FEB 18 — 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. 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. The more Singaporeans there are at the bottom of the distribution and the fewer at the top, the better our financial position.
Reduce disability years
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. — Today
For Part 1, “Help not just with healthcare, but also health”, click here.
* 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.
** This is the personal opinion of the writer or publication and does not necessarily represent the views of The Malay Mail Online.
