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SINGAPORE Public hospital funding is derived from a block budget. Part of the budget is based on Casemix, which classifies medical conditions based on diagnosis-related groups. Hospitals can reallocate savings from the block budget to develop other aspects of public health care services. The block budgets are reviewed every three to five years to ensure that subvention models keep up with changes in models of care and hospital operations. In addition to the block grants, government funds are available for manpower training and research. Wards in Singapore’s public hospitals are tiered in four main classes, according to level of amenities. Patients in the highest-class wards are treated as private patients and therefore not subsidized. Patients in the other classes receive varying subsidies depending on the choice of ward and means-testing levels. The private sector provides about 20 percent of secondary and tertiary care services. Raffles Medical Group and Parkway Health are two of the main private hospital groups; they generally offer faster service and more amenities, and are also more involved in medical tourism, than public facilities do. The public sector has begun renting private hospitals’ spare capacity to treat subsidized patients, as private hospitals currently have more beds available. Mental health care: Health care and social service agencies involved in mental health care are guided by the National Mental Health Blueprint of 2007, and provide integrated services such as education and prevention, early detection, and treatment for at-risk individuals or people facing emotional difficulties. The blueprint laid the groundwork for a network of care and support systems that will enable integrated community living. The Institute of Mental Health is Singapore’s only acute tertiary psychiatric hospital. It provides psychiatric, rehabilitative, and counseling services for children, adolescents, adults, and the elderly, as well as long-term care and forensic services. Patients with addictions can be treated in the Institute’s National Addictions Management Services unit. General and specialized treatment services for eating, sleep, and addictions disorders, and for geriatric psychiatry, are also offered at a number of public hospitals. To cope with projected increase in demand for mental health care and to improve accessibility, the National Mental Health Blueprint calls for more community-based mental health services, led mainly by tertiary facilities. Components of the program include multidisciplinary shared-care teams operating in service networks in the community; support for caregivers; community safety networks for people with dementia and depression and their caregivers; and general practitioner training and support for the care and management of people with mental illnesses. There are also community-based mental health programs targeting youth, adults, and the elderly. Most cases requiring residential care or a transition period, with close supervision provided by the Institute of Mental Health and by two voluntary welfare organizations (Singapore Association for Mental Health and Singapore Anglican Community Services). Long-term care and social supports: Management of long-term care services for the elderly is provided by voluntary welfare organizations and private operators. Services are financed in a number of ways, including direct payment by individuals and families, direct government subsidy to patients through providers, and capital and recurrent funding for intermediate and long-term care providers to provide means-tested, subsidized care. ElderShield, a long-term care insurance program regulated by the government but run through designated private insurers, is also available. ElderShield makes monthly direct cash payouts to those who can no longer take care of themselves. These payouts are intended to be setting-neutral, so that families and seniors can choose the type of care that best suits their needs. Eligible care includes nursing home, facility-based, and home-based health care, including hospice care. Financial support is available for informal and family caregivers. The Agency for Integrated Care administers the Caregivers Training Grant that provides an annual SGD200 (USD228) subsidy to attend approved training courses in caring for elderly or persons with disability. The grant is allocated per care recipient, not per caregiver. Care recipients must be Singaporeans or permanent residents age 65 or older or with disability. The Foreign Domestic Worker Grant, a monthly grant of SGD120 (USD137) for hiring a foreign domestic worker to care for the frail elderly or for an individual with at least moderate disability, is also available through the Agency for Integrated Care. Eligibility requires a maximum household monthly income of SGD2,600 (USD2,965) (Ministry of Health, 2013). 146 The Commonwealth Fund
What are the key entities for health system governance? SINGAPORE Organization and planning: Singapore’s Ministry of Health has overall responsibility for health care, setting policy direction and managing the public health care system. Its responsibilities include needs assessment, services planning, manpower planning, system governance and financing, provider fee-setting, cost control, and health information technology, with an overall goal of ensuring quality of care and responsiveness to Singaporeans’ needs. Regulation: The Ministry of Health regulates the health system through legislation and enforcement. Among the its core regulatory functions are licensing health care institutions under the Private Hospitals and Medical Clinics Act and conducting regular inspections and audits. Advertising is subject to monitoring and analysis to identify potential problems, which can lead to compliance audits and prosecutions in some cases. Marketing by licensed facilities is also regulated in order to safeguard the public against false or unsubstantiated claims and to prevent inducements to using nonessential services, such as aesthetic medicine. Professional bodies, including the Singapore Medical Council, Singapore Dental Council, Singapore Nursing Board, and Singapore Pharmacy Board, regulate professionals through practice guidelines and codes of ethics and conduct. The Ministry of Health also engages these bodies to explain policy rationale and to garner support for various initiatives. The Health Sciences Authority regulates the manufacture, import, supply, presentation, and advertisement of health products, including conventional medicines, complementary medicines (traditional medicine and health supplements), cosmetic products, medical devices, tobacco products, and medicinal therapies for clinical trials. Its mission is to ensure that all these products meet internationally benchmarked standards of safety, quality, and efficacy. The insurance industry is regulated by the Monetary Authority of Singapore as part of its financial regulatory role. Organization of the Health System in Singapore The Ministry of Health Statutory Boards Healthcare Institutions Singapore Medical Council Singapore Dental Council Singapore Nursing Board Singapore Pharmacy Council MOH Holdings Pte Ltd Public Hospital Clusters Private Hospitals and Providers Traditional Chinese Medicine Practitioners Board Optometrists and Opticians Board Health Sciences Authority Allied Health Professions Council Source: Adapted from Singapore Ministry of Health website. International Profiles of Health Care Systems, 2015 147
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JANUARY 2016 2015 International Pro
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2015 International Profiles of Heal
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Table 1. Health Care System Financi
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Table 3. Selected Health System Per
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The Australian Health Care System,
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AUSTRALIA low-income adults, childr
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AUSTRALIA In 2013, the federal gove
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What is being done to reduce dispar
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References AUSTRALIA Australian Bur
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CANADA What is covered? Services: T
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CANADA funding to 145 not-for-profi
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CANADA Organization of the Health S
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CANADA provides recommendations to
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CANADA Health Council of Canada (20
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CHINA Private health insurance: Com
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CHINA is not substantially more exp
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CHINA Organization of the Health Sy
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CHINA References Chen, X. (2014).
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DENMARK In addition, nearly 1.5 mil
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DENMARK Social psychiatry and care
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DENMARK Quality data for a number o
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DENMARK portion is small, it makes
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ENGLAND immunization, and vaccinati
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ENGLAND Hospitals: Publicly owned h
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ENGLAND Organization of the Health
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ENGLAND How are costs contained? Ra
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ENGLAND Organisation for Economic C
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FRANCE VHI finances 13.8 percent of
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FRANCE The average income of primar
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FRANCE What are the key entities fo
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FRANCE inequities in prevention rel
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FRANCE Nolte, E., C. Knai, and M. M
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GERMANY There were 42 substitutive
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GERMANY The 16 state governments de
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GERMANY management system, by the s
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GERMANY What major innovations and
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INDIA Private health insurance: The
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INDIA provide after-hour care, reim
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INDIA are provided by other ministr
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INDIA How are costs contained? Ther
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ISRAEL Together, these two types of
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ISRAEL Primary care physicians are
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ISRAEL Organization of the Health S
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ISRAEL • Using electronic health
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Page 98 and 99: ITALY during hospitalization (Thoms
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Page 102 and 103: ITALY Organization of the Health Sy
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Page 108 and 109: JAPAN What is covered? Services: Al
Page 110 and 111: JAPAN incentives for providers to c
Page 112 and 113: JAPAN Organization of the Health Sy
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Page 116 and 117: THE NETHERLANDS receive faster acce
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Page 120 and 121: THE NETHERLANDS Organization of the
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Page 126 and 127: NEW ZEALAND management (e.g., clean
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Page 134 and 135: NORWAY Primary, preventive, and nur
Page 136 and 137: NORWAY Patients are free to choose
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Page 144 and 145: SINGAPORE Medifund is the governmen
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Page 162 and 163: SWITZERLAND Insurers offer premiums
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Page 172 and 173: UNITED STATES What is covered? Serv
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