Comments at the WHO Ministerial Round Table Discussion

20 Sep 2006

By Mr Khaw Boon Wan, Minister for Health

Venue: Auckland, New Zealand

"The Art and Science of Medicine"

It is obvious that health policies and healthcare practices should be based on reliable scientific evidence.  After all, we are in the scientific business.

But in reality, no country can honestly claim that its policies, and no doctor, his medical practices, are always evidence-based and scientifically grounded.  Why is this so?

Science vs Art

A short answer to that is that medicine is not a pure science.  Rather, medicine is both a science and an art.  As Health Ministers, our portfolio covers from one extreme of direct doctor-patient relationships at the micro level to the other extreme of managing national healthcare systems at the macro level.  As we move along this spectrum from the micro to the macro, science increasingly gives way to the art.  

At the macro level of national healthcare systems which are defined by health policies, politics and ideological beliefs compete with the science of medicine to be major determining factors.  And as we all know, politics is the art of the possible.

Let me give some illustrations.

First, the scientific evidence that smoking kills and causes an unnecessary burden on the healthcare system is overwhelming and should naturally lead to its ban.  But so far a smoke-free environment is a national health policy only in Bhutan.      

Second, in the management of bird flu, the scientific evidence for culling of infected poultry to prevent human spread is indisputable. However, not all countries afflicted with bird flu have successfully translated this into real action on the ground, putting their populations at risk.     

Even at the micro level of clinical practice, well established science has not been fully translated into consistent evidence-based medical practice. In the US, for example, only about 60% of heart attack patients who require aspirin received the drug, a therapy which has been shown to significantly reduce the risk of death.   

More Science

But this is not a call to throw in the towel and concede defeat by the science.  Indeed, it is precisely because health policies will by default be dominated by the art of politics, that we should work even harder to ensure that greater and better scientific evidences be generated and shared among member countries.  Rational health policies and effective health systems are more likely to happen if the scientific content behind the policies is robust and well communicated to our people. 

Collective Learning

In 2000, WHO dedicated its World Health Report to improving the performance of national health systems. The report presented for the first time, an index of national health systems' performance in trying to achieve three basic goals: (a) good health, (b) responsiveness to the people's expectations, and (c) fairness of financial contribution.

Like the other WHO Regions, our Western Pacific Region displays great diversity in terms of health systems' performance.  Six Member States were ranked among the top 50 in the world, while some others were assessed to be weaker.

Being a first attempt, the WHO Report is open to improvement. Perhaps, it is timely for the WHO to update this Report and enhance its evaluation criteria and measurement processes.  The purpose is so that Member States can learn from one another, identify the gaps and together raise our health systems to a higher plane.

Grave Challenges Ahead

This is urgent because we face grave challenges: rising healthcare costs, rapid ageing of population, threats of emerging and re-emerging diseases and global epidemics.  The supply of healthcare services simply cannot catch up with the pace of increasing demand.  It is clear that we need to ration, but how to do it in the most humane and the fairest way possible is open to debate.

The US is already consuming 16% of its GDP on healthcare, with no natural ceiling in sight.  Few countries can afford that luxury.  The fact is that even the US is worried that they cannot afford it, if current trend continues. 

Before the world collapses under the weight of its healthcare systems, we must find new ways to deliver better health outcomes at lower costs.  This calls for more intensive search for practical innovative solutions, and active sharing of best practices.  And we should not be shy to learn from other industries and other professions.  In recent years, I discover that Toyota has much to teach us, even though patients are not motorcars.

Simple Things Work

We know a few simple things will solve a significant portion of our national health problems: get people to eat wisely, exercise regularly, do not smoke and take care of personal and public hygiene.  But as Health Ministers, we know too how difficult it is to get everyone to actually do it regularly.   It is uphill but we must persevere. 

Singapore is fortunate that our founding fathers were successful in developing the economy, creating jobs and improving our living conditions.  With clean water, clean air and good sanitation, the health of our people has improved over the years.  We now enjoy high life expectancy and very low infant mortality rates.  Credit should go to our Ministries in charge of economy, education, housing and the environment for these achievements. 

But the Health Ministry has also done its part.  Over the years, we have set up proper manpower planning, modernised our healthcare facilities, and created a viable and affordable healthcare system.  Today, we spend only 4% of our GDP on healthcare.  For the good health outcomes that our people enjoy, it is good value for money. 

It is partly because the population is still young.  But anticipating future problems brought about by ageing and affluence, we have over the years, systematically reformed our healthcare system. 

First, we are aggressively saving for the rainy day, getting the people and the Government to set aside reserves for future healthcare needs while we are still young, healthy and working.

Second, we are getting Singaporeans to subscribe to catastrophic illness insurance, with high deductible and hence affordable premiums.  This gives them peace of mind.

Third, we are nagging Singaporeans to embrace a healthy lifestyle, both at home and in workplace.  Ultimately, the best way to manage future healthcare challenges is to maintain our health for as long as possible.

Nevertheless, I know our challenges ahead are awesome: rising expectation, unlimited demand by patients many of whom are at the same time unwilling to take responsibility for their own health, not to mention the need to tackle many sensitive end-of-life issues. 

Travellers On A Journey

But I know I am not alone.  You face similar problems too.  We are travellers on the same journey and we have much to learn from one another.  (An old Chinese saying: among three travellers, one is bound to be my teacher.)  We all have a compelling interest to participate in this global search for a better health system and more sensible health policies.  Countries which have the expertise and resources should do more to support such health systems research and share their findings with others.

The Europeans are making a contribution. The WHO European Region has established the Health Evidence Network or HEN, which is a network of technical agencies and institutions in that region.  HEN provides an open source database of health information and evidence-based reports on the internet which public health and health care decision-makers can depend on, to guide health policies.  In Singapore, we tap on this source occasionally for reference and advice.

More Research

In Singapore, the Health Ministry has decided to set aside part of our annual budget to support research, besides our core mission of providing health care services. We have updated our Ministry portfolio to formally include in clinical research as part of the Ministry mandate.  This is partly to lend our support to the national priority of promoting translational and clinical research in our next phase of life sciences development.

Within this new initiative, we will pay particular attention to health systems research. We aim to examine how the entire health system and its component health services are performing in terms of access, safety, cost-effectiveness, efficiency and patient-centeredness. In parallel, the National University of Singapore has also decided to build up research capabilities in this area by setting up a national health services research centre, in partnership with the RAND Corporation.  We hope that these efforts will accelerate the development of good health services research in Singapore.  We are a small country with limited resources, but we will do our part in the global search for sound health policies. 

Better Results

For the Western Pacific Region, a strong health research environment among our Member States will be a major asset.  If the findings become systematically translated into consistent evidence-based care and rational national health policies, our people will all get to enjoy better health outcomes.   That must be our common aim.