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Title: Master of Science Health Services Management


1
Master of ScienceHealth Services Management
  • Current Issues
  • in Health Services Management
  • Question 1
  • What are the existing major problems and
    challenges confronting the country?

2
Singapore Health Care System
04413461G CHU Shuk Fong, Milly
04726404G LAM Mai Yuk, Nicole
04412046G LOU Wing On, Ada
04731973G LUI Tat Man, Ted
04416703G TANG Dan Ni, Danni
04704196G TANG Sau Kuen, Frances
3
Background Information (1)
Singapore
4
Background Information (2)
  • Land Area 699.0sq km
  • Total Population 43514000
  • Race Chinese 76.0
  • Malay 13.8
  • Indian 8.4
  • Others 1.8
  • Source Ministy of Health (2005)

5
Background Information (3)
Source Ministy of Health (2005)
6
Background Information (4)
Population (Mid Year Estimates) Area 2005
Total Population ('000) 4,351.4
   Annual Growth () 2.6
Singapore Residents ('000) 3,553.5
    Annual Growth () 1.9
    Below 15 yrs ('000) 699.0
    15 - 64 yrs ('000) 2,557.6
    65 yrs over ('000) 296.9
Median Age (Yrs) 36.0
Total Dependency Ratio (Per 100 Residents Aged 15-64 Years) 38.9
    Child Dependency Ratio 27.3
     Old-Age Dependency Ratio 11.6
Sex Ratio (Males per 1,000 Females) 987
Population Density (Per Sq Km) 6,222
Source Singapore Department of Statistics
(2006)
7
Political Status of Singapore
  • The Peoples Action Party (PAP)
  • holds 90 votes in parliament
  • Semi-autocratic
  • Paternalistic
  • Interventionist
  • Strong Government trusted by most
  • Singaporean

8
Health Care Reform in Singapore (1)
  • 1819 Founded as a British trading colony
  • 1963 Joined the Malaysian Federation
  • 1965 Became independent

9
Health Care Reform in Singapore (2)
1984 Implemented the Singapore National Health
Plan
1983 Initiated the Singapore National
Health Plan
10
Singapore Health Care Delivery System (1)
  • Primary Medical Care
  • Secondary / Hospital Services
  • Tertiary Specialized Services
  • Elderly, Long Term and
  • Rehabilitation Care Services

11
Singapore Health Care Delivery System (2) - In
the year 2003
  • 24 hospitals with a total of 10,500 beds
  • 3.5 beds per thousand population
  • 5 acute hospitals for inpatient,
  • specialist and AE services
  • Tertiary Specialized Services
  • delivered in Singapore General
  • Hospital and National University
  • Hospital

12
Singapore Health Care Delivery System (3) - In
the year 2003
Private Sectors Public Sectors
Primary health care services (Outpatients) 80 20
Hospital care services (Inpatients) 20 80
13
Problems Before Health Care Reform in Singapore
  • Historical Problems
  • Demographic Social Problems
  • Financing Problems

14
Historical Problems (1)
  • Since 1965, inherited from the British colonial
    government a largely tax-based publicly provided
    health care system with expenditure increasing
    year by year.
  • Publicly funded approximate 40- 50 of total
    health care expenditure.

15
Historical Problems (2)
  • Embedded traditional British style Entitlement
    Culture its political status.
  • This is a common phenomenon in most former
    British colonies that people used to rely on the
    government to provide free or heavily subsidized
    basic health care service.

16
Historical Problems (3)
  • Singapores public health expenditure rose 5
    times from 50 million in 1971 to 250 million
    in
  • 1981.
  • Public health expenditure rose in an alarming
    rate.

17
Historical Problems (4)
  • Singapore faced a dilemma Whether continue to
    put larger proportion of public expenditure in
    free or heavily subsidized health care.
  • Singapore being a small new born country with no
    natural resources would be extremely difficult to
    cope with such a crisis.

18
Historical Problems (5)
Health Care Expenditure per Capita from 1960 to
1988
Source Department of Statistics (1988)
19
Historical Problems (6)
Health Care Expenditure per Capita from 1960 to
1988
Total Health Expenditure from 1960 to 1988
Source Department of Statistics (1988)
20
Historical Problems (7)
5 Times
Source Department of Statistics (1988)
21
Demographic Social Problems
  • Increasing population
  • Aging population
  • Changing diseases pattern
  • Demand for higher quality services
  • Technological development in health care
  • Manpower problem

22
Increasing Population (1)
Key Demographic Indicators 1970 -2004 Key Demographic Indicators 1970 -2004 Key Demographic Indicators 1970 -2004 Key Demographic Indicators 1970 -2004 Key Demographic Indicators 1970 -2004 Key Demographic Indicators 1970 -2004

  1970 1980 1990 2000 2004
Total Population ('000) 2074.5 2413.9 3047.1 4017.7 4240.3
Resident Population ('000) 2013.6 2282.1 2735.9 3263.2 3486.9
Median Age (years) 19.5 24.4 29.8 34.2 35.7
0-14 39.1 27.6 23 21.5 20.1
15-64 57.5 67.5 71 71.2 71.9
65 over 3.4 4.9 6 7.3 8
Increasing Population
Source Singapore Department of Statistics (2005)
23
Increasing Population (2)
Source Singapore Department of Statistics (2006)
24
Increasing Population (3)
Singapore Demographic Projection
Aging Population
Source D R Phillips A C M Chan, Ageing and
Long-term Care National Policies in the
Asia-Pacific (2002)
25
Aging Population (1)
DEMOGRAPHIC INDICATORS 2005
Total Live-Births 37,593
Total Deaths 16,217
Crude Birth Rate   (Per 1,000 Population) 10.0
Crude Death Rate (Per 1,000 Population) 4.3
Total Fertility Rate(Per Resident Female) na
Infant Mortality Rate(Per 1,000 Live-births) 2.1
Life Expectancy at Birth (Yrs) 79.7
Males 77.9
Females 81.6
Life Expectancy at Age 65 (Yrs) 18.2
Males 17.0
Females 19.3
Source Singapore Department of Statistics (2006)
26
Aging Population (2)
81.6
79.7
77.9
Source Singapore Department of Statistics (2006)
27
Aging Population (3)
2.1
Source Singapore Department of Statistics (2006)
28
Aging Population (4)
Source Singapore Department of Statistics (2006)
29
Aging Population (5)
Source Singapore Department of Statistics (2006)
30
Aging Population (6)
Source Singapore Department of Statistics (2006)
31
Aging Population (7)
32
Changing Diseases Pattern (1)
Leading Causes of Death in Singapore
  • 2005
  • Cancer
  • Heart Disease
  • Cerebrovascular
  • Disease Accidents
  • 1950
  • Tuberculosis
  • Pneumonia
  • Diarrhea
  • Infections of newborn

33
Changing Diseases Pattern (2)
Source Ministy of Health (2005)
34
Changing Diseases Pattern (3)
  • Chronic degenerative diseases, e.g. cancer and
    heart disease, replaced infectious diseases as
    the major causes of death.

35
Changing Diseases Pattern (4)
  • Chronic illness required long-term treatments and
    also more likely to require expensive
    medications.
  • Hi-tech equipments, e.g. CT, MRI, laser,
    micro-surgery, may be used to cure these
    diseases.
  • Ultimately pushed up health
  • care expenditure.

36
Demand for Higher Quality Services (1)
  • As people became more educated and they demanded
    for higher quality of health care services.

Higher Quality Services Always Equal To Higher
Costs
37
Technology Development (1)
  • Advanced technology saves more lives

Increase Health Care Costs
Health Costs 8
Drug Costs per outpatient 10
Drug Costs per Inpatient 14
Source Ministry of Health (2005)
38
Manpower Problem (1)
  • Training of health care professionals is
    expensive.
  • Prevention of over-supply is needed because
    experience shows that over supply of doctors
    specialists will cause inflated health care
    expenditure.

39
Financing of Singapore Health Care Services
40
Financing Problems (1)
Increasing public total health expenditure in
Singapore (1960 1995)
Source E LIU S Y YUE, Health Care Expenditure
and Financing in Singapore (1999)
41
Financing Problems (2)
Source Ministy of Health (2005)
42
Financing Problems (3)
  • Due to the historical, demographic and social
    problems, health care expenditure increased
    rapidly.

43
Major Challenges Confronting Singapore (1)
  • How can Singapore provide its people with a
    quality health care service which will be
    sustainable, affordable and accessible to all
    without pumping more and more public funds to
    support it?

44
Major Challenges Confronting Singapore (2)
  • Can Singapore change its people's perception to
    believe that health care is not a "take for
    granted" service?

45
Major Challenges Confronting Singapore (3)
  • Can Singapore also change its people's perception
    to accept that accessible to all only means
    emergency and secondary care that are within
    reasonable reach of the community?

46
Challenges After Health Care Reform in Singapore
  • Hospital Structure Challenges
  • Efficiency Services Quality
  • Financing Challenges
  • Catastrophic illness
  • Poor or disadvantage group care
  • Elderly care

47
Hospital Structure Challenge (1)
  • Enhancement of Efficiency Services Quality
  • Centralized (MOH) or decentralized
  • (HCS)
  • Autonomy in strategic direction,
  • recruitment and remuneration
  • required?

48
Hospital Structure Challenge (2)
  • Enhancement of Efficiency Services Quality
  • Flexibility in business and financing
  • discipline
  • Competition between public
  • hospitals

49
Financing Challenge (1)
  • Catastrophic Illness
  • Limitations of Medisave
  • Lack of coverage of major or chronic illnesses
  • Prolong treatment is too costly and expensive
  • Medisave did not provide any protection for
    people with catastrophic illness

50
Financing Challenge (2)
  • Poor or Disadvantage Group Care
  • Limitations of Medisave
  • Lack of coverage of primary care
  • Poor or disadvantage group people were not able
    to make financial contribution towards their
    Medisave account.
  • Poor or disadvantage group sought health care
    services from the public sector.

51
Financing Challenge (3)
  • Elderly Care
  • Limitations of Medisave
  • Due to aging population and changed diseases
    pattern, elderly needs more and longer health
    care than ever before.
  • Inadequacy of Medisave to pay for the health care
    long-term care expenditure.

52
Financing Challenge (4)
Source Health Care Financing Systems in Selected
Places Classification and Reform (2006)
53
Financing Challenge (5)
Source M K LIM, Transforming Singapore Health
Care (2005)
54
Financing Challenge (6)
Year 2002
Source The Singapore Health System Achieving
positive health outcomes with low expenditure
(2004)
55
Financing Challenge (7)
Source Singapore Department of Statistics (2005)
56
Financing Challenges (8)
Year 2003
Countries GDP
Singapore 3
China 3.8
Hong Kong 4.7
Taiwan 5
Korea 5.4
Japan 5.9
UK 6
USA 14
Source Singapore Department of Statistics (2005)
57
Financing Challenges (9)
Universal Medisave
Catastrophic Medishield
Poor Medifund
Elderly Eldershield
58
Summary
  • Problems illustrated
  • Historical Problems
  • Demographic Social Problems
  • Financing Problems
  • Challenges illustrated
  • Hospital Structure Challenges
  • Financing Challenges

59
References
  • D R Phillips A C M Chan, 2002, Aging and
    Long-term Care National Policies in the
    Asia-Pacific, Institute of Southeast Asian
    Studies/International Development Research.
  • E LIU S Y YUE, 1999, Health Care Expenditure
    and Financing in Singapore, Hong Kong Research
    and Library Services Division Legislative Council
    Secretariat.
  • Health Care Financing Systems in Selected
    Places Classification and Reform, 2006,
    Online, Available http//www.legco.gov.hk/yr05-
    06/english/sec/library/0506in08e.pdf 10 March
    2006.
  • Ministry of Health Singapore 2005, Health Facts
    Singapore 2005, Online, Available
    http//www.moh.gov.sg/corp/publications/statistics
    /population.do 10 March 2006.
  • Singapore Department of Statistics 1988, Key
    Annual Indicators, Online, Available
    http//www.moh.gov.sg/corp/publications/statistics
    /principal.do 10 March 2006.
  • Singapore Department of Statistics 2005, Key
    Annual Indicators, Online, Available
    http//www.moh.gov.sg/corp/publications/statistics
    /principal.do 10 March 2006.
  • Singapore Department of Statistics 2006, Key
    Annual Indicators, Online, Available
    http//www.moh.gov.sg/corp/publications/statistics
    /principal.do 10 March 2006.
  • M K Lim, 2005, Transforming Singapore Health
    Care, Annals Academy of Medicine, Vol.34, No.7,
    pp.461-466.
  • The Singapore Health System Achieving positive
    health outcomes with low expenditure 2004,
    Healthcare Market Review, Online, Available
    http//www.watsonwyatt.com/europe/pubs/healthcare/
    render2.asp?ID13850 10 March 2006.

60
Master of ScienceHealth Services Management
  • Current Issues
  • in Health Services Management
  • Question 2
  • Singapore Health Care System
  • What are the measure and policies adopted?

61
Presentation Outline
  • 1. Health Care Reform Background
  • 2. Health Financing Reform
  • 3M Medisave, Medishield, Medifund
  • 2E Eldershield, Eldercare Fund
  • 3. Hospital Reform
  • Corporatization
  • Clustering
  • 4. Long Term Care

62
1. Health Care Reform Background
  • Problems before Reform
  • Historical Problems
  • Demographic Social Problems
  • Financing Problems
  • Challenges after Reform
  • Hospital Structure Challenges
  • Financing Challenges

63
Problems Challenges
Policies adopted Policies adopted

Health Hospital Long Term Financing Restructuring Care Health Hospital Long Term Financing Restructuring Care

64
Health Care Reform
1983 Blue Paper Ministry of Health promulgated National Health Plan to include Medical Saving Account under Central Provident Fund
1993 White Paper Paper of Affordable Health Care set out the governments philosophy and approach to controlling healthcare cost based on 5 foundational objectives
1999 Report of Inter-Ministerial Committee on Health Care for the Elderly Set up infrastructure and new service delivery system to revamp funding policy and care continuum to voluntary care service and targeted elderly
65
White Paper 5 Objectives
1. To nurture a healthy nation by promoting good health
2. To promote personal responsibility for ones health and avoid over-reliance on state welfare or medical insurance
3. To provide good and affordable basic medical services to all Singaporeans
4. To rely on competition and market forces to improve service and raise efficiency
5. To intervene directly in health care sector, when necessary, where the market fails to keep health care costs down
Source White Paper on Affordable Health Care,
Ministry of Health 1993
66
2. Health Financing Reform
1984 Medisave
1990 Medishield
1993 Medifund
1994 Medishield Plus
2000 Eldercare Fund
2002 Eldershield
2005 Medishield Plus renamed to IncomeShield Plan MA MB
67
Health Financing Policy
3M Medisave Medishield Medifund 2E Eldershield Eldercare Fund
68
Medisave
  • 1st country to launch Medical Savings Accounts
    (MSA)
  • Known as Medisave
  • Concept
  • Shifted from a tax-based NHS model to a new
  • model (saving)
  • Principles
  • Individual responsibility, cost sharing
    co-payment
  • Principles

69
Medisave
Date 1/4/1984
Scheme Compulsory savings scheme under CPF
Aims Pay for hospital bill and certain outpatient expenses (individual immediate family members)
Principle Individual Responsibility reduce moral hazard
Contribution Each employee contributes 6 8.5 of monthly salary (depending on age group) Share equally between employers and employees Self-employed contributes 6 8 Interest earning and tax free
Enhancement Effective from 1/4/2006, Medisave daily withdrawal limit will be adjusted from S300 to S400
70
CPF and Medisave
71
CPF and Medisave Contribution
Credit into account per month Credit into account per month Credit into account per month Total
Employees Age Ordinary Account Special Account Medisave Account Total
35 below 22 5 6 33
Above 35 to 45 20 6 7 33
Above 45 to 50 18 7 8 33
Above 50 to 55 12 7 8 27
Above 55 to 60 10.5 -- 8 18.5
Above 60 to 65 2.5 -- 8.5 11
Above 65 -- -- 8.5 8.5
Source Singapore Central Provident Fund Board
2006
72
Medisave Withdrawal
  • Contribution ceiling gtS32,500 rolls over to the
    CPF Ordinary Account.
  • Payment for
  • Private Public Hospitals inpatient bills up to
    S400
  • per day (w.e.f. 1.4.06)
  • Limited Surgical Fee S150 to S5,000
  • Premium of Medishield Eldershield
  • Member is able to withdraw balance at age 55
  • But needs to keep a minimum of S27,500.

Source Ministry of Health, Singapore 2005
73
Medishield
  • Concept
  • Medisave cannot cover large medical bills
  • Medishield was introduced to complement Medisave
  • Maximum entry age 75
  • Maximum coverage age 80
  • Premium
  • Annual premium is S30 (below age of 30) to
  • S510 (between 79 to 80)
  • Reimbursement
  • Based on three parameters claimable limits,
    deductible
  • and co-insurance
  • Maximum claim limits are S50,000(for per policy
    year)
  • S200,000 (for lifetime)

74
Medishield
Date 1/7/1990
Scheme Low cost catastrophic illness insurance scheme
Aims Pay for heavy medical expenses
Implication Reduce moral hazard Increase risk pooling effect
Coverage Each Medisave member enrolls the scheme automatically Voluntary opt-out scheme Premium is deducted from Medisave account Risk pooling insurance
Enhancement In 1994, Medishield Plus was introduced to cover larger medical expense in higher class Reformed Medishield in 2005
75
Medishield Plus
  • High claimable limit deductibles
  • Public hospitals higher bed class reimbursement
  • Private hospitals reimbursement for
    accommodation
  • Medishield Plus transferred to NTUC Income
    (insurer) in 2005

76
Medifund
  • Concept
  • - Inadequate fund to cover medical expenses
    (low wage Medisave members)
  • - Endowment fund to help the poor
  • Funding
  • -Initial injection was S200 million, then
    S100
  • million per year and now reached S1
    billion
  • (Singapore Budget 2004)

77
Medifund
Date 1/4/1993
Scheme Endowment Fund
Aims Safety net for the poor to pay for medical expenses
Implication This is a mean of last resort health cost payment
Coverage Interest income is used to pay for hospitalization in open wards (Class C and B2) or subsidized outpatient payment in public hospitals
Enhancement Extended to VWO residential step down unit in 2001
78
Eldercare Fund ElderShield
Eldercare Fund Eldershield
Date 2000 2002
Scheme Government subsidy Opt-out insurance scheme
Eligibility Elderly using facilities run by VWO Medisave members age 44-69 with ?3 ADLS disabilities
Provider Government NTUC Income Great Eastern
Contribution -- Regular Single Premium Plan
79
Eldercare Fund ElderShield
  • Eldercare Fund -2000
  • Initial fund S200 million
  • Top up S100 million at 2006
  • Target of S2.5 Billion by 2010
  • 3 subsidy framework acute cares, step-down
    cares community cares
  • ElderShield 2002
  • A severe disability insurance scheme
  • Automatically joined at age 40
  • (Source Singapore Budget 2006
    Phua 2001)

80
Health Financing Reform - Summary
Employee Employer Government
Central Provident Fund
Tax
Medisave
Subsidies for polyclinic and bed class in public
hospital
Medifund / Eldercare Fund
Premium
Medishield
Eldershield
Out-of Pocket Payment
Payment
Payment
Payment
Payment
Health Care Providers
81
3. Hospital Reform
1983 Blue Paper National Health Plan
1987 Health Corporation of Singapore (HCS)
1993 White Paper Affordable Healthcare
1997 Report of Inter-Ministerial Committee on Health Care for the Elderly
1999 Casemix Funding
2000 Hospital Clustering Primary Care Partnership Scheme
2002 Interim Disability Assistance Programme for Elderly
82
Hospital Structure - Before 1984
14 hospitals 26 outpatients dispensaries 64
maternal and child health clinics
Source Barr (2005)
83
Hospital Structure After 1984
Health Corporation of Singapore
Western Cluster
Eastern Cluster
National Healthcare Group 4 Hospitals 1
National Centre 9 Polyclinics 3 Specialty
Institutes 5 Business Divisions
Singapore Health Services 3 Hospitals 5
National Centre Network of primary healthcare
clinics
84
Hospital Restructure - Corporatization
  • Concept
  • Health Corporation of Singapore (HCS)
    established 1987
  • Government own
  • Responsible to Ministry of Health (MOH)
  • Recruitment, remuneration, hospitals strategic
    directions are decentralized.
  • Increase in fee is subject to government
    approval
  • Commercial accounting system and auditing
    procedures
  • Uses Market Mechanism to create competition and
    incentives
  • To replace Old Bureaucratic system

85
Hospital Restructure - Clustering
Concept Reorganized the restructured Hospitals One-Stop Seamless Care services 2 vertically integrated health systems provide
Primary, Secondary and Tertiary care services Effective utilization of resources and minimize duplication of services as cost control strategy Clients Affordability and Accessibility addressed
86
Hospital RestructureCorporatization Clustering
1984 Pilot at Kent Ridge Hospital Incorporatized as University Hospital Ltd, with Board of Directors chaired by Ministry of Health
1985 Applied to National University Hospital
1987 Health Corporation of Singapore established Incorporatized as a holding company with hospitals specialist institutions Owned by Government and responsible to Ministry of Health
87
Hospital RestructureCorporatization Clustering
1985 Corporatized National University Hospital Ltd
1990 Corporatized Singapore General Hospital Ltd
2000 Clustering National Healthcare Group into Western Cluster Singapore Health Services into Eastern Cluster Each cluster covers primary, secondary tertiary care to provide comprehensive and affordable health services
88
Hospital Reform - Cost Control
  • Regulation Supply of Doctors Hospitals
  • Limit the no of Class A beds in public hospitals
    (9)
  • Increase the no of Class B2,B2 C ( 65)
  • Casemix Funding DRG is a fairer system
  • Means Testing Income assessment for eligibility
    for government subsidies.

89
Hospital Reform - Competition
Clusters Patient management Partnership GPs IT
Eastern Shared care programme SingHealths GP Empowerment Programme E-Health Portal
Western Direct Access Programme, O G services NHGs partners programme Netcare
90
Hospital Reform Casemix Funding DRG
  • A classification system
  • Group patients under same condition
  • Determine amount of subsidies for acute inpatient
  • day surgery on average costs
  • Cost-effective treatment, good clinical outcome
  • Standardization of quality service and length of
    stay
  • DRG funding is a fairer resources distribution

91
Hospital Reform - Subsidy Policy
Class Bed Target Subsidy by Government
A 1 - 2 bedded 0
B1 3 4 bedded 20
B2 5 bedded 50
B2 6 bedded 65
C gt 6 bedded 80
Source White Paper on Affordable Health Care,
Ministry of Health 1993
92
Hospital Reform - Collaboration
Year Primary Care Hospital Care
Public Sector 1993 20 80
Public Sector 2010 n/a n/a
Private Sector 1993 80 20
Private Sector 2010 70 30
Source White Paper on Affordable Health Care,
Ministry of Health 1993
93
Hospital Reform - Collaboration
  • Public Private Partnership
  • Consultation Fee Scheme (CFS)
  • - Consultants from Public sectors allow to see
    Private patients.
  • Faculty Practice Plan
  • - Specialists can work part-time in Private
    sector and vice versa
  • Primary Care Partnership Scheme (PCPS)
  • - Contracted GPs to provide Primary care for
    the Elderly
  • who are distant from the polyclinics
  • - Cover by the same Polyclinic fee subsidies
  • - Extended to cove Dental care in 2002

Source Repot of the Inter-Ministerial Committee
on Health Care for Elderly , 1999
94
4. Long Term Care
  • Acute Care Services
  • Step-down Care Services
  • Primary Care Services

95
Long Term Care - Philosophy
  • Health promotion disease prevention to enable
    healthy of elderly
  • Cost-effective system for disease and disability
  • Affordable to individual, family, community
    country
  • Personal responsibility family support with
    Aging in Place concept at first,
    institutionalization as last resort

Source Repot of the Inter-Ministerial Committee
on Health Care for Elderly , 1999
96
Long Term Care Financing Policy
Eldershield An opt-out insurance scheme for elderly with disability
Elder Care Fund Government subsidiary for elderly care facilities run by voluntary welfare organization
Primary Care Partnership Scheme Elderly use private health services with polyclinic fees
97
Long Term Care Policy
  • Maintenance of Parents Act in 1995
  • Legal obligation to maintain parents.
  • Age Dependant Tax Relief for co-residential
    child/child in-law
  • Incentive for family members.
  • CPF Housing Grant Scheme
  • Incentive for married first time children
    to live near to parents
  • Subsidies health screening for the elderly
  • Support Preventive care for the elderly
  • (Mehta, 2002)


98
Long Term Care - Provision
Types Providers Care Facilities
Residential LTC Government Acute care Acute hospitals Rehabilitation hospitals Nursing homes Living apartments
Residential LTC Government Step Down Care Community hospitals Nursing home West, Central East Zones
Non-Residential LTC VWO Private sectors Primary Care Day rehabilitation centers Day care centers
Community-based support service VWO Primary Care Home care supporting services to elderly at home
99
Long Term Care Service Types
Type of service Planning Ratio Caps Year Year Year Year Year
Type of service Planning Ratio Caps 1997 2000 2010 2020 2030
Acute-care geriatric beds 1 bed per 1,000 elderly 217 (188) 235 5,226 10 530 500
Geriatric specialist 2 specialists per 1,000 elderly 22 (15 ) 25 21 30 55 80
Community hospital beds 3.5 beds per 1,000 elderly 761 (426) 820 426 1,090 1,855 2,800
Sick hospital beds for the chronically ill 1.5 beds per 1,000 elderly 326 (218) 352 218 480 800 1,200
Nursing home beds (including beds for dementia patients) 28 beds per 1,000 elderly 6,087 (4,700 ) 6,566 5,635 8,800 14,900 22,400
Day rehabilitation day care units (including laces for dementia patients) 3.5 beds per 1,000 elderly 761 (701 ) 821 820 1,100 1,900 2,800
Home medical care service (projection unit home medical care units per months) 5 elderly needing 1 visit per month per 1,000 elderly 1,087 (750 ) 1,173 825 1,600 2,700 4,000
Home nursing service (projection unit home nursing units per months) 15 elderly needing 2 visits per month per 1,000 elderly 6,522 (5,000) 7,035 5,500 9,400 15,900 24,000
Home help service (projection unit no of home help visit per day) 4 elderly needing daily visits per 1,000 elderly 870 (255) 930 300 1,250 2,120 3,200
Notes Estimated availability will
improve by 2003, Chronic sick beds for the
chronically ill (400),Nursing home beds (7,300)
( ) Availability in 1997
Estimated availability in 2000
Source Repot of the Inter-Ministerial Committee
on Health Care for Elderly , 1999
100
Health Care Reform Policies
  • Problem Based Approach
  • Financing 3M 2E
  • State People
  • Public Cost Share lt30
  • Private Cost Share gt70
  • (Lim,2003)

State
Co-payment
Employees
Employer
l
101
Health Care Reform - Measures
  • Problem Based Approach
  • Health Services
  • Hospital Community
  • Elderly Family / VWO
  • Partnership Public Private
  • Supply Casemix funding
  • Demand Means Testing

102
Health Care Reform - Summary
Health Financing Ensure cost containment Reduce moral hazard Enhance risk pooling Ensure equitable funding distribution

Hospital Delivery System Autonomy motivation productivity Competitive cost control innovation Efficiency service standard Integration seamless healthcare Effectiveness Equity of access Sustainability of health care
103
References
  • Singapore Central Provident Fund Board (2006) CPF
    Contribution,online. Available from
    http//www.cpf.gov.sg/cpf_info/goto.asp?pageOnlin
    e/ContriRa.asp Accessed on 19 March 2006.
  • Singapore Ministry of Finance. 2004, Budget 2004
    Key Budget Initiatives, online. Available from
    http//www. mof.gov.sg/budget_2004/key_measure/ind
    ex.html Accessed on 26 February 2006.
  • Singapore Ministry of Finance. 2006, Budget 2006
    Key Budget Initiatives, online. Available
    from http//www. mof.gov.sg/budget_2006/key_initi
    atives/sharing.html Accessed on 26 February
    2006.
  • Singapore Ministry of Health.1993, Affordable
    Health Care A White Paper.
  • Singapore Ministry of Health.1999, Report of the
    Inter-Ministerial Committee on Health Care for
    the Elderly.
  • Singapore Ministry of Health. 2005, Ministry of
    Health website online. Available from
    http//www.moh.gov.sg.
  • Barr, M. 2005, Singapore, Gauld, Robin ed.,
    Comparative Health Policy in the Asia-Pacific,
    Maidenhead Open University Press.
  • Mehta, K.K. 2002, National Policies on Ageing and
    Long-term Care in Singapore A Case of Cautious
    Wisdom?, Phillips, David R Chan, Alfred CM
    eds., Ageing and Long-term Care National
    Policies in the Asia-Pacific, International
    Development Research Centre.

104
References
Barr, M. D. (2004) Singapore. In (Eds) Robin, G. Comparative Health Policy in the Asia-pacific Chapter 7, pp147-173. Hong Kong Open University Press Mehta, K. K. (2002) National Policies on Ageing and Long-term Care in Singapore A Case of Cautious Wisdom? In David. R.P., Alfred, C. M. Chan (eds) Aging and Long Term Care National Policies in the Asia-Pacific. Chp 5. Singapore Institute of Southeast Asian Studies Singapore Central Provident Fund Board (2006) CPF Contribution,online. Available from http//www.cpf.gov.sg/cpf_info/goto.asp?pageOnline/ContriRa.asp Accessed on 19 March 2006. Singapore Ministry of Finance. 2004, Budget 2004 Key Budget Initiatives, online. Available from http//www. mof.gov.sg/budget_2004/key_measure/index.html Accessed on 26 February 2006. Singapore Ministry of Finance. 2006, Budget 2006 Key Budget Initiatives, online. Available from http//www. mof.gov.sg/budget_2006/key_initiatives/sharing.html Accessed on 26 February 2006. Singapore Ministry of Health.1993, Affordable Health Care A White Paper. Singapore Ministry of Health.1999, Report of the Inter-Ministerial Committee on Health Care for the Elderly. Singapore Ministry of Health. 2005, Ministry of Health website online. Available from http//www.moh.gov.sg.
105
Master of ScienceHealth Services Management
  • Current Issues
  • in Health Services Management
  • Question 3
  • Singapore Health Care System
  • How effective are these measures
  • and policies?

106
Presentation Outline
  • Evaluation on Health Financing
  • Evaluation on Health Service
  • Evaluation Long Term Care
  • Limitations of Evaluation

107
Singapore Health System Ranking
Singapore HK Korea Switzerland Germany Canada
Total Population, million 3.95 6.72 47.28 7.19 82.14 30.75
Health Provision Bed per 1000 population (Public ) 2.9 (81) 4.7 (88) 5.1 (72) 5.2 7.1 (55) 4.1
Doctor per 1000 population (Public ) 1.4 (48) 1.3(45) 1.3 3.4 3.5 2.1
Admission per year per 1000 population 94.5 NA NA 168.8 226.8 100.6
Share of the GDP 3.6 4.8 5.1 10.6 10.3 9.3
Health System Performance Ranking Responsiveness 20 NA 35 2 5 7
Health Distribution 29 NA 37 10 20 18
Responsiveness Distribution 3 NA 43 3 3 3
Fairness of Financing 101 NA 53 38 6 17
Health Level Performance 14 NA 107 26 41 35
Overall Health System Performance 6 NA 35 20 25 30
Source WHO Report by Hanvoravongchai, 2002
108
Singapore Health Care Financing System
Payers Individual Family Employer Government

Financing Medisave Medishield Medifund Eldercare Fund Eldershield

Payment Methods Taxation Savings Insurance Co-payment
Individual responsibility

Cost containment Demand side control Enhance risk pooling Ensure equitable funding

Cost sharing
109
Healthcare Financing Strategies
Cost-sharing Fee for service Instill personal and family responsibility
Savings Medisave, Medishield, Medifund Ensure future sustainability with ageing and avoid inter-generational problems
Insurance Social insurance Enhance risk-pooling and social protection
Taxation Tax funded Target subsidy and equitable distribution
110
Health Care System Evaluation
Structure
Process
Outcome
Effectiveness Efficiency Equity Quality Sustai
nability
Moral hazard Risk pooling Cost Containment Equitab
le funding
Health Financing
Autonomy Competition Efficiency Integration
Health Services
(Aday et al, 2004)
111
Effectiveness
  • Singapore Health Care Financing
  • Achieving cost containment??
  • Promoting cost efficiency??

112
Effectiveness
  • Successfully shift the financial burden from the
    government to the individual / private sector
    (table 1)
  • 3M system of health care financing was able in
    mobilizing private financial resources
  • Reserve accrued from CPF can underwrite
    Singapores total health care expenditure for the
    next 5 years (MK Lim, 2005)

113
Effectiveness
  • BUT, it fails to contain cost as
  • Annual rate of health care is 1.7 higher than
    inflation rate (table 3,GDP, household
    expenditure)
  • Per capita cost of health care rose faster after
    introduction of MSA (table 4, per capita)
  • MSA create moral hazard by supply induced demand
    (table 5, bed upgrade, saving, admission)

114
Effectiveness
  • Market force competition induce change in health
    care spending
  • cost of health care personnel (table 6)
  • duplication of expensive of medical equipments,
    advance technologies services
  • Ageing population mounting cost pressure
  • drug consumption
  • hospital services

115
Promote cost efficiencies
  • Supply side control
  • Restricted ceiling entry of local doctor and
    foreign trained professionals
  • Subsidy rate and bed stock are predetermined
  • Hospital services are price-caps
  • New techniques and specialisms are controlled

(Reisman, 2006)
116
Promote cost efficiencies
  • Demand side control
  • List of procedures not match up to consumer
    demand
  • GP reduce waste by counselling on side-effect and
    assisting clients to overcome their information
    asymmetry
  • Out-of pocket deductibles and rationing
    co-payment are incentives to spend prudently
  • Reimbursement by DRG discourages
    supplier-induced-demand

(Reisman, 2006)
117
Equity
  • Equity is about the fair distribution of
    something
  • Two types of equity
  • Horizontal equal treatment of equals
  • Vertical unequal but fair treatment of
    unequals

118
Equity
  • MSA got no risk pooling
  • Demand for health care is rationed implicitly
    through consumer purchasing power
  • User fees with high deductibles and cost-sharing
    constitute financial barriers to the poor
  • Does it means inequity??

119
Equity
  • The mix of safety nets continues to assure
    universal access to the Singaporean with the
    existence of mandatory catastrophic insurance
    program (Medisheild) and safety net program
    (Medifund)

120
Evaluation
Health Services Casemix Long Term Care
121
Health Service - Technical Efficiency
  • Production of health services at the least cost
  • Evaluating components
  • Mortality
  • Life expectancy
  • Healthcare expenditure revenues
  • Capacity of utilization
  • Cost accountability price competitive
  • Productivity

(Over et al, 2003 Aday et al, 2004)
122
Mortality and Life Expectancy
2002 2003 2004
Crude Birth Rate (per 1,000 population) 11.4 10.3 10.1
Crude Death Rate (per 1,000 population) 4.4 4.4 4.3
Infant Mortality Rate (per 1,000 population) 2.9 2.5 1.9
Maternal Mortality Ratio (per 100,000 live-births still-births) 12 5 5
Life Expectancy at Birth (years) Male Female 78.6 78.9 79.3
Life Expectancy at Birth (years) Male Female 76.6 76.9 77.4
Source Ministry of Health Singapore, 2005
123
Evaluation on Technical Efficiency

Figure Cost-recovery Ratio, Restructure
Hospital 1990-1997 ( (Adapted
from Phua 2003)
124
Evaluation on Technical Efficiency

Figure Hospital Expenditure 1990-1997

(Adapted from Phua 2003)
125
Evaluation on Technical Efficiency

Figure Hospital Revenues 1990-1997

(Adapted from Phua 2003)
126
Health Service Technical Efficiency
  • Maximization of health outcomes with a given mix
    of inputs
  • Evaluating Components
  • Public private share
  • Bed days
  • Admission rate
  • Average length of stay
  • Doctors consultation

(Over et al, 2003 Aday et al, 2004)
127
Public Private Market Share
  • Private sector shrunk workload from 20 to
    16, revenues from 45 to 36

1993 1993 2002 2002
Public Private Public Private
Inpatient Discharge 78.7 21.3 83.7 16.3
Day Surgery 80.4 19.6 84.0 16.0
Revenue inpatient 55.0 45.0 63.7 36.3
Revenue day surgery 59.3 40.7 63.2 36.8
Figure Public-Private market Share 1993-2002
Source Singapore
Ministry of Health
128
Evaluation on Technical Efficiency
Figure Admission Rate of Public and Private
from 1989- 2004
(Adapted
from Phua 2003 Singapore Ministry of Health)
129
Evaluation on Technical Efficiency
1991 2002 Remarks
Admission 105.4 per 1000 population 91.2 per 1000 population ?
Day Surgery 16 per 1000 population 44.3 per 1000 population as growing fast from 2000 -2002
Inpatient Surgery 53.6 per 1000 population 45.3 per 1000 population as substitute effect of day surgery
Patients Day 540 per 1000 population 440 per 1000 population ?
Bed Occupancy 77.9 73.1 ? As lower patient load
Average length of stay 5.1 days 4.8 days ?
Figure Key Utilization of Hospital Services

Source Singapore Ministry of Health
Discussion Paper 2004/03
130
Evaluation on Technical Efficiency
Median Waiting Time for 1996
Appointment at specialist out-patients clinic 6 days
Elective surgical operations 8 days
Consultation at specialist out-patients clinics 20 minutes
Consultation at polyclinics 21 minutes
Consultation at A E department 26 minutes
Figure Median waiting time for selected public
care service in 1996 Source Adapted from Liu
Yue,1999 MOH
131
Evaluation on Health Services
  • Inter-cluster Competition
  • Splitting into 2 clusters not indicate to improve
    the competition or render health care more
    economically
  • Compete to recruit physician with high pay or
    purchase expensive technology
  • Difficult to regulate since Government has too
    much hats regulator, purchaser and provider
  • Lack of transparency and choice for consumer

(Lim, 2005)
132
Evaluation on Health Services
  • Inter-cluster Collaboration
  • Enhance medical hub of excellence to attract more
    foreign patients
  • e.g share of expensive equipments
  • Electronic medical records link with casemix
    funding system facilitate accurate capture of
    clinical data

133
Evaluation on Health Services
  • Increase no of foreign patients to seek treatment

134
Evaluation on Casemix Funding
  • Strength
  • Incentives to economize cost effectiveness
    treatment
  • Collaborate to manage entire patient centered
    care
  • Standardize common outputs to measure cost,
    quality access
  • Limitation
  • Controlling the price along is not going to
    restrain quantity of services supplied.
  • E (expenditure) P (price) X Q (quantity)
  • More effective at clustering level but less
    effective at departmental level

(Lim Lee, 2004, Lim, 2005)
135
Evaluation on Long Term Care
Figure Use of Acute Care Services by Older
Persons 1995 Projection to 2030
Source Inter-Ministerial
Committee on Health Care for Elderly, 1999
136
Evaluation on Long Term Care
  • Financing
  • Means test is complicated consider the
    household income
  • Government only funding for 90 of capital costs
  • Subvention for home medical care / nursing
    services not yet available
  • Lack of incentive for private sector
    participation
  • Community medicine, primary care and hospitals
    services are financed from different resources
    and diverse institutions

(Mehta, 2002Teo, 2004)
137
Evaluation on Long Term Care
  • Care Provision
  • Fragmented care services lacking of co-ordination
  • Lack of standardized procedures for gate-keeping
    of residential care assessment
  • Lack of trained nurses, occupational therapists
    and physiotherapists for long term care
  • Emphasis as voluntary welfare but spirit of
    voluntarism is low in Singapore

(Mehta, 2002, Teo,2004)
138
Evaluation on Political Party Influence
  • Peoples Action Party adopts the polity of
    paternalistic and self-determination
  • One party government with clear agenda and belief
    to maintain political stability
  • Strong political commitment that strive to be
    proactive in health system facing cost of
    ageing population

(Barr, 2004 Lim, 2004 Low Aw, 2004 )
139
Concluding Remarks
  • Heart of Success
  • Strong political commitment of parsimony and
    paternalistic in strict control and rationing of
    health funding system
  • Small managerial size, conspicuous absence of
    urban-rural divide
  • High national saving rates, high level of
    education and income, relatively young population

(Taylor Blair, 2003 Barr, 2004 Lim, 2004 )
140
Limitation of the Evaluation
  • Data not easy to be access as government is not
    forthcoming about detailed operation of its
    system
  • Lack of systematic research to assess full impact
    and in-depth analysis of health financing and
    policies

(Hsiao,1995 Barr, 2004 Lim 2004 )
141
References
Aday, L. A., Begley, C. E., Lairson, D. R., Balkrishnan, R. (2004) Evaluating the Healthcare System Effectiveness, Efficiency and Equity. 3rd Ed. Chicago Health Administration Press. Barr, M. D (2001) Medical Savings Accounts in Singapore a Critical Inquiry. Journal of Health Politics, Policy and Law, vol 26(4) , August, pp 709-726 Barr, M. D. (2004) Singapore. In (Eds) Robin, G. Comparative Health Policy in the Asia-pacific Chapter 7, pp147-173. Hong Kong Open University Press Hanvoravongchai, P (2002) Medical Savings Accounts Lessons Learned from Limited International Experience. Geneva World Health Organization Hsiao, W. C. (2001) Behind the Ideology and Theory What is the Empirical Evidence for Medical Savings Accounts? Journal of Health Politics, Policy and Law, vol 26(4), August, pp 733-737 Lim, E K., Lee, C. E. (2004) Casemix in Singapore 5 Years On. Annals Academy of Medicine, Sept, vol 33, no 5,pp660-661 Lim, J. (1997) Health Care Reform in Singapore the Medisave Scheme in T. T. Meng, C. S. Bend (eds) Affordable Health Care Issues and Prospects. Singapore Prentice Hall pp277-285 Lim, M. K. (2004) Quest for Quality Care and Patient Safety the Case of Singapore. Quality Safety Health Care, vol 13, pp 71-75 Lim M. K. (2005) Transforming Singapore Health Care Public-Private Partnership. Annals Academy of Medicine, Aug, vol 34, no 7, pp 461-467 Low, L., Aw, T. C. (2004) Social Insecurity in the New Millennium the Central Provident Fund in Singapore. Singapore Marshall Cavendish Academic
142
References
Mehta, K. K. (2002) National Policies on Ageing and Long-term Care in Singapore A Case of Cautious Wisdom? In David. R.P., Alfred, C. M. Chan (eds) Aging and Long Term Care National Policies in the Asia-Pacific. Chp 5. Singapore Institute of Southeast Asian Studies Ramsay, C. (2001). Beyond the public-private debate an examination on quality, access and cost in the health-care system of eight countries. Marigold Foundation Phua, K. H. (2001) Tha Savings Approach to Financing Long-Term Care in Singapore. In Chi, I., Mehta, K. K., Howe, A. L. (Eds) Long-Term Care in the 21st Century Perspectives from Around the Asia-Pacific Rim. Oxford Haworth Press, Inc Reisman, D. (2006) Payment for Health in Singapore. International Journal of Social Economics, vol 33, no2, pp132-159 Phua, K. H. (2003) Attacking Hospital Performances on Two Fronts Network Corporatization and Financing Reforms in Singapore. In Alexander S. P, April, H. (eds) Innovations in Health Service Delivery the Corporatization of Public Hospitals. Washington, D.C. World Bank Singapore Ministry of Health available at http//www.moh.sg.com Singapore Central Provident Fund available at http//www.cpf.sg.com White Paper on Affordable Health Care, Ministry of Health 1993
143
  • Thank
  • You

144
Outcome of Health Financing
Figure Sources of Financing at 2004
145
Private health expenditure in Singapore, 2002
Source World Health Organization
146
Health Expenditure
Figure Real GDP and total health spending in
Singapore(in 1995 S) (Hanvoravongchai,2002)
147
Average Monthly Household Expenditure by type of
Good Services 1998 and 2003
  • Source MOH, Singapore

148
Per capita cost
FY02 FY03
Recurrent Health Expenditure (Sm) 1,451 1,904
Development Health Expenditure (Sm) 82 103
Recurrent Health Expenditure/GDP 0.9 1.1
of Total Government Health Expenditure/Total Government Expenditure 5.6 7.0
Total Government Health Expenditure per person1 (S) 454 584
Notes 1 Refers to Singapore Residents 2 Refers
to MOH's Budget Source MOH, Singapore
149
Bed upgrade
Percentile (Episode) Patient Bills by Ward Class (in S) Patient Bills by Ward Class (in S) Patient Bills by Ward Class (in S) Patient Bills by Ward Class (in S)
Percentile (Episode) Class A Class B1 Class B2 Class C
Average 3,246 2,448 1,054 786
50th 2,375 1,658 670 470
90th 6,346 4,917 2,124 1,597
95th 9,128 7,118 3,334 2,412
Figure Distribution of Patient Bills (Episodic)
by Ward Class in 2004 Source Singapore
Ministry of Health Information Paper 2004/2003
150
Medisave Account in 2006
36
S
22
11
13
8
10
Source Singapore Central Provident Fund
151
Admissions
Hospital Admissions 2002 2003 2004
Public Sector Hospitals 310,597 270,691 311,081
Private Sector Hospitals 81,892 85,844 94,225
  • Source Ministry of Health Information Paper
    2004/2003

152
Cost of health care providers
2002 2003 2004
Total No. of Doctors 6,029 6,292 6,492
- Public Sector 2,907 3,044 3,142
- Private Sector 2,936 2,863 2,845
Doctor to Population Ratio 1690 1670 1650
Doctor per 1,000 Population 1.4 1.5 1.5
Total No. of Dentists 1,130 1,183 1,227
- Public Sector 231 263 282
- Private Sector 787 798 802
Dentist to Population Ratio 1 3,690 1 3,540 1 3,460
Dentist per 1,000 Population 0.3 0.3 0.3
Total No. of Nurses/Midwives 18,034 18,763 19,329
- Public Sector 9,690 10,314 10,585
- Private Sector 4,313 4,480 4,749
Nurse to Population Ratio 1230 1220 1220
Nurse per 1,000 Population 4.3 4.5 4.6
Total No. of Pharmacists 1,191 1,236 1,288
- Public Sector 307 377 376
- Private Sector 642 659 719
Pharmacist to Population Ratio 1 3,500 1 3,390 1 3,290
  • Source MOH, Singapore

153
Health Expenditure
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