Managing Healthcare: Case Studies of Singapore and Britain

Managing healthcare
What challenges do governments face in managing healthcare? - A challenge for most governments because of the need to provide basic healthcare for the sick even if they are unable to pay for it. - Healthcare is a public good which governments have to provide for the people, given the limited resources and competing needs of the countries. - EG: Mauritania in Africa has only one large hospital in the capital city No basic healthcare facilities or lack thereof. In Sweden though people can make use of the healthcare services provided by the government. Providing quality healthcare - Improvements in science and healthcare have enabled people to live better and longer - Today, people in more developed countries expect more and better healthcare services. - Policies made and implemented to meet the demands of the people in healthcare may determine the success of a government Increasing expenditure on healthcare - Over the years, funds have been invested in research for better treatments, more effective medicines and training for better-qualified medical staff. - Individuals and governments want to have the best possible healthcare they can afford for themselves and their citizens respectively increase in healthcare cost

How is healthcare paid for?

Individual - Self: People can pay for healthcare services when they receive treatment. - Personal insurance: People can buy medical insurance. They can make claims from the insurance company to pay for certain medical treatment such as surgery Employer - Employer-paid insurance: Employers pay a certain sum of money for insurance for their works. Employers can claim medical fees from the insurance company when medical services are used by their workers. - Government taxes: Government collects taxes from the people and uses a percentage of the taxes to pay for medical services used.

Healthcare in Singapore
How was healthcare managed in the 1960s and 1970s? - In the 1960s, healthcare was part of Singapores overall plans for improvement and development after independence Eg: healthcare measures were taken as part of the public housing programme, squatters and overcrowded areas cleared and people moved to HDB flats - There was a need for basic healthcare for the people (infectious diseases eg tuberculosis were common and spread easily). - Hospitals, clinics and outpatient dispensaries were also built to provide healthcare for a growing population. All the people in Singapore were asked to go for vaccination against diseases, medical officers and nurses sent to schools to provide healthcare for students. - By the 1970s, the Singapore economy had improved and people enjoyed a better standard of living and wanted better healthcare services. - Old outpatient dispensaries were replaced with polyclinics, providing a wider range of healthcare eg medical check-ups for babies. These polyclinics were conveniently located in town centres. Facilities in government hospitals and the quality of healthcare were improved. - Money used to pay for the building of polyclinics, government hospitals and providing healthcare services comes from the government budget. - Every year, the government plans to spend a certain amount of money on meeting the needs of the people (this amount of money is known as the government budget). - If the government spends more on healthcare will have less money to spend on other needs eg education. How has the approach to manage healthcare changed since the 1980s? - Healthcare cost rose. In 1983, Ministry of Health published a document called the National Health Plan (NHP) government wanted to encourage public debate on the suggestions mad eon how to manage the long-term healthcare needs of the people - NHP AIMS: 1. Build a healthy and physically fit population. 2. Encourage Singaporeans to stay well and reward those who do. 3. Build up individual financial resources so that those who fall sick will be able to pay. - NHP suggested that healthcare policies should not put a strain on government spending and encourage self responsibility as well as community support and keep healthcare affordable. - NHP AIMS INDIVIDUAL: Encourages self-reliance & maintains good health NHP AIMS GOVERNMENT: Keeps healthcare affordable & promotes healthy lifestyle NHP AIMS COMMUNITY: Provides some healthcare services & provides support services. Encouraging self-reliance Medisave - Medisave encourages Singaporeans to be responsible for their own health. - A certain amount of money from workers Central Provident Fund (CPF) contributions every month is channeled into their Medisave accounts. This

amount of money can be used to pay hospital bills and certain medical treatment when needed. Over the years, most Singaporeans have accepted Medisave as a means to pay for part of their hospital bills. With more feedback from the people, the use of Medisave has been extended to pay for certain medical treatments which are expensive. Medisave can also pay for more types of medical treatments eg chemotherapy and medication to control high blood pressure Not all make CPF contributions and thus do not have Medisave. By encouraging Singaporeans to have money in their Medisave accounts, they are better able to pay for healthcare In this way, the people share the costs of healthcare with the government Medisave helps to lighten the governments burden of paying for healthcare services Healthcare becomes a shared responsibility. Government need not depend on raising taxes to pay for rising healthcare costs.

Encouraging self-reliance MediShield - MediShield is a national healthcare insurance scheme. - Singaporeans pay for this scheme with their Medisave Patients can make claims from MediShield to pay for large medical bills which Medisave does not cover (more serious long-term illnesses) - Use of MediShield has been expanded to meet the specific needs of the people eg by paying premiums for Eldershield, people above 40 years old would be able to pay for healthcare in case of disability. Keeping healthcare affordable - Governments have to use limited resources to provide public services to meet the needs of the people Shared responsibility in Singapores healthcare system Encourages self-reliance in individuals while governments provide safety nets to ensure that healthcare remains affordable - Government subsidies: Direct subsidies are given to government hospitals, polyclinics and some nursing homes for the elderly to ensure that basic healthcare services are available for all Singaporeans (eg in 2000, subsidies mad eup one quarter of government spending on healthcare), and to ensure that healthcare remains affordable for most Singaporeans (especially lowerincome group), government gives different rates of subsidies to the different classes of wards in hospitals (eg Class C wards Most subsidies) - Medifund: Healthcare is a public good no person should be in a situation where he is not given healthcare because he cannot afford it. There are needy Singaporeans who despite Medisave, MediShield and government subsidies, still cannot afford to pay for their medical expenses. In 1993, Medifund was set up as a way to provide help to those who are not able to pay for healthcare. The government started with a fund of $200 million and the interest earned from this fund is given to public hospitals to provide help for needy patients. Patients who need help apply for the fund at the hospital where they are being treated.

Restructuring of hospitals: Restructuring the hospitals meant that hospitals would have more freedom to reorganize to meet the needs of Singaporeans government would also be able to reduce the amount of subsidies to hospitals. However, many felt that restructuring higher hospital bills. Means-testing: Subsidies provided by the government should benefit patients who need them most. Resources would be more fairly distributed if those who cannot afford to pay for healthcare get the most subsidies. In the same way, those who are more well-to-do would benefit less from subsidies. The way to check whether the patients are able to pay for healthcare is called means-testing. It has been debated for many years, however, it has not been implemented in government hospitals yet because the government needs to consider how much a policy would affect Singaporeans.

Promoting a healthy lifestyle - Adopting a healthy lifestyle is one way of coping with rising cost of healthcare for both the government and individuals eg schools and workplaces have programmes to emphasis the need to maintain good health, such as regular physical exercises and well-balanced diets are encouraged. Working with organizations - The community also provides some healthcare support services to meet the needs of the people because it is not possible for the government to run all healthcare services - EG: Some patients who are discharged from hospitals may still need medical care voluntary welfare organizations and some private organizations are given grants to run community hospitals, nursing homes and day rehabilitation centres for this group of patients - Support is also given by the government to organizations that provide specific healthcare support services.

Have Singapores healthcare policies met the needs of the people?

Despite the various schemes to help Singaporeans pay for healthcare, there are still some people who cannot pay for the healthcare services they need EG: 1. Elderly who did not have opportunity to save for healthcare when they were earning an income have to depend on family/community/government to look after their needs 2. Those who are unable to work

Healthcare in Britain
In Britain, healthcare is a public good that is provided by the National Health Service (NHS).

How did the National Health Service come about?

Before the 20th Century British government did not provide much medical care for its citizens; poor, aged or homeless had to depend on private charities/friends/family In 1940s, government felt it was their responsibility to look after its citizens. In 1942, senior government official William Beveridge delivered The Beveridge Report and recommended that the government put an end to poverty, disease and unemployment to help rebuild peoples lives after World War II, to reward the people for the sacrifices that they had made during the war. Government accepted the report and went about creating a welfare system for the people of Britain. In a welfare state, the government looks after its citizens from cradles to grave to ensure that every citizen would have a minimum standard of welfare for a decent life (a job, a home and healthcare) In order for the government to provide this, the people of the country agree to contribute to a national fund to help the more needy people in their country In Britain, the NHS was set up as part of the welfare system to provide free healthcare for its people at the point of need people do not have to pay for the medical treatments that they receive when they are attended to by doctors at clinics/hospitals. When NHS started in 1948, it was very popular with the people free basic medical service for all citizens, inclusive of dental and optical treatments, all free of charge. With the NHS, the British government expected demand for healthcare to increase and then stabilize after a while. However the increase went beyond expectations just too many people who wanted to use the free medical care. In addition, doctors used or recommended medical treatment freely without much consideration for cost. By 1951, NHS unable to meet the expectations of a healthcare system that was free at the point of service medical treatment was no longer free (eg NHS had to charge a small fee for medicine given to patients and from 1951, dental treatment was also chargeable)

How has the British government managed the NHS over the years?
Managing government spending - Under the welfare system, government is expected to make benefits such as healthcare available to everyone free of charge, and money to pay for healthcare comes from the people. - If healthcare costs increase, the government has to collect more taxes to pay for healthcare and other expenditure. Over the years, the British governments biggest challenge in healthcare is in trying to control spending on healthcare.

In the 1980s, the government under Margaret Thatcher tried to manage the NHS better by cutting back on government spending on welfare benefits such as healthcare. She wanted to create a system that would make the individual more responsible for his own healthcare and welfare because the government was spending too much on welfare benefits. At the same time she realized that it would not be possible to remove free healthcare for the people of Britain without losing their support. There was always fear that any reduction in government spending on healthcare would result in the inability of the NHS to provide free and quality healthcare services something that British were not willing to accept as many have come to see the NHS as the most important public good provided b the government. In more recent years the British government has tried to manage government spending while meeting the needs of the people at the same time (eg In 2000, Tony Blair promised the people that the government would increase public spending on healthcare and improve the NHS) However, the increase in spending by the government in healthcare was accompanied by increases in the National Insurance contributions in 2003.

Increasing efficiency - In the 1980s, Britain experienced an increase in the demand for healthcare with the growing number of the elderly population growth had slowed down and the number of people paying taxes would also reduce over time - At the same time, people expected more and better treatments and although NHS had grown very large but there were still not enough resources to cope with the demand (eg insufficient doctors/nurses/facilities in hospitals for surgeries) - Margaret Thatcher introduced the policy of privatization within the NHS privatization aims to reduce government subsidies, save costs and make the NHS more efficient. - Private companies had to be efficient to make profits, patients would have more choices and hospitals would improve their services to meet the peoples needs. - One example of privatization: NHS hospitals to contract out non-medical services involved using private contractors to provide services such as laundry, cleaning and catering in hospitals would allow hospitals to concentrate on providing medical services. - British citizens were encouraged to take responsibility for their own welfare and health Medicine, dental treatment and services provided by opticians were no longer free except for a few groups of people (students under 19 years of age, expectant mothers and mothers with children under one year old) Providing quality service - Still not enough money despite government pumping in more into NHS! By the late 1980s, the increase in demand over the years led to what the people felt were poor standards within the NHS. - One of the improvements made to the NHS was to focus on providing quality service for patients. Patients were given more information to help them decide on their own treatment and care and inspite of the changes made to the NHS,

the people of Britain often had to wait for a long time before receiving medical treatment. The British government continued to make plans to improve NHS two other plans aimed to deliver quality service by putting the needs of the patients as the top priority introduced (NHS Plan in 2000 and NHS Improvement Plan in 2004) NHS PLAN: Made changes based on feedback from staff, patients and all those involved in healthcare. It provided for increase in the amount of government spending till 2004, and also planned to work towards offering patients faster and more convenient services (eg let the NHS make use of facilities in private hospitals without having the patient pay for it) NHS IMPROVEMENT PLAN: Under this plan, patients would have the right to choose from four different healthcare providers and the NHS would pay for the treatment. Every patient would also have access to their own personal HealthSpace on the Internet where they can see their care records. Another example under NHS I.P.: Introduction of NHS Direct, a service to provide medical advice over the phone to patients with minor illnesses so that they can save a visit to the doctor and also would not strain the resources of the NHS with doctors having to attend to too many patients.

Have British healthcare policies met the needs of the people?

NHS has been a public service that the people of Britain identify themselves with and feel strongly about and has also been used as a model for countries like Sweden, Italy and Spain which also have welfare systems Over the years, many changes have been made to improve NHS and the intention of providing healthcare based on need and not the ability to pay has remained unchanged since 1948. The welfare system, including NHS was created to achieve the goal of providing a better future for Britains citizens at the end of World War II. One of the challenges the NHS faces is how to ensure that resources are best used to meet the needs of the people, and this involves the provision of funds and the management of the NHS. Many groups of people have different views about NHS Many Britons are thankful for NHS and feel safe knowing they can have medical services when they need them, and there are also doctors who feel that NHS has improved over the years while othrs feel that there has been no real improvement. For the last 50 years, the British government has tried to keep up with the changing needs of the people in healthcare through reforms in the NHS, showing us how difficult it is to make and implement government policies to meet the needs and expectations of people.

Conclusion
Singapore Approach is one that emphasizes shared responsibility Britain Approach is to provide welfare in healthcare Different governments adopt different approaches to solve their problems based on the needs of their people and the resources that they have.

The cradle-to-grave benefits provided by the welfare state (healthcare in Britain) Maternity grant & allowance Child benefit Sickness, injury, unemployment: supplementary benefit Retirement pension Death grant