Healthcare delivery in Singapore

A decade ago, when I visited Singapore, I happened to interact with Dr V Anantharaman, Professor-Senior Consultant at Singapore General Hospital working in the area of emergency medicine. Singapore's healthcare delivery system provides population the primary healthcare, hospital care, long-term care and other integrated care. The city-country has a network of outpatient polyclinics and private medical practitioner's clinics to provide primary medical treatments, preventive healthcare as well as health education.

Unlike in many countries, in Singapore, 80 percent of primary healthcare services are offered by 2000 private medical clinics; whereas the remaining is delivered by 18 government polyclinics. In Singapore, Hospital care consists of inpatient, outpatient and emergency services. By contrast to primary healthcare, public hospitals provide 80 per cent of hospital care including specialty treatment. Even in the bed strength, government hospitals account for 80 per cent, whereas private hospitals just 20 per cent. The percentage of registered doctors (excluding specialists) and in the public institutions is about 80 and that of private sector is a mere 20.

Singapore, an island country with population of little over five million, has one of the highest medical standards across Asia. It is well-known for its efficient and widely covered healthcare system. Government promoted a National Health Plan in 1983. It detailed the infrastructural plan for the next 20 years together with the idea of Medisave. The plan is being up-dated from time to time to suit the needs.

There are three main regulators in the system, Minister of Health (MOH), Central Provident Fund (CPF) and Monetary Authority of Singapore (MAS). The well-established healthcare system in Singapore is composed of 13 private hospitals, 10 government hospitals and a number of specialist clinics, each one specialising in catering to the needs of different patients at varying costs. Patients are free to choose the providers within the government or private healthcare delivery system and can walk in for a consultation at any private clinic or any government polyclinic. For emergency services, patients can go at any time to the 24-hour Accident and Emergency Departments located in the government hospitals. Both the private and public hospitals of Singapore are equipped with state-of-the-art medical equipment in order to maintain the highest standards of medical services.

The government's healthcare system is based upon the "3M" framework. This has three components: Medi fund, which provides a safety net for those not able to otherwise afford healthcare, Medisave, a compulsory health savings scheme covering about 85 per cent of the population, and Medi shield, a government-funded health insurance scheme. Singapore government ensures affordability of healthcare within the public health system, largely through a system of compulsory savings, subsidies and price controls. Singapore's system uses a combination of compulsory savings from payroll deductions to provide subsidies within a nationalized health insurance plan known as Medisave.

Medisave introduced in April 1984 allows Singaporeans to put aside part of their income into a Medisave account to meet future personal or immediate family's hospitalisation, day surgery and for certain outpatient expenses. The savings can be withdrawn to pay the hospital bills of the account holder and immediate family members.

A key principle of Singapore's national health scheme is that no medical service is provided free of charge, regardless of the level of subsidy, even within the public healthcare system. At the same time no one is refused treatment on the pretext that payment has not been made. Normally the charges are collected at the time of discharge and irrespective of bill paid or not the patient is discharged first. The increasingly large private sector provides care to those who are privately insured, foreign patients, or public patients who are able to afford what often amount to very large out-of-pocket payments above the levels provided by government subsidies. Approximately 70-80 per cent of Singaporeans obtain their medical care within the public health system.

The Singapore General Hospital (SGH) is the largest and oldest hospital in Singapore. The Tan Tock Seng Hospital is the second largest hospital, but, its accident and emergency departments are the busiest in the country largely due to its geographically centralized location. Sing-Health is Singapore's largest group of healthcare institutions. The group was formed in 2000 and consists of two public hospitals across the island, five specialist centers and a network of nine polyclinics. The group operates Singapore General Hospital and KK Women's and Children's Hospital. The group runs five specialist centers which include National Cancer Centre Singapore, National Heart Centre Singapore, Singapore National Eye Centre, National Dental Centre of Singapore and the National Neuroscience Institute.

At SGH, patients have access to over 600 doctors from 29 clinical specialties. Except for emergency cases, patients are admitted to Singapore General Hospital only on recommendation from their medical specialists from the Specialist Outpatient Clinic. Once a date for admission is confirmed, patients are encouraged to visit the Hospital's Pre-Admission Testing (PAT) Centre to seek information on ward accommodation and register themselves for their desired accommodation class. Patients will also be advised on estimated bill size, average length of stay, various modes of payment accepted, documents to bring on day of admission and assistance available for those in financial difficulties. The PAT Centre will also schedule appointments for patients to undergo compulsory pre admission investigations such as blood tests, chest x-ray, electrocardiogram, which are conducted one week before admission.

A unique feature of Singapore healthcare is that, patients who seek medical treatment at any Public Health-Care Institution, from hospitals to specialist centers and polyclinics need not recount their medical history to the doctors. This information is captured in a centralized database known as National Electronic Health Records System.

In the Emergency Department, priority is to attend to patients with serious illnesses and injuries. The Emergency Department at SGH is one of the busiest in the country. There is a Senior Emergency Physician on duty on every shift. Patient will be assigned a specific priority level according to the severity of his or her medical condition. Hospital staff will advise the patient appropriate area to go to for consultation and treatment. There are separate waiting areas for patients with different priority levels. Patients with fever will be managed in a separate area in the Emergency Department. This is to reduce the risk of infection to the other patients in the Emergency Department.

In Singapore, the Emergency Ambulance Service (EAS) is operated by the Singapore Civil Defense Force (SCDF) and it can be reached by dialing 995. The service is designed to provide an immediate response to patients with life-threatening situations. 995 ambulance services are free only if it is a true emergency. In all there are 40 ambulances parked in 14 ambulance stations providing this service. I went round the SGH with Dr Anantharaman and found every part of it being maintained with highest standards and better than the best of the private hospital in India.