD6,000 in 2019).
The MOH dictated that individuals could only withdraw funds from their own Medisave account for a prescribed range of hospital treatments either for them or for a member of their immediate family. Significantly, outpatient treatment was excluded, although outpatient costs were subsidised by the state. The NHP also included plans to streamline outpatient services with the creation of modern polyclinics. These provided frontline preventative and curative healthcare in consolidated facilities, including GPs, health screening, limited diagnostic services (including X-rays), pharmacy services, outpatient treatment, and non-emergency, out-of-hours treatment.
Long-term treatment for the chronically sick was also excluded from Medisave. In particular, the example of long-term dialysis treatment was frequently raised by critics. The NHP intended instead that such illnesses would be covered by “other programmes”, by which it meant treatment that is heavily subsidised by the government and medical insurance schemes. The NHP also made it clear that essential medical treatment would not be denied to any Singaporean on the grounds of financial hardship. Medisave accounts could be overdrawn and the “loan” be paid back in instalments, attracting interest at a rate set by the CPF.
The second major proposal in the NHP was the corporatisation of hospitals. A corporatised hospital would be fully autonomous, with independent management in all of its functions. The government still wholly owns the hospitals and provides general policy guidelines and annual subsidies for the provision of medical services, allowing it to influence the hospitals sufficiently to achieve greater competition, avoid wasteful duplication, and ensure a better distribution of services. The corporatisation of hospitals was intended to keep healthcare costs down through the action of market forces, by encouraging hospitals to compete with one another.
On top of these two major proposals that the NHP put forward, the plan included other objectives to improve healthcare provision, including refurbishing existing hospital wards in line with patient demand, planning sites for future hospitals, and increasing the ratio of healthcare professionals to the population.
During the period of colonial rule, the British had implemented in Singapore a healthcare system of free hospital care and subsidised government clinics, largely influenced by the UK's National Health Service. Post-independence, this healthcare system continued; however, with both GDP and the standard of living on the increase, Singapore saw its public expenditure on healthcare quadruple in just a decade, from SGD59 million in 1971 to SGD257 million in 1981. There was a steady increase in the number of hospital admissions and visits to outpatient clinics throughout the 1960s and 1970s. It was estimated that these figures would continue to increase with the “embourgeoisement of Singapore”, as the population grew, aged, and became more affluent and health-conscious. Healthcare costs as a proportion of GDP were set to rise.
The government was aware that a young population keeps healthcare expenditure down, but following its overly-successful “Two-is-Enough” population control campaign of the early 1970s, Singapore's birthrate plummeted from 3.07 to 1.43 per woman. The population was set to age considerably, with Singapore's Ministry of Health (MOH) predicting an increase of the population aged 60+ from 7 percent in 1983 to 10 percent in 2000. Studies had shown that, in some countries, the elderly occupied more than 50 percent of the non-psychiatric hospital beds, despite representing less than 15 percent of the population. Such statistics made the government conscious of the risks of a dramatic future rise in healthcare expenditure, which was made likely by its increasingly elderly population.
Despite the apparently sharp rise in healthcare expenditure, there was no immediate funding problem because of the rapid growth of Singapore's GDP : “in fact healthcare costs fell dramatically as a proportion of GDP between 1960 and 1984”. Going forward, however, healthcare costs were set to increase as a proportion of GDP, and the Singaporean government wanted to be proactive, recognising that Singapore's postcolonial healthcare system would struggle under the predicted growth in future healthcare expenditure.
The government of the late 1970s and early 1980s decided to address the issue before it became a problem, being especially aware that Singapore's restricted land, human and financial resources meant that public infrastructure faced additional challenges not felt in larger states. At the same time, the Singaporean government believed that in countries with a prepaid healthcare system (whether funded by general taxes or mandatory insurance), demand would invariably overload such systems and lower the standard of healthcare.
Accordingly, the challenge the government faced was how to address rising healthcare costs while still keeping high-quality healthcare available to all and avoiding the pitfalls of a prepaid healthcare system - all in the context of Singapore's unique resource limitations.
The public impact
Today, Singapore is frequently cited as the most successful healthcare system in the world, being the only country to appear in the top five for low infant mortality, high life expectancy and low maternal morbidity rates. Other countries, such as Japan and Hong Kong have achieved similar rates, but Singapore stands out with its extremely low healthcare expenditure: in 2016, the figures were reported at just 4.7 percent of GDP, compared with other developed nations (including Canada, Japan and the UK) which spend between 9 and 12 percent, and the US, which spends 18 percent of GDP on healthcare. “Major surgeries cost 62 to 92 percent less in Singapore. As just one example, a heart-bypass surgery that would cost SGD130,000 in the United States costs just SGD18,000 in Singapore. Overall, Singapore spends 72 percent less per person on healthcare than the United States and between 46 and 57 percent less than Canada, Japan, France, and the United Kingdom.”
The flipside of this low healthcare expenditure is that one-third of total health spending is paid by individuals directly as Out-of-Pocket (OOP) expenses, while employer medical benefits account for another third. Medisave (which can only be used to fund a limited range of hospital treatments, as dictated by the MOH) accounts for less than 8.5 percent of total spending. The NHP had envisaged both that individuals would be responsible for their own medical expenses and that employer benefit schemes would play a significant role in healthcare funding, so the public impact of these reforms played out as intended.
The immediate public impact of the NHP also increased government outgoings, with one academic noting that “immediately following the introduction of Medisave in 1984, the rate of increase of health expenditure per capita jumped from 11 percent to 13 percent per annum”. The share of GDP absorbed by health expenditure also increased in the immediate post-Medisave period, due largely to a sudden increase in expenditure on physician fees and the purchase of new technology, as hospitals competed with each other for business and reputation in the new fee-paying environment.
That being said, it is difficult to draw conclusions about the public impact of the NHP itself, for two reasons. Firstly, the lack of clear data on Singapore's healthcare expenditure: the MOH publishes only limited data on healthcare expenditure, it does not follow World Health Organization standards in measuring it, and its methods of calculation are kept secret. This means drawing direct comparisons of Singapore's healthcare figures with those of other nations is difficult, and some suggest that Singapore's figures may be higher in reality.
Secondly, some academics contend that Singapore's combination of favourable health indicators with the low proportion of GDP spent on health expenditure owes more to socioeconomic factors than to the NHP. The suggestion is that the nation's diet, lifestyle, strong family and community ties, and overall social culture play a large part in keeping the population healthy. In particular, comparisons are made with Hong Kong and Taiwan, countries with similar socioeconomic cultures, environments and challenges. Neither has an official system of MSAs in place, yet they both enjoy “relatively low levels of health spending with comparably good health outcomes”. In 2001, it was reported that “the Hong Kong and Taiwan governments each spend around 5 percent on health: a figure that is higher than Singapore's 3-4 percent, but not drastically so”.
In the 35 years since the introduction of the NHP, Singapore's healthcare system is not only thriving but also keeping Singaporeans healthier for significantly less expenditure relative to GDP than any other nation. While it is debatable whether this can be attributed entirely to the NHP, the objectives of the NHP have nevertheless led to Singapore retaining an active and healthy population - which is primarily responsible for the costs of its own healthcare.
Written by Glynn Sullings
From the outset, the MOH consulted with the stakeholders involved in the development of the NHP, receiving a number of suggestions (none of which were incorporated into the NHP to any significant extent). Nevertheless, the NHP was implemented smoothly with no notable opposition, and all stakeholders played their part, including the public, medical bodies, hospital administrators, medical professionals, and government officials.
When development of the NHP began in 1981, several activities were initiated to gather ideas, especially from academics and key players in the healthcare system. The MOH stated that “the ministry had widely discussed its proposed plans with a cross-section of Singaporeans before publishing it as a Blue Paper. These include eminent members of the medical and dental profession, knowledgeable journalists and community leaders from the Citizens' Consultative Committees and the Residents' Committees.”
The MOH then expressly invited members of the public to “air their opinions and suggestions” for a six-month consultation period, either directly to the permanent health secretary or by writing to the forum page of the Straits Times, which would be monitored for such views. Goh Chok Tong, the principal architect of the NHP, was reported to have “lamented the poor feedback on the NHP” after the public forum had been concluded.
During the consultation period, the NHP was also tabled before parliament, following discussions and consultation not only with officials from the MOH but also with numerous representatives from the medical profession and professional bodies.
Most stakeholders agreed with the NHP's “basic thrusts and objectives”, but some raised specific criticisms. The Singapore Medical Association (SMA) commented that while Medisave was an ingenious way of helping the majority of the population to look after their own healthcare needs, it did not provide for the sick, the indigent or the disabled, nor did it deal with the problem of the elderly who suffered from ill health. The SMA also suggested that Medisave be accompanied by a national insurance system as a safety net. The Singapore Association of Social Workers expressed its belief that Medisave coverage should include outpatient treatment and long-term hospitalisation for the chronically sick. The Singapore Government Medical, Dental and Pharmaceutical Officers' Association highlighted the risk of abuse with the scheme and the limited scope of Medisave, which was only to be used in cases that required hospitalisation.
None of the comments, criticisms and suggestions made of the Blue Paper led to any significant alterations to the NHP before it was enacted. Arguably, the voices of the stakeholders in the public consultation were disregarded, although the stakeholders still supported the implementation of the NHP and its radical reforms, all of which were introduced without opposition.
Political support from the ruling People's Action Party (PAP) was almost unanimous, with only a handful of concerns expressed in parliament and only 2 dissenting voices out of 75 MPs. In the December 1980 general election, the PAP had won all 75 seats in Parliament. Governing all but unopposed meant that the MOH faced no political hurdles in enacting the NHP as it saw fit, and that any scrutiny or criticisms of the NHP were merely suggestions that required neither action nor consideration. The Medisave scheme was presented to parliament for debate and approval in a two-day debate on 30 and 31 August 1983.
Fourteen MPs gave their views and while some reservations were expressed, support was unanimous with only two exceptions. Dr. Toh Chin Chye abstained from voting on the grounds of his conviction that the government should inherently assume the task of healthcare. Dr. Chye, who was formerly the minister for health, argued that healthcare was primarily the government's responsibility. It was therefore the government's duty to find ways of using taxpayers' money to fulfil its different objectives, rather than implementing a CPF savings scheme. The MP Joshua Jeyaretnam also voted against the scheme.
Receiving 75.6 percent of the votes cast in the 1980 general election (up from 72.4 percent in the 1976 general election) and winning all 75 seats in parliament, the PAP had strong public support. Whether this support related to the government's plans for healthcare is difficult to determine, since it was not one of the key issues in the election nor an issue upon which PAP candidates or the opposition were standing.
In the run-up to the general election, some opposition candidates had been making calls for either free or less expensive healthcare. Dr. Chye touched upon the PAP's position on healthcare at a rally ahead of the general election. He stated that as the standard of living increased, so too did the wages that made up a significant part of the costs of healthcare, and therefore reducing the costs of healthcare was unrealistic: “the price people had to pay for their health was a case of your money or your life”.
In the 1984 general election, following the implementation of the NHP, the PAP lost ground slightly, receiving just 62.9 percent of the votes and losing 3 of the now 79 seats in parliament. Nevertheless, this continued an astounding, if now not quite complete, majority and represented significant and continued public confidence and support for the party. Once again, healthcare was not a key issue or platform in this election.
Clarity of objectives
The NHP set out a range of objectives to be achieved over the following two decades, including both quantitative targets and qualitative policies. “Prevention is better than cure” is the maxim quoted throughout the NHP. With this in mind, the NHP Blue Paper set out two major objectives for the plan. Firstly, the financial burden of healthcare was to be shifted from the government to individuals and employers, through a mandatory MSA called Medisave, and secondly, all government hospitals were to be corporatised (rather than privatised).
The NHP Blue Paper's stated policy objectives were to:
- Build a healthy, vigorous, active and physically fit population
- Encourage Singaporeans to stay well and reward those who do
- Build up individual financial resources so that those who fall sick would have the means to pay their healthcare
- Divert the public health sector's energy and resources into preventative medicine and health education
- Encourage the private health sector to take on greater responsibility of providing care at reasonable cost
- Coordinate the planning and development of both sectors to achieve a better distribution of services, avoid wasteful duplication, stimulate healthy competition, and enhance efficiency.
In addition to policy objectives, the NHP Blue Paper also set out clear, quantitatively measurable targets for numbers of hospital beds and outpatient consultations needed by the year 2000, based on their projections of demand. They set targets of 13,400 beds and 20 million consultations per annum, which implied a predicted increase in demand from 1982 of 3,480 beds and 16 million consultations per annum. Other clearly measurable objectives included not only maintaining the levels of medical services but actually improving them by increasing the ratio of practitioners to the population. Targets for numbers of doctors, nurses and dentists were also identified.
An editorial in The Straits Times criticised the objectives stated in the Blue Paper, however, saying that “the striking feature is the brevity of the document. Bland statements abound and examples like ‘prevention is better than cure', and ‘health cannot be imposed, it must be attained', give a simplistic answer to a very complex problem”. There were also some less measurable objectives, including:
- Reserving future hospital sites
- Refurbishing wards
- Developing primary healthcare services to provide frontline preventative and curative healthcare
- Expanding school dental clinics
- Encouraging the community to care for the old and chronically sick
- Moving towards outpatient treatment for non-acute psychiatric illness.
Strength of evidence
While extensive consultations with relevant professionals, experts and academics in the healthcare field were undertaken in the development of the NHP, it is unclear what evidence the policy's approach was based on.
The MOH explained that the Medisave scheme was designed after studies of countries with prepaid healthcare systems. These systems were primarily financed through general taxes or compulsory health insurance instead of fees at the point of consumption. The MOH concluded that these prepaid systems were failures, creating an overutilisation by the public and overproduction by the healthcare providers. Personal accountability became key to Singapore's future healthcare planning.
Some academics argue that the approach had ideological and speculative rather than evidential roots, claiming that “the perceived failures of ‘social and health welfare' in Europe and the US [is] a perception premised more on ideological preconceptions than on empirical data”.
Whatever the reason for rejecting a prepaid healthcare system, there would have been little evidence available to evaluate the efficacy of an MSA-based system, particularly on the scale that Singapore would be applying. Indeed the concept of MSAs had only been created in the late 1970s by the American Medical Association's former chief economist, Jesse Hixson.
Quantitative projections of future healthcare supply and demand were made by extrapolating directly from relevant data from the preceding decade's records. The NHP Blue Paper expressly explained that the size of the mandatory Medisave wage deduction had been determined using a computer simulation performed on a random sample of almost 10,000 households. The SMA cautioned against this evidential approach, stating that “predicting future trends from past figures by ad hoc surveys ‘is fraught with pitfalls'”.
In some respects, the Medicare scheme was to be its own pilot scheme. Initially, Medisave withdrawals were limited to the amounts charged for treatment in a public hospital's Class C ward. From the outset, however, the NHP included plans to review and increase spending limits after two years, “to allow the ministry to gather relevant data to derive a proper percentage of the bill in relation to the total balance in the Medisave Account”.
The MOH was cautious about the figures they had imposed for Medisave, ensuring that the scheme would be feasible. In Medisave's first year, the scheme collected SGD786 million - more than double the running costs of the entire public health system. Only 30 percent of the fund for that year was paid out, a figure that was predicted to rise as the population aged.
As part of the NHP, admissions targets for relevant medical training institutions were put in place to help create the supply of manpower needed to meet the predicted targets of practitioner numbers for the population.
Singaporeans and their employers were already mandatorily paying into the CPF for pensions and the Public Housing Scheme. The administrative institution that was needed to manage and operate the Medisave scheme was already established and operational, and the population was familiar with the concept of mandatory personal savings schemes. These factors made the introduction of Medisave and MSAs a feasible and practical overhaul of the public healthcare infrastructure.
The MOH retained full management control over the implementation and operation of the NHP, save in the administration of the Medisave programme, which was managed by the CPF. The principal architect of the NHP was the nation's second prime minister, Goh Chok Tong.
Central to the NHP was the idea of corporatising hospitals. Hospitals that were previously free public institutions were granted a high degree of autonomy. Effectively acting as private bodies, these hospitals were granted a “freer hand to implement management practices for improving effectiveness and efficiency, and much more freedom in their day-to-day decisions regarding staffing, compensation, deployment of resources, and some user fees”. The MOH retained ownership, overall control, and management of corporatised hospitals through a private corporate structure, passing ownership of the hospitals to a purposely created private holding company owned entirely by the MOH. This was the Health Corporation of Singapore (HCOS), which later became MOH Holdings Private Limited. The MOH appointed the HCOS board members, and the CEOs and management of the hospitals were accountable to this board. The structure allowed the MOH to continue exercising its authority in larger, strategic decision-making and macro healthcare system management.
On the finance side of the NHP, Medisave was to be managed by the existing CPF, a national agency that was well established, having been formed almost 30 years earlier in 1955. The MOH, however, still retained tight control over where - and for what treatments or services - an individual citizen's Medisave fund could be spent.
All accountability for the implementation and management of the NHP was applied by the MOH to itself. There were no specific mechanisms in place nor were there any reporting targets that were made public. Market forces came into play within the corporatised hospitals system, with any underperforming management or administrators of individual hospitals being held accountable by the MOH-controlled HCOS board to which they reported.
Measuring the public impact of the NHP is a difficult task to undertake because the MOH does not often make healthcare data publicly available. Some metrics were identified in the NHP Blue Paper, which can be tracked and measured, notably numbers of hospital beds and the ratios of medical practitioners to the population. Whether these figures are specifically tracked by the MOH is unclear, and they are certainly not announced routinely.
Nevertheless, significant changes have been made in the implementation of the NHP since it came into effect, most notably in extending the MSA system's offering from Medisave alone to include a voluntary insurance scheme (Medishield) and an endowment fund to assist those facing financial difficulties in paying their medical bills (Medifund). Integrated Shield Plans (IPs) were introduced in 2014, combining Medishield coverage with private coverage and allowing payment of premiums from MSA funds. IPs were intended to lower OOP spending on healthcare and ensure universal coverage, demonstrating that the MOH is still monitoring associated data and issues. These adaptive changes to the NHP provide a strong indication that the MOH is measuring and monitoring the public impact and effect of the NHP in order to make adjustments and improvements, but choosing not to make the measurements public.
The NHP was launched without addressing criticisms made by stakeholders about the treatment of chronic illnesses, care for the elderly, and pressures on the financially destitute. Further down the line, however, these concerns were directly addressed and the stakeholders brought further into alignment with the introduction of Medishield and the Medifund.
The corporatisation of hospitals attempted to combine free market forces with government control and intervention. That the MOH felt it needed to step in is a direct result of the natural misalignment between the interests of patients, private hospitals, and the government. Upon admission, for instance, a hospital is required to provide a patient in Singapore with not only an estimate of their bill but also an estimate of the average bill at other hospitals. Any autonomous private hospital would be very unlikely to operate in this manner if it were not required to do so by law.
Despite the naturally conflicting requirements of patients wanting cheap, subsidised healthcare, private hospitals and professionals wanting to make as much profit as possible, and the government wanting a comprehensive, affordable healthcare system, the NHP was introduced smoothly without public protests or objections.
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