Fail to understand burden of disease, fail to understand healthcare reform (Part 3)

April 4, 2012
Singapore Democrats

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Ansari Abudeen



In this third and final part, I would like to answer some questions that I have noticed in relation to
Part 1 and
Part 2 of this series and to look at how the THE, CIHE and CIHS can be managed in a sustainable manner.

I also want to examine how the SDP healthcare plan takes into consideration these three types of costs in order to work towards a longer term vision of cutting costs in healthcare and reducing the burden of diseases in the population.


Are you an SDP member? Why are you weighing in on this issue?

I am not an SDP member. I do not look at the SDP healthcare plan as a partisan issue or political issue. For instance, I also support Reform Party’s call for universal healthcare policy shift. I maintain this position due to the prevailing evidence in medicine and healthcare not because of political considerations. I am a policy researcher, not a politician.

I look at this whole thing as part of the broader healthcare debate that Singapore needs. If you look at the world outside Singapore other than US, you will have a hard time finding a society that is so divided in arguing about the merits of universal healthcare.

Most of the world have moved on. Their debate is pretty much about which features of universal healthcare are better. In fact almost all Organisation for Economic Cooperation and Development (OECD) countries have adopted universal healthcare systems. The World Health Organization (WHO), World Bank (WB) and other global agencies are advocating that countries that do not already have a universal healthcare system shift towards it.

In 2005, member states of the WHO adopted a resolution that encouraged countries to develop healthcare financing systems aimed at providing universal coverage. The conventional standpoint of experts in healthcare and medical sciences is that universal healthcare is better than one that is not.

Hence there is a responsibility for health policy researchers like myself to participate in this healthcare debate. In fact healthcare is not an issue that politicians and bureaucrats alone know best. As I stated in Part 1, no one holds a monopoly to solutions in healthcare. In this debate you need the participation and voice of everyone including the patients, their families, researchers, service providers etc.

What triggered you to write the three articles?

Essentially, I notice that the opponents of universal healthcare in Singapore insist that arbitrarily capping healthcare spending is the only way to prevent expenditure to spiral out of control. This is an implicit acceptance that healthcare spending is not at the level of what it should be.

Their argument ignores the issue of the full burden of diseases on society and just calls for limiting government spending. This argument is flawed. Past experience has shown that we cannot address the healthcare challenge by just controlling government spending. If we want to understand whether Singapore needs healthcare reform, then we should pay attention to the burden on the society due to the diseases in the population.

And if we want to compare whether alternative healthcare models such as what SDP proposes is better, we cannot just compare what each model proposes to spend on the healthcare system. If we do that, we are limiting ourselves to considering just considering the costs while ignoring health gains that a model can potentially produce. More importantly, we are making the mistake of saying that a dollar spent in SDP model is equivalent to the dollar spent in current model.

Whatwe really need to do is to compare the relative cost effectiveness of the SDP’s model and current system. While we do not have data to determine the precise relative cost-effectiveness, we do know that the SDP’s proposed government budget is $10.5 billion – $2.5 billion more than the $8 billion that the PAP government proposes (but over the next five years). 

While the SDP’s budget is slightly higher, the health gains would probably be greater too. This is because SDP’s model is patient-centric, focusing heavily on alleviating patients’ hardships, improving their well-being, and preventing their future health risks. A basic justification for universal healthcare is that it produces greater health gains than a non-universal healthcare system.

How will you characterise the healthcare debate in Singapore?

We are basically two decades late in debating whether or not to shift towards universal healthcare. Essentially, the division in Singapore over universal healthcare is actually a division between the “I” group and “We” group. The “I” group is selfishly looking at just their own world in terms of how much more they must pay, how much longer they must wait in the queue, etc.

The “We” group gives greater priority to impact of healthcare polices on society at large. They are concerned with how many more lives can be saved, by how much hardship of patients and their families can be reduced, and so on.

So is the healthcare challenge in Singapore all about shift to universal healthcare?

The challenge in healthcare in Singapore is two-fold. The first is politicians and society finding the will to adopt universal healthcare. The second is the healthcare system being able to manage and reduce the burden that diseases impose on the society.

As I stated earlier, most countries have figured out the merits of universal healthcare and are only concerned with the second aspect. In Singapore, however, we are still arguing about both aspects.

How does SDP’s healthcare plan attempt to deal with this healthcare challenge that you state?

In the first aspect, the SDP healthcare plan clearly advocates a shift to universal healthcare. That is going to be the harder aspect for now given how polarised opinion is amongst politicians and society.

As for the second part, the plan has proposed various strategies. No plan can offer a ‘how-to dummies’ guide of final solutions and, as far as I can tell, there is nothing in the report that suggests that SDP is attempting to do this.

Instead, as it should be, some of the strategies point towards actual final policies whereas others are indications or identification of frameworks for policy directions. You cannot solve the second aspect with just a plan but you need a plan to start working in that area.

How long do you think this healthcare debate can take? What will be the likely outcome?

The debate will be a long drawn-out one. However, it will eventually shift to universal healthcare. A decade ago the SDP’s healthcare plan would not have received half the support it has received today.

If you look at the US, what President Obama has achieved in healthcare reform was something former president Clinton and his predecessors also tried but were unable to do because of insufficient support. Many developing countries that have decided to give priority to universal healthcare were not even talking about it a decade ago.

But the longer this debate drags on, the more time is wasted. There is an urgent need for a quicker shift because after that, it will take 5 to 10 years for Singapore to restructure towards universal healthcare because there are many areas that must be looked at such as building capacity and constructing new frameworks. The restructuring also has to be evidence-based to see which structures work and which ones don’t.

Another problematic aspect that is making this debate so long drawn is the lack of publicly available and independently gathered evidence. I find this very unique because in my in work in Asia, bureaucrats are more willing to publicly evaluate the effectiveness and cost-effectiveness of their policies and actions through independent experts. They make the decisions independently, without relying on other ministries’ support or their minister’s support, even if they know such studies may yield findings that will recommend major policy changes to improve the system.

If you look at SDP’s healthcare plan, it is put together by a team that has nine medical doctors. Many of the issues they raise are observations they have made over the years at the front line of service provision. These matters would have been raised long before if there had been independent evaluations. Unfortunately. there has been much denial over the years about the shortcomings and limitations of the current healthcare system. Worse, the denial still goes on.

Can SDP’s proposed healthcare expenditures be sustained for ten years or more?

When we talk about sustainability, we need to understand that sustainability issues not only exist for government spending or total spending on the healthcare system (THE). There are sustainability issues for the patient, patient’s family, the economy and society as a whole. We know the current system has serious sustainability issues for the patient and patient’s family, and that the SDP’s plan is very focused on tackling these issues.

Government spending on healthcare system is sustainable as long as the universal healthcare system gives evidence-based policies due consideration and priority. This is why the vast majority of OECD countries that have universal healthcare have not found any reason abandon this approach. Those who are worried about sustainability of the government spending are attempting to tackle the issue from the evidence side and they are not convinced about shifting to a non-universal healthcare approach. They do not find evidence to support that kind of policy shift.

So as long as the SDP’s healthcare plan continues to give priority to what works and what doesn’t, the plan will be sustainable.

How will SDP’s proposed plans reduce the costs of CIHE and CIHS?

It is the universal healthcare character of SDP’s plans that will reduce CIHE and CIHS better than the current system.

If one looks at universal healthcare models across the world, every model reduces CIHE and CIHS at the different rates. This is due to several factors, one of which is that evidence-based care is implemented at a different pace (because evidence is gathered at a different pace).

How effective the SDP’s plan is in reducing the CIHE and CIHS is dependent on the speed it generates evidence on the effectiveness and cost-effectiveness of the programme and how quickly the information is used in adjusting the system.

What is your advice to Singaporeans?

One, the shift to universal healthcare is a no-brainer. What we need to worry about is what type or features of universal healthcare Singapore should adopt. This decision should be guided by scientific evidence and not ideology of politicians and policy-makers.

To achieve sustainability in the universal healthcare system after implementation, we need to focus on continually evaluating the effectiveness and cost-effectiveness of the system, bearing in mind that every universal healthcare system progresses at different speeds depending on how the system is set up and implemented. It is, therefore, important to pay attention these.

Two, we need to also focus on the range and magnitude of the burden that diseases impose on a society and the economy as a whole when we talk about healthcare costs and not limit ourselves to looking at spending on the healthcare system alone.

Ansari Abudeen is a Singaporean working as a health economist in the National Drug and Alcohol Research Centre, Faculty of Medicine, University of New South Wales. He is also a PhD candidate. In 2011, one of his research projects won a national award for research excellence. Ansari has also provided consultancy on evaluating cost effectiveness of communtiy pharmacy service provisions and economic value of asthma research. Currently, he is providing consultancy to a state ministry of health, Indigenous community organisations and service providers in Australia on implementing frameworks to monitor and evaluate health outcomes.

Reas also:
The SDP National Healthcare Plan: Caring for All Singaporeans (pdf)
The SDP healthcare plan made simple