Keynote Lecture by Health Minister Gan Kim Yong at the 4th World Health Summit in Berlin, Germany, 23 October 2012

“Healthcare Challenges for Asia: Living longer, healthier and with peace of mind into the future”

Prof Detlev Ganten, Founding President,  of M8 Alliance

Prof Michael Klag, President, World Health Summit 2012

Distinguished Guests

Ladies and Gentlemen

Good Afternoon to all of you

1.            It is my pleasure to be here at the World Health Summit to share an Asian perspective to healthcare challenges confronting us.  This is an excellent platform for global healthcare thought leaders, policy makers and academics to contribute and glean useful ideas and I am glad to be part of it.   

 Introduction to Asia’s landscape

2.            Asia is a large and diverse continent.  It contains three (3) of the world’s largest countries, by population – China, India and Indonesia.  It has among the world’s most rapidly aging societies – in Japan, Korea, Taiwan, Hong Kong and Singapore.  But also economies, like Indonesia and India, which expect to reap dramatic demographic dividends in the next two (2) decades as their working-age populations swell.  

3.            There is thus no one single story of healthcare in Asia, but multiple threads.  From these multiple threads, we can discern some shared goals which we all aspire towards, some common challenges we have to address and also similar underlying forces that will impact how we plan, design and implement healthcare policies and solutions.

4.            The value of a forum like this is that we get to travel back and forth in time, all at the same place.  We anticipate what we need to do by studying the experiences of countries which are ahead of us in confronting certain challenges, be it fiscal tightness or a rapidly aging society.  We also derive a keener understanding of ourselves by knowing where we have come from.

5.            Notwithstanding the different starting points and trajectories that our healthcare systems are on, we have the same end goal in mind - that is to provide good and affordable healthcare for our population in a sustainable way.

6.            To do so, we need to consider the question: “What can and should we do today to enable our people to live longer, live healthier and with peace of mind in the future?”

Investing in the basics for public health

7.            Better nutrition and control of infectious disease have led life expectancy to improve significantly across Asia.  There are many examples of projects, large and small, that aim to uplift millions of Asians out from poor health. 

8.            Even as we succeed in our battles against the communicable diseases of old, some (like tuberculosis) have re-emerged while new ones, like H1N1 and SARS have surprised us.

9.            We cannot let our guard down when it comes to preventing and containing the spread of highly transmittable conditions as we get increasingly connected around the world today.  Otherwise, our gains from better infectious disease control can be easily eroded.

10.         Because infectious diseases transcend boundaries, we rely heavily on international cooperation to counter public health threats. Just recently, a new coronavirus strain was detected by laboratories in the UK and Netherlands. The novel virus was found in two patients who were diagnosed with lung infections months apart and in different countries. Within days, a diagnostic method was developed in collaboration with a German laboratory for use by others around the world. The following week, a suspected case involving a foreigner who had travelled from the Middle East was admitted to a hospital in Singapore with respiratory symptoms. We were able to use the newly developed diagnostic test to confirm that the foreigner did not have the novel coronavirus infection. 

11.         However, sharing of information is not limited to scientists.  Under the WHO’s International Health Regulations, we have an established network of national focal points to communicate with each other as public health authorities.  This network is used regularly, for example, to identify those who might have been exposed to a tuberculosis case in the airplane, or to exchange outbreak information during a pandemic.  

12.         Cross-border collaboration is essential for combating infectious diseases and this includes sharing of best practices. As a member of the ASEAN Task Force on AIDS, Singapore has organised a Regional Workshop on HIV/AIDS Education in the Workplace for all ASEAN Member States. It brought together domestic and regional experts to share their frameworks and best practices on workplace HIV/AIDS initiatives. This is yet another example of how countries can work together to build up the region’s public health capability.

13.         A network of public health experts, linked to one another and sharing the latest information, insights, genetic codes and even tissue samples, remains a strong bulwark against new communicable diseases.  I encourage the building of such networks not just within Asia, but across continents.

Motivating people to live healthier

14.         While investing in basic infrastructure like sanitation and a clean water supply can do wonders to improve public health, the efforts needed to sustain health are more challenging.  This is because we are dealing with a deadly enemy – our own behaviour and habits.

15.         We were pleasantly surprised when Bloomberg announced that Singapore was the ‘Healthiest Nation’ in 2012.  However, this belies the uphill challenges that Singapore faces in the years ahead. In Singapore, a city state of about five (5) million people, we recognize that non-communicable diseases (NCDs) – especially cardiovascular diseases and cancer – account for about 60% of deaths each year. Based on our National Health Survey findings, one in nine (9) Singaporeans have diabetes. A similar proportion is obese; slightly less than one in four (4) have hypertension; and more than half do not exercise adequately. Despite the low incidence rate in smoking, we are seeing an increasing number of our youths taking up smoking, and developing obesity too. How do we stop and better still, reverse such trends?  

16.         Allow me to share a few ideas that Singapore has tried out. They involve changing the ecosystem in which we live, work and play, so that this will translate into changes in people’s mindsets towards health, and making behavioural and lifestyle changes that are more sustainable. 

17.         Leveraging on ground-up community engagement to drive health promotion efforts. A face-less heath promotion advocacy drive often appears too distant for the individuals, therefore our Health Promotion Board has been appointing individuals as  ‘health ambassadors’ who work as early adopters and motivators in the community. I think you would agree with me that it is more effective for someone whom you know to encourage you to change your behaviour, than a mere pamphlet or brochure that you may receive.  This is the kind of community engagement that we target to achieve and permeate across the system.

18.         We have seen successful examples of such engagements from the North Karelia project in Finland, where they managed to reduce cardiac mortality by 70% in just 30 years through combined ground-up community engagement through advocacy and partnerships with public, private and people sectors. We certainly hope to achieve similar results or better results. 

19.         Making eco-system modifications to encourage healthy living - Changing the physical and nutritional environment or ecosystem is as important as changing individual behaviour. In Singapore, we have meals outside of our homes rather frequently as a result of our lifestyle. In fact 60% of Singaporeans eat out about 4 times a week or more. Hence we have worked with food stall owners to reduce the amount of oil and salt used during cooking and to use the healthier option of brown rice over polished white rice.  We have also introduced a programme to help consumers better identify food options that are healthier. Currently, there are 3,000 of such products and the outreach to the masses is fast expanding, with sales of such products growing at an average rate of 8% every year.  Those who include these healthier food choices in their diets, do indeed have diets that are richer in nutrition, have lower levels of sodium and saturated fat as shown in our survey results.  By making healthier choices more widely available, we hope to influence individuals to eat healthily.  

20.         We also need to start young. Experiments conducted by some Cornell researchers have also shown that by making a few low-cost changes to the set-up and presentation of fruits in a school cafeteria, the average sales of fruits doubled.  The modifications were simple to implement, allowed for students to retain the choice and the sense of responsibility over what they eat and yet increased the chances that they would more consume fruits, nudging them towards a healthier diet.  Although this area of behavioural nudging is still fairly new, we should keep an open mind and eye on such developments as it has the potential to shift paradigms. 

21.         In terms of improving our propensity to exercise, we have developed an island-wide network of linear open spaces around major residential areas, linking up parks and nature sites in Singapore, to make exercising an activity that everyone can engage in and enjoy, no matter where they are.  For some individuals, dedicated exercise venues may not appeal to them.  So, we have created opportunistic exercise venues; for instance by having “mall walks”, which are brisk walks conducted in the mornings at shopping malls, for those who prefer to exercise indoors and are very used to staying within the four walls of a shopping mall. Shopping is a favourite pastime for Singaporeans. After that, they can go on shopping, when the shops open after their exercise. 

22.         Creating non-financial disincentives/support to discourage unhealthy behaviour – As we all know, smoking harms not just the smoker, but also those around them. However, it is a highly addictive habit that is difficult to quit despite knowing these facts.  On average, a smoker would go through six, seven attempts before they can quit their habit successfully. Heavy tax duties have worked to a certain extent but have to be augmented by other measures to reduce our smoking prevalence rates. To this end, we have sought to make smoking an inconvenient affair by systematically and progressively restricting smoking at workplaces, places of entertainment, hospitals, bus stops and even common spaces in residential areas.

23.         In parallel, we have put in efforts on several platforms to help smokers quit the habit by providing a comprehensive support network to them.  This includes a personalised hotline services for all who wish to quit smoking, as well as family and friends who would like to find out how they can help their loved ones. Being cognisant of the power of influence and social media, we have launched a ground-up movement called “I Quit” which aims to inspire people to make a similar attempt at quitting their smoking habit through real-life testimonials and role models.  Let us take this short opportunity to take a look at the video for “I Quit” Platforms such as Facebook and a smoking cessation mobile application are used to provide support tools and tips to quit smoking, as well as for family members and friends to provide the “online” support for those who wish to quit.

24.         Beyond public campaigns to encourage smokers to quit, we have also sought to create community touch-points that are commonplace in one’s everyday life. For most of us, we spend a great deal of time at work, hence it makes sense for us to enter into the workplace setting and collaborate with companies and employers to reduce the incidence of smoking. 

25.         Using collaboration instead of regulation is our next strategy. Making a strong stand in favour of healthier food and drinks is an important part of the battle against the bulge.  Some countries, including Denmark, Finland and Hungary, have implemented taxes to curb the intake of high-fat food and sugar-laden drinks.

26.         Besides measures like a “soda tax”, it is also possible to work with food manufacturers to reduce sugar content in their products so that consumers would take in less sugar in their diet.  We now have a good variety of reduced-sugar sweetened drinks that have 20% less sugar content. 

Living with peace of mind

27.         Having talked about the strategies to help our populations live longer and healthier, we would also need to ensure that sufficient resources are set aside to pay for their healthcare needs today, as well as in the future.  After all, we are likely to require healthcare services more frequently as we grow older, and with each episode becoming more costly.  For example in Singapore, our seniors seek acute care services four times more frequently and the cost incurred are one and a half (1.5) to two (2) times higher.  Compounded with a growing number of elderly, the burden of financing such expenditure is expected to grow exponentially in the years to come.  Our response to such a challenge has to involve setting up a sustainable and effective healthcare financing system so that we will be able to provide peace of mind that healthcare will always remain affordable when we ourselves grow old.

Universal features for a sustainable and effective healthcare financing system

28.         To start off, let me outline the features of such a universal, sustainable and effective healthcare funding system:

a.    Firstly, it provides universal healthcare coverage, ensuring that the sick and poor are not denied good quality healthcare because of their inability to pay.

b.    Secondly, it is affordable to both present and future generations.

c.    Thirdly, it encourages patients and doctors to choose effective and appropriate healthcare.

29.         The road towards achieving universal healthcare coverage is not easy to navigate and requires a firm commitment by various stakeholders for it to happen in due course.  Despite rapid rates of economic development, mature Asian economies like Korea, Japan and Taiwan have taken much time to carefully consider and institutionalise their national health insurance schemes. In Singapore too, the building blocks for universal health coverage were progressively put in place over an extended period of time.  Countries that are only starting to work their way toward universal healthcare coverage now have an advantage as they can learn from the experiences of those who have gone before them. But they face a mammoth challenge of having to do so in a much shorter period of time and amidst a slowdown in the global economy.  At the same time, they have to bear in mind that the foundation which they lay today should not simply solve short-term problems without a view for the future. Otherwise, the efforts to undo ingrained structural issues later would be far more intensive and require greater trade-offs. 

30.         Moving on to the second feature, a sustainable and effective system must be affordable not just for our present generation but also for our future generations as well.  We cannot borrow against our children’s future to finance our present needs. There is a strong case for family support. But we have to be careful and ensure that intergenerational transfers are managed appropriately for future sustainability.

31.         Our foremost reason for introducing Medical Savings Accounts, what we call Medisave in the 1980s, was our concern about the long-term fiscal sustainability of the tax-financed healthcare system that we inherited from the British.  With an ageing society, our working population will shrink in time to come and the number of elderly dependents is set to grow.  Under such circumstances, it is extremely challenging to provide comprehensive healthcare benefits for the elderly without creating a heavy burden on our future generations and thus calls for the need for us to put in a savings mechanism to ensure that we set aside sufficient resources for ourselves.

32.         Newly rising Asian economies will need to save up whether at the level of the individual, family, or the country as a whole in anticipation of future healthcare costs.  Therefore, it is important that policymakers are far-sighted and forthright enough to prescribe such medicine where necessary.  

33.         Third, an effective financing system must incentivise individuals and doctors to make the appropriate treatment choices.  This entails the use of supply-side cost-containment as well as demand-side cost-sharing in the form of user fees and patient co-payments. We have employed both in Singapore – on the supply-side, subsidies for our public hospitals are given out based on diagnosis-related groups rather than on a fee-for-service model.  This has been highly effective in reducing over-servicing and increasing hospital efficiency.

34.         Our national health insurance scheme, MediShield is designed with deductibles and co-payments. Such patient cost sharing features instil individual responsibility when making healthcare decisions, and prevent flagrant abuse.  On the other hand, co-payments should not be overly large such that it creates a financial burden on the patient and his family.

35.          Here too, health services research plays a critical role in identifying cost-effective treatment, understanding patient responses to both monetary and non-monetary incentives, and designing optimal supplier contracts and insurance plans.

36.         Overall, these design principles do not prescribe a particular form of healthcare financing system – whether it is tax-financed system, social insurance-based one, or a medical-savings funded one.  We see a variety of such systems in matured Asian economies, and we are likely to see an emergence of different healthcare financing models as countries develop and strengthen their systems accordingly to meet their own needs and circumstances.  There are strengths and weaknesses inherent in each system, what is critical is that we have the objectivity to judge each system on its merits,  the willingness to adopt features that work and refine them to meet with the evolving environment.  

Organising for excellence

37.         Having addressed the broad strategies in helping our population to live longer, healthier and with a peace of mind, I think that it is an appropriate juncture to talk about how we should organise ourselves in achieving excellence in healthcare.

38.         Beyond establishing high quality of healthcare service at each care setting, we must avoid creating silos but go one step further to provide a well-integrated healthcare network where patients can move around seamlessly across providers of care. There are many ways to do so – by setting up IT enablers to facilitate information sharing, by making use of physical proximity between different service providers or simply to put them in a one-stop centre.

39.         There are good examples of excellent care integration around the world.  Geisinger’s patient-centred medical home framework in the United States is one of the examples that we have studied.  Aimed at improving a person’s health status and the care he receives through better co-ordination, it leverages on electronic health records and well-structured incentives to empower both patients and doctors in taking the appropriate actions and decisions.   

40.         In Singapore too, we are exploring how we can improve in this aspect of care integration.  For instance, we are looking at delivering new models of care at the primary care setting.  Traditionally, this is largely delivered by solo practitioners but their small size limits their ability to provide comprehensive care for patients with multiple chronic conditions.  To improve upon this area, we are looking to set up centres that bring together doctors, nurses, and allied health professionals in one place.  This allows us to deliver care in an integrated way in the community so that patients can benefit from better care that is nearer to them.

41.         And as citizens move across the care spectrum, from seeing a family physician, to a specialist in the hospital and perhaps back to their family physician when they have gotten better, it is important that every healthcare professional they consult have visibility of where they have been.  Previously, while patients can travel, their medical records and the test results could not.  This resulted in a lot of friction costs, such as going through duplicate tests as well as a less-than-optimal patient experience.  A few years ago, we embarked on a journey to develop the National Electronic Health Records system.  I am glad that we have rolled out Phase 1, connecting all public healthcare institutions and organisations, and providing additional access to 22 private providers from the primary and long-term care sector.    

42.         As we conduct self evaluation on the areas that we are lacking and seek improvements, it is equally important to know where we stand among the rest of the world and to learn from others who are doing better.  Benchmarking and collaboration will help to build up a body of knowledge which providers can tap on to improve and collectively move our healthcare system forward.  These efforts can be taken further – regionally, and even globally. Each and every one of us, committed to improving our domestic health systems, can benefit from such sharing of experiences, knowledge, and innovative solutions.  Many such platforms already exist; one example, which Singapore is a part of, is the HealthTracker project – a region-level benchmarking project that provides a framework to share information on healthcare improvement, compare performance, and to identify best practices

43.         More importantly, we need to learn how to translate these best practices into real changes in the way we provide care, in the way we think about health policy, and in the way we structure our care delivery systems.  This will require not just clinical benchmarking and change management at the provider level. It must stem from a more fundamental understanding of how we shape our governance structures and organisations, the incentives and disincentives inherent in our system, and their implications on our policy decisions. We should “dig deeper” as each of us strive to reform our healthcare systems, and we should learn from one another through this process.

44.         One way which we can do this is to establish communities of practice among researchers, practitioners, and policy-makers.  Singapore would be glad to be part of an endeavour to bring together like-minded individuals, in the spirit of sharing policy-relevant research and knowledge.  With our common aspiration of achieving better health outcomes for our citizens, designing better healthcare systems, and tackling future health challenges in collaborative and collective ways, I am confident that we can establish productive platforms for engagement and exchange. 

Conclusion

Invitation to inaugural regional WHS hosted by Singapore in April 2013

45.         As we gather together at the World Health Summit in the past few days, I believe that we have learnt a lot from each other.  In keeping with the momentum of collaboration and sharing, I would like to take this opportunity to share that Singapore will be hosting the first regional meeting of the World Health Summit outside of Berlin next year. This regional meeting continues the aim of the World Health Summit to engender improvement of health care and health-systems with a focus on Asia.

46.          With Asia becoming one of the major global economic engines for the next decade, the varied challenges such as growth in population, wealth creation, urbanisation, ageing issues and growing prevalence of chronic diseases will also be bringing unprecedented challenges for healthcare in the region.  The issues are daunting but not insurmountable.  Health care leaders will be coming together in Singapore at this regional meeting to move research and knowledge to policy and implementation in Asia and beyond. We welcome you to join us in Singapore to share about building “Health for Sustainable Development in Asia”.

47.         Thank you.