By Ghui

The issue of affordable healthcare is a hotbed for discussion. This is not surprising considering that it is a matter that affects each person intimately. Be it for you or for a loved one, we would all have had experiences with the medical care industry.

Do a Google search on Singapore healthcare and a wealth of websites and articles would spring up lauding the healthcare system of Singapore for being world class and sustainable. It is so widely praised that it was even the subject of a book by Professor William Haseltine: “Affordable Excellence”.

Before critics rubbish this statement, please note that by affordability, Haseltine was largely heralding Singapore’s healthcare system for being sustainable – i.e. not excessively draining the government coffers. Such benchmarks are based on the cost effectiveness of a system, and Singapore ranks among the top three in the world. This is in comparison with the system in, say, the US which by contrast costs a lot more. Before detractors on the other side of the fence jump at me, I am also not suggesting that a system must not be cost effective.

Singapore’s healthcare system was formulated in the 50s and 60s when Singapore was focused on gaining independence and nation building. While a cost benefit analysis is always important, it is safe to assume that the set of concerns that governed the day then would not be the same as those that prevail today. Healthcare affordability was not just a matter of good governance then, it was a question of survival as a country. The parameters of healthcare reforms must therefore take into consideration the new needs and circumstances that now face Singapore.

Singapore relies on a tripartite arrangement of forced savings (Medicare), insurance (MediShield) and subsidies (Medifund and Eldershield). In theory, this is the magic formula. The government will not have to worry about overstretching its finances – particularly relevant in the 50s and 60s – and people have a safety net in terms of subsidies should all else fails.

This however fails to address the mounting debts that could cripple a middle income family. Medicare saving amounts depends entirely on how much one makes. If you make less, you will have less. MediShield premiums may be a heavy burden on low to middle income families. Although premiums can be funded by Medisave, a very large medical bill (which can happen to anyone) can wipe out a substantial chunk of one’s Medisave, leaving no room for MediShield premiums or a potential future health calamity. The means test for Medifund is stringent and Eldershield will not benefit younger or middle aged Singapores.

Let’s not forget that there are limits to Medisave and Medishield, too – the types of illnesses it can be used for is limited as are the amounts you can draw from it. This leaves the bulk of young to middle aged average income families in a very vulnerable position indeed.

Whatever the window dressing, 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. Our leaders have clearly stated, at every available opportunity, that this was meant to reduce overutilisation of healthcare services.

This is done to the extent that “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.” (

Singapore’s system is well run, efficient and inexpensive. It worked a treat for its time. But now that we are more affluent, more must be done to ensure that the fruits of development are more evenly distributed. Surely, Singapore can afford to spend a little more than the 30 percent it currently invests?

Personally, I think that Singapore has a good foundation from which to build reforms upon. What the system needs is refinement and that is where the government needs to move in line with Singapore 2013 and the future. It cannot operate a system based on 1965 scenarios for a population set in 2013.

The tripartite funding system unique to Singapore is by no means a failure. Sustainability is of crucial importance and many countries the world over, most notably the USA, want to learn from Singapore. However, adjustments will definitely have to be made to facilitate the needs of Singaporeans.

The government itself has acknowledged this by making a few tweaks in Budget 2013/14. That notwithstanding, issues still remain, chiefly the question of how increased Medishield premiums is to be funded and the persistently high out of pocket costs. The limits of what illnesses it can be used for should also be widened.

As MD, MHS. Dean Emeritus, Johns Hopkins Bloomberg School of Public Health, Professor of Ophthalmology, Epidemiology, & International Health, The Wilmer Eye Institute, The Johns Hopkins School of Medicine once said: “There is no perfect healthcare system in the world. The ability to constantly change and evolve to stay relevant to the needs of the people is the quintessential quality for a good healthcare system.”

For a healthcare system to truly benefit its citizens, it has to constantly be cognizant to the needs of the population, and understand that this is an issue very close to our hearts. The government will have to step up, and likewise Singaporeans. Robust debate, keen interest and questions will ensure that the system is constantly refined to keep up with the times.

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