Demystifying CNN’s 10 Healthiest Cities report

I refer to the “CNN 10 Healthiest Cities” report (http://edition.cnn.com/interactive/2014/09/health/cnn10-healthiest-cities/) rating Singapore 9 of 10 for health care system.

Spending less or not depends on definitions

By choosing a particular definition of health care spending and a particular subset of wealthy countries, CNN came to the conclusion that Singapore spends less on health care than any other wealthy country in the world.

But there are two definitions of health care spending:

1) Health care spending per capita
2) Health care spending per GDP

CNN only compared health spending per GDP but not health spending per capita even though both are important and are accounted for by Bloomberg in its Most Efficient Health Care Ranking 2014. Similarly, CNN limited itself to a subset of wealthy countries that excluded oil rich countries.

The following table shows that on a per capita health spending basis, 12 other wealthy nations or economies in the IMF list of advanced economies spend less on healthcare than Singapore.

Country Name 2012 health care spending per capita (current US$)
Latvia $792
Estonia $1,010
Slovak Republic $1,326
Czech Republic $1,432
Korea, Rep. $1,703
Malta $1,835
Portugal $1,905
Slovenia $1,942
Hong Kong (from Bloomberg 2014) $1,944
Cyprus $1,949
Greece $2,044
Israel $2,289
Singapore $2,426

The following table shows that on a per GDP health spending basis, Singapore also does not spend the least when oil rich nations and Monaco are included.

Country Name 2012 World Bank health spending / GDP (%)
Qatar 2.2
Brunei Darussalam 2.3
Kuwait 2.5
Oman 2.6
United Arab Emirates 2.8
Saudi Arabia 3.2
Bahrain 3.9
Monaco 4.4
Singapore 4.7

Singapore spends the least only when comparing health spending per GDP but without including oil rich nations. But there is an inherent contradiction in the imposition of this double condition. The reason why health spending per GDP is more often compared than health spending per capita is due to the recognition that wealthier nations tend to spend more on health care. So oil rich nations should spend more on health care by virtue of their high GDP. The fact that they don’t and are therefore thriftier than they should be is worth commending but no; they are all excluded leaving Singapore the thriftiest of them all.

Medisave offers no security

Our Medisave offers no security to Singaporeans who worry about escalating health care costs and cost of ageing.

Failing health spooks Singaporeans more than any other concern they have about old age, according to new findings by financial services group Manulife. It found that 71 per cent of those surveyed pointed to increasing illness as they age as the top concern with costs of paying for health care the next biggest nightmare.
That’s the highest in Asia … – significantly above the 64 per cent regional average. The poll, which was taken in the first three months of the year, surveyed reasonably well-off to affluent investors over 25 … It showed that 55 per cent of Singapore respondents are worried health care will become unaffordable when they retire.

[Straits Times, Failing health top worry about old age: Survey, 23 May 2014]

SINGAPORE – The No. 1 worry of Singaporeans is the cost linked to the growing pool of old folk, according to a global survey. It eclipses even such risks as the economy not doing well, terrorism and climate change. Half of 1,000 Singaporeans surveyed have picked ageing population cost as the biggest risk confronting the country. The extent of their anxiety on this front is the most pronounced in Asia, reports the Gallup survey commissioned by global insurer Swiss Re … In fact, the anxiety felt by Singaporeans is greater than even Japan, which is also battling the silver tsunami … The Singaporeans’ view of their top risk stands in stark contrast to that of many developed economies.

[Straits Times, 25 Oct 2013, Cost of ageing population S’poreans’ top worry: Poll]

A recent Ministry of Health (MOH) survey showed that Singaporeans “suffer eight years of poor health”. The current Medisave balance of $33,000 isn’t going to pay for eight years of medical treatment even if you also have MediShield, after taking into account payment for the deductibles, co-insurance and anything beyond the amount paid by the schedule of benefits. Many Singaporeans do not have adequate funds in their Medisave accounts to pay for their own medical bills, because their Medisave funds have been used to pay the bills of spouses, parents or siblings. The baby boomers have often had to take care of their parents’ medical cost.

[Medisave, Medishield … Medi-crisis? Stanley Jeremiah, https://www.moh.gov.sg/content/moh_web/home/pressRoom/Media_Forums/2008/Medisave_Medishield_Medi-crisis.html%5D

Others

There is no evidence that Singapore’s preventive care has been effective in reducing health problems.

HIGH rates of obesity and smoking already put Malays at risk of heart attacks, yet this group is also the least active in getting screened and looking for treatment … In 2011, there were 439.2 heart attacks per 100,000 people for Malays, compared to 421.5 for Indians and 173.2 for Chinese. Death rates were also higher for Malays … About 24 per cent of Malay adults are obese, compared with 16.9 per cent of Indians and 7.9 per cent of Chinese, according to the latest National Health Survey … About 24 per cent of Malay adults are obese, compared with 16.9 per cent for Indians and 7.9 per cent for Chinese, according to the latest National Health Survey.

[Straits Times, Malays at higher risk, but fewer go for checks, 6 Mar 2013]

It’s bewildering how CNN and Professor Haseltine have come to the conclusion that Singapore has been ‘more successful’ with rental bicycle when it is hardly heard of as a means of getting to and from work and when cycling in space constrained Singapore is so dangerous and problematic.

So why don’t more people ride bikes to work or school? Answer: because they may end up being killed or maimed by motorists. Singapore promotes cycling half-heartedly … There are no cycle lanes in Singapore so cyclist have to literally risk their lives to ride on the roads. There were apparently more cyclists killed and injured on the roads of Singapore in 2013 than any previous year … When I say target I mean that many cars are known to swerve deliberately into cyclists, ride close to them, many do not give them room, many come within a hairs breath of knocking them off their bikes, many generally intimidate them and of course we know of many cyclists who were killed and injured by vehicles in 2013 … If you think are I am exaggerating try it out. I cycle to work and back every day and deliberately spend only 10% of that time on roads, the rest on paths, parks and gardens which may be longer but at least I will get there in one piece. That 10% I take my life in my hands every day … Cars swerve deliberately to intimidate me off the road into the gutter for no reason and that is a common gripe amongst cyclists in Singapore. The fact that the roads are designed with the drains on the cycling side means that if a car/lorry/van gets too close a cyclist literally has nowhere to go … Compare this with New York where they successfully not only introduced a cycle scheme of sharing 6,000 new bikes but have had no deaths on the roads in the first 5 months of it being implemented. That’s on New York’s notorious roads where drivers are much more aggressive than they are Singapore.

[Singapore Business Review, Is cycling the most dangerous thing that you can do in Singapore?, 10 Jan 2014, Chris Reed]

… Many Forum letters have touched on irresponsible and dangerous cycling behaviour in areas with heavy pedestrian traffic, but nothing discernible seems to have been done, both in terms of education and prosecution … pavements are narrow, there ought to be some rules of engagement if they are to be shared by pedestrians and cyclists. Otherwise, cyclists will use them irresponsibly, posing great danger to pedestrians, especially the elderly, who lack agility and quick reflexes. Last week, I was almost hit by a bicycle while walking on a pavement. The cyclist had a pillion rider and could hardly control his bicycle, given the extra weight and the high speed he was riding at. I commented on his dangerous cycling and he had the audacity to show me an obscene gesture … The problem is becoming endemic … Lawrence Loh Kiah Muan

[Strais Times, Rein in dangerous cycling habits, 28 Aug 2014]

SINGAPORE – A cyclist riding in the middle of a lane was caught on video refusing to give way to a car with an “L” plate despite repeated sounding of the horn by the driver.

[Asiaone Transport, Lane-hogging cyclist refuses to give way to ‘L’ plate car, 2 Jul 2014]

SINGAPORE – A video that has made its way onto social media channels shows a cyclist attempting to provoke a driver to a confrontation after riding recklessly on a busy Singapore road. Uploaded on YouTube on Oct 8, the cyclist is first seen beating a red light at a traffic junction. He then occupies the right-most lane of a busy road and is seen cycling haphazardly on the dotted line. At one point in the video, he suddenly cuts into the lane of a driver … the cyclist’s behaviour had caused him to “jam on (his) brakes and honk” … The cyclist stops his bike in the middle of the road and motions the driver to come forward. He does this repeatedly in what seems to be an attempt to provoke the driver.

[Asiaone Transport, Caucasian cyclist hogs road, rides recklessly then taunts driver, 10 Oct 2013]

WITH the dispute between pedestrians and cyclists along pavements heating up in Woodlands Avenue 9, Traffic Police mounted an operation yesterday morning to nab errant cyclists. At least 100 cyclists were caught within an hour and 15 people were issued fines of $20, Shin Min Daily News reported … there were many cyclists riding along the pavements of Woodlands Avenue 9 and many near-misses with pedestrians … One resident, Ms Chen, said that many cyclists are very reckless. “My five-year-old son was nearly knocked down by a bicycle a few days ago. It was really dangerous,” … Shin Min reported that the pavement where the operation took place was narrow, but in a span of 10 seconds, at least 30 bicycles would pass by … Before the Traffic Police operation started, some reckless cyclists were spotted, with two cyclists brushing against each other … Many cyclists interviewed by Shin Min said that cycling on the roads was too dangerous, so they decided to cycle on the pavement … Construction worker Mr Lin, 22, said that it was dangerous to cycle on the roads as there were too many cars. “The cars travelling on the road are very fast, we can’t possibly cycle on the road,” he explained.

[MyPaper, Pavement-hogging cyclists caught in the act, 17 Oct 17 2014]

CNN, Care that costs less, http://edition.cnn.com/interactive/2014/09/health/cnn10-healthiest-cities/, Sara Cheshire

9 of 10
CITY – Singapore
POPULATION – 5.3 million
RANKED FOR Health care system

If you’re going to get sick, Singapore is the place to do it.
Ranked as one of the most efficient systems on the planet, the city-state’s public health-care program is used by 80% of residents.
More important, Singapore spends less on health care than any other wealthy country in the world. In 2013, 4.7% of its gross domestic product went to health; the United States spent 17.9%, according to the World Bank.
So what’s its secret? The Ministry of Health requires all citizens to participate in a health savings program called Medisave, which ensures that they have enough put aside to cover future expenses. Residents also receive health care subsidies based on income level. Medical costs must be clearly presented, and the government controls insurance companies.
“Price and outcome transparency are very important to quality,” said William Haseltine, chairman and president of ACCESS Health International Inc. and a former professor at Harvard Medical School and the Harvard School of Public Health. “Without it, it is very difficult to manage a health care system.”
In his book, “Affordable Excellence: The Singapore Healthcare Story,” Haseltine says that Singapore understood early on the need to integrate health with every aspect of urban planning. Housing, water, food, air quality, road traffic, parks and more were considered to be part of a holistic health system.
Paying attention to social and environmental conditions such as these is a hallmark of successful health care systems, says Kisha B. Holden, associate professor of psychiatry and behavioral sciences at the Morehouse School of Medicine, who specializes in health disparities.
Quality health programs pay attention to the needs of the people being served, she says. They have attractive financial systems, provide community education and focus on preventive care — all of which Singapore does.
Haseltine says some of Singapore’s more successful health campaigns have included rental bicycle, trans fat-free and anti-smoking programs. There’s also an entire government agency, the Health Promotion Board, dedicated to promoting healthy diets, exercise, health education and regular screenings.
“They have developed a very high-quality health care system that provides uniform care regardless of income,” Haseltine said.
He believes the principles that make the Singapore health system work so well can also be applied in other places.
“It is important to look at what can be done. High-quality health care can be delivered at the fraction of the cost.”

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