Singapore’s reputation for the world’s best healthcare is being challenged after improvements in the systems of its ASEAN neighbours.
By Francesca Ross
Singapore has long enjoyed a reputation as the ASEAN region’s premier healthcare destination. Bloomberg regularly lists the city state as having one of the world’s most efficient systems. There were about 850,000 medical tourists in Singapore in 2012. This generated S$1.1 billion (US$1.4 billion) in receipts and contributed 5% to the country’s total tourism receipts.
This poses the question, is this efficiency the most useful measure of healthcare provision? Vietnam has the highest investment in healthcare as a percentage of GDP, and Brunei’s government takes the largest burden of the people’s healthcare costs. Singapore has the most doctors and hospital beds but the money spent does not necessarily correlate to significantly higher life expectancy.
Healthcare rankings reflect government priorities and opportunities
A recent study of global healthcare services over the last 25 years did give Singapore the ASEAN region’s top ranking (21st in the world based on mortality from causes amenable to personal health care.) Malaysia came in at 66, Thailand at 88, and Vietnam followed at 93. The Philippines trailed its ASEAN brothers at 120, then Indonesia at 124, Cambodia at 143, Myanmar at 151 and Laos at 152.
This ranking mirrors the importance of healthcare as a policy issue. Singapore has a high-spending and advanced system while Brunei, Malaysia and Thailand have good outcomes for a lower level of investment. Indonesia, the Philippines and Vietnam offer just basic services due to social and bureaucratic barriers. Cambodia, Laos and Myanmar cannot guarantee quality services at all thanks to low levels of investment and poor infrastructure.
Healthcare spending across the region is lower than the global average at around 4% of GDP. This is compared to an Organisation for Economic Co-operation and Development (OECD) average of 9.5%. This is despite significant increases in spending between 1998 and 2010 as citizens and governments have prospered. Annual spending has increased to over US$68 billion. That is up by 250%.
Source: World Bank
Singapore’s system offers flexibility
Singapore saw government healthcare spending of S$8.2 billion (US$5.9 billion) in 2015. This was a comparatively low portion of GDP compared to other countries in the region. Citizens and permanent residents enjoy a universal healthcare system with government-applied cost controls. There are also subsidies derived from mandatory savings schemes or low-cost insurance which cover the cost of treatments or services.
This allows the patient to receive services at the location of their choice (within the constraints of the funding they can access) in either public or private facilities. Foreigners, even those with legitimate business in the country and tax responsibilities, have no access to public services.
Source: World Bank
Malaysia in increasing investment into its growing healthcare sector
Malaysia is quickly becoming a player in the provision of high-quality medical care. Citizens enjoy a system of universal coverage through a combination of public and private amenities. Investment in these services has recently been strengthened and there was a budget of RM25 billion (US$4.8 billion) for this in 2017. The government is investing more in co-provision with private providers while public hospitals often suffer from staff shortages and overcrowding. Further investment will be needed to fill service gaps and these are particularly obvious in rural areas. Medical tourism is a growth industry for Malaysia’s private services – the sector has been growing by close to 30% since 2010.
This growing reputation means Malaysia is challenging Singapore for custom and healthcare growth. For example, leading provider “Health Management International (HMI) has been stepping up efforts to develop Centres of Excellence by hiring more sub-specialties, as well as expanding the comprehensiveness of services,” explained UOB lead analyst Thai Wei Ying.
“Furthermore, increased accreditation of healthcare facilities by internationally-recognised programme MSQH has also helped to raise confidence in hospital standards,” he added.
|Government financed||Compulsory savings||Social insurance
|Singapore||Subsidised public hospitals—subsidy varies by class of ward; public primary health clinics—subsidised; subsidy through Medifund||Medisave||Medishield
Integrated Shield Plans
|Thailand||Subsidised public hospitals provide free of charge care to registered citizens.||Compulsory Social Security Scheme (SSS) Civil Servant Medical Benefit Scheme (CSMBS) Universal Coverage Scheme (UCS)|
|Malaysia||Subsidised public hospitals—varies by class of ward; subsidised public primary health clinics; free public primary health centres in rural areas||Account III in Employees
|Indoensia||Subsidised public hospitals and services through direct government funding. Care provision is free of charge but patients can pay top-ups to use smaller or private rooms.||National Social Health Insurance Scheme, or JKN. Contributions are staggered according to income and employment status. Lowest class of care = Rp 80,000 (US$5.98) per month for the self-employed. For employees, 5% of monthly salary up to a salary cap of Rp 8 million (US$597.55)|
Indonesia and Thailand have expanded their provision to all in recent years
High-quality Indonesian services are still taking root following the introduction of universal health insurance in 2014. Public spending on healthcare was budgeted at 3.1% of GDP in the most recent data and is expected to reach US$46 billion a year by 2019. Citizen contributions towards this provision are staggered according to income but there are concerns the programme is over-ambitious. Indonesians who can afford it still regularly travel to foreign hospitals for treatment.
Thailand has a long history of providing enviable services. A system of universal healthcare was put in place in 2002 and this is financed by multiple schemes based on employment status and need. Treatments and services are funded on a 77/23 split (as of 2011) between the government and private insurance. That is around 4.3% of GDP.
These programmes include pro-poor policies which allow people to get medical help at a very low price. Coverage includes items such as free prescription drugs, disease prevention and surgery and critical care for accidents and emergencies.
Changing demographics will require shifts in health policy
Healthcare provision in the ASEAN region is facing a dual shock from rising levels of education and an aging population. This means that demand and awareness of services will increase without significantly larger funding streams. The current public systems where those in work pay (via taxes) for the care of the elderly will become unsustainable.
Medical tourism and private funding has never been more important. These services will make hospitals and healthcare providers their money for research and top-quality equipment as public subsidies falter. The growth in this market is already making customers more selective.
Singapore’s facilities can no longer even rely on the custom of Singaporeans. Thailand’s Bumrungrad International often sees Singaporean patients for health screening and specialist treatment explained Sudi Narasimhan, the hospital’s corporate director of marketing and business development.
Cost is the key factor in this switch. “We are 25 to 35% cheaper than Singaporean private hospitals, and have been benchmarked by third parties to have similar or higher quality levels as the top hospitals there,” he said. Singapore may still have the best healthcare – providing you have the right money or status – but Thailand is on the rise.