SOUTH Africa’s healthcare system is rightly called a “sickcare system”, and a terminally ill one at that.
With the public health system collapsing, ever-widening chasms between public and private health sectors in terms of access and quality, and soaring medical costs all round, it’s a given that a hefty dose of healthcare reform is required.
One prescription for that can be found in Singapore’s healthcare system, says visiting US specialist Dr William Haseltine.
Dr Haseltine is a former professor at Harvard Medical School and Harvard School of Public Health, well known for his pioneering work on cancer, HIV/AIDS and genomics.
He is chairman and president of Access Health International, a not-for-profit organisation that supports access to affordable, high-quality health services in low-, middle-and high-income countries. Dr Haseltine is in South Africa to promote his new book, Affordable Excellence, The Singapore Healthcare Story.
Why Singapore? After all, it is only number six on the World Health Organisation (WHO) rankings of healthcare in 191 countries. France tops the list, followed by Italy, San Marino, Andorra and Malta, with South Africa trailing at 175.
Dr Haseltine says that as an example of healthcare reform from an emerging economy that transformed itself rapidly from third to first world, Singapore is “an easier model for people to understand and emulate, rather than a country that has been wealthy for a long time”.
It also offers the highest cost:benefit ratio, measured by the fraction of its gross domestic product (GDP) spent on health and by costs per person.
It spends less than 4% of its GDP on health. That is less than half South Africa’s GDP spending on healthcare (8.3%), and by far the lowest figure among all other high-income countries.
Yet Singapore maintains a top-quality, universal healthcare system, measured in terms of all important parameters, especially accessibility, affordability and quality of care. The WHO ranks Singapore’s life expectancy as the world’s fourth highest — women can expect to live to 85, men to 80. In South Africa it is 61 for women and 58 for men. Singapore also has one of the world’s lowest maternal and child mortality rates.
The country’s health system is the result of a unique risk system between the individual and the collective that extends “far beyond health”, Dr Haseltine says. Widespread home ownership is pivotal to the philosophy. “Although not part of the healthcare system per se, the early housing initiative has contributed immeasurably to the health and wellness of Singaporeans.”
More than 85% own their own homes through low-cost, quality public housing provided by Singapore’s statutory Housing Development Board.
The board is part of the country’s Central Provident Fund (CPF) set up during British colonial rule as a compulsory savings programme for retirement which was extended after independence to allow for funds to be used for home-buying and healthcare. “It’s difficult to overstate CPF’s contribution to the viability of Singapore’s healthcare system,” says Dr Haseltine.
It helps control costs by instilling in patients a sense of responsibility about their spending, he says. After all, it is their own money to save, spend or pass on to other family members or next generations.
The government pays interest on CPF savings (currently 4%, tax-free at that), all of which helps to make healthcare available and affordable for all.
The system avoids the pitfalls of over-reliance on state aid that bedevils social welfare systems in countries such as England and the Scandinavian states.
Instead, it fosters personal responsibility through the CPF’s “3M” (Medisave, Medishield and Medifund) system.
It provides coverage from daily health needs to catastrophic illness, and a safety net ensuring that even the poorest Singaporeans receive a level of care that would otherwise be out of reach. “Virtually no one ever goes bankrupt because of healthcare expenses in Singapore,” Dr Haseltine says.
People are free to use either the public or private system, according to willingness and ability to pay, he says.
There are no measurable differences in outcomes between the two systems, according to the health ministry.
Public hospitals are obliged to provide care regardless of ability to pay; no proof of ability to pay is required before admission.
The government has to keep healthcare costs down by controlling supply sides of the healthcare services and providing heavy subsidies at public healthcare institutions.
Singapore’s health system is also premised on the importance of women’s education and health, a principle established early on and considered essential to the country’s future.
There is high-quality maternal and childcare throughout. Childhood nutrition is taken seriously, and the country is a world leader in vaccine coverage. “The government accomplished a great deal well before the women’s movement established itself in many countries,” Dr Haseltine says.
Singapore has a ministry of wellness, separate from the health ministry, that organises an annual month devoted to healthy lifestyle awareness. A well-developed infrastructure supports healthy living and includes an inexpensive mass transit system, neighbourhood wet markets (fresh food markets), island-wide park connectors and exercise stations, and ministry-funded community centres in every neighbourhood.
The government is developing a master plan to broaden the current public-private partnership to enhance treatment of chronic disease by bringing together private doctors with other healthcare professionals to form a team approach to care, says Dr Haseltine.
He is not saying Singapore’s health system is perfect. The country is not immune from rising costs that face healthcare systems globally, he says, but due in this case mainly to demographic trends, new and expensive technology, and changing disease patterns.
It has made strides in cancer and heart disease treatment, but diabetes remains a problem in Singapore, as it is for many emerging countries, says Dr Haseltine.
SA’s healthcare challenges and sociopolitical and economic conditions are vastly different from Singapore.
Still, Dr Haseltine believes aspects of its public health system can be implemented in South Africa, even under current circumstances. South Africa can also learn about health reforms from other countries. Access Health International is studying a recent programme in Andhra Pradesh in central India that provides free hospital care to all below the poverty line, a free ambulance service, and a sophisticated tele-consultation and electronic prescription system that cares for simple issues. The cost? The equivalent of about R120 per family per year.
“The political popularity of such programmes assures their continuance, even as violently opposed political parties come and go in power,” Dr Haseltine says. “It could be easily instituted in South Africa.”
Long-range planning and implementation require continuous commitment, but “political expediency trumps political difference under most circumstances”, he says.
Dr Jonathan Broomberg, a medical doctor and CEO of Discovery Health, has researched and written widely on healthcare issues in South Africa and agrees that Singapore’s healthcare system can be of relevance.
South Africa faces a complex disease burden with an epidemic of non-communicable lifestyle diseases, and one of the worlds largest burdens of communicable diseases, including HIV/AIDS and TB, Dr Broomberg says.
“In this context, excellent public health services, especially prevention and screening are vital,” he says. “People must be encouraged to live healthier lifestyles, and the quality, accessibility and efficiency of the supply side of South Africa’s healthcare system needs significant improvement.”
What Singapore can teach SA about healthcare
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