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20 Oct 2003
By Mr Khaw Boon Wan
Venue: Camden Medical Centre
"Old Dream, Renewed Ambition"
Old Dream
Our dream to make Singapore a regional medical hub is an old one.
The late Dr Winsemius suggested it decades ago, when he came here to advise us on economic development. He made many useful suggestions. Many were realised: petrochemicals hub, the Asian Currency Unit, logistics hub, etc.
But the medical hub idea has not fully blossomed.
To be sure, Singapore does attract large numbers of foreign patients. Last year, more than 200,000 foreigners came here for medical services. That is not a small number.
But our dream was much more ambitious. With 500 million people in ASEAN, just 10% alone would be a sizeable volume for our healthcare sector. And now with tens of millions in China and India entering the middle class every year, we can be even more ambitious.
The Economic Review Committee reaffirmed this ambition. It projected a target of serving 1 million foreign patients annually by 2012, 5 times the current number. This is a good stretched target and within our grasp. With some of our brightest students in each cohort entering medicine and with our big push on life sciences, we should strive to fully exploit this sector. This will create well paying jobs for many Singaporeans.
"Same Bed, Different Dreams"
Not all, however, are completely comfortable dreaming this dream. The Ministry of Health itself has had some reservations. MOH's priority is to provide Singaporeans with low cost healthcare. It has harboured concerns that a busy medical hub treating many foreign patients will push up health care cost, as public hospitals will then have to compete with private hospitals for specialists and nurses.
This is a legitimate worry. Soon after I joined MOH in 1978, Mt Elizabeth Hospital opened with great fanfare. It was quite a success. For several years, it served more foreigners than locals. A large proportion of the patients were Indonesians. Taxi-drivers called it the "Indonesian hospital". It was also a major client of EDB, enjoying tax benefits.
But it created quite a headache for MOH. Some of our well-trained consultants left to join MEH. Almost overnight, SGH was partially hollowed out. It took the public hospitals several years to rebuild our clinical departments, strengthen them and regain our eminent position. But along the way, wages crept up to a different level. Healthcare cost was no longer the same as pre-MEH days.
I recall this development to highlight the medical hub dilemma. Being a medical hub may be a positive outcome by itself, but along with that may come other problems which can cause headaches.
"Fish or Bear's Paw?"
But should we accept the equation that "regional medical hub leads to higher healthcare cost" as a given fact? Or can we somehow reconcile the two seemingly contradictory policy objectives?
After 14 years in MOH and 7 years in MTI, I believe that the dream of becoming a regional medical hub and containing healthcare costs are not mutually exclusive. I look at the cause-effect equation differently. I would turn the formula around based on basic economics. If we want to become a regional medical hub, then we must fix our healthcare cost. If our healthcare cost is too high, we cannot possibly succeed as a regional medical hub.
Ten years ago, Singapore was the undisputed medical hub for this region. We were the clear leader. Indonesians, Malaysians, Bruneians came here for treatment, in large numbers. Today, many foreign patients are still coming here, but competition from the region has increased and foreign patients now have choices.
As is the case with other sectors of the economy, if we do not have a good handle over our cost-competitiveness, we will not be able to fully maximize our potential as a regional medical hub.
The Toyota Way
We should draw inspiration from Toyota. Toyota produces Corolla for the masses and Lexus for those who demand more. It also takes part in Formula-1 racing.
To sell Corollas, it pushes "zero defects" and mass production to derive quality at the lowest possible cost. Likewise, for the common medical conditions that the bulk of our patients come to us for treatment, we should also ensure maximum reliability, zero defects and lowest possible cost. These are our Corollas.
That is why I publish on the MOH website the price comparison of the common medical conditions. The public seems to welcome such transparency. It is to push our hospitals and doctors to critically review their operations, to see how they can do more with less, and bring their Corolla production cost to as low as possible, while ensuring good quality control.
This requires us to make sure that we do not over-engineer our Corollas. Of course, there are patients who demand frills, branded implants, just as there will be buyers of Lexus who can afford and want more than Corollas. Our response should be to offer them Lexus, with the wood paneling, full leather upholstery and custom-made Levinson sound system. We should not attempt to fit all these into our Corollas, driving up costs and putting them beyond the reach of the masses.
Separately, we should take part in Formula-1 to show the world that we can hold our own against the best in the world and win. Hence, we do IVF, heart transplants, liver transplants and separation of conjoint twins.
To be a regional medical hub requires us to do well at all three levels. There is actually no money to be made racing in Formula-1. In fact, you lose money. But we need to take part in order to push up our capabilities and to benchmark ourselves against the best in the world.
By mandate, the public hospitals' focus is on Corollas for the masses. But the private hospitals especially should leverage on our Formula-1 reputation, build on the Corolla platform, and enhance it with extras to offer their customers the Lexus. Public hospitals have started making our hospital bill size transparent. The private hospitals should also take step to make their charges transparent so that their patients can select more wisely and be more reassured.
Renewed Ambition - The Road Ahead
To fully realise our old dream of becoming a regional medical hub requires a concerted effort, by all sectors, public or private, and by all relevant agencies: MOH, MTI, NUS, EDB, STB, IE Singapore. SingaporeMedicine that we are launching today shall be the rallying point and a powerful symbol of our collective will and commitment towards this ambition.
Fortunately, we have clear strengths relative to the competition. We have very well trained doctors, nurses, pharmacists, laboratory technologists etc. HIV is not a major problem here and we have a very safe blood supply. Our hospitals are well organized and well managed, with a high standard of care. Our life sciences efforts add a further boost as we can leverage on the pharmaceutical companies and the research community to achieve breakthroughs in clinical care and translational research. And we have a tradition of working well together as Singapore Inc, once the vision is clear and the strategy, well articulated.
In three specialties alone, heart, eye and cancer, I see tens of millions of middle-class patients within a 7-hour flying radius, waiting to be served. If they can be attracted here, they will keep us all very busy. But we must collaborate more, cut out unnecessary cost, further enhance reliability and make it easy for the patients to seek treatment here.
Another important component of our overall strategy is to recruit and train many more doctors and nurses. This is critical because matching supply of healthcare workers with demand is the key to ensuring that becoming a medical hub does not push up healthcare cost. If foreign patient load grows, without corresponding increase in doctors and nurses, then healthcare cost is bound to rise.
Hence, NUS is working with Duke University to set up a Graduate Medical School at the SGH campus. There is also on-going collaboration with Johns Hopkins. Meanwhile, we should see how we can admit more foreign specialists to beef up our capacity. Hospitals should also re-design jobs and re-engineer their processes to make nursing a desirable profession again. This will improve students' attitude towards nursing as a profession. Perhaps setting up a local degree course in nursing in our university may be an important part of the strategy.
To establish ourselves as a sustainable centre of medical excellence, we need clinical leaders with the bigness of heart and confidence in their own capabilities. Their responsibility will be to grow future generations of leaders and open doors to outside talent. The late Prof SS Ratnam, who pioneered IVF in Asia, was one such leader. There are others, but our talent pool is still limited, and we can do with many more.
Recently, I was at the closing dinner for the National Healthcare Group Scientific Congress. Many excellent papers were presented. We should pull in the Singhealth Group and the private sector as well and make it a mega annual event for SingaporeMedicine. It can be a week-long meeting, with workshops for different specialties, on different days of the week. We can also bring in experts from other countries and target the medical community in the region to participate and network with our specialists.
Mayo of the East
Making Singapore a regional medical hub is one of MOH's 8 priorities. I have asked Mr Philip Yeo to champion this priority. I can think of no better champion: he is highly focused and he delivers results.
We should draw inspiration from the Mayo Clinic. It is in the middle of nowhere. Yet it is recognized as a centre of medical excellence and patients from all over the world go there for treatment. But Mayo is high-cost medicine.
In the 1950s, the Japanese car-makers went to Detroit to learn the art and science of car making. They returned to make excellent cars at much lower cost and conquered the world market.
Can we do the same for healthcare services?
Can we be the Mayo of the East without the high cost?
Can we be a centre of learning, where doctors and nurses from the region apply to work in our hospitals because we offer excellent opportunities for research, education and patient care?
These questions will take years to answer. But as we build and nurture the culture of learning and sharing, we will see a growing exchange of talent, in and out of the country. This is my dream for Singapore as the regional medical hub, where regional doctors and nurses compete to work here to learn, and where international patients seek us out for care and treatment.
It requires us to compete within, while partnering with the doctors in the region and work as one to conquer the world.
Mr Philip Yeo, as Commander of the ship, that is your mission. May the Force be with you.