Misunderstanding European Healthcare Once Again

It is hard to be European. Despite substantial changes in healthcare financing in Europe over the last 2 decades with a shift towards larger use of cost sharing, many in Singapore still believe that European healthcare is ‘free’. The latest is a remark attributed to a minister by Channel News Asia: “… said the government cannot put in place schemes like those in Europe, where there is no co-payment.” This may be a mis-quote as it is unlikely that senior public servants would not be aware of developments occurring in large economies like the European Union.

What are the facts? Tambor et al published a review of cost sharing in European healthcare in 2011. The salient comments from the article:

“The review indicates that in more than half of the EU countries, there is formal patient cost-sharing for GP’s, out-patient specialists’ and in-patient hospital services. The most common type is co-payment (in case of all three types of services), followed by co-insurance (in case of GPs’ and specialists’ services), and a mixture of these two types.”

And more importantly:

“In virtually all EU countries where patient cost-sharing is implemented, there are some cost-sharing limits that apply to all patients. Maternity and preventive services are often excluded from patient cost-sharing. In all countries, there is some form of exemptions or fee reductions for the key vulnerable population groups, i.e. children, elderly/pensioners, low-income individuals and those with chronic or severe illnesses.”

Patient cost-sharing arrangements in the EU

A cursory examination of current European healthcare financing will highlight a few key points:

a. Virtually all systems are tax- or insurance-financed in the main and all citizens are enrolled, i.e. universal health coverage

b. User fees or co-payments are present in more than half of EU countries. In fact, of the four largest economies in Europe (Germany, France, UK and Italy), only the UK does not have co-payments for services although there are prescription fees imposed in England (currently at GBP7.65).

c. There are specific schemes to limit the quantum of co-payments to avoid excessively onerous imposition on citizens, especially those belonging to vulnerable groups.

There is much to learn from, both good and bad from other countries’ health systems, and a key starting point is to get our facts correct.


The relevant excerpt from “Healthcare co-payment promotes self-reliance: Grace Fu” (CNA website 14 April 2013) http://www.channelnewsasia.com/news/singapore/govt-prepared-to-take/638184.html

Minister in Prime Minister’s Office Grace Fu said even as the government is prepared to shoulder a larger share of healthcare costs, the need for Singaporeans to continue making co-payments will remain.
Speaking at a dialogue session with Ang Mo Kio residents as part of a ministerial visit on Sunday, Ms Fu said this will promote self-reliance and avoid fiscal problems seen in other countries.
Issues concerning healthcare dominated the dialogue. Some wanted to know if more subsidies can be provided to help Singaporeans cope with rising medical costs.
Ms Fu said: “We can have a 20 per cent subsidy or 80 per cent subsidy, but if the total medical bill is very big, any small percentage or even big percentage will be a lot of money for the residents here.”
Ms Fu said the issue of health-care costs has been a common concern among Singaporeans. She assured no matter what their income level is, no one will be deprived of good quality healthcare.
Ms Fu noted that compared to other countries like Malaysia, Singapore’s healthcare costs can be higher. One reason is due to drug companies charging different prices in different countries.
She said the government is trying to reduce costs by bulk-purchasing items and is reviewing various financing models. She said the government cannot put in place schemes like those in Europe, where there is no co-payment.
She said: “With the very ageing population that we are anticipating, the costs of supporting that system will actually fall on our children. They have to support us with their taxes, so we have to make sure that we do not go down the route of some of the countries or nations that we see are now having great difficulties supporting such a social security system.”



  1. She said the government cannot put in place schemes like those in Europe, where there is no co-payment.

    This is technically true.
    She does not say all European system has no copayment just that we cant follow those system with no copayment.

    1. Point taken :). Anyway, I think the important issue here is to be able to learn with an open mind from all health systems and not caricaturize some as the ‘bogey man’ Singapore needs to avoid at all costs. Personally, despite the financial challenges, I am impressed by the European commitment by and large to equity and protection of financially vulnerable populations. We are not quite there yet here in Singapore but I think changes are afoot and I am optimistic!

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