“Why Singapore needs foreign patients” ST 22 July 2015- Follow Up Responses

My recent commentary “Why Singapore must have foreign patients” (Straits Times 22 July 2015) created quite a stir with many lambasting the views presented or thanking me for raising issues which had been difficult in this political climate to voice publicly especially if one was in the public sector.

SG Foreign Pts

Two issues are probably worth clarifying further- the data on bypass surgeries and the notion of ‘scalpel-like precision’ in foreign patient policies.

I. Data on bypass surgeries

In retrospect, isolated heart bypass surgeries (which I had considered in the commentary) were a bad example to use and my apologies to the heart surgeons for this.

Maybe complex vascular procedures/ liver transplants/ kidney transplants/ some forms of cancer would have been better illustrations of the fundamental point that a domestic population of just over 5 million cannot support Singapore’s massive ambitions in biomedical research and health services.

The source of the data I cited is the Ministry of Health ‘hospital bill sizes’ website and it refers specifically as I wrote in the commentary to bypass only surgeries (in the technical lingo, isolated CABGs).

2015 MOH Hos Bill Size Cardiac Surg

What the MOH is referring to in its letter to the Straits Times Forum today is likely the total number of bypass surgeries including combined surgeries (bypass surgeries + valve replacement etc). I thank the MOH for clarifying and providing the latest numbers.

A heart surgeon from the public sector posted on Facebook very useful comments which I reproduce here (edited) as they are very helpful in placing the data into context:

The numbers at the MOH website refer only to uncomplicated CABGs. They also excluded groups where the numbers were below 35 from the calculations. Our cardiac surgeons do somewhere between 70 to 120 cardiac surgical procedures a year each. Probably enough to maintain competency.

II. ‘Scalpel-like Precision’ in foreign patient policies

Many brickbats hurled against opinions raised in the commentary take the position that the public sector is already under such strain and it would be imprudent to add even more patient numbers. Some also repeat the argument of ‘crowding out’ locals and the unhealthy tensions when foreigners are perceived to have special treatment compared to locals.

Analogies with foreign workforce policies

There are useful parallels with Singapore’s overall foreign worker policies and it is worth summarizing the main points in that debate:

  1. Singapore needs foreign workers to boost economic growth and also do the jobs Singaporeans do not want to undertake
  2. The public unhappiness has centered on the numbers of foreign workers, the perceived patchy ‘quality control’ and how in especially the PMET employment segment, foreign workers are competing with Singaporeans for jobs and economic opportunities. Singaporeans are not anti-foreigner.
  3. What is needed is a more calibrated workforce policy that has differentiated and carefully thought out foreign worker policies that are industry- and sector-specific to support the industries where there are not enough workers or Singaporeans unwilling to perform these roles.
  4. Overall numbers will still need to be carefully managed to ensure public infrastructure and services are not overwhelmed by the population increases.

Taking this logic into our discussions on foreign patients, the equivalents would be:

  1. There are medical areas of strategic importance to Singapore for which the domestic population is insufficient to enable true medical excellence and world-class clinical research
  2. Foreign patients especially in the public sector should not be competing with locals for scarce clinical resources and infrastructure
  3. There is merit in more calibrated SingaporeMedicine or medical tourism policies that are specialty- or therapeutic area-focused. This way, we can be competitive as a medical hub or biomedical research center in the areas of strategic value to Singapore. Such policies could include both ‘positive’ measures akin to what the Economic Development Board (EDB) and other agencies under the Ministry of Trade and Industry offer to companies such as funding support, access to publicly-funded resources such as high end laboratories, equipment or people as well as ‘negative’ ones such as restriction of visas for health care sought in the public sector to only patients with specific medical conditions.
  4. Overall numbers of foreign patients in the public sector should be carefully managed to ensure there is not an inadvertent adverse impact on healthcare for Singaporeans

The essential argument in my commentary I believe, after considering all the opinions is still sound:

  1. We are a small population with very big ambitions as a medical hub and as a biomedical powerhouse
  2. To punch above our weight in the areas in medicine we choose (The emphasis in ‘punching above our weight’ is excellence and not merely competence), we need foreign patients to augment our domestic numbers. Note that these foreign patients need not be in the public sector, only that the value the foreign patients bring beyond the economic benefits can be optimized at the national level. This would potentially mean private sector involvement in research like the IBN-Fortis Surgical Hospital collaboration which has resulted in tangible scientific output. Opening up to the private sector publicly-funded facilities and sharing innovations that improves patient care should be considered. There is a potential win-win: the private sector which has the bulk of foreign patients can differentiate itself more strongly from its regional peers, (which is increasingly needed to justify Singapore’s higher price points) and publicly-funded research institutions can avail themselves of a larger pool of patient biological specimens and clinical data.
  3. The wrong way to do this is to be simplistic (“Foreign patients are good” or “Foreign patients are bad”). The other wrong way to do this is to be parochial and think only of one’s hospital or institution- the imperative should be what makes sense for all parties and is in Singapore’s best interests. The train of logic is complex but for the good of Singapore, stakeholders in the health system should endeavor to communicate the finer points appropriately to the public to avoid misconceptions.

In thinking through these issues, perhaps the dual role of the Monetary Authority of Singapore should be studied in more detail. In the document “Objectives and Principles of Financial Supervision in Singapore“, MAS states that it

seeks to promote a sound and progressive financial services sector through both financial supervision and developmental initiatives. We supervise the banking and insurance industries, as well as the capital markets. At the same time, we work in partnership with the private sector to identify and implement strategies for developing Singapore as an international financial centre (emphasis added).

As regulator and industry promoter/ enabler, MAS has to straddle a fine line and manage the potential tensions and conflicting interests. The equivalent in the healthcare sector would need to be actively monitoring and intervening with ‘scalpel-like precision’ to ensure we have well-performing, progressing and sustainable institutions in both the public and private sectors that balance our economic, social and academic aspirations.

Medical tourism is not good or bad. It is a tool to further Singapore’s interests, be these economic, social, academic or a mix of all of these. Let’s move away from arguments that needlessly dichotomize and recognize that in all opportunities, there are also challenges and trade-offs.



  1. taco cat · · Reply

    Can you kindly explain why / how do you arrive at the below sentence please?

    “Foreign patients especially in the public sector should not be competing with locals for scarce clinical resources and infrastructure”

    1. The public sector hospitals and clinics are set up using public monies to benefit Singaporeans and Permanent Residents. There is currently significant shortages in infrastructure and hence priority should be given to locals. For humanitarian reasons, they should not turn away any patients, foreign or local but in the main, public hospitals should not be in my view actively wooing foreign patients who can be appropriately treated in private hospitals.

  2. Good to see your reflection on that piece! One correction and one comment:
    1) MOH pointed out that there are thousands of bypass operations at the two public centers. The big difference is that the bill size data only shows CABG without complications. You know all about up-coding so I will not belabour the point that these represent the minority of CABG (Without valves etc)
    2) I personally believe that medicine is about competition with disease and pathogens not cities or countries. In the 1930s, Singapore was the home of the Eastern Epidemic Intelligence Service where we shared the knowledge from our medical school with the region and the world and were a beacon for outstanding medical care – not by stealing wealthy patients but by training doctors who went on to lead new schools or medical centers in the region. We could still do that and many do…

  3. no choice. we don’t have the numbers. just like singapore army is trained to take the battle to the enemy… we have to search/canvass for the foreign patients

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