Thank you, Singapore

The country’s healthcare system is not just low cost but also very effective in terms of saving lives

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A decade ago, I had an experience that left me profoundly grateful to Singapore’s healthcare system. During a work trip to the island state, I was suddenly taken ill and succumbed to a rare variety of meningitis. In many countries, I would have died but two extraordinary things occurred. First, a work colleague had a strange premonition that something was wrong and came to my hotel room, where she found me sliding into a coma. Second, the colleague then had me rushed to a local hospital, where Singaporean doctors identified the problem with astonishing efficiency and then took a bold medical gamble to save my life. (Essentially, they injected every type of antibiotic they possessed directly into my heart because they did not have any tailored way of treating the rare strain of meningitis I had.)

When that risky gamble pulled me out of the coma, the hospital staff set me on the long path to rehabilitation, with further efficiency and grace. And, a few months later, came another surprise. When I stumbled on some of the paperwork between the hospital and my insurance group, I noticed that the bill for the intervention was not that large. “If this had happened in America, it would be many times that size,” a colleague later grimly remarked in New York. (To which I retorted that if the incident had happened in America, I might not have survived at all since litigation risk might have deterred the doctors from engaging in that antibiotic gamble.)

Was this just a piece of random good luck? Yes, in part. But in recent weeks I have been flicking through a fascinating ebook, Affordable Excellence, that an American scientist friend, William Haseltine, has written about Singaporean medicine for the Brookings Institution. And this leaves me convinced that I have even more reasons to say “thank you” to Singapore than I realised at the time. For if Haseltine is correct, Singapore’s healthcare system is not just low cost but also very effective in terms of saving lives – both during emergencies and in less dramatic cases too. Indeed, the success is so striking that it might offer lessons elsewhere, particularly in America, which is now embarking on its own radical health reforms via Obamacare.

The statistics are striking. At present, America spends about 18 per cent of its gross domestic product on healthcare, more than any other western nation. But while this produces fantastic results in some niches (such as cancer treatment), the metrics for infant mortality, adult deaths, life expectancy and other health issues are worse than many western nations. Singapore’s healthcare costs, by contrast, are just 4.6 per cent of its GDP; and while the system is based on insurance programmes, premiums per capita are just 2 per cent of those paid by Americans. But on issues such as life expectancy, infant mortality, premature adult death – and, yes, emergency care – Singapore produces much better outcomes.

Why? One reason, Haseltine suggests, is that Singapore had the luxury of creating a healthcare system from scratch a few decades ago, and thus could adopt a rational, holistic plan that focuses on the total health experience of the population in a joined-up way. America, by contrast, is marred by competing and wasteful silos. Singaporean society also subscribes to the idea of “managed capitalism”, which means that the state sometimes intervenes in the system to keep costs down. But the main weapon for lowering costs is consumer pressure: hospitals are forced to publish prices for medical procedures and outcomes so that consumers can quickly compare them. Patients are always forced to co-pay for treatment, alongside insurance groups, to create incentives to scrutinise their bill.

Now, it would be impossible to replicate some of this in a vast, fragmented system such as the US. After all, most Americans hate the idea of excessive state meddling or state planning; “social harmony” is not a stated goal. But there is one aspect of Haseltine’s report which is highly relevant right now: accountability. Most notably, if Americans could compare the price of treatments as easily as they can in Singapore, that might lower treatment prices – doubly so if the use of co-payments was as widespread among the rich as well as the poor.

The good news is that America is slowly moving that way since there is growing support within the medical world now for co-payments and price transparency as part of Barack Obama’s wave of healthcare reforms. But the bad news is that any changes are achingly slow and patchy, precisely because the American system is so fragmented. For the foreseeable future, in other words, those statistics from Singapore are likely to keep putting the US to shame (not to mention some European countries too).

It is a distinctly sobering thought, given that behind those stark statistics stand millions of human stories, many of which were not as blessed with as much good fortune as mine.

Letters in response to this article:

Meaningful healthcare comparisons / From Mr Jeremiah Norris

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