Quick Facts:

• Population (2009): 4,657,542
• GDP per capita (2008): $52,000
• Life Expectancy (years): M 79, F 83
• Physicians per 10,000 people (2000-2009): 15
• Infant mortality: 2.3 per 1,000 birth, one of the lowest in the world
• Government health expenditures as percent of total government expenditures (2007): 7.2%
• Compulsory participation in “Medisave accounts”: covers inpatient services, hospitals, physicians fees, surgical procedures, immunizations, screenings, family planning services, and psychiatric care, with some limits to usage
• Medishield is a high-deductible catastrophic insurance plan for those under 70 years old; all Medisave are enrolled but can opt out (88% enroll)
• Medisave financed through medical savings accounts, and income
• Patients have the choice of providers; rates at all public facilities are capped

Sources: CIA World Fact Book  and WHO World Health Statistics 2010; more statistics can be found at http://www.globalhealthfacts.org

Background Brief

In 1984, Singapore adopted a health care system of health savings accounts, called Medisave accounts, that emphasizes personal responsibility. Along with the compulsory medical savings accounts, most Singaporeans also enroll in Medishield, a voluntary catastrophic insurance plan. Prior to 1984, the Singapore health care system resembled that of the United Kingdom, where medical services were financed through general taxes and provided free or at a nominal charge. In the face of escalating health care costs and low labor productivity, the Singaporean government developed the National Health Plan to reform the structure and financing of the health care system, creating the Medisave system.

Singapore’s health care system is particularly known for its low expenditures on health care, spending 3.1% of its GDP and approximately $1,148 per capita on health care in 2007. These low expenditures can be attributed to the government’s cost control, rationing based on wealth, and social and demographic characteristics unique to Singapore. Despite the low level of expenditure, the Singapore health care system is among the most effective in the world. For example, Singapore's infant mortality rate was 2 per 1,000 birth compared with 7 in the United States. [1] In addition, the healthcare philosophy in Singapore emphasizes health promotion and disease prevention, as evidenced by the government’s multi-pronged strategy involving health education and preventive health programs.

In a survey assessing public perceptions of the Singapore health care system, respondents were generally satisfied with the health care: 77% agreed or strongly agreed with the statement that Singapore has a good health care system. In addition, 56% agreed that the government provides good and affordable basic medical care to Singaporeans. [2]

Access
Participation in Medisave is mandatory for the working population and covers inpatient services such as hospital charges, physician fees and surgical procedures and a few outpatient services such as chemotherapy and radiotherapy. Polyclinics are also offered as one-stop centers to provide services including immunizations, health screening, family planning services and psychiatric services. Patients not only have choice over providers, but they also can choose different classes of wards with varying levels of physical amenities. The government subsidy rates for the public hospital ward accommodation vary from 80% for an open ward to 0% for a room that has 1-2 beds. [3] Patients receive their treatment within a reasonable time; for example, waiting time for elective surgical operations is eight days on average. [4]

Financing
Medisave and Medishield are managed under a broader government-regulated compulsory savings program called the Central Provident Fund (CPF). Forty percent of an employee’s wages (split equally between employer and employee) go into the individual’s CPF account, which can be used for housing, college loans, health care (applied to the Medisave account) and retirement.

The Singapore health care system has compulsory savings funded by employees and employers, a national catastrophic health plan, and government subsidies that provide financing and keep costs in check for its universal health care system. Subsidies are based on a sliding income scale and the patient's ability to pay. The individual can use funds from the Medisave account or out-of-pocket to pay for health care services in methods of direct payment, co-payment, or deductibles. The employer contributes to the individuals’ Medisave accounts. The government subsidizes the provision of health care services based on the setting which care is delivered and the amenities provided. For example, public hospitals charge the patient fees representing at least 19% of total costs, with the government meeting the balance from general revenue, whereas private hospitals charge the patient 100% of costs.

Medisave: Singapore’s Medisave system is financed primarily through medical savings accounts. The contribution rate from the CPF for Medisave ranges from 6.5 to 9 percent of a worker’s pre-tax income, depending on age, with older workers paying more. [5] These contributions are exempt from income tax, earn interest, saved for medical expenses in old age and form part of one’s estate after death. Singapore places limits on how much of Medisave funds can be used for daily hospital charges, physician fees and surgical fees to discourage unnecessary hospitalization. In 2008, Singaporeans had an average of $10,000 saved in Medisave accounts. [6]

Medishield: Established in 1990, Medishield is a high-deductible catastrophic insurance plan that is intended to protect people from catastrophic medical expenses. Unlike Medisave, Medishield is a risk-pooling insurance plan for those under 70 years of age developed to assist low-income Singaporeans. Medishield has a high deductible and does not cover services such as vaccinations, psychiatric treatment or drug and alcohol rehabilitation. Every Medisave member is automatically enrolled, but they can opt-out. About 88% of Medisave account holders participate in Medishield. [7] Annual Medishield premiums are deducted from a member’s Medisave account. Medishield is protected from a considerable amount of liability because it operates on insurance underwriting principles, which allows it to exclude some illnesses if the patient has been receiving treatment before joining Medishield. Singaporeans also have the option of joining supplemental insurance plans provided that they are enrolled in Medishield.

Medifund: This government support was created in 1993 as a safety net to those whose Medisave accounts are low and can’t pay out of pocket. This fund is not an entitlement and is distributed on a case-by-case basis. The interest from this fund is distributed to public hospitals to cover the costs of patients unable to pay their medical bills.

Service Delivery
Under Medisave, patients are able to choose their providers and pay directly for the services at the point of delivery. There are 13 public hospitals, over 2,000 private medical clinics and 15 government polyclinics (similar to community health centers in the United States) that provide health care services. [8] Singapore has a mixed medical care delivery system. In acute care the public sector providers make up nearly 80% of the market while private providers dominated the primary care sector, also with nearly 80% of the market. Eighty percent of hospital care in Singapore is provided by public hospitals, where the government puts price caps on all services and procedures. [9] Rates at private clinics and hospitals are unregulated by the government.

Despite health care accounting for a low share of GDP, the Singaporean health care system is arriving at a crossroad as they face rapid growth and the challenges of cost containment as their currently young population ages and medical technology advances. The current financing of health care currently does not include long-term nursing care for the elderly since Medisave and Medishield are mainly used for acute hospital care. One of the proposals is to establish a long-term care insurance product, similar to Medishield. The government is also working towards harnessing information technology by establishing a National Health Information System that will incorporate electronic medical records across the health care system.

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Resources

Barr, M.D. (2001). Medical Savings Accounts in Singapore: A Critical Inquiry. Journal of Health Politics, Policy and Law, 26.4:709-726.
This article examines the system of medical savings accounts in Singapore and the comparison of personal responsibility for health care with government control of health services.

Pauly, M. (August 2001). Medical Savings Accounts in Singapore: What can we Know? Journal of Health Politics, Policy and Law, 26:727-732.
This article reviews Michael Barr’s article and examines the impact of the combination of medical savings accounts and catastrophic health insurance for the non-poor on health care access.

Ham, C. (August 2001). Values and Health Policy: The Case of Singapore. Journal of Health Politics, Policy and Law, 26.4:739-45.
This commentary discusses the unique case of Singaporean health care and the influence of social embeddedness and values in health care.

Kaiser Family Foundation. Globalhealthfacts.org
This site provides up-to-date and easy-to-access data by country on HIV/AIDS, tuberculosis, malaria and other key health and socio-economic indicators.

Lim, J.F.Y. and V.D. Johsi. (2008). Public Perceptions of Healthcare in Singapore. Ann Acad Med Singapore, 37:91-5.
This article describes the results of a survey of Singapore residents on affordability and quality of healthcare in Singapore.

Lim, M.K. (2005).Transforming Singapore Health Care: Public-Private Partnership. Ann Acad Med Singapore, 34:461-7.
This commentary discusses Singapore’s experience in health care finance, provision and the challenge of cost containment and ensuring quality and patient safety.

Liu, E. and S.Y. Yue. (1999). Health Care Expenditure and Financing in Singapore.
This report examines the structure, the delivery system and financing of the health care system in Singapore. It also provides an analysis of health care expenditures, the financing arrangements and the performance of the system.

Massaro, T.A. and Y. Wong. (1996). Medical Savings Accounts: The Singapore Experience. National Center for Policy Analysis Policy Report.
This report discusses Singapore’s experience with medical savings accounts and evaluates the success of this program.

Meng-Kim, L. Health Care Systems in Transition II. Singapore, Part I. An Overview of Health Care Systems in Singapore. Journal of Public Health Medicine, 20.1:16-22.
This article gives a background to Singapore’s health care system including the financing structure, the general philosophy behind the system and future challenges.

Ministry of Health. 2007. Singapore Health Care System.
This is the website for the Singapore ministry of health that includes an overview of the health care system and information on four specific programs (Medisave, Medishield, and Medifund).

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