False justifications on why Singapore’s health-care system works

Dear Gillian,

Taking calculated risks to save lives is not the sole premise of Singapore doctors but doctors all over the world including American doctors. The following case is very similar to yours where US doctors injected different kinds of antibiotics to save a patient suffering from meningitis:

• Eric had Bacterial Meningitis and the prognosis was not good. They immediately started him on several different antibiotics and sent him to P.I.C.U … [2-1].

The following is an example where US doctors took risks to treat meningitis even before tests had been processed.

• It was our paediatrician’s nurse that first advised us to immediately go to the hospital with Paisley, and pressed us not to delay based upon what we thought of as unremarkable symptoms. The doctors at the hospital took the strongest actions possible, assuming the worst case scenario and treating for meningitis before the tests had been processed. Their proactive playbook and prioritization of her case made a difference, in a struggle where lost time can mean irreversible repercussions [2-2].

Thus, contrary to your insinuation, American doctors do take risks to save lives. It’s never useful to form conclusions from anecdotal evidences, it is more important to rely on statistical evidence to form proper judgements instead. Although there is no worldwide meningitis mortality rate statistics to compare, we can compare communicable disease mortality rates instead since meningitis is a form of communicable disease. The following table [3] shows that Singapore has a far higher mortality rate due to communicable diseases than most First World nations. In fact, our mortality rate is even higher than China’s. US mortality rate due to communicable disease is almost half that of Singapore’s, a statistic you can be proud of.

Rank Country 2008 age-standardized mortality rate (per 100 000 population) – communicable disease
1 Finland 11
2 Austria 14
3 New Zealand 15
4 Hungary 16
5 Italy 16
6 Andorra 16
7 Montenegro 17
8 Switzerland 17
9 Serbia 17
10 Cyprus 17
11 Australia 18
15 Sweden 20
16 Germany 21
22 Canada 23
23 France 23
25 Spain 24
26 Luxembourg 25
30 Denmark 27
31 Norway 27
32 Netherlands 28
34 Ireland 29
35 Republic of Korea 29
42 Belgium 33
43 United States of America 34
46 United Kingdom 36
48 Japan 40
60 China 58
66 Singapore 66

It is unfortunate that you should also quote the work of Professor William Haseltine because his work contains a fundamental flaw which basically invalidates what he is trying to establish. Professor Haseltine, like nearly everyone else, compares healthcare costs without taking into consideration old age dependency. Western nations, having higher old age dependency ratios than Singapore are bound to have higher healthcare costs than us all else being the same. Comparing the healthcare cost of Singapore with those of Western nations without adjusting for old age dependency is like comparing the healthcare cost of yourself with that of your grandmother’s. It’s a no brainer that your grandma’s healthcare costs will be higher than yours on average even though both of you are under the same healthcare system. The following table [4] shows that after adjusting for old age dependency, Singapore is far from top notch in terms of healthcare cost efficiency.

Country 2011 old age dependency ratio 2011 per capita health expenditure 2011 old age dependency predicted per capita health expenditure 2011 % healthcare overspending compared to predicted value
Italy 31.5 $3,436 $4,305 -20%
Korea, Rep. 15.9 $1,616 $1,765 -8%
Spain 25.3 $3,027 $3,290 -8%
UK 25.6 $3,609 $3,340 8%
Germany 31.2 $4,875 $4,251 15%
Finland 27 $4,325 $3,571 21%
Sweden 28.6 $5,331 $3,837 39%
Belgium 26.9 $4,962 $3,551 40%
France 26.4 $4,952 $3,480 42%
New Zealand 20 $3,666 $2,441 50%
Austria 26.4 $5,280 $3,478 52%
Singapore 12.7 $2,286 $1,248 83%
Denmark 25.8 $6,648 $3,384 96%
Netherlands 23.6 $5,995 $3,020 99%
Ireland 17.8 $4,542 $2,079 118%
Canada 20.8 $5,630 $2,570 119%
Australia 20.3 $5,939 $2,487 139%
Switzerland 25.1 $9,121 $3,255 180%
Norway 22.6 $8,987 $2,852 215%
Luxembourg 20.3 $8,798 $2,486 254%
United States 20 $8,608 $2,426 255%

The other issue with Professor Haseltine’s study is his comparison of healthcare costs as a percentage of GDP. That is like comparing your healthcare expenditure as a percentage of your salary. Suppose your healthcare expenditure didn’t change but you now earn twice as much as before, your healthcare expenditure as a percentage of your salary will halve so that your numbers will look twice as good as before even though your healthcare expenditure never changed. So it’s better and more meaningful to compare per capita healthcare expenditure itself instead.

The claim that Singapore has much better life expectancy, infant mortality, premature adult death and emergency care is also questionable. The following table [5] shows that very little separates Singapore from Western nations in terms of life expectancy, infant mortality or adult death.

Country 2011 Life Expectancy (both sexes) 2011 infant survival rate (probability of surviving between birth and age 1 per 1000 live births for both sexes) 2011 adult survival rate (probability of surviving between 15 and 60 years per 1000 population, both sexes) Average
San Marino 100% 100% 100% 100%
Switzerland 100% 100% 100% 100%
Iceland 99% 100% 100% 100%
Japan 100% 100% 99% 100%
Singapore 99% 100% 99% 99%
Italy 99% 100% 99% 99%
Sweden 99% 100% 99% 99%
Israel 99% 100% 99% 99%
Australia 99% 100% 99% 99%
Spain 99% 100% 98% 99%
Luxembourg 99% 100% 98% 99%
Andorra 99% 100% 98% 99%
Cyprus 98% 100% 99% 99%
Canada 99% 100% 98% 99%
Qatar 99% 100% 98% 99%
Norway 98% 100% 99% 99%
Netherlands 98% 100% 99% 99%
Ireland 98% 100% 98% 99%
Monaco 99% 100% 97% 99%
Kuwait 96% 99% 100% 98%
France 99% 100% 97% 98%
New Zealand 98% 100% 98% 98%
Austria 98% 100% 98% 98%
Malta 96% 100% 99% 98%
South Korea 98% 100% 98% 98%
Greece 98% 100% 98% 98%
Germany 98% 100% 98% 98%
Finland 98% 100% 97% 98%
United Kingdom 96% 100% 98% 98%
Bahrain 95% 99% 99% 98%
Belgium 96% 100% 97% 98%
Portugal 96% 100% 97% 98%
Slovenia 96% 100% 96% 98%
Denmark 95% 100% 97% 97%
Chile 95% 99% 96% 97%
Costa Rica 95% 99% 96% 97%
Saudi Arabia 92% 99% 99% 97%
Maldives 93% 99% 97% 96%
Czech Republic 94% 100% 95% 96%
USA 95% 100% 94% 96%

Our healthcare insurance premiums may be a fraction of those in America but our coverage is also much lower too [6]. To begin with, our Medishield has a deductible of $1,500 for C class wards or $2,000 for B2 class wards or better [7], which means only medical bills that go beyond $1,500 or $2,000 respectively are covered. Our Medishield claims totalled $291.4 million for 262,009 claims in 2011 or an average of $1,112 per claim. This means that on average, patients only claimed $1,112 while paying $1,500 or $2,000 from their own pockets. In percentage terms, patients only claimed back between 35.7% and 42.6% while footing between 57.4% and 64.3% of medical bills themselves. This is excluding many other patients whose medical bills didn’t exceed $1,500 or $2,000 and so claimed nothing but had to pay everything themselves.

It is a shame that you are of the opinion that Singapore statistics puts US and other Western nations to shame because they don’t. Singapore healthcare when adjusted for old age dependency is more costly than countries like UK and Germany. At the same time, Singapore healthcare outcomes are not significantly better than most Western nations. So it should be the wrong use of statistics that ought to be shamed instead.

[1] Straits Times, Why Singapore’s health-care system works, 9 Jun 2013, Gillian Tett

[2] http://www.nmaus.org/programs/share-your-story/readotherstories.htm
[2-1] Beverly, Parent of Josh, meningococcal disease survivor Iowa
[2-2] Paisley: Texas, 12 days old

[3] World Health Organisation, Global Health Observatory Data Repository, Cause-specific mortality and morbidity (2008 is latest available)

[4]
• 2011 old age dependency ratio is from World Bank data
• 2011 per capita healthcare expenditure is from World Health Organisation

[5]
• 2011 Life Expectancy, Infant mortality and Adult mortality are from World Health Organisation
• For life expectancy, comparison is based on percentage of highest life expectancy which is 83 years for San Marino, Switzerland and Japan
• Infant survival rate is used instead of infant mortality to convert the score to one where the higher it is the better it is. Infant survival rate is 1000 – infant mortality rate. Comparison is based on percentage of highest infant survival rate which is close to 100% for almost all First World nations.
• Adult survival rate is used instead of adult mortality to convert the score to one where the higher it is the better it is. Adult survival rate is 1000 – adult mortality rate. Comparison is based on percentage of highest adult survival rate which is 95% for San Marino, Switzerland and Iceland.
• WHO has no emergency care statistics to compare

[6]

Today, ElderShield under fire, 26 April 2012

Lee Kuan Yew School of Public Policy Professor Phua Kai Hong, an authoritative figure in the region on healthcare policy and management, first voiced his concern about ElderShield, which is the sole national insurance scheme for intermediate and long-term care, at a closed-door discussion earlier this month.

Speaking to Today, he reiterated that the scheme is “completely inadequate”. Said Prof Phua: “People are calling our hospitals a First World sector, but that our long-term care is Third World standard. Besides the over-reliance on voluntary welfare organisations, patients’ families and cheap labour, the financial structure in this sector needs to be thoroughly re-looked.”

[7]

http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/schemes_subsidies/Medishield/How_MediShield_Works.html

A deductible is the initial amount you need to pay for claim(s) made in a policy year, before there is MediShield payout. No reimbursement would be made from the MediShield if the claimable amount falls below the deductible.

If you choose to stay in a Class C ward during your hospitalisation, the applicable deductible would be $1,500. For Class B2 and above wards, the applicable deductible would be $2,000.

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4 Responses to “False justifications on why Singapore’s health-care system works”

  1. passerby Says:

    And how exactly did you arrive at “2011 old age dependency predicted per capita health expenditure”?

  2. Tessa Wong Says:

    Wow, you are truly amazing sir. I must add this to my daily must read blog from now on. Forget about the shit times forum where sycophants reside. Thanks!

  3. public adjuster Houston Texas Says:

    Aw, this was an incredibly good post. Finding the time and actual effort to create a great article… but what
    can I say… I procrastinate a lot and don’t manage to get anything done.

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