The Equity of Universal Health Coverage: Some Reflections from Singapore

The challenges confronting health systems in Asia include known and emerging infectious diseases and an increasing prevalence of non-communicable diseases. For a number of countries, such as Singapore, a rapidly aging population is expected to exacerbate the latter. In 2005, member states of the World Health Organization (WHO) from East Asia and elsewhere made a commitment to develop their health financing systems in ways that will ensure that all people have access to health services and do not suffer financial hardship in paying for them.[1] By this initiative, how successfully health systems meet the challenges ahead will depend on the extent that equity in access and equity in financing are achieved. Equity is difficult to define simply, but it is regarded as a cornerstone not only of policy decisions, but also of ethically legitimate social institutions.[2] Broadly speaking, equity is concerned with maximizing the benefits, capabilities and general well-being of the worst off members of a society. In the context of universal health care (UHC), equity in access could be understood as necessitating the prioritization of those who with the greatest health needs in order to secure for them equality of opportunity or capability to the furthest extent possible. At the same time, health systems must ensure that households are not made to contribute more than their ability to pay in order for equity in financing to be also secured.

Equity in healthcare

For many health systems in East Asia, there is as yet inadequate information on whether coverage meets the healthcare needs of their populations, and how they ensure that patients receive appropriate services at costs that households and systems can afford. When the coverage does not meet important population needs, equity in financing is compromised and households are put at risk of impoverishment.[3] Inadequate investment in primary healthcare could raise inequities in both the access and finance components, since payment for hospitalisation could have been avoided with affordable access to outpatient care.[4] For this reason, the 2008 World Health Report focused on improving the place of primary healthcare in health systems. It calls for all WHO member states to:

• Aim for UHC reforms to improve health equity, end exclusion and promote social justice;
• Reorganize services around primary care through service delivery reforms;
• Integrate public health initiatives into primary care delivery and to aim for intersectoral collaboration; and
• Adopt a participatory style that promotes policy dialogue with multiple stakeholders in leadership reforms. [5]

All countries provide some degree of health coverage and financial protection, and perhaps none can claim to have attained UHC in a substantively comprehensive way. Hence UHC continues to be a policy challenge for all countries, and different paths are embarked upon. When evaluated in terms of its key dimensions of range of services, direct costs, and population, it is questionable if equity in UHC is always and only about the need for member states to “extend coverage to more people, offer more services, and/or pay a greater part of the cost.”[6] Take for instance the private healthcare sector in health systems. Equity in access and finance may require a multiplicity of arrangements and orderings, depending on the values, social institutions, politics and traditions (or “path dependency”) of the health systems concerned, rather than a radical transformation towards a single ideal-typified system.[7] It may also require a clearer evaluation of the contributory roles and responsibilities of the different stakeholders entailed.

Singapore’s experience

Singapore’s health system gives emphasis to self-reliance, individual responsibility for one’s own health, and collective responsibility in maintaining healthcare affordability. These values are manifest in a number of distinct system features and could point to a particular conception of equity in access and finance. Similar to Hong Kong, Singapore has a predominantly private primary healthcare sector. About 80 percent of the primary healthcare needs of Singapore are met mainly by private general practitioners (GPs). These GPs dispense their own medicines, which are (along with cost of consultation) usually fully paid for by patients, unless subsidized by employment insurance. In contrast, public healthcare centers (or polyclinics) provide about 20 per cent of the primary care services to all citizens at a subsidized rate, with certain groups of Singaporeans (such as those under the age of 18 years or above the age of 65 years) receiving greater subsidy. In giving effect to self-reliance and individual responsibility as desirable ends, most Singaporeans are expected to pay for their own primary healthcare needs. This health financing arrangement is also intended to discourage the over-consumption of healthcare services.

Responsibility for one’s own health needs is also the philosophy that underpins Medisave, a mandatory savings account scheme. Depending on his or her age, a working Singaporean contributes 7 to 9.5 percent of his or her monthly salary into this personal account. Savings can be used to meet the healthcare expenses of the account holder, including hospitalization, certain vaccinations, health screening and other outpatient services, and home-based hospice services. In addition, Medisave may also be drawn on to pay the premium for MediShield, a low cost basic medical insurance scheme designed to meet the cost of hospitalization for treatment of catastrophic illnesses or prolonged hospitalisation in moderate to lower-grade wards of “public” restructured hospitals.[8] Claimable limits and co-payment features of MediShield, such as co-insurance and deductibles, are similarly directed at ensuring a level of self-reliance and individual responsibility.[9] More recently, a severe disability insurance known as ElderShield has been introduced to enable risk sharing as a means of providing a level of financial protection to those who need long term care, especially in advanced in years. Under certain medical diagnoses, the insured may receive a monthly payout of S$400 over a maximum period of 72 months. Again, coverage under this scheme is at best supplementary as it is unlikely to be adequate in the light of rising costs and the very real prospect of long-term care extending beyond six years.

Beyond the individual, families are expected to be the first line of support. Consequently, funds in the Medisave account may also be drawn upon to meet the healthcare expenses of dependents of the account holder. Some have argued that these policies, along with a statutory requirement for adult children to care for their aged parents, are reflective of Confucian precepts that are deeply embedded in Singapore’s predominantly Chinese population.[10] While the actual influence of particular ideologies on public policy is difficult to establish with certainty, it seems clear that the state has emphasised the involvement of the private sector and the voluntary sector in its “Many Helping Hands” approach. By this approach, community organizations are promoted as the next level of support after the individual and the family.[11] In addition, the participation of private insurers has been evident: insurance coverage in addition to MediShield may be purchased from a private insurer as Medisave-approved Integrated Shield Plan. Premiums for this enhanced coverage may be paid using Medisave funds. Similarly, ElderShield Supplements may be purchased from private insurers to enhance the disability benefits coverage provided under the ElderShield scheme.

The Community Health Assist Scheme (CHAS; or the Primary Care Partnership Scheme as it was known until 15 January 2012) also represents an innovative policy of public-private partnership.[12] Started in 2000 by the Ministry of Health, a key objective of CHAS is to improve accessibility of primary care to needy elderly, disabled and low-income Singaporeans. Under this scheme, private GPs and dentists provide common outpatient medical and dental treatment to enrollees at subsidized prices. Since its inception, CHAS has undergone a number of changes, and in the past five years the coverage of the scheme has been progressively broadened. In 2009, it was extended to cover more chronic conditions. In 2012, the qualifying age was lowered from 65 years to 40 years and the income criteria raised from $800 to $1,500 per capita monthly household income, significantly broadening the pool of potential enrollees. Two subsidy tiers (Blue Health Assist scheme for individuals with per capita household monthly income of < S$900; and Orange Health Assist scheme for individuals with per capita household monthly income > S$900 but ≤ S$1,500) have been added to increase accessibility of primary care services for more needy Singaporeans. From January 2014, further changes will be introduced to expand coverage even more: the qualifying age limit of 40 years will be removed, five new chronic conditions will be added to the list of subsidized conditions, and greater subsidies will be provided for specified screening tests, including those conducted by a GP. Aside from these, charges at Specialists Outpatient Clinics in public hospitals will be lowered for lower and middle income groups. In addition, a number of changes are being considered in enhancing MediShield as MediShield Life. These include enhancing MediShield benefits by raising claim limits and reducing the co-insurance borne by patients for large bills, and by providing lifetime coverage. MediShield coverage will be extended to all Singaporeans, including those currently uninsured. For those who are unable to pay premiums for coverage under MediShield Life, additional government support will be provided.

Measuring effectiveness

In general, eligible individuals with income levels below $900 per month (bottom 30^th percentile of the population by income) can receive treatment at the same prices as at government run polyclinics. Conceivably, enrollees under the scheme would be more likely to seek outpatient care at GP clinics, rather than at tertiary care institutions, given the greater accessibility of the former, in terms of number of clinics and by wide geographical distribution. A difficulty in ascertaining whether CHAS has been effective in enhancing coverage for its target population is the scheme’s reliance on self-identification and enrollment by qualifying individuals. In addition, it will be difficult to assess the actual impact of CHAS, as available data is unlikely to provide information on incidence of catastrophic expenditures prior to enrollment or otherwise in a control group. Furthermore, nothing definite can be said about those who are eligible, but not enrolled in the scheme. It is also currently unclear if CHAS has been effective in encouraging the greater utilisation of GP clinics for outpatient care. While CHAS is undoubtedly an important policy innovation that is likely to be impactful, its contribution to the UHC agenda should be considered against these limitations.

In moving away from a full capitation funding model like the United Kingdom (where co-payment is not required), the role of Singapore’s government in providing healthcare access and financial protection is rather more circumscribed. The state assumes a more prominent role in meeting the acute healthcare needs of citizens, as public hospitals account for about 80 percent of tertiary care. A majority of the public hospitals’ beds (about 81 percent) in moderate and lower-class wards are heavily subsidized. It has been reported that, in 2012, the average length of stay in public acute care hospitals was about 5.8 days while the average occupancy rate was around 85 percent.[13] Apart from acute hospitals, community hospitals have more recently been introduced for the convalescent sick and aged. For the impoverished, Medifund has been set up as a public endowment fund to serve as a safety net for Singaporeans who cannot afford to pay for subsidized bill charges. In 2012, the capital sum was reported as S$3 billion. In November 2007, a capital sum of S$500 million was set apart as Medifund Silver to provide aid specifically to needy elderly Singaporean patients.[14]

In anticipation of growing healthcare needs and challenges, the government has committed to doubling its healthcare expenditure over the next five years from S$4 billion to S$8 billion.[15] If this means that the government will now pay a greater part of healthcare cost for greater healthcare coverage to more people for  more services, does this also mean that greater equity in access and finance is achieved? Not necessarily. Where the prevailing philosophy is still a mix of self-reliance, individual responsibility for one’s own health, and collective responsibility in maintaining healthcare affordability, equity in access and finance is also a question of contributory roles and responsibilities of the different stakeholders, as well as the arrangements and orderings that they put in place.

[1] World Health Assembly Resolution 58.33.  2005. Geneva: World Health Organization.  Available at: http://www.who.int/health_financing/documents/cov-wharesolution5833/en/.

[2] Rawls J. 1999 (1971 org. ed.). A Theory of Justice. Cambridge MA: Harvard University Press.

[3] Yip W, Hsiao WC.  “Non-evidence-based policy: How effective is China’s new cooperative medical scheme in reducing medical impoverishment?” Social Science & Medicine 2009; 68:201-209; Parry J.  Nine of 10 Chinese are covered by medical insurance, but access to treatment remains a problem. BMJ 2012; 344:e248.

[4] Wagner AK, Valera M, Graves AJ,Laviña S, Ross-Degnan D. Costs of hospital care for hypertension in an insured population without an outpatient medicines benefit: an observational study in the Philippines. BMC Health Services Research 2008; 8:161.

[5] World Health Organization. 2008. The World Health Report 2008: Primary Health Care – Now More Than Ever. Geneva: World Health Organization.

[6] World Health Organization. 2010. The World Health Report 2010: Health Systems Financing –The Path to Universal Coverage. Geneva: World Health Organization, at 13.

[7] Gauld R, Blank R, Burgers J, Cohen AB, Dobrow M. “The World Health Report 2008 – Primary Healthcare: How Wide is the Gap between Its Agenda and Implementation in 12 High-Income Health Systems?” Healthcare Policy 2012; 7,3: 38-58.

[8]   For information on restructured acute hospitals and specialty centers, see: http://www.moh.gov.sg/content/moh_web/home/our_healthcare_system/Healthcare_Services/Hospitals.html. It has been observed that a quasi-free market for healthcare has been developed in Singapore to control cost and maintain high service quality: Haseltine WA, Affordable Excellence: The Singapore Healthcare Story. 2013. Singapore: Ridge Books, at 64-82.

[9] For information on MediShield, see: http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/schemes_subsidies/Medishield/How_MediShield_Works.html.  

[10] Lim M-k, “Values and Health Care: The Confucian Dimension in Health Care Reform.” J Med Philos 2012; 37,6: 545-555.

[11] Lim J, Myth or Magic – The Singapore Healthcare System. 2013. Singapore: Select Publishing, at 24; See also Rozario PA, Rosetti AL, “Many Helping Hands”: a review and analysis of long-term care policies, programs, and practices in Singapore. J Gerontol Soc Work 2012; 55,7: 641-58.

[12] Ng TT-l, “Enhancing Universal Health Coverage through Public-Private Partnerships in Primary Care – The Case of Community Health Assist Scheme in Singapore.” Available at: http://www.economistinsights.com/sites/default/files/legacy/ecasia/uploaded-resources/CHAS-Sinagapore.pdf.  

[13] For more information, see: http://www.moh.gov.sg/content/moh_web/home/our_healthcare_system/Healthcare_Services/Hospitals.html.

[14] For more information on Medifund and Medifund Silver, see: http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/schemes_subsidies/Medifund.html.

[15] Ho M, Budget 2012: “A Snapshot of Its Impact on Local Healthcare.” SMA News 2012; 4-7. Available at: http://news.sma.org.sg/4403/Feature.pdf.