A POLICY FRAMEWORK FOR REFORMS IN HEALTH CARE

2. HEALTH DEVELOPMENT IN OTHER SELECT COUNTRIES

Health services for the country are provided through 3 different Ministries, as well as by the private sector:

Ministry of Health (MOH) is responsible for providing preventive, curative and rehabilitative health services in Singapore. MOH formulates national health policies, coordinates the development and planning of the private and public health sectors, as well as regulates health standards.

Ministry of the Environment (MOE) is responsible for environmental health services such as sewerage, drainage and waste disposal systems, control of air and water pollution and of toxic chemicals and poisons, the control of outbreak of infectious diseases, vector or insect control and the safety of the food prepared and sold in Singapore.

Ministry of Manpower (MOM) is responsible for the industrial and occupational health of the workers

In Singapore, there is a dual system of health care delivery. The public system is run by the Government while the private system is provided by the private hospitals and general practitioners. The health care delivery system comprises primary health care provision at private medical practitioners' clinics and the Government outpatient polyclinics, and secondary and tertiary specialist care in the private and public hospitals.

80% of the primary health care services is provided by the private practitioners while the Government polyclinics provide the remaining 20%. For the more costly hospital care, it is the reverse situation with 80% of the hospital care being provided by the public sector and the remaining 20% by the private sector.

Patients are free to choose the providers within the dual health care delivery system and can walk in for a consultation at any private clinic or any government polyclinic. For emergency services, patients can go at any time to the 24-hour accident & emergency departments located in the Government hospitals. The Singapore Civil Defence Force runs an emergency ambulance service to transport accident and trauma cases and medical emergencies to the acute general hospitals.

The Singapore health care philosophy emphasises the building of a healthy population through preventive health care programmes and the promotion of healthy living. The population is encouraged through the public health education programme to adopt a healthy lifestyle and be responsible for his own health. The public is made aware of the adverse consequences of harmful habits like smoking, alcohol consumption, bad dietary intakes and sedentary lifestyles.

The child immunisation programme which is targeted against infectious diseases like tuberculosis, poliomyelitis, diphtheria, whooping cough, tetanus, measles, mumps and rubella and Hepatitis B, is offered at the Government polyclinics.

Health screening programmes have been introduced for the early detection of common ailments like cancers, heart diseases, hypertension and diabetes mellitus.

The Government ensures that good and affordable basic medical services are made available to all Singaporeans through the provision of heavily subsidised medical services at the public hospitals and government clinics. The basic medical package will reflect good, up-to-date medical practice, which is cost-effective and of proven value. But it will not provide the latest and best of everything. The treatment will be delivered without frills by trained personnel using appropriate facilities. It will exclude non-essential or cosmetic services, experimental drugs and procedures of unproven value.

All private hospitals, medical clinics, clinical laboratories and nursing homes are required to maintain a good standard of medical services through licensing by the Ministry of Health.

The Singapore health care delivery system is based on individual responsibility coupled with Government subsidies to keep basic health care affordable. Patients are expected to pay part of the cost of medical services which they use, and pay more when they demand a higher level of services. The principle of co-payment applies even to the most heavily subsidised wards to avoid the pitfalls of providing free medical services.

For those who choose to be accommodated in the lower classes or types of wards in the public hospitals, their hospitalisation expenses are subsidised up to 80% by the government.

Individuals are encouraged to take responsibility for their own health by saving for medical expenses. Under the Medisave scheme, every working person is required by law to set aside 6-8% of his income into his personal Medisave account which can be used to pay for the hospitalisation expenses incurred by himself or his immediate family members.

MediShield, a catastrophic illness insurance scheme, is designed to help individuals meet the medical expenses from major or prolonged illnesses.

Medifund acts as a safety net of last resort for those who are truly indigent. Therefore, no Singaporeans will be denied access into the health care system or turned away by the public hospitals because of the inability to pay.

Waiting time for elective operation is between 2 to 4 weeks on average. Patients requiring emergency or urgent surgery are always admitted immediately without any waiting.

The primary health services provide primary medical care for the family, health screening and preventive health programmes for school children, home nursing, day care and rehabilitation for the elderly and health education and promotion for the population.

The public sector comprises 17 one-stop Government polyclinics located throughout the country in the more populated areas. Each polyclinic provides outpatient medical care, follow-up of patients discharged from hospitals, immunisation, health screening and education, investigative facilities and pharmacy services.

The private sector has about 900 private clinics run by about 1,200 medical practitioners. The private clinics are located at the door-step of the population in the city, housing estates and satellite towns.

The average outpatient consultation fee (inclusive of medication) is only about S$10 to S$15, well within the means of every Singaporean. At the government polyclinics, Singapore citizens age 65 years and above, children up to 18 years of age and all school children are given up to 50% concession in their consultation and treatment fees.

There are a total of about 11,390 hospital beds in the twenty hospitals in Singapore, giving a ratio of 3.6 beds per 1,000 population. 81% of the beds are in the eight public hospitals whose bed complements range between 180 beds to 3,110 beds. On the other hand, the twelve private hospitals tend to be smaller, providing 25 to 500 beds each. Government’s role as the dominant health care provider allows the Government to control the supply on number of hospital beds, the introduction of high-tech/high-cost medicine, and the rate of cost increases in the public sector which sets the bench mark in terms of pricing for the private sector.

The eight public hospitals comprise five acute general hospitals, two hospitals specialising in obstetrics & gynaecology and psychiatry, and one community hospital. The general hospitals provide multi-disciplinary acute inpatient and specialist outpatient services and a 24-hour accident & emergency service. In addition, there are six speciality institutes for ophthalmology, dermatology, oncology, cardiology, neuroscience and dentistry. The tertiary specialist care on cardiology, renal medicine, haematology, neurology, oncology, radiotherapy, plastic and reconstructive surgery, paediatric surgery, neurosurgery, cardiothoracic surgery and transplant surgery are centralised in two of the larger general hospitals, the Singapore General Hospital and the National University Hospital. The private hospitals have similar specialist disciplines and comparable facilities.

Within the public hospitals, patients have a choice of the different types of ward accommodation on their admission. 79% of the public hospitals' beds are heavily subsidised with the remaining 21% being either private (1-2 bedded) or semi-private (4-bedded) beds. Patients pay more when they request for higher level of physical amenities while the standard of medical care is the same for all types of accommodation. Generally, the more serious medical conditions are attended to in the public hospitals, by the senior consultants or specialists regardless of the type of ward accommodation chosen by the patients. The average length of stay in the general hospitals is about 5.6 days. The hospital beds are well-utilised, with an average occupancy rate of about 81%.

Since 1985, the Government has restructured five of its acute hospitals and six speciality institutes to be run as private companies wholly-owned by the Government. This is to enable the restructured hospitals to have the management autonomy and flexibility to respond more promptly to the needs of the patients. In the process, commercial accounting systems have been introduced, providing a more accurate picture of the operating costs and instilling greater financial discipline and accountability. The restructured hospitals are different from the other private hospitals in that they receive an annual Government subvention or subsidy for the provision of subsidised medical services to the patients. They are expected to be managed like a not-for-profit organisation. The restructured hospitals are subject to broad policy guidance by the Government through the Ministry of Health.

The Government has also introduced low cost community hospitals for intermediate health care for the convalescent sick and aged who do not require the more expensive care of the acute general hospitals

Singapore today, has about 5,150 doctors for its health care delivery system. This gives a doctor to population ratio of 1:750. Slightly more than half of the doctors (53%) is in the private sector. About 42% of the doctors are trained specialists with postgraduate medical degrees and advanced speciality training.

There are 980 dentists, giving a ratio of 1 dentist to 4,230 population. About 82% of the dentists are in private practice.

The nurse to population ratio is 1:250, with a total of about 15,570 nurses. 52% of the nurses work in the public sector.

In 1998, Singapore spent about S$4.1 billion or 2.9% of GDP on health care. Per capita health care spending was S$1,292. Government subsidy on the public health care services was S$1,242 million or 0.9% of GDP in 1998

 

2.5 South Korea

To improve the level of national health and medical care, Government implements the following policies:

Improvement of national nutrition and maternal and child health.

Prevention of disease and effective management of acute and chronic diseases through strengthening of health education.

Increase of quantity and enhancement of quality of medical services through expansion of supply.

Concentration of efforts on strengthening hygienic and safety control for food and medicine.

Stabilisation of the health insurance system, which has been extended to the entire country since 1989.

Establishment of a system for income security in case of sickness and old age, with the extension of coverage of the national pension system to enterprises with five employees or more in 1992 and to the self-employed in the rural areas, farmers and fishermen in 1995.

Expansion of social welfare services for vulnerable people such as the poor, the elderly, the disabled and children.

Korea is now experiencing an epidemiological transition. During the last few decades, the incidence of infectious diseases has decreased while the incidence of chronic degenerative diseases has been consistently growing. To cope with the epidemiological change, the Korean Government has placed more emphasis on health promotion.

To strengthen health promotion programmes a National Health Promotion Fund of about 17 million USD every year has been established. The health promotion programme consists of health education, disease prevention, improvement of nutrition, and practice of healthy life style as defined in the National Health Promotion Act. The directions of health policy is as follows ;

Objectives

To enhance quality of life and healthy life span through encouragement of healthy life style, improvement of accessibility to the preventive services and formulation of social environment for encouraging healthy life style.

Strategies

Encouragement of practice of healthy life style through strengthening of health education and promotion of a nation-wide movement for practice of healthy life style.

Improvement of accessibility to preventive services through strengthening of preventive services of health centers, activating preventive programmes of NGOs and strengthening of the health examination programme at schools/industries.

Formulation of social environment for encouraging healthy life style through establishment of health promotion facilities such as exercise/recreation facilities, enforcement of legal regulations on tobacco/alcohol marketing, advertisement etc.

As most chronic degenerative diseases need long-term care, and have to be treated, the importance of prevention and health promotion have been stressed. In this regard, the Korean Government enacted the National Health Promotion Act in 1995, which is the basis of the national health policy

In implementing national public health program, the Korean Government has laid great emphasis on preventive services rather than curative and on education for people to acquire basic knowledge of health to maintain and promote their health. The Government has developed various materials for health education and distributed them to the local Governments and other government authorities concerned. It has also arranged training courses for health personnel to cope with the rapidly evolving health environment.

To enhance the effectiveness and efficiency of the health education system, the Government is planning to establish a Health Education Material Development Centre which will collect and publish available information and develop education materials.

The traditional practice of medicine in Korea was influenced primarily, though not exclusively, by China. Over the centuries, Koreans had used acupuncture and herbal remedies to treat a wide variety of illnesses

The number of physicians, nurses, dentists, pharmacists, and other health personnel and the number of hospitals and clinics have increased dramatically. The number of doctors per 1000,000 people was 127 and the number of nurses per 100,000 people was 232 in 1993. In the last two decades, the number of general hospitals have grown from 36 to 156 and the number of hospital beds has tripled from 19,062 to 59,099. Most facilities, however, are concentrated in urban areas, particularly in Seoul and Pusan.

Rural areas had limited medical facilities, because in the past there was little incentive for physicians to work in areas outside the cities, where the majority of the people could not pay for treatment. Several private rural hospitals had been established with Government encouragement but had gone bankrupt in the late 1980s.

The extension of medical insurance programs to the rural populace, however, was expected to alleviate this problem to some extent during the 1990s.

South Korea is increasingly getting afflicted with the health and social problems generally associated with the West, such as Acquired Immune Deficiency Syndrome (AIDS) and addictive drugs. A handful of AIDS cases was reported during the late 1980s. Seoul responded by increasing the budget for education programs and instituting mandatory AIDS testing of prostitutes and employees of entertainment establishments. An AIDS Prevention Law was promulgated in November 1987.

The South Korean Government committed itself to making medical security (medical insurance and medical aid) available to virtually the entire population by 1991. There was no unified national health insurance system, but the Ministry of Health and Social Affairs co-ordinated its efforts with those of employers and private insurance firms to achieve this goal.

Two programs were established in 1977: the Free and Subsidised Medical Aid Program for people whose income was below a certain level, and a medical insurance program that provided coverage for individuals and their immediate families working in enterprises of sixteen people or more. Expenses were shared equally by employers and workers. More than 79 percent of the population, had medical insurance under the above schemes.

In 1989, however, Seoul extended medical insurance to cover these self-employed urbanites, so that the medical insurance system extended to almost all South Koreans. Medical insurance programs for farming and fishing communities, where the majority of people were self-employed or worked for very small enterprises, also were initiated by the Government.

As of 1992, 94% of the population was covered by health insurance plans and the remaining 6% by the Medicaid program

For the purpose of promoting co-operative research activities among industrial, academic, and research organisations, and to maximise research effectiveness, the Government plans to construct the Health Care Technopolis. The construction of the Health Care Technopolis will be completed in ten years (1997-2006) in an area of 9.2 million sq. m.

The Government provides funds for researches on major seven sectors of medical science, pharmaceutical products, biomedical engineering, biotechnology, food, health information, and G7 medical engineering.

2.6 Thailand

The health care protection system consists of two major components - rural and urban -that differ according to the needs of China's rural and urban populations and supply-side capacities serving these populations.

China was the first large country in the world to develop community financing schemes that covered the rural population nation-wide, called the rural "Co-operative Medical System" (CMS). These schemes primarily served to fund and organise prevention, primary care, and secondary health care for the rural population. Gradually developed in the 1950s as a mutual assistance mechanism to establish access to basic drugs and primary health care, the CMS was given political priority and developed rapidly during the 1960s and 1970s.

The rural CMS organised health stations, paid village doctors to deliver primary care, provided drugs and partially reimbursed patients for services received at township and county facilities. At the peak of expansion prior to economic reforms, CMS covered 90% of China's rural population.

China's relative success in extending health care to the rural population at a fairly low cost by mobilising local resources played a key role in China's envious record of health status improvement during the 1960s and 1970s. However, CMS also suffered from problems of poor management and a small risk-pooling base, contributing to the downfall of these early co-operative financing schemes after the initiation of agricultural reforms in the early 1980s.

The health protection system for China's urban workers was established in the early 1950s. The two primary components are the Government Insurance Scheme (GIS) and the Labour Insurance Scheme (LIS). Financed by government budgets, GIS covers Government employees, retirees, disabled veterans, university teachers and students. LIS covers state enterprise employees, retirees and their dependants. Only state enterprises (enterprises owned and managed by central or provincial Governments) with more than 100 employees are required to participate; smaller state enterprises and industries owned by county or town governments can provide LIS on a voluntary basis.

Each year, each participating State-Owned Enterprise (SOE) sets aside an amount equal to 11-14% of total wages as a welfare fund to finance health expenditures incurred by that work unit's LIS beneficiaries. In 1993, GIS and LIS respectively covered approximately 9% and 40 % of the urban, or 2.5% and 11.7% of the total, population (National Health Survey 1993).

China has developed a three-tiered organisation for the delivery of health care. The tiers consist of village stations, township health centres, and county hospitals in the rural sector and street health stations, community health centres, and district hospitals in the urban areas.

Village stations are staffed by village doctors who are trained for three to six months after junior high school and receive an average of two to three weeks of continuing education each year.

Township health centres usually have 10 to 20 beds overseen by a physician with three years of medical school education after high school, aided by assistant physicians and village doctors.

County hospitals usually have 250 to 300 beds and are staffed by physicians with four to five years of medical training after high school, as well as by nurses and technicians.

This three-tier system was designed to promote the efficient allocation of health care resources between primary and tertiary care facilities. This system provided a structure for efficient patient-referral for treatment of health problems in the most appropriate setting.

Beginning in the early 1980s economic reforms greatly influenced China's health sector, revealing the weaknesses of the old health care protection system in adapting to the new socio-economic environment.

In rural areas, agricultural reforms in the early 1980s led to the disintegration of the co-operative organisations that formed the basis of CMS financing. The Government adopted a laissez-faire policy, and rural health care reverted to primarily private financing (self-pay). CMS coverage shrank precipitously; currently fewer than 10 percent of China's village have CMS. Township health centres and country hospitals are also largely financed by out-of-pocket payment.

In urban areas, the Government and enterprises faced increasingly difficult financial constraints in supporting GIS and LIS medical expenditures. With the rapid introduction of high technology medical services, increasing incomes feeding demand for health care, and without an effective constraint placed directly on consumers or providers of health care, China faced a serious problem of medical care cost inflation. This cost inflation-an international phenomenon but with particular roots in China's health care financing and organisation systems-was the primary force spurring China's first phase of health sector reforms.

The primary objective of reforms was cost containment. Major reform measures included introduction of demand-side and supply-side cost sharing.

These measures played a role in mitigating China's rapid health care cost escalation, relieving some of the financial pressure on enterprises, and decreasing the inequity of health care expenses between enterprises or government work units.

Beginning in 1992, the second phase of health sector reforms shifted to addressing issues such as increasing the level of socialisation or risk pooling-along with the original goal of cost containment. This shift took place along with a significant increase in the overall pace of social protection system reforms, as the linkage of a new social safety net.

In early 1996, based on success in pilot reforms conducted in some areas, it was decided to expand and adapt the reforms to over fifty other cities in 27 provinces and administrative regions. The cities are encouraged to explore creative methods to solve currently unsolved problems.

During 1996 it was decided that by the year 2000, China would establish the preliminary framework for a health system with Chinese characteristics that includes health service supply, health protection, and legal monitoring, so that every Chinese will have access to basic health protection.

During the entire process of economic reforms, China's central Government has encouraged local experimentation and development of successful models that can later be adopted (and adapted) on a national scale. In the health sector, as mentioned previously, pilot cities have been the focus of urban health reforms since 1992.

 

2.8 Lessons for India

Social insurance schemes need to have in-built mechanisms, such as cross subsidisation of premiums/lower premium percentages for lower income quintiles to prevent an excessive burden on lower wage employees.

Private insurance improves the availability and quality of health care, can give consumers a choice of providers and reduces the burden on the Government.

Financing schemes implemented should have adequate incentives and safe-guards for consumers in order to prevent excessive use of services and ignorance of preventive care because of easy availability of curative care.

Mandatory, universal social insurance is desirable, but can cover only a small fraction of the population in developing countries like India (e.g. those in the formal sector).

A well-structured urban and rural public delivery system enables a country to follow its agenda for equitable and accessible health care to all citizens.

Competition – typically introduced by enabling the public and private sectors to compete in the provision of health care services - is effective in stimulating innovation, efficiency and greater productivity.

Increasing private sector participation usually entails a much broader range of options: corporatisation of Government enterprises; selective out-sourcing of hospital services, clinical support and other services etc. The selection from this menu should be based on local circumstances and practical feasibility.

Utilising trained or partly trained traditional practitioners, and providing them with additional training in primary health care, greatly increases the health care coverage of rural areas.

Strengthening referral systems can contain health care costs by avoiding inappropriate and over-utilisation of health care.

Medical education and training should be characterised by a great degree of heterogeneity to address the demands of health care at different tiers (primary, secondary and tertiary) and also different geographies (urban, rural etc). and Governance:

Decentralisation has accelerated health sector improvements – particularly health services delivery because it increases accountability and aligns health care service provision with local needs.

Decentralisation of funding and service delivery to the local level helps ensure that medical services are driven by consumers rather than by providers and technology.

Decentralisation and a more effective role for the private sector entails a new task for the Central Government: from being the prime financier, purchaser and provider of health care to the role of planner, vigilant monitor, regulator, enabler and financier.

Quality assurance systems are essential to maximise health impact: they not only improve quality, but tend to improve efficiency by focussing attention on benchmarking and business process reengineering.

Accreditation and quality processes must be national initiatives and built into the health system at all points.