March Musings

On the day after the Budget was delivered by the Finance Minister (19 Feb 2022), an important infographic appeared in The Straits Times. It showed something that this hobbit didn’t think he will see in this lifetime.

It showed that MOH now had the biggest budget in the government – S$19.29B, even higher than MINDEF, which traditionally had the biggest budget all these years. For the coming government Financial Year, MINDEF’s budget was $16.36B. In third place was Ministry of Education (MOE) at $13.6B. Traditionally, MINDEF and MOE always had the biggest and second biggest budgets in government.

MOH’s budget is going to grow by 4.7% from last year and takes up 18.8% of Total Expenditure (estimated to be $102.41B). This $102.41B is carved up by 15 ministries as well as Organs of State and the Prime Minister’s Office making a total of 17 buckets. But MOH’s bucket alone takes up 18.8%, almost a fifth of total expenditure.

One can say that well, we are in the middle of a pandemic and everyone is spending a lot on health, which is true. But there is no denying that even without the pandemic, MOH budgets over that 15 years or so have been growing very quickly. In 2007, government healthcare expenditure was 2.283B1; by 2019 (the last year before Covid-19 struck) this had risen to 11.147B. In other words, between 2007 and 2019, a period of 12 years, government healthcare expenditure grew 4.9 times. Put in the effect of Covid-19 and over a longer period (from 2007 to 2022), government healthcare expenditure is expected to grow by 8.4 times in these 15 years!

Some of this growth along the way can also be attributed to a change in strategy for healthcare funding. In 2013, the government decided to raise its share of total healthcare expenditure from 30% to 40%, which was the correct thing to do as the population aged rapidly.

So it is of little surprise that the Health Minister announced MOH’s strategy for the next 10 years in this year’s Budget – Healthier SG

He outlined the five pillars of Healthier SG –

  • Activate Family Physicians (FP) Networks – Everyone should have a FP
  • Everyone Should Have a Care Plan with heavy emphasis on prevention
  • Community Partnerships
  • And if the above three are in place, then everyone can take part in a National Healthier SG Enrolment Programme
  • Structures and policies to support healthcare reform, e.g. Manpower, IT, Finance

A White Paper will be presented in Parliament to debate Healthier SG. The need for Healthier SG can be reduced to two main factors – a fast ageing population, as well as a population that is getting unhealthier. To underscore this second point, he said pithily in Mandarin, “what should be high is not high, and what should be low is not low”. (Somehow when this is said in English, there’s no kick)

Also indicated in not so big print is that with the National Healthier SG Enrol Programme, capitation can be explored and that each cluster can enrol up to 1.5M patients.

Chope. Wait. Tunggu. 等。

Capitation. A four syllable word that can trigger some serious action potentials in many a doctor’s neurons.

It would seem we are moving from paying for workload to capitation. And we have heard some horror stories about capitation from overseas examples. These would include, just to name a few:

  • Hospitals avoiding expensive, complicated cases and pushing the work to other providers. For example, how would national specialty centres be funded for the management of complicated cases and provision of tertiary care?
  • Hospitals running out of money before the funding cycle is up. For example in some places, when there is no more money, public hospitals then stop total knee reconstruction surgeries in the last two to three months of the year.
  • Insufficient funding for cutting edge medicine as hospitals thereby leading to erosion of excellence.
  • While clusters are paid by capitation, how would healthcare workers, especially specialists be paid? Will they be incentivised to see more patients or not under a capitation system?
  • Will patient choice be limited? Currently, a patient can theoretically go to a NHG Polyclinic in the morning, go to a Specialist Outpatient Clinic in a Singhealth hospital in the afternoon and then to a NUHS Hospital A&E at night. If patient choice is not limited, how will capitation work under such circumstances? Can better efficiencies be realised without limiting patient choice?

These questions are not new and have been asked in other countries that have adopted a capitation financing model. The truth is there are pros and cons, strengths and weaknesses to both capitation and pay-for-volume models. Some have avoided the worst and adopted the best of both models and lived to tell the tale. But not many. How will we fare? This hobbit wishes the best for those policy wonks working in the White Building; the folks that have to come up with the White Paper. Incidentally, the last time MOH has published a While Paper was in 1993: “Affordable Health Care” White Paper. Yup, it’s so long ago “health care” was spelt in two words and not one word, i.e. “healthcare”. Anyone with any memory of contributing to this White Paper in MOH would have taken their CPF or pension by now…

Of particular local interest is how will patients be split among the three clusters. The minister has said that each cluster can enrol up to 1.5M patients. But the truth is one cluster is significantly larger than the other two. How will the work and financing be split?

Putting the issue of capitation aside, this hobbit is most heartened that prevention is put front and centre. It remains to be seen how GPs and Polyclinics will be funded to achieve better disease prevention for all. As we all know, results of these efforts will not manifest early. It may be years before a healthier Singapore materialises. So it is important for politicians and policymakers to stay the course even when early and interim outcomes are not encouraging.

Onto another aspect of the Budget debates. NMP aka SMA President Dr Tan Yia Swam asked what was MOH’s position with regard to managing or regulating Third Party Administrators (TPA). The answer given was “We are monitoring the situation”. Turns out that that was the same answer given 6 years ago to essentially the same question. Ooops. Monitor so long, still monitoring? What has been monitored and what is the outcome of this very long monitoring? Anyway, Dr Tan’s suggestion to this long-term monitoring is that maybe it is time for MOH to be more “proactive” than just monitoring. This hobbit cannot agree more.

Actually to this hobbit, the whole thing is quite simple. When you have a problem, you have to regulate all major parties such they have skin in the regulatory game. Take gambling – you have a regulatory framework that covers the problem gambler, the legal gambling providers, including casinos, Singapore Pools etc and includes punitive and enforcement action against illegal or unlicensed gambling providers as well. Similarly, for smoking, you regulate the folks that import and sell cigarettes and the smokers and even the potential future smokers (i.e. the young adults and teenagers).

But when it comes to TPAs and their commercial arrangements with doctors and their corporate customers, only the doctor is subject to any regulation (through the SMC). It would seem that ONLY doctors have the responsibility and obligation to ensure the system stays ethical and clean. The TPAs have no such responsibility or legal obligation whatsoever. In many regulatory regimes, a good regulatory approach is often cited as “multi-pronged”, “comprehensive” etc. But when it comes to managing TPAs, it is uni-pronged and one-sided – Just regulate the doctors and everything will be fine. That’s wishful thinking isn’t it?

You will NEVER solve the problem with this one-sided approach even if you monitor the situation to kingdom come. In fact, the current TPA milieu may just impede the smooth implementation of programmes and policies that are necessary for a Healthier SG.

Finally, a follow up on the last post “A Tale of Two Cities”. Since that was posted, things have gotten rapidly worse for Hong Kong, unfortunately. How bad?

On 1 March 2022, both places had roughly the same number of Covid-19 deaths. Singapore by then had recorded a cumulative total of 1030 deaths; HK had a total 1013 deaths from public hospitals (according to the Hospital Authority). There are probably more deaths than 1013 since a small number of deaths occurred outside of HK public hospitals, but let’s just stick to a discounted number of 1013 for now.

14 days later, as of 15 March, Singapore has 1153 deaths while HK has recorded a staggering total of 4568 deaths. HK has a population of 7.6M, which is 36% larger than Singapore’s 5.6M. For the purpose of comparison with HK, lets add another 36% to Singapore’s 1153 deaths to give a weighted total of 1568 deaths. In other words, we assume that had Singapore had a population of 7.6m (Similar to HK), it would have recorded a total of 1568 deaths on 15 March 2022.

There is nothing to indicate that HK’s hospitals and doctors and nurses are any inferior to Singapore’s. The age group distribution profiles of the two places are roughly similar. In the period of 14 days, HK has logged an excess of 3000 deaths (4568-1568=3000) over Singapore’s weighted number of 1568 deaths.  That’s an excess of 214 deaths a day over 14 days. This difference can be largely attributed to the fact that they had a much lower vaccination rate for their elderly and for residents of nursing and elderly homes. This point was admitted to by Chief Executive Carrie Lam herself when she said the efforts to get the elderly vaccinated were “not enough” and the vaccination rates for these groups were lower than “China, Singapore and certain European countries” just a few days ago. The difference between vaccination rates for HK and Singapore’s elderly is best represented by the charts in this article2 which in turn was first published in the Financial Times.

Sometimes the human mind cannot quite fathom what exponential growth is. To give an example, on 1 March it was reported in Bloomberg that according to an updated forecast from the Laboratory of Data Discovery for Health and the University of Hong Kong’s WHO Collaborating Centre for Infectious Disease Epidemiology and Control, “the cumulative number of deaths by the end of April (emphasis mine) could be around 4,645″. (Hong Kong’s Covid Death Rate is Now One of the World’s Highest, Bloomberg, 1 March 2022) Well, its the middle of March, and we are already at 4,568.

The hobbit is NOT highlighting the mistakes that HK may have made in their pandemic fight for the sake of making Singapore look good or HK look bad, but rather to make the point to all these rabid anti-vaxxers out there in Singapore (and there are still quite a number lurking around) that had the government and people of Singapore listened to their anti-vaccination rhetoric, then we may well have more than 4000 Covid-19 deaths by now as well. The hobbit derives no joy at all from what is happening to HK, a place he happens to like very much, but unfortunately there are quite a few tragic lessons that HK has in store for us now which we must learn from. Every death is tragic, let alone 3000 excess deaths.

1https://www.moh.gov.sg/resources-statistics/singapore-health-facts/government-health-expenditure-and-healthcare-financing (accessed 12 March, with link to excel spreadsheet)

2https://yourlocalepidemiologist.substack.com/p/state-of-affairs-march-14

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