Universal Health Coverage in Singapore:
Common lessons from and for the rest of the world
Dr. Kelvin Bryan Tan / Director
Ministry of Health Singapore / Policy Research and Economics Office
Singapore
[email protected]
Universal Health Coverage is a
challenging and ongoing endeavour…
• Evolution of UHC in Singapore
• Convergence? Rather than divergence?
• Ongoing journey
• What do we have to bring along this journey?
2
Why look at Singapore?
Difficult to understand, but hard to ignore…
“I don’t think there’s a single [healthcare] system in the world
that spends as little as Singapore does in terms of percentage
of GDP and gets the [health] outcomes that it gets.”
- Dr. Jim Yong Kim
President, World Bank
“Through foresighted and visionary planning, Singapore
achieved first-rate health care, with outstanding health
outcomes, at a cost lower than in any other high-income
country in the world.
In terms of return on investment, you are No. 1 in the world.”
- Dr. Margaret Chan
Director-General, World Health Organisation
3
All countries strive to develop a healthcare financing
system that is universal, effective and sustainable…
Universal
- Accessibility to Healthcare
Trade-offs
Effective
- Quality
- Health outcomes
Sustainability
- Cost to current and future
generations
 Universal Health Coverage (UHC) is thus an on-going journey for all
countries involved
4
Singapore inherited a strong single-payer
NHS system from the British
•
•
With universal health coverage provided by government subsidies
However, we started worrying over the fiscal sustainability of a PayAs-You-Go system in early 80s
Resident Old-Age Support Ratio
No. of Residents Aged 20-64 Years Per Resident Aged 65
Years & Over
16
14
13.5
Source: Population Trends 2012,
Department of Statistics (up to 2012)
12
Source: MOH projections
(2013 onwards)
9.0
10
7.2
8
6.7 in 2012
6
4.3
4
2.6
1.8
2
0
1970
1980
1990
2000
2010
2020
2030
2040
2050
 Recognising the challenges of financing such coverage sustainably…
5
Embarked on a systematic series of reforms to
restructure the healthcare delivery system…
• Recognising shared responsibility
o
Individuals and families: healthy living and saving for
healthcare expenses
o
Providers: efficient delivery of cost-effective care
o
Insurers: mitigating financial risk associated with illness
o
Government: safety net, help the needy, channel subsidies to
the poor and sick
6
Patient financing system put in
place to empower individuals
• 1984 Medisave
o
Compulsory medical savings account for family use
o
6.5—9% of income
o
Restricted to inpatient, day surgery, selected outpatient
• 1990 Medishield
o
High deductible health insurance
o
Opt-out
o
Actuarial premiums
• 1998 Medifund
o
Endowment fund to help those who cannot afford copays
7
Healthcare financing
National Healthcare Expenditure (NHE)
Employer
benefits
Medisave
MediShield
&
Cash
Eldershield
Individual Financing
Medi
fund
Government
Subvention
Government Expenditure
8
Our model has evolved to incorporate
elements of other systems
Tax-based subsidies
Retained NHS style heavy Govt
Subsidies; ownership over majority of
acute care providers
Compulsory
healthcare savings
Unique Element  Medisave
Risk-pooling
via insurance
schemes
Ultimate
safety net
for the
needy
Govt-run insurance 
MediShield
Private insurance 
Integrated Private
Plans
Not insurance per se, but protection
of needy  Medifund
9
Public sector providers focus on
social mission of accessible, affordable care
Primary Healthcare
- 17 Polyclinics (20%)
- Private GP Clinics
(80%)
•
•
Secondary & Tertiary Care
- 8 Restructured Hospitals
& 6 specialty centers (80%)
- 16 Private Hospitals (20%)
Step-down & Long
Term Care
- Voluntary welfare
Organizations (70%)
- Private Healthcare
Organizations (30%)
Pre-1985: Government owned & operated all public sector hospitals
1985 - 2000: Corporatised government-owned hospitals
o Competition encourages providers to be more efficient,
innovative & service-oriented
o Corporatised model provides:
 Operational autonomy
 Greater financial discipline
 Alignment to social goals;
10
Financial coverage not sufficient for UHC…
• MDGs continue to be important
• Social determinants of health – education, literacy,
employment
• Primary, Prevention and Health Promotion
• Access to care
• Manpower training
• Social networks and support
All this has to be done in a integrated, coordinated fashion
11
CHALLENGES GOING AHEAD…
12
Convergence as most countries
deal with the same healthcare challenges
• Increasing use of appropriate copayments in
healthcare
• Use of cost-effectiveness analysis for coverage
decisions
• Capitation and prospective payments systems for
provider cost-sharing
• Focus on Preventable Disease
• Choice of providers, insurers to promote greater
competition
13
What do we have to bring along this journey?
• Measuring where we are
• Investing in prevention
• Doing the right things
• Saving for the future
14
Good set of metrics to measure progress…
• Aggregate metrics like % Out-of-Pocket payment will
be less useful as income disparity increases
o
Measures of distribution of OOP payment by income-tier
more useful
o
Problem is that expenditures of healthcare are in old age
groups where income is low
• Ideal metric
o
Looks at distribution of lifetime expenditure/lifetime income
15
Large proportion of DALYs
can be avoided with prevention…
 Design of UHC must include encouragement for lifestyle and
dietary changes
16
Getting people to make better decisions…
• Medical decisions will increasingly be joint decisions
o
Government/Insurers
o
Physicians/Providers
o
Patients
• Cost effectiveness analysis to better inform such
decisions
o
Both… collectively and individualised
• Appropriate co-payments and cost-sharing
o
Value-based insurance design
o
Providing incentives for innovation and increasing productivity
of providers
17
Saving for the future…
• Healthcare expenditures increase exponentially
with age
o
Healthcare prices are increasing faster than CPI
• There needs to be ways to facilitate payment for
healthcare expenditures
o
Medical Savings Accounts
o
Prefunded Premiums (pay more when young)
o
Ringfenced social insurance
• Critical for government to set aside sufficient savings
for future healthcare needs
18
Thank you... Any questions?