A Comparative Analysis Of Healthcare Systems And Governance In Singapore, United States And Canada

At the completion of this topic, students will be able to:

1. Discuss the definition of health.

2. Critique various definitions of health in terms of their comprehensiveness, usefulness for health services management purposes and accuracy.

3. Describe health systems in a systematic and accurate way.

4. Analyse a health system according the WHO building blocks for health systems.

5. Develop a framework for assessment the typology of health systems

6. Compare the health system of Singapore to at least one other country’s system.

7. Discuss the global challenges to health and the extent to which these are being addressed in Singapore.

Healthcare System Performance Indicators

Healthcare Systems are affected by its funding, funding system, GDP growth and spent of healthcare,and its performance can be analyzed through indicators like maternal mortality rate, infant mortality rate and life expectancy at birth as well as through health system performance indicators like prevalence of low birth weight, obesity, diabetes, asthma, hypertension and cancer. Additionally, efficient management of quality and safety of healthcare systems ensures the providence of healthcare, and maintains the standards of efficient system. The aim of the report is to compare the healthcare system and its governance between Singapore, United States of America and Canada. Singapore has been considered to provide cheap and good quality healthcare to its citizens (Ranked 6^th by World Health Organization) (Frakt & Carroll, 2017). The Hybrid Model used by Singapore, makes it one of the best healthcare systems (Tan, 2017). A comparative analysis of the key aspects affecting healthcare systems and performance indicators can allow to identify the different aspects where developments can be further made to the healthcare systems of Singapore, to ensure an improved care for its citizen, and maintain the quality and efficiency of the care.

As of 2017, reports show the Singapore government spends USD 381 per capita on healthcare (Klein, 2017). Lim, (2017) points out that the Singapore government spends a third of the healthcare cost, while the citizen pays two thirds of the expense. An estimated amount of USD 30 billion is invested by the government towards Medifund. The funding is ranked fifth for public funds (Bai et al., 2012).

The expense of the United States Government on healthcare costs, per capita is estimated to be USD 5,960 out of the total per capita expense of USD 9,267 (and the citizen paying the rest USD 3,307. This placed US above Canada and United Kingdom in healthcare funding (Almberg, 2016).

The spending by the Canadian government is estimated to be about USD 2,209 per capita, out of the total cost of USD 4,095, with the citizens paying the rest of USD 1,886. The total investment of the government adds up to about USD 68.5 billion (Barua, Palacois & Emes, 2017).

Singapore employs a mixed funding system for healthcare, using multiple tiers of protection to ensure the providence of healthcare for every Singaporeans. The system includes 4 levels of funding, with Subsidies acting as the first safety net that allows affordability of healthcare, followed by the next safety net, the Medisave that allows the building of savings for smaller healthcare expenses. The third line of protection is provided by Insurance schemes (like MediSheild Life, Integrated Shield Plans, ElderSheild and ElderSheild supplement) that support large medical expense, and long term medical care. The final tier of protection is provided by Medifund that assist the needy citizens to meet their healthcare costs (Moh.gov.sg, 2018).

Funding Models

Figure 1: Funding levels on healthcare in Singapore; source: (Moh.gov.sg, 2018).

Government Funding for healthcare in US is through programs like Medicare and Medicaid (Trivedi, 2018). The healthcare professionals are paid through private insurance, government insurance and personal payment by citizens in the form of out of pocket funding. Private insurances are also subsidized by the government, and are purchased by corporations to benefit the employees, and exempted from taxation. The Patient Protection and Affordable Care Act (PPACA) or Affordable Care Act (ACA) is aimed to improve both availability and affordability of healthcare service to citizens (HHS.gov, 2018). Apart from Medicare (for the healthcare of elderly, disabled and long term treatment) and Medicaid (for people with disability or those below the poverty level), the government also has other programs like State Children’s Health Insurance Program (for uninsured children), Tricare (for military personnel and their families), Veterans Health Administration (VHA) (for military veterans) and Indian Health Service (for American Indians and Alaskan natives).

Healthcare funding in Canada is through Canada Health Transfer from the federal government that funds provinces and territories, and Fiscal Transfer for additional federal funding (Canada.ca., 2018). The finances are provided via taxation system apart from lottery proceedings, and revenues of the federal, provincial and territorial governments (Funding for Health Care., 2018). As per Canada Health Act, exempts payment for premiums on health insurances, and funds are allocated via Canadian Health and Social Transfer (CHST) (Canadian-healthcare.org., 2018).

The healthcare system in Singapore is governed and administered by the Ministry of Health that assesses the health needs and plans delivery services through a network of health and hospital services, day cares, nursing homes and medical facilities. The financing involves Publicly Financed programs like Medisave, MediSheild and Medifund, also called the 3M system. The system is based on the philosophies of individual responsibility and provision of affordable healthcare for everyone. Medisave is a medical savings account that is contributed by each worker by a percentage of their salary, and an equal contribution from the employers. It covers for medical expenses like hospitalization, day surgery and outpatient services for the employee and their families. MediSheild covers long term medical expenses, not covered under Medisave, and operates on co-payments and deductibles, and can be paid through Medisave. It covers the Singaporean citizens automatically. Medifund supports the poor and needy citizens who are unable to cover the medical expense in spite of Medisave and MediSheild coverage. Private Health insurances like Integrated Shield Plans acts to supplement MediSheild coverage, and are purchased from their MediSave account. MediSheild pays 80%-90% of the claimable amount exceeding the deductibles for treatments like kidney dialysis, chemotherapy, erythropoietin, for chronic kidney failure. A co-insurance of 20% is imposed for outpatient services on the patient. Medifund services are also extended for needy children by Medifund Junior and for elderly patients from low and middle income profiles in intermediate and long term care by Eldercare fund (International.commonwealthfund.org, 2018).

Maternal Mortality Rate

The US Department of Health and Human Services (HHS) is the principal agency under the federal government associated with healthcare, and includes Centers of Medicare and Medicaid services, Centers of Disease Control and Prevention, National Institutes of Health, Health Resources and Services Administration, Agency for Healthcare Research and Quality, Food and Drug Administration, Center for Medicare and Medicaid Innovation and Patient-Centered Outcomes Research Institute (International.commonwealthfund.org, 2018). The Governance Institute, (2018) is a service under NRC health, provides trustworthy and independent data, resources, tools, and solutions to board members, healthcare professionals, healthcare leaders to support their efforts towards leadership and governance of the healthcare organizations.

In Canada, organization, healthcare service delivery, and supervision of providers are done by the provincial and territorial governments, often through regional health authorities. These authorities are responsible for the provision of funding, and delivery of hospital based, community based or long term care, apart from mental and public health services, in adherence to the Canada Health Act (1985). The services generally covered by the federal contributions include physicians, diagnostic costs, and hospital expenses (like inpatient prescriptions). Additional benefits like outpatient prescription costs, non physician mental healthcare, vision care, dental care, home care, hospice services are also covered by the territorial and provincial governments. Out of pocket expense is not applicable for insured physician, diagnostic and hospital service, and covers 21% for prescription drugs, 22% for long term care, 16% for dental care, 9% for vision care and 10% for over the counter medicines (international.commonwealthfund.org, 2018).

In Singapore, as of 2015, the maternal mortality rate was estimated to be about 4.8 (per 100,000 live births), dropping from 7.1 on 2014, however showing a rise since 2013 and 2014 at 2.5 and 2.4 respectively (Data.gov.sg, 2018).

Maternal mortality rate in the US is at 26.4 (per 100,000 live births), as of 2015, which places it above UK, Portugal, Germany, France, Canada, Netherlands, Spain, Australia, Ireland, Sweden, Italy, Denmark and Finland. The mortality rate is about 3 times that of UK, and has seen a constant growth from 2000 which had a maternal mortality rate of about 15.

In Canada, the maternal mortality rate as of 2015 was 7 (per 100,000 live births), that showed a slight drop from 2010 that had a mortality rate of 8, and 2005 with a rate of 9 (Who.int, 2018).

Infant mortality rate

In Singapore, as of 2016, the infant mortality rate was estimated to be 2.4 (per 1000 resident life births, with the mortality rate of males at 2.3, females at 2.5, neonates at 1.4, and 2.7 for mortality under the age of 5 years. The infant mortality rate has increased since 2015 (at 1.7 for both male and female, 2.2 for male and 1.2 for female) (Data.gov.sg., 2018).

Infant Mortality Rate

Infant mortality rate in US was about 5.9 (per 1,000 live births) in 2015 (amounting to about 23,000 deaths), with the southern states having the highest number of deaths. Also, the infant mortality rates were higher among Non-Hispanic black (11.3), followed by American Indian and Alaskan Notices (8.3) (Cdc.gov., 2018).

In Canada, the infant mortality rate as of 2015 was estimated at 4.5 (per 1000 live births, and have shown a slow decline since 2000 (that showed a mortality rate of 5.2) (Data.worldbank.org, 2018).

As of 2015, the estimated life expectancy of Singaporeans was estimated to be 80 years for male, and 86 years for female (Singapore, 2018). While life expectancy at birth for Canadians was estimated to be 80 for male and 84 for female (Canada., 2018). For US, the life expectancy at birth was estimated to be 77 for male and 82 for female (United States of America., 2018). This shows Singapore having better average life expectancy, compared to US and Canada (Life expectancy of females). This is a key indicator of health among Singaporeans.

According to WHO, the percentage of low birth weight in Singapore was 10%, as of 2011, amounting to about 5 in number per 1,000 babies. United States has a lesser percentage of low birth weight incident at 8% (as of 2010), while for Canada, it was 6 (as of 2011) (Data.unicef.org, 2014). This shows that Canada has a better birth weight ratio, compared to US and Singapore, which has the highest birth weight ratio.

Obesity is a condition characterized by a Body Mass Index higher than 30. WHO estimates that the worldwide prevalence of obesity have almost doubled since 1980, and as of 2014, 11% of men and 15% of women above 18 are obese (Apps.who.int, 2014). Singapore, as of 2014 had an obesity rate of 5.4 (4.8 for males and 6.1 for females) for citizens above 18 years. In comparison, United States has an overall obesity rate of 32.4 (30.8 for males and 34.0 for females), and for Canada, the obesity rates are 25.9 (24.6 for males and 27.2 for females) (Who.int., 2016). This shows a much lower incidence of obesity among Singaporeans, compared to Americans and Canadians.

The Global prevalence of Diabetes in 2014 was estimated by WHO to be at 9%, contributing to 4% of death due to non communicable diseases. In Singapore, as of 2014, WHO estimates shows diabetes 9.8% (11.7% for males and 7.9% for females). For US, is estimate to be 8.4% (9.4% for males and 7.5% for females) and for Canada it was 7.1% (8.1% for males and 6.1% for females) (GLOBAL STATUS REPORT on no communicable diseases, 2014). As per reports, Singapore has one of the highest number of diabetes in the world (Nlb.gov.sg, 2018).

Life Expectancy at Birth

Reports suggest about 300million people suffering from Asthma globally as of 2007 (Aaaai.org, 2018).In Singapore, the number of death due to asthma and chronic respiratory disease (CPD) was 19.5 for males and 5.8 for females, per 100,000 individuals of the population. For United States, the rate was 43.1 for males and 32.8 for females, while for Canada, it was 28.0 for males and 18.6 for females per 100,000 populations (Apps.who.int, 2014).

Hypertension is characterized by a systolic blood pressure above 140, and diastolic blood pressure above 90. The prevalence of Hypertension or high blood pressure among Singaporeans, as of 2014 was estimated by WHO to be at 17.7% with 20.8% for males and 14.6% for females. While for US, the rate was estimated at 18.1%, with 19.7% for males and 16.5% for females, and for Canada it was  15.1% with 17.9% for males and 12.4% for females, (Apps.who.int, 2014). This shows Singapore has more prevalence of hypertension compared to Canada, but lesser then US (Apps.who.int, 2014).

Number of deaths due to cancer among Singaporeans in 2014, was estimated at 127.1 for males and 86.0 for females, per 100,000 individuals of the population. For US, the mortality due to cancer was 143.6 for males and 104.2 for females (per 100,000 population), and for Canada, it was 138.9 for males and 104.0 for females (Apps.who.int, 2014).

In Singapore, quality of healthcare is maintained by Singapore Ministry of Health, apart from setting policy directions, managing the healthcare system and its responsiveness to the needs of its citizens. They are also involved in the assessments of healthcare needs, planning of healthcare services, healthcare personnel planning, governance and financing of healthcare systems, setting up provider fee, cost control, and utilization of health information technology. The regulation is through a system of legislation and enforcements (International.commonwealthfund.org, 2018).

In the US, the Department of Health and Human Service maintains the quality of healthcare system through the National Quality Strategy, which is a component of the Affordable Care Act (ACA). The policy enables reporting of provider performance data, like hospital compare service that compares the data of more than 4,000 hospitals, across aspects like care process and outcomes and patient experience, which promotes transparency and quality of care. Additionally, consumer led groups like Consumer’s Union and Leapfrog group also monitor quality and safety (International.commonwealthfund.org, 2018).

Canadian Medical Association, provincial regulatory colleges, is responsible for licensing healthcare professionals as well as the development and enforcement of standards of healthcare practice. Additionally, providers are also self governed under provincial and territorial legislatures, which ensures quality of healthcare, apart from the training and education of healthcare professionals, and maintenance of standards of care. Agencies are also there in many provinces that monitor and reports healthcare system performance, the data of which can be used to monitor and improve the quality.

Healthcare System Governance in Singapore

Safety in healthcare in Singapore is managed through SafetyNet that is aimed to support the needy and poor. Professional bodies like Medical Council, Dental Council, Nursing Board, Pharmacy Council, regulates and manages safety, quality and efficacy, through a set of guidelines, code of ethics and conduct, while Health Sciences Authority regulates the manufacture, import, supply, presentation and advertisement of healthcare products, ensuring that they meet the international standards of quality and safety (International.commonwealthfund.org, 2018).

In the US, SafetyNet ensures healthcare for the uninsured, poor and vulnerable patients through a network of public hospitals, local health department, free clinic and Medicaid. The Centers Of Disease Control and Prevention researches on public health and safety. Agency for Healthcare Research and Quality utilizes evidenced based research practices to ensure safety. Additionally, public reporting services and Consumer led groups also monitors and reports quality and safety (International.commonwealthfund.org, 2018).

In Canada, efficacy and safety of medical devices, pharmaceuticals, health products, health research, are regulated by the Federal Government. Different provinces and territories also have different policies regarding the providence of Safety Net for the uninsured. The federal ministry of health, Canadian Patient Safety Institute additionally monitors the safety of healthcare, and develops strategies and tools to maintain the standards of safety ( international.commonwealthfund.org, 2018).

Conclusion:

With a comparative overview of the health performance indicators of Singapore, USA and Canada, it can be understood that Singapore provides an affordable care for its citizens. However, the comparison shows that US and Canadian Governments spends the highest percent of its GDP, and investment per capita towards healthcare. In Singapore, the citizens are still required to pay for two thirds of their healthcare costs. It can be suggestible therefore to increase the funding and investment on healthcare by the Singapore government. However, it can also be seen that Singapore has a better performance across population health indicators, showing the lowest incidence of maternal mortality, infant mortality and a higher average life expectancy, compared to US and Canada, which highlights the efficiency of Singapore’s healthcare systems, making it one of the best among the developed countries. However, the prevalence of low birth weight, Diabetes and Hypertension for Singapore is still higher than Canada or US, while the prevelance of Obesity, Cancer and Asthma is comparatively lower. This points out the key health conditions (like Diabetes and Hypertension) that needs to be addressed, and its prevelance further reduced to improved the health of the population as well as fostering further improvement in the healthcare system of Singapore.

Healthcare System Governance in United States

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