Keynote Speech By Mr Gan Kim Yong, Minister for Health, At The Economist’s “Healthcare In Asia 2012” Conference, 28 March 2012, at The Fullerton Hotel Ballroom

“A Healthcare System for Singaporeans” - How an outcomes-oriented approach has enabled Singapore to develop a healthcare system to meet the needs of its population

1     It is truly an honour for Singapore to host this Economist Conference on Healthcare in Asia.  Let me begin by extending a warm welcome to all our overseas delegates and speakers.

Challenges facing healthcare in Asia

2     A paper published by the Economist Intelligence Unit to coincide with the Healthcare in Asia Conference two years ago (2010), highlighted several key challenges faced by countries in the region, in particular the impact of economic development and ageing.  The report emphasised the need for healthcare systems, most notably in Singapore, Taiwan, Hong Kong, and South Korea, to come to grips with rapidly ageing populations. 

3     The paper also stated that “Wealth needs to come with a health warning”.  A more affluent lifestyle and longer life expectancy has led to non-communicable diseases becoming the leading cause of death in Asia. Infectious diseases however remain a significant part of the disease burden in many Asian countries.  Health systems in these countries are now facing this epidemiologic transition and have to fight on both fronts.

4     Developed and developing countries have to meet these challenges in the while managing resource constraints.  A study by the Organisation for Economic Cooperation and Development (OECD) showed that per-capita spending on healthcare among its 34 members had risen by 3.2% in real terms every year since the early 1990s, compared to economic growth of just 2.4% a year.  Given the economic outlook and the expanding ranks of the non-earning elderly, many believe that such spending is becoming unsustainable.

5     Adding to the above is the reality that expectations for better healthcare will continue to.  The challenge therefore is to do more with less and produce better outcome at lower cost.  Is this a dream or can this become a reality?  Let me share with you how Singapore has fared and how are we preparing to face these imminent challenges.   

Singapore’s healthcare performance

6     Singapore’s healthcare system is internationally recognised for good outcomes, universal coverage and financial sustainability. In 2000, the World Health Organisation ranked Singapore 6th out of 191 countries in terms of health systems performance.  More recently, Singapore was ranked 3rd on Health Infrastructure by the International Institute for Management Development (IMD); and 3rd lowest in the world on infant mortality and 7th highest in life expectancy in the World Economic Forum (WEF) Global Competitiveness Report 2009-2010.  All these were achieved with a national health expenditure of 4% of GDP.  This is a “Made in Singapore” result created by generations of healthcare leaders who invested wisely to address prevailing needs while preparing for the future. 

7     Our healthcare system is facing similar challenges as many other countries in Asia.  Firstly, our population has been growing rapidly.  Over the last ten years our population increased by 25%. We are also ageing rapidly.  By 2030, 1 in 5 Singaporean residents will be aged 65 and above.  This is a threefold increase to 960,000 elderly, from around 350,000 today.  With increasing life expectancy and changing lifestyles, we are faced with a growing burden of chronic diseases.  As we plan for the future, we must also recognise that economic cycles will be increasingly volatile, and our economic growth expected to be more modest compared to the strong growth we enjoyed in the 80s and 90s.

8     More of the same will not do.  We need to fundamentally re-examine how healthcare services are structured and delivered. In the past when the population was younger, our healthcare system was focused mainly on the acute hospitals because diseases then were more episodic in nature.  With the population ageing rapidly, prevalence of chronic diseases is likely to rise.  Effective chronic disease management is important and will require new models of care, especially within the community, to provide sustainable intermediate and long term care and support.  This will help reduce subsequent complications, which will not only add to the load on our healthcare system, but are also costly to treat, and more importantly, will adversely impacts patients’ quality of life. We have therefore been shifting our focus from episodic care in acute hospitals to a more holistic approach. 

Singapore’s approach to healthcare challenges

9     The approach that we have adopted to achieve these goals is a pragmatic one, focusing on what works in practice and adapting to the local context best practices from around the world.  We have also sought to distinguish between means and outcomes.  It is not how much we spend on healthcare, but how we spend the least resources to achieve the best outcomes. 

10     Firstly, we focussed on evidence-based interventions that have proven to yield good clinical outcomes.  Secondly, we adopted a systems approach in planning healthcare delivery, transcending institutional boundaries to ensure high quality, integrated care at the patient level.  Thirdly, we focussed on cost effectiveness, and not just cost per se. I shall now describe each point in turn.

Focus on evidence-based interventions

11     In 2006, we introduced the Medisave for Chronic Disease Management Scheme which for the first time allowed patients to tap on their Medisave, a Medical Savings Account, for outpatient treatment of chronic conditions.  A requirement under this Scheme was for participating doctors to follow evidence-based disease management protocols, hence ensuring delivery of high quality care to patients.

12     Over the past year, we have been working to develop Integrated Care Pathways (ICPs) for five common clinical conditions. These include Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Heart Failure, Stroke and Hip Fracture. Our aim is to chart out the care that patients should receive across the continuum of care from prevention to end-of-life care.  For each condition, a workgroup of local clinical experts will identify and prioritise clinical interventions based on a detailed scan of medical literature to determine the cost-effectiveness of each intervention, and the types of patients most likely to benefit from it.  The workgroup will then determine when, where and how the prioritised services should be delivered. The workgroup will also identify enablers, such as IT systems that are required to deliver the services effectively and efficiently.  We are also working on the performance framework for each pathway to ensure that the identified interventions are consistently delivered to the appropriate patients.

Adopt a systems view in planning healthcare delivery

13     Over the years, we have invested heavily in building our acute hospitals.  They have attained high standards of care, with some achieving peaks of excellence and earning themselves international recognition.  There is however room for improvement. 

14     Firstly, we need to focus upstream on prevention to reduce avoidable admissions.  All of us recognise the need to live healthy lives. Translating this knowledge into sustained action is however often a challenge.  As the saying goes, the spirit is willing but the flesh is weak. To overcome this inertia, our Health Promotion Board (HPB) is leading the strategic shift in health promotion by moving from the traditional awareness campaigns to the creation of social movements, rallying the community to co-create and own ground up initiatives, customised for their respective local communities.  Our aim is to create a health-promoting ecosystem where healthy living is the new norm.  To this end, the HPB aims to recruit an army of Health Ambassadors to advocate healthy living among their peers.  To date we have recruited more than 2,000 Health Ambassadors and their impact is already being felt on the ground.  

15     One example where the ecosystem and health ambassadors come together is HPB's Integrated Screening Programme which encourages Singaporeans to be screened for obesity, diabetes, high blood pressure, high blood cholesterol and for selected cancers, as well as to encourage proper follow-up and management. Under the ISP, Singaporeans who turn 40 will receive invitations from HPB to go for the recommended screening tests based on age and gender. The integrated screening programme has now been enhanced to include the screening of seniors for functional decline. Patients with abnormal results are referred to a network of GPs to ensure that they are appropriately followed up. HPB leverages on its Health Ambassadors to encourage those who should be screened to come forward and also to organise local healthy lifestyle events.  This way, the local community brings people together and provides opportunities for them to start adopting regular physical activity and healthy eating habits.

16     Let me illustrate this. Mr Tan Kin Teo, one of HPB’s Health Ambassadors, volunteers regularly in his local area.  He helps to conduct simple health checks such as BMI and blood pressure measurement for the residents and shares healthy lifestyle advice with them.  One day, he found a resident with a high blood pressure reading.  On speaking with her, he realised that she had stopped taking her medication for high blood pressure.  He advised her to see a doctor as soon as possible.  But he did not stop there.  He visited her the next day to check on her and help her along on her healthcare journey.  Kin Teo and many other Health Ambassadors have also championed health-related interest groups such as brisk walking clubs to help their fellow friends and residents embrace healthy living in the community.  The Ministry also conducts dialogues with these ambassadors to get feedback on the issues they encounter on the ground and fine tune our policies where necessary.

17     Secondly we need to integrate care for patients to move seamlessly across care settings and be cared for in the most appropriate setting.  We have therefore been working on enhancing care in the community in particular primary, intermediate and long term care. Let me elaborate.

18     In Singapore, 80% of primary care is provided by the private General Practitioners (GPs). Therefore, we have been working with private sector GPs to introduce new models of care to better manage chronic diseases. For example, Family Medicine clinics will be set up in the community with 4-6 GPs in each clinic supported by pharmacy and laboratory services, nurse educators and allied health professionals.  We have also enhanced our Community Health Assist Scheme, a portable subsidy scheme for lower and middle income patients, so that they can enjoy subsidised care when they visit their GPs.  We hope through these initiatives to tap on the capacity and capability of private GPs to provide high quality team based care that is affordable and easily accessible for our population, rather than to rely solely on government polyclinics for subsidised treatment.

19     We are also developing a range of home- and community-based aged care services to enable seniors to age in their communities and support families in caring for their loved ones at home.  For example we are working with our Ministry for Community Youth and Sports to develop Integrated Day Facilities (IDF) to provide day care for frail elderly, together with rehabilitation and dementia programmes for those who need more support.

20     Together with the introduction of new care models, we are reorganising our healthcare system into Regional Health Systems (RHS) to ensure hassle-free, integrated/ joined-up care from the patient’s perspective.  Each RHS would have an acute general hospital that works in close partnership with the public, private and people sector within the region to provide seamless care for patients.  These collaborations would extend beyond healthcare providers to also include providers from the social and other relevant sectors.  Each RHS is expected to focus not just on treating those who are ill but also on improving the health of the population.   

21     One of our RHS is the  Eastern Health Alliance which is anchored by an acute hospital (Changi General Hospital)  working in collaboration  Peacehaven Nursing Home, SingHealth Polyclinics and St. Andrew’s Community Hospital to enable patients to move seamlessly  across settings and receive appropriate care through the development of shared clinical pathways and care protocols.  

22     We have put in place key enablers to support the implementation of this integrated approach. Allow me to briefly elaborate on some of them.

• Agency for Integrated Care (AIC): Set up in 2008, AIC functions as the ‘national care integrators’, helping patients navigate the healthcare system and referring them to the most appropriate care provider post-discharge;

• IT interfaces such as National Electronic Health Records (NEHR): A key enabler of ensuring ‘joined-up’ integrated care across the various settings of care is the seamless exchange of health information via Information Technology (IT).  We started in 2004 among public sector hospitals with the EMR Exchange; and ‘upgraded’ in 2011 to the National Electronic Health Records (NEHR), which not only contains more information but has expanded in scope and coverage to include the primary and intermediate and long term care.  The aim is to enable healthcare professionals to better coordinate care for each patient, no matter where he or she has been, to reduce duplications of tests and enhance patient safety. 

Focus on cost effectiveness, and not just cost per se

23     Over the years, we have built a robust healthcare financing system based on the principal of personal responsibility with copayment to avoid the buffet syndrome with overconsumption of services.  This is supported with government subsidies to ensure healthcare remains affordable. We have also introduced various patient financing measures – such as the 3Ms (Medisave, MediShield and Medifund) and ElderShield – to help patients pay their share of the bill.  Our financing system has enabled us to achieve good health outcomes at relatively low cost overall.

24     As our needs change, our financing framework will also need to evolve to help Singaporeans meet the new realities.  In the past, we focused our financing framework to address the needs of inpatients.  This was the right approach for that time – our population was young, and the main financial impact was from hospitalisation. However, an ageing population requires more frequent care and this care should where possible be delivered in the community instead of in our acute hospitals.  While individual outpatient bills may be smaller compared to hospital bills, their cumulative impact can be substantial.  We have thus been enhancing our financing system such as increasing subsidies for long term care, increased assistance for drug costs for the lower and middle income and enhancing portable subsidies for primary care I mentioned earlier.  We hope through these measures to help patients to be managed in the most appropriate and cost effective setting. 

25     To ensure that healthcare remains affordable, we also need as a system, to do our best to bend the cost curve by reducing inefficiencies and discourage over-consumption.  We are therefore judicious in deciding what to subsidise, focusing on measures that would achieve the best outcomes.  We have also sought to innovate, increase productivity and develop new cost-effective models of care.  One of the ways we achieve this is through technology.  Take tele-ophthalmology, which allows ophthalmologists, located in the hospitals, to ‘look into’ the eyes and retina of patients in the polyclinic.  Those with minor conditions can receive the medication that they need at the polyclinic, and only those with more serious conditions will need to be referred to the eye specialist clinic for further investigation.  This brings care to the community level, and cuts down unnecessary visits to specialists, saving time and costs for patients and freeing up resources at the hospitals.

Conclusion

26     The Singapore healthcare system is still very much a work in progress.  While we have our successes, we also have our challenges.  This conference offers a unique opportunity for healthcare leaders in the region to come together to share our experiences and ideas in developing and managing our healthcare systems.  As our respective contexts differ, some of our approaches may not be applicable in other countries.  I believe however that there is much we can learn from each other to do better for our people. With clarity of objectives and rigour and innovativeness in implementation, we can each find ways to improve our healthcare systems for the benefit of our population.  

27     Let me end by wishing you all a productive meeting and a valuable two days together.  Thank you and have an enjoyable conference ahead.