What can the ‘average citizen’ do?

I recently received an email from a reader with the poignant comment below:

“If there’s anything a retired citizen like me can do to bring about the transition to universal healthcare coverage in Singapore, please let me know. If we need to pay more taxes to give individuals peace of mind about their health, let’s do it. It’s an outrage that an affluent community such as ours can’t form a collective insurance pool and manage abuse and over-consumption. Let’s hope the policy-makers can do something fundamental and imaginative in the review.”

‘What can the average citizen do?’ is an interesting question I have been thinking about for a while. Let me attempt an answer.

Some context which I concede some may find ‘left-of-center’: First, I firmly believe government and policy-makers are there to serve the people and not the other way round. Second, “Singapore is rich but Singaporeans are poor” is a phrase I have heard many times and each time I hear it, I still feel the same sharp sting of indignation. Third, my view of mankind (including womankind) is a more optimistic, uplifting one. Call me naïve but I do think that more people want to do the right thing than ‘cheat’ the system or abuse privileges. Let not our views be jaundiced by our own prejudices. For example, much negativity has been expressed against foreigners but ten years ago, our foreign colleagues stayed and fought the good fight with us:

“In Singapore, about 40 per cent of SARS cases were reported in healthcare workers. Professionalism was at its finest moment.  Many answered the call of duty in the battle against SARS. Both our foreign and local healthcare workers stayed on to fight alongside one another.  This was not always the case elsewhere in the world.”  (Emphasis added)

Minister for Health Gan Kim Yong, at Tan Tock Seng Hospital “Remembering SARS: 10 Years On”, 20 March 2013

 

When it comes to healthcare, ‘What can the average citizen do?’ in my mind can be answered in five ‘Be’s’.

Be comfortable with one’s own views– A starting point is to be reflective and think through one’s own world view and whether to use the conventional political characterization, one is left, center, right etc. Healthcare and the design of the health system are very much driven by political philosophy and it is essential to understand both what the government’s inclinations and what one’s own orientation is along the political spectrum. There is no right (pardon the pun!) or wrong and societies need to have candid discussions. Health systems reflect the political drivers and healthcare reform articulates more fundamentally what sort of society reformers hope to see. It’s vital for advocates to be clear what they viscerally believe and want to see materialize.

Be informed– This is difficult, I agree. Healthcare is complex and Singapore’ healthcare system frankly is exceptionally complicated. Whether this is by design to bamboozle citizens or just ‘policy creep’ I cannot say. But I certainly hope the underlying intent is not the so-called ‘mushroom management’ – keep them in the dark, feed them s*it. Singaporeans deserve better. Readers would know I am writing a book on the Singapore health system which should be out on the bookshelves by the end of August. One key motivation for me to write the book is to hopefully inform a wider audience and so that more can participate and contribute to the evolving debate on what our health system should look like. There is actually a lot of information on the Ministry of Health website and examining the data captured there compared against the OECD or World Bank data can be very instructive. This is a shameless pitch for my book, but do get a copy when it comes out!

Be proactive– There is no need to let the government know what you think only at the ballot box. In a previous post, I discussed how the government is wrongly thought of as monolithic and homogenous when the truth is far more likely that there is a broad spectrum of opinions with constant debate and dialogue within the government. Being a silent majority is unhelpful- even Ministers may wrongly think they are on the right track policy-wise and just need to do a better job communicating. Everyone has blinkers and some more than others. Actively voicing the sentiments from the ground can help politicians and senior civil servants who run a very real risk of being out of touch remain connected to what the ‘average citizen’ actually thinks and feels. It also helps those reformers within government to press their cases more strongly. Without going into details, I can assure that the health ministry takes every letter to the forum pages of the newspapers seriously. The online voices perhaps a little less so but as the recent MDA regulations show, there is recognition of the power of the online voice. So don’t be hesitant. Write to the forum pages of the newspapers, write to your MP, post concerns, suggestions etc. on your blog and so on. ‘Little drops maketh a mighty ocean’ and while not an exact science, policy makers do try to get a sensing of the ‘hot button’ issues and respond accordingly.

Be organized– This has been traditionally downplayed in Singapore society. Petition writers, organizers of policy forums (other than the government and the think tanks), coordinators for protests in Hong Lim Square Park have been typically seen as trouble-makers to be eyed with suspicion but this does not have to be so. There must be space in Singapore for thoughtful alternative perspectives, especially those well-researched and well-articulated. While there have been largely ignored petitions previously to ‘save the dolphins’, preserve a park, not build a casino and so on, times have changed and woe befall the politician who dismisses out of hand a petition signed by thousands of Singaporeans.

In fairness to policy makers, there are literally thousands of issues that can potentially catch their attention- why should any one be singled out for attention? Much of the ‘inattention’ may actually be ignorance, especially so since many politicians and policy makers in the healthcare space don’t actually have domain expertise. One anecdote describes how a politician was shocked at a ‘Meet the People’ session by the price of medicines for a rare disease and declared to his staff the next day “We must do something to help these poor people”.

The caricature of the arrogant, ‘I know best’, self-serving mandarin is over-blown. Virtually every minister and policy maker in healthcare I know personally is sincere in wanting to do his/ her best to improve the system. The ‘average citizen’ can help the politicians and civil servant do their jobs better and especially by presenting the voice of the ‘average citizen’ in an organized manner. Yes, they may be much better paid than you are and should know their stuff but let’s not be the foolish man in the sinking boat who says “I don’t need to worry; the hole is on his side of the boat”. We have only one Singapore, our Singapore.

“Be the change you want to see”– This oft-quoted saying of the great Mahatma Gandhi in this setting is about more about changing mind sets by our actions. Our politicians and civil servant have been driven for decades by a fear of ‘welfarism’ and the specter of moral hazard. What will change their minds? The fear of ouster may invite a few cosmetic changes but will there be fundamental reform? The reality of potential abuse of an overly-generous system is very real and easily measured; the damage in human lives of a miserly model where citizens deprive themselves of needed healthcare less visible and easier to turn away from.

ORB Riau 1998It is a two-way street. We as Singaporeans need to play our part and be responsible users of the health system even as we call for the government to loosen the binders. Every patient in the queue who does not really need to see a specialist is pushing a genuine case further back the line. The medicines taken and wasted “because the government is subsidizing/ paying” are paid for out of the same dollar that could have been used to build the next hospice.

More insidiously, the ‘abuse’ reinforces policy makers already firmly held belief that people cannot be trusted and ratchets back a little the dials of reform. The shared responsibility of stewardship for the scarce resources in our health system is exactly that, a shared responsibility amongst all of us, policy makers, providers, payers, patients, members of the public. One of my favorite sayings is by Marcel Proust “The real voyage of discovery consists not in seeking new landscapes but in having new eyes”.

Help policy makers see Singapore and Singaporeans with ‘new eyes’. That’s what the average citizen can do.

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3 comments

  1. […] – Insighs Health Associates: What can the ‘average citizen’ do? […]

  2. Lorena Tan · · Reply

    Thank you for the 5 ‘Be’s, some of which are not so difficult but others more challenging. Being an informed advocate is challenging because the Singapore healthcare system is complex and the layman can at best know only a bit of the proverbial elephant. One is afraid to publicly state a view (in the ST forum for instance) in case one may not have all the facts, and speaking from emotions is merely embarrassing.

    If someone else is organizing a petition, I’d like to know – not so proactive i know. But I’ll consider writing to the Health Minister to let him know what it looks like from where I’m sitting. (Perhaps he might arrange for a secretariat to receive views from the public as part of the review.) It may not be a citizen’s right to be assured of help from fellow citizens when he’s facing a medical catastrophe, but who would not want to be, and be proud to be, part of such a community? Help should be part of he system, not by special application to Medifund.

  3. Hi Lorena, thank you for the comment. Spot on! It is precisely because there is insufficient knowledge of the system that the public feel ‘intimidated’ in raising issues publicly. This need not be the case moving forward. I am personally seeing some activity in the patient advocacy space- a number of ‘disease focused groups’ have approached me for some informal advice on how best to engage the government and I suspect some will do some behind-the-scenes while others will do so in the public realm. My view is that a balance is needed as some debate in the public space can be educational for all of us and advance collective understanding of the health system. On my part, I am happy to play a more active role in sharing experiences and helping to ‘educate’ (Yes, presumptuous word!).

    It’s fine to write to the Ministry of Health directly although I would caution against expecting immediate policy changes or even being able to relate any policy tweaks to public attention. The Singapore government simply by and large does not work in this way. There is a ‘national conversation’ going on and for health, the appropriate email address to send perspectives to would be: MOH_OSC2013@moh.gov.sg.

    One last point: the political philosophy is still dominated by ‘targeted subsidies’ and I think Medifund and other means-tested mechanisms will continue to be a large part of the ‘help’ framework. The keen sense of financial sustainability for the government and not over-committing is also very strong and this is not unreasonable. Have a look at what the Finance Minister said about healthcare earlier this year: “We do need to provide greater support for older Singaporeans, particularly in healthcare and for their retirement needs. That’s something which we want to do. And we have to go about it in a way that doesn’t lead us to the problems we see in Europe and the United States or Japan, go about it in a way that’s sustainable. And it means that subsidies do have to be targeted, they can’t be across the board, including for the upper middle income group or upper income individuals, they have to be targeted at the middle and lower end of our retirees. It does mean that some co-payment is necessary because that leads to individual responsibility. But, very importantly, it means also shifting the balance of our spending in healthcare so that over time, we place greater priority on preventive care and primary care and not just on what happens in the acute hospitals. So it’s not just what happens when you end up in hospital but it’s about managing diseases well and preventing diseases from growing. So that’s a very important strategy long-term as well.” If you feel very strongly that ‘targeted subsidies’ decided on a post hoc basis with very limited ‘rights’ to affordable healthcare is a fundamentally wrong approach which erodes ‘peace of mind’ and denies dignity, do engage with the political leadership. It is a question of values and no real right or wrong.

    Thanks once again for your comments.

    Jeremy

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