“More of the same”, “Quantity does not equate to quality”. These were some initial comments I received about the Ministry of Health budget speeches. These relatively uncharitable remarks do reflect disappointment, likely after expectations had been raised by earlier hints of a ‘transformative’ budget. I confess I had to read through the speeches a couple of times to feel better. There are ‘green shoots’, and continued public debate and discourse can help keep the gardener focused not on how many plants there are, or even what types, but on the taste of the final produce at the dinner table for hungry Singaporeans.
To readers of this blog, please keep the attention of policy makers squarely focused on outcomes and whether and how all these infrastructure initiatives actually improve the lot of the average Singaporean.
Laying groundwork for a heart transplant (‘Today’ 13 March 2013)
If Health Minister Gan was a cardiac surgeon and the healthcare financing system a patient with heart failure, yesterday’s Committee of Supply budget announcements would be a ‘bridge to transplant’, necessary measures to keep the patient alive and with the latest devices, even walking about with reasonable function. However, the definitive treatment would be a heart transplant, a new heart free of the diseases that plagued the old one and prevented living life to fullest potential.
Minister Gan announced substantial financing initiatives, but he conceded these were temporary salves while he and his officers worked on a major review of the system. Saying in Parliament yesterday “The review of our healthcare financing system will be extensive, and will involve fundamental shifts”, the health minister pleaded for time to study the changes needed carefully. Minister Gan urged caution and patience as “If we get it wrong, we leave a heavy burden of debt for our children and grandchildren”.
Many of the initiatives are a welcome start. The Minister has acknowledged the concerns of the man in the street and is courageously following through on the ‘vow’ he made that no Singaporean will be denied healthcare because he cannot afford it. Many of the temporalizing measures are incremental, more beds, more hospitals, more doctors and nurses, but some changes hinted at are potentially transformative. Shifting funding from the acute hospitals to the other parts of the healthcare system, especially primary and extended care, will encourage transformation. Liberalizing Medisave usage more extensively beyond hospitals, expanding MediShield to include even more outpatient services, will facilitate development of the healthcare system in a more balanced manner. The current somewhat unbalanced growth with muscular hospitals and anaemic ‘everything else’ is a consequence of the emphasis on acute hospitals all these years; shifting the flows of financials can effect profound transformations of primary care and the intermediate and long term care sectors. Will it work? We don’t know. Will it help? Most definitely. Professor Steven Landsberg, author of the popular ‘The Armchair Economist’ has baldly stated: “People respond to incentives. The rest is commentary.”
The announcements yesterday are encouraging. Even more encouraging is the recognition that more infrastructure, a much larger healthcare workforce and much more funding are necessary but insufficient. Nonetheless, there is cause for concern. The challenges in healthcare facing us today are a crisis in slow motion. There is a very real danger we will lose momentum and be satisfied with ‘stop-gap’ measures, falsely believing they will suffice. The heart surgeon may be happy after successful implantation of a device as a ‘bridge to transplant’ for a failing heart, but he does not let up on finding a suitable heart for transplant.
“With an ageing population, rising labour costs and the use of expensive technology in modern medicine, further increases in healthcare expenditure are to be expected… There is therefore an urgent need to seek out and use cost effective approaches to healthcare.” These words could have been spoken in the hallowed chambers of Parliament yesterday but they were actually written in 1991 by Dr. Aline Wong, then Minister of State for Health, on behalf of the Review Committee on National Health Policies.
Did we drop the ball? I don’t think so, but it is clear that we did not as a country prioritize population ageing with the urgency that it deserved. There is an interesting parallel with defence. No one questions whether defence is financially sustainable. Defence is ‘existential’ and it is a given Singapore will do whatever it takes to have a strong effective defence force. If the ‘health and wellbeing of Singaporeans’ were equally existential, would we be framing the issues differently and with a different tempo?
A civil servant commented to me recently, “The current narrative is still heavily weighed on the economics ‘existential threat’… But we do not sufficiently ask if we may be the ones with the systemic blindside, that perhaps it is the government that has not understood the people’s “irrational” concerns and downplayed the social realities. The intent is not to automatically conclude that we must sacrifice economic growth, but if we began to treat social issues as ‘existential’ and put as much energies in finding creative solutions we may come up with a very different set of new possibilities, more than the current almost black-white scenarios painted.”
One final observation. Dr. Wong’s 1991 Report was low on financials and high on outcomes, setting targets such as “to reduce the overall obesity level in the population to 3%” and “to increase the proportion of Singaporeans who exercise regularly to 40% by the year 2000”. Yesterday’s speeches were high on dollars, beds and hospitals, but short on targets. I hope in the review to follow, the government will focus its efforts not just on outputs, but also on outcomes. Only by doing so, and emphasizing outcomes that put the Singaporean at the centre, will we truly know whether our healthcare transformation has been successful.