Elsevier

The Lancet

Volume 398, Issue 10305, 18–24 September 2021, Pages 1091-1104
The Lancet

Review
Singapore's health-care system: key features, challenges, and shifts

https://doi.org/10.1016/S0140-6736(21)00252-XGet rights and content

Summary

Since Singapore became an independent nation in 1965, the development of its health-care system has been underpinned by an emphasis on personal responsibility for health, and active government intervention to ensure access and affordability through targeted subsidies and to reduce unnecessary costs. Singapore is achieving good health outcomes, with a total health expenditure of 4·47% of gross domestic product in 2016. However, the health-care system is contending with increased stress, as reflected in so-called pain points that have led to public concern, including shortages in acute hospital beds and intermediate and long-term care (ILTC) services, and high out-of-pocket payments. The main drivers of these challenges are the rising prevalence of non-communicable diseases and rapid population ageing, limitations in the delivery and organisation of primary care and ILTC, and financial incentives that might inadvertently impede care integration. To address these challenges, Singapore's Ministry of Health implemented a comprehensive set of reforms in 2012 under its Healthcare 2020 Masterplan. These reforms substantially increased the capacity of public hospital beds and ILTC services in the community, expanded subsidies for primary care and long-term care, and introduced a series of financing health-care reforms to strengthen financial protection and coverage. However, it became clear that these measures alone would not address the underlying drivers of system stress in the long term. Instead, the system requires, and is making, much more fundamental changes to its approach. In 2016, the Ministry of Health encapsulated the required shifts in terms of the so-called Three Beyonds—namely, beyond health care to health, beyond hospital to community, and beyond quality to value.

Introduction

Singapore is a multi-ethnic city state with a total population of 5·7 million people, of which 4·02 million are citizens and permanent residents. As a former British colony, Singapore inherited a health system that provided essentially free services, but introduced patient copayments for outpatient services in 1960 because of concerns that free health care would encourage unnecessary use and would be financially unsustainable.1 Since Singapore became an independent nation in 1965, the development of its health-care system has been underpinned by a philosophy that emphasises an individual's personal responsibility for health. The 1993 White Paper on affordable health care, which shaped the development of Singapore's current health system, stated that “we owe it to ourselves individually to keep fit and healthy. The health care system needs to be structured to strengthen this sense of personal responsibility. It must give the individual maximum incentive to stay healthy, save for his medical expenses and avoid using more medical services than he absolutely needs”.2 The White Paper also highlighted that, although market forces are needed to keep hospitals efficient, there are market failures in health care that require the government to intervene actively to prevent unnecessary and supplier-induced demand.2

Overall, Singapore is achieving good health outcomes, with a total health expenditure of 4·47% of gross domestic product in 2016,3 of which the government's share was about a third.4, 5 Singapore is rated well in international comparisons of health indicators and systems.6 However, since 2011, various sources of public concern have emerged in the form of shortages in acute hospital beds and intermediate and long-term care (ILTC) services, as well as the affordability of health care. These so-called pain points are particularly salient indicators of broader stresses across the health-care system, with major drivers including the increasing prevalence of non-communicable diseases (NCDs) and rapid population ageing, limitations in the organisation of primary care and ILTC delivery, and the unintended consequences of some financing approaches. In 2012, Singapore's Ministry of Health launched a set of reforms under its Healthcare 2020 Masterplan, which were targeted at alleviating these pain points.7, 8 However, recognising that these reforms would not be sufficient in the long term, Singapore has also embarked on a systematic effort to understand and address the underlying drivers of system stress and to develop a strategy for a fundamental transformation of the health system.

This Review summarises key aspects of Singapore's health-care system, approach, and health outcomes; explores the motivation to transform the health system; and discusses the factors that underpin Singapore's approach to a positive and sustainable transformation of the health system. Furthermore, this Review briefly covers salient aspects of Singapore's response to the COVID-19 pandemic.

Section snippets

Singapore's health-care services

The main features of Singapore's health-care services have been described previously.9 In Singapore, the epidemiological transition from infectious diseases to NCDs took place around 1970. At that point, NCDs were responsible for 71% of annual mortality, whereas communicable diseases contributed to 21% of annual mortality.10 In the 1980s and 1990s, there was substantial expansion and development of public hospitals, a strong focus on increasing subspecialisation, and the establishment of seven

Challenges and pain points

Since 2011, two salient pain points have emerged that reflect broader stresses to the existing system. First, between 2011 and 2014, there was major public concern about acute public hospital bed shortages, which were causing high average bed occupancy rates, overstretched medical staff, and long waiting times for available beds for patients admitted to emergency departments.33

The affordability of health care emerged as a second public concern during that period. In 2011, overall out-of-pocket

Factors driving pain points

These challenges reflect broader stresses to the health-care system, which are driven by several factors that also interact together (figure 2).

Immediate responses to pain points: the Ministry of Health's Healthcare 2020 Masterplan

To address the emerging stresses in the health system, in 2012, the Ministry of Health announced the Healthcare 2020 Masterplan to increase health-care capacity and to enhance health-care affordability and financial protection.55

Promoting long-term transformational change

Simply expanding existing structures and approaches will not be sufficient to address the underlying drivers of system stress in the long term. In 2016, the Ministry of Health articulated three fundamental shifts that would guide the long-term transformation of the health-care system. These shifts were encapsulated in terms of the so-called Three Beyonds—namely, beyond health care to health, beyond hospital to community, and beyond quality to value. Underlying these shifts is an understanding

Singapore's experience with COVID-19

As has been the case globally, the COVID-19 pandemic has been a major test for Singapore and its health-care system. Since the severe acute respiratory syndrome epidemic of 2003, Singapore has systematically raised its preparedness levels by expanding the physical infrastructure to manage outbreaks in health facilities; constructing a new purpose-built National Centre for Infectious Diseases; stockpiling personal protective equipment, medical supplies, and ventilators; and maintaining an

Conclusion

Singapore has been able to achieve good health outcomes at relatively low health-care expenditure levels. However, its health-care system is contending with stresses driven by rapid population ageing and the rising prevalence of NCDs, exacerbated by characteristics of the primary care system and the ILTC sector that limit their ability to respond to these, as well as fragmentation across sectors. As an immediate response, in 2012, Singapore embarked on a comprehensive series of initiatives

Declaration of interests

CCT reports personal fees from Verily Life Sciences, as a member of its advisory board. CSPL is supported by a Clinician Scientist Award from the National Medical Research Council of Singapore and has received research support from Boston Scientific, Bayer, Roche Diagnostics, AstraZeneca, Medtronic, and Vifor Pharma. CSPL has also served as consultant or on the advisory board, steering committee, or executive committee for Abbott Diagnostics, Amgen, Applied Therapeutics, AstraZeneca, Bayer,

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