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Singapore: Singapore Health Profile

2015/02/17

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Singapore Healthcare System

Hhealthcare system comprises public and private healthcare, complemented by rising standards of living, housing, education, medical services, safe water supply and sanitation, and preventive medicine.
 
Over the years, MOH has followed the principle of ensuring that good and affordable basic medical services are available to all Singaporeans. We have been continuously fine-tuning our system to ensure we are always aligned with this principle and developed our healthcare system into one that has received praise and recognition both locally and internationally.
 
Singapore healthcare begins with building a healthy people through preventive healthcare programmes and promoting a healthy lifestyle.
Good, affordable basic healthcare is available to Singaporeans through subsidised medical services at public hospitals and clinics. Our hospitals and healthcare system will at no time withhold help to a Singaporean because of financial limitations. From presently on our philosophy promotes individual responsibility towards healthy living and medical expenses. Medisave, Medishield, ElderShield and Medifund schemes exist to help Singaporeans “co-pay” their medical expenses.


Primary Healthcare


Primary health care includes preventive healthcare and health education. Private practitioners provide 80% of primary healthcare services while government polyclinics provide the remaining 20%. However, public hospitals provide 80% of the additional costly hospital care with the remaining 20% by private hospital care.
Singapore network of 18 outpatient polyclinics and some 2,000 private medical practitioner's clinics provides our primary health care services. Each polyclinic is an affordable subsidised one-stop health centre, providing outpatient medical care, follow-up of patients discharged from hospitals, immunisation, health screening and education, investigative facilities and pharmacy services. The needy elderly receive further help through the Primary Care Partnership Scheme (PCPS). PCPS is most helpful for those who cannot travel to polyclinics.
 

Hospital Care

 
Singapore 7 public hospitals comprise 5 general hospitals, a women's and children's hospital and a psychiatry hospital. The general hospitals provide inpatient and specialist outpatient services, and a 24-hour emergency department. 75% of public hospital beds are heavily subsidised. There are as well 6 national specialty centres for cancer, cardiac, eye, skin, neuroscience and dental care.


Intermediate and Long Term Care

 
There is a comprehensive range of residential and community-based healthcare services that caters to the long-term care needs of Singaporeans. The services available include community hospitals, chronic sick hospitals, nursing homes, sheltered homes for the ex-mentally ill, inpatient hospice institutions, home medical, home nursing and home hospice care services, day rehabilitation centres, dementia day care centres, psychiatric day care centres and psychiatric rehabilitation homes.
Through the Chronic Disease Management Programme (CDMP), patients work with their doctors to manage their diseases. They regularly monitor their conditions, seek early medical treatment and make the necessary lifestyle changes. Medisave may be used for the outpatient treatments of four chronic diseases (diabetes, high blood pressure, lipid disorder and stroke), which affects about 1 million Singaporeans. MediShield provides a low cost catastrophic illness insurance scheme, designed to help members meet medical expenses from major or prolonged illnesses
 

Integrated Care

 
Partners and stakeholders, they seek to provide patients with holistic and integrated care. The Agency for Integrated Care (AIC) was set up to smooth the transition of patients from one care setting to an extra. Each regional healthcare cluster is anchored by a regional Hospital working with a variety of Primary, Intermediate and Long-Term care sector and support services to deliver patient-centric care. Our healthcare clusters - Alexandra Health (managing Khoo Teck Puat Hospital in the north), National Healthcare Group (managing Tan Tock Seng Hospital in the central region), National University Health System (managing National University Hospital), Jurong Health Services (managing the upcoming Jurong General Hospital in the west) and SingHealth (managing Changi General Hospital in the East) - have as well been set up to drive the movement towards integrated care.
 

Dental services

 
Dental care begins with preventive dentistry promoted through the Health Promotion Board. The Board targets students through a network of 200 static clinics located in the schools inclunding 30 mobile dental clinics. This plus fluoridation of potable water and availability of fluoridated toothpaste has greatly diminished dental decay and tooth loss. Public dental services are available in some polyclinics and hospitals, and the National Dental Centre.


Budget

 
In 2008, Singapore spent about S$ 10.2 billion or 3.9% of GDP on healthcare. Out of this the Government expended S$2.7 billion or 1.0% of GDP on health services.
 

Ministry of Health's mission, vision and objectives

 
The vision of the Ministry of Health is to develop the world's most cost-effective health care system to keep Singaporeans in good health. Its mission is to promote good health and reduce illness, ensure access to good and affordable health care, and pursue medical excellence. This is to be completed through three strategies:
 
  • Promote good health and reduce illness
  • Ensure access to good and affordable health care
  • Pursue medical excellence

Organization of health services and delivery systems

 
Health services are provided through three cooperating ministries, inclunding the private sector.
The Ministry of Health is responsible for providing preventive, curative and rehabilitative health services. The Ministry formulates national health policies, coordinates the development and planning of the private and public health sectors, and regulates health standards.
 
The Ministry of Environment and Water Resources manages water resources and the supply of drinking-water to the country. It is responsible for weather forecasting services; environmental and public health services, such as collection and treatment of used water, pollution and toxic chemicals and poisons; control of vectors that could spread diseases; and the hygienic preparation of food. The Ministry as well licenses food-stall proprietors and looks next all public markets and food centres, public toilets and public cemeteries and crematoria.
 
The Ministry of Manpower is responsible for the health, safety and welfare of employed persons. The Ministry enforces requirements on employment conditions under the Employment Act, has provisions in the Workplace Safety and Health Act to safeguard the health and safety of the workforce, and administers the Workmen’s Compensation Act to ensure equitable compensation for persons with work-related injuries and diseases.
 
There is a dual system of health care delivery. The public system is managed by the Government, while the private system is provided by private hospitals and general practitioners. The health care delivery system comprises primary health care provision at outpatient polyclinics and private medical practitioners’ clinics, and secondary and tertiary specialist care in public and private hospitals. Eighty % of primary health care services are provided by private practitioners, while government polyclinics provide the remainder. For hospital care, the ratios are reversed, with 80% provided by the public sector and the remainder by the private sector.
 
Patients are free to choose their health care providers within the dual health care delivery system, and can walk in for a consultation at any private clinic or any government polyclinic. For emergency services, patients can access the 24-hour accident and emergency departments located in government hospitals. The Singapore Civil Defence Force runs an emergency ambulance service to transport accident and trauma cases and medical emergencies to the acute general hospitals.
 
Primary health care involves the provision of primary medical treatment, preventive health care and health education. Primary health care is provided through an island network of 18 outpatient polyclinics and over 2400 private medical practitioners’ clinics. Each polyclinic is an affordable, subsidized, one-stop health centre, providing outpatient medical care, follow-up of patients discharged from hospital, immunization, health screening and education, investigative facilities and pharmacy services. The needy elderly receive further help through the Primary Care Partnership Scheme (PCPS). PCPS is most helpful for those who cannot travel to polyclinics. The private clinics are located in close proximity to people centres in the city, housing estates and satellite towns. The average outpatient consultation fee is between S$ 10 (US$ 6.00) and S$15 (US$ 9.00), well within the means of Singaporeans. At government polyclinics, Singapore citizens aged 65 and above, children up to 18 years of age and all schoolchildren are given a discount of up to 57% on their consultation and treatment fees. Other Singapore citizens are given a 50% discount.
 
There are about 11 431 hospital beds in the 29 public and private hospitals and speciality centres, giving a ratio of 3.1 beds per 1000 residents; 72.5% of the beds are in the 13 public-sector, specialty centres and hospitals, each with between 185 and 2064 beds. The 15 private-sector hospitals are smaller, with a capacity of between 24 and 505 beds. The Government’s role as the dominant provider of secondary and tertiary care allows it to manage the supply of hospital beds, the adoption of high-tech/ high-cost medicine, and cost increases in the public sector, which serves as a price benchmark for the private sector.
 
The seven public hospitals comprise five general hospitals, a women's and children's hospital and a psychiatric hospital. The general hospitals provide inpatient and specialist outpatient services, and a 24-hour emergency department. Seventy-five % of public hospital beds are heavily subsidized. There are as well six national specialty centres for oncology, cardiology, ophthalmology, dermatology, neuroscience and dentistry. Tertiary specialist care in the areas of cardiology, renal medicine, haematology, neurology, oncology, radiotherapy, plastic and reconstructive surgery, paediatric surgery, neurosurgery, cardiothoracic surgery and transplant surgery is centralized in two of the larger general hospitals, the Singapore General Hospital and the National University Hospital. The private hospitals have similar specialist disciplines and comparable facilities.
 
The Government has structured all its 13 hospitals and specialty institutes as private companies all owned by the Government and managed as not-for-profit organizations. This has granted the public hospitals management autonomy and flexibility to respond additional promptly to the needs of their patients. In the process, better financial discipline and accountability have been introduced. The corporatized health care institutions are as well clustered into vertically integrated networks to deliver comprehensive, from presently on affordable quality health care services through cooperation and collaboration between public health care establishments. Unlike private hospitals, the restructured public hospitals receive an annual government subsidy for the provision of subsidized patient care, and are subject to broad government policy guidance through the Ministry of Health. The Government has as well introduced low-cost community hospitals for intermediate health care for the convalescent sick and aged who do not require the additional expensive care provided by the acute general hospitals.
 
Support services for the hospital and primary health care programmes include forensic pathology, pharmaceutical services and the blood transfusion service. Except for forensic pathology and the blood transfusion service, which are centralized in the Ministry of Health, most of the other services can be found in both the public and private sectors.
 
Dental care begins with preventive dentistry promoted through the Health Promotion Board. The Board targets students through a network of 200 static clinics located in schools, inclunding 30 mobile dental clinics. This, plus fluoridation of potable water and availability of fluoridated toothpaste, has greatly diminished dental decay and tooth loss. Public dental services are available in some polyclinics and hospitals, and in the National Dental Centre.


Health policy, planning and regulatory framework

 
The Singapore health care philosophy emphasizes the building of a healthy people through preventive health care programmes and the promotion of healthy living. Singaporeans are encouraged, through the public health education programme, to adopt healthy lifestyles and be responsible for their health, and are made aware of the adverse consequences of harmful habits like smoking, alcohol consumption, bad diet and sedentary lifestyles. The child immunization programme, which targets infectious diseases like tuberculosis, poliomyelitis, diphtheria, whooping cough, tetanus, measles, mumps, rubella and hepatitis B, is offered at government polyclinics, inclunding private primary health care clinics. Health screening programmes have been introduced for the early detection of common ailments, such as cancer, heart disease, hypertension and diabetes mellitus. These are available in both primary and secondary care settings.
 
The Government ensures that good and affordable basic medical services are made available to all Singaporeans through heavily subsidized medical services at public hospitals and government clinics. The basic medical package includes evidence-based medical practices, and is delivered cost-entirely by trained personnel. Experimental, non-evidence-based treatments, inclunding cosmetic and aesthetic treatments may be excluded.
 
The health care regulatory framework consists mainly of two parties; the regulator (comprising the Ministry of Health along with its statutory boards) and the regulated (comprising public and private providers). All hospitals, clinics, clinical laboratories and nursing homes are required to maintain a good standard of medical services through licensing by the Ministry. Health care professionals are self-regulated by their relevant professional bodies:
  • Singapore Medical Council,
  • Singapore Dental Council,
  • Singapore Nursing Board, and the
  • Singapore Pharmacy Council
  • Traditional Chinese Medicine Practitioners Board
  • Optometrists and Opticians Board
In addition, health-related products, such as medicines and medical devices, are regulated by the Health Sciences Authority.


Health care financing

 
In the 2008 financial year, Singapore spent about S$ 10.4 billion (US$ 7.2 billion) or 4.0% of GDP on health care. Out of this, the Government expended S$2.7 billion (US$1.9 billion) or 1.1% of GDP on health services.
The philosophy of Singapore's public health care delivery system is one of strong government support combined with individual responsibility and community support. Multiple tiers of protection have been built into the health care financing system to ensure universal coverage for all citizens. The initial level of protection is through heavy government subsidies of up to 80% for patients who choose to remain in subsidised wards within the public hospitals.. The second level of protection is provided by Medisave, a compulsory individual medical savings account scheme that helps Singaporeans to save and pay for their share of medical treatment without financial difficulty. The third level of protection is provided by MediShield and ElderShield, which riskpool the financial risk of patients suffering a major illness or severe disability. Finally, Medifund, a medical endowment fund act as the ultimate safety net for needy patients.
 
Individuals are encouraged to take responsibility for their own health by saving for their medical expenses. Medisave, as a national savings scheme, helps individuals set aside part of their gain into Medisave accounts to meet their personal or immediate family's hospitalization expenses. Medisave can be used to pay for an individual’s co-payment portion of his or her medical bill, inclunding the premiums of approved medical insurance products.
 
In 2006, the Ministry of Health initiated the Medisave for Chronic Disease Management programme, a coordinated, nationwide effort to transform care for common chronic illnesses, starting with diabetes mellitus. Participating medical institutions include all public hospitals and polyclinics, inclunding about half of the 1400 private primary care clinics in the country. Since again, the programme has been extended progressively to cover hypertension, lipid disorder, stroke, asthma and chronic obstructive pulmonary disease (COPD). Two additional diseases, schizophrenia and major depression were added in 2009, bringing the number of chronic diseases to eight. The programme seeks to improve chronic disease care through two chief avenues: (1) enhancing access and (2) improving care. By liberalizing the use of Medisave to cover outpatient treatment for the chronic diseases (enhancing access) and implementing evidence-based disease management programmes, together with clinical quality development efforts (improving care), complications arising from these chronic diseases can be better prevented. Correspondingly, patients will be healthier and the risks of expensive hospitalization and potential disabilities will be reduced. The programme is supported by the participation of medical and allied health professionals in the public and private sectors, enhancements to IT systems to improve sharing of essential medical data, and education tools to improve patients’ ability to manage their conditions.
 
MediShield is a low-cost, catastrophic illness insurance scheme designed to help members meet the medical expenses from major or prolonged illnesses, for which their Medisave balance would be insufficient. Individual responsibility is promoted through the features of deductibles and co-payment in MediShield. Annual premiums for MediShield can be paid from the individual's Medisave account. There are as well private supplementary insurance products offering additional coverage. These are integrated with MediShield to provide a national risk pool for basic coverage.
Medifund is an endowment fund set up by the Government as a safety net to help poor Singaporeans pay for their medical care. Medifund is meant to be an avenue of last resort for patients who, despite heavy government subsidies and Medisave and MediShield coverage, are unable to pay for their medical expenses. Therefore, no Singaporeans are denied access into the health care system or turned away by the public hospitals because of their inability to pay. In 2007, part of Medifund was specifically set aside for needy, elderly patients (65 years and above).
 
ElderShield is an affordable, severe-disability insurance scheme designed to provide Singaporeans with basic financial protection against long-term care expenses. Introduced in September 2002, it was further reformed in 2007 to improve its benefits, and private insurers are presently allowed to provide supplementary products with higher coverage.
Public-sector health services are provided to cater for lower gain groups who cannot afford private-sector charges, and as well to set the benchmark for the private sector on professional standards and charges. To support the latter objective, the Government requires public hospitals to publish basic consultation and ward charges to ensure better price transparency.
The Ministry of Health as well publishes hospital pricing data and bill sizes for common conditions on its website.


Human resources for health

 
In 2009, Singapore had 8323 doctors in its health care delivery system, giving a doctor-to-people ratio of 1:600. Thirty-eight % of the doctors were trained specialists.
There were 1531 dentists, giving a dentist-to-total people ratio of 1:3258 in 2009. There were as well 263 oral health therapists, giving an oral health therapist-to-total people ratio of 1:18964. Seventeen % of the dentists were trained dental specialists.
Singapore had 1658 registered pharmacists in 2009, giving a pharmacist-to-people ratio of 1:3008. The number of pharmacists is expected to increase to meet request due to growing health care needs and anticipated increase in the biomedical and pharmaceutical sectors.
In 2009, Singapore had 26 792 nurses and 294 registered midwives, giving a nurse-to-people ratio of 1:186 or 5.38 nurses per 1000 people.
As the people grows and patient expectations rise, there is a need for better investment in human resources for health. Besides increasing the number of health care professionals, the skills of the workforce must as well change as chronic diseases become additional prevalent with the ageing of the people. Efforts are being made to increase local training capacity and to facilitate mid-career conversions, inclunding the movement of overseas-trained health care professionals to Singapore.
 
Examples include:
  • The intake of medical students was recently increased to 260, while the number of overseas medical schools recognized by the Singapore Medical Council has increased to 160.
  • The Duke-NUS Graduate Medical School, which offers a postgraduate doctoral medicine (MD) programme, began their inaugural academic year in 2007 with a batch of 26 students, followed by an increased intake of 48 students in 2008 and 56 students in 2009.
  • The intake of nursing students has as well expanded over the years, with the Diploma in Nursing being offered in two polytechnics. A third Diploma in Nursing course offered by a private college was accredited by the Singapore Nursing Board in 2008. In 2006, the National University of Singapore introduced the Bachelor of Science (Nursing) programme, a full-time undergraduate degree programme, and the numbers will be increased over the years. To meet the needs of an ageing people, an advanced diploma nursing course in palliative care is in the pipeline.
  • In 2007, the Professional Conversion Programme was expanded to help mid-career entrants pursue a career in allied health.
  • The intake for the diploma courses in optometry, physiotherapy, occupational therapy and diagnostic radiography have been doubled in recent years in line with increasing request for allied health professionals. New programmes, such as the Masters in Speech and Language Pathology, and Masters in Psychology (Clinical), have as well been established in the National University of Singapore.
  • To prepare the workforce for the changing skills required to look next an ageing people, efforts have as well been made to enhance their capabilities. For example,
  • The Singapore Nursing Board implemented an Advanced Practice Nurse Register in 2006.
  • Qualifying examinations were as well implemented in the same year to ensure that foreign allied health professionals in physiotherapy, occupational therapy, diagnostic radiography and radiation therapy have the required knowledge and skills to provide good care to patients.
  • The Ministry as well offers post-graduate scholarships for health care professionals to further their training locally or overseas.
Policy efforts will continue to be geared towards ensuring adequate health care manpower to meet the evolving health care demands of the growing and rapidly ageing people.


Partnerships

 
Harnessing and forging strong partnerships is significant for the attainment of national health goals. The Ministry of Health maintains strong partnerships and strategic alliances with voluntary welfare organizations and charities involved in health to ensure that their activities are aligned with the national health care framework. The Ministry of Health continues to work with health care institutions, organizations, professional associations, private general practitioners and other partners to develop health services in an integrated manner throughout the continuum of primary, intermediate and long-term care services.


Challenges to health system strengthening

 
Singapore is facing an ageing people. It is projected that the number of residents aged 65 years or older will increase from the current 8.5% to 19% by 2030, and careful planning is needed to ensure that provision is made for this people. To this end, the Government has set up the Ministerial Committee on Aging to spearhead a whole-of-government response to the opportunities and challenges presented by the ageing people. The Government aims to achieve its vision of successful ageing for Singapore by creating an environment where Singaporeans can look forward to leading healthy, active and productive lives as they grow old.
 
The health workforce as well faces the challenges of an ageing people, inclunding new technologies, lifestyle medicine and higher demands for good medical care. There are shortages of professional staff that will have to be filled. At the same time, the increase of the private sector may lead to higher attrition from the public sector. High quality care will be delivered by health care professionals who are trained in an holistic way to meet the required standards of care in a changing, additional sophisticated people. The challenge is to ensure adequate numbers of such health care professionals are trained in different disciplines, particularly in those health care disciplines that are currently undersubscribed.
 
Chronic diseases are an extra area of concern. An estimated one million Singaporeans suffer from four major chronic diseases: diabetes, hypertension, lipid disorder and stroke, and the numbers are expected to rise with the ageing people base.
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