now has a First-World healthcare system, rated sixth in the world by the World Health Organization and ahead of most high-income economies.1 By most common measures, the nation has achieved noteworthy outcomes in all areas of healthcare. It has increased the life expectancy of its citizens; increased infant survival rates, and achieved one of the lowest under-five mortality rates in the world. Singapore's cancer survival rates are similar to Europe's, while its cardiovascular disease death rate is half that of the rest of the Asia Pacific region. As I will show throughout this chapter, Singapore produces world-class outcomes on par with the most-developed nations of the world, but it does so at a fraction of the cost usually associated with high-quality care.
A quick look at cost comparisons with other nations brings the point home. Countries like the United States and the United Kingdom struggle with the budget-busting, ever-rising cost increases of providing care. The United States, for example, spends almost 18 percent of GDP on healthcare. Singapore, on the other hand, spends slightly under four percent of GDP. The government's expenditure for healthcare has been slightly under one percent, far less than other most developed countries. It is, however, beginning to break the one percent barrier, coming in at just under 1.5 percent in 2010.2
I would like to begin our exploration of the Singapore healthcare system's achievements with a close-up look at some representative outcomes (see Table 2.1), how they have improved over the years, and how they compare with other nations in the region and around the world.
Table 2.1
Life Expectancy
The number of years we may be expected to live is of utmost interest to all of us, and is a key measure of the efficacy of a nation's healthcare system. A Singaporean woman can now expect to live until 84, versus 66 in 1960. Singaporean men also live longer—up to 79 years, versus 62 in 1960. This enhancement of life is a direct result of the quality of healthcare services, but the system must share some credit with the improved standard of living, improved sanitation, good quality water, and a cleaner environment. Such improvements were part of a well-thought-out effort to raise the quality of health of all Singaporeans.
Singaporeans now live two to three years longer than the citizens of the UK and the US. They also live longer than inhabitants of other high-income economies, with the exception of Japan and Hong Kong, where life expectancy is up to 83 years.
In the Asia Pacific region, there is a dramatic divide among nations. On one side are countries like Japan, Singapore, Hong Kong, and Australia where people live beyond 80 years, and on the other are lower-middle-income countries where citizens can only expect a lifespan of about 70 years. Then there is the case of India, where the numbers are even less promising, with men living until 63, women to 66 (see Table 2.2).
Newborn and Infant Mortality
Another key measure of the success of Singapore's healthcare initiatives is the vastly improved survival rate among newborns and infants. A number of factors affect infant mortality, such as health of the mother, maternal care, and birth weight.
The newborn mortality rate per 1,000 live births in Singapore declined from five in the 1990s to just one in 2009. The United Kingdom, Australia, and Canada had the same mortality rate of five in the 1990s, but by 2009 had declined to three in the United Kingdom and Australia, and four in Canada. In the United States, the rate stands at four. Singapore's infant mortality rate (the probability of dying in the first year per 1,000 live births) has fallen from 36 in 1960 to just over two in 2009; a decrease of almost 94 percent in just under 50 years. Aside from Japan among the high-income economies, Singapore has the lowest neonatal and infant mortality rate for both sexes. Over the past 20 years, the upper-middle and lower-middle-income economies throughout Asia have achieved major reductions in infant mortality rates, but they still remain very high—50 for example, in India, 30 in Indonesia, 17 in China, and 12 in Vietnam (see Table 2.3).
Maternal mortality rates have also declined precipitously, from 86 deaths in 1950 to 12 deaths in 1975, to 3 in 2008.
Table 2.2
Table 2.3
Under-Five Mortality Rate
This measure is an indication of the probability of dying by age five per 1,000 live births, and Singapore has achieved one of the lowest rates in the world. With ten deaths among men and eight among women in 1990, Singapore's current rate is three for men and two for women. Japan's numbers are similar, whereas the United States stands at eight for men and seven for women. The United Kingdom is at six for men and five for women. Under-five death rates are generally lower for women, even in the upper-middle and lower-middle-income countries with the exception of China and India. Within some countries, the disparities based on income are very large. For example, in India, children in the poorest 20 percent of the population are three times more likely to die before turning five as those in the richest 20 percent (see Table 2.4).
Childhood Diseases
Through the National Childhood Immunisation Programme, most childhood diseases have declined, with diphtheria, neonatal tetanus, poliomyelitis and congenital rubella virtually eliminated.3
Adult Mortality Rate
Singapore's adult mortality rate (defined as the probability of dying between the ages of 15 and 60 per 1,000 population) is significantly lower than the rest of Southeast Asia and even lower than developed countries. The rate has halved since 1990 and now stands at just under 60. The United States, by contrast, is just over 100 and Australia just over 60. Among the nations of Southeast Asia, there are very large variations in the rate—much greater than that observed for child mortality. Very high rates include India and Thailand at about 200 and China well over 100 (see Table 2.5).
Number of Physicians and Hospital Beds
Singapore performs well on other health indicators related to system infrastructure, including hospital beds available and physicians serving the population. A common measure of both is the number of beds or number of physicians (physician density) per 10,000 population. Another and perhaps more accurate way to find the ratio is to use the total number of beds in the acute sector in 2011 while excluding those in the Community Hospitals and the Chronic Sick Hospitals. Dividing the acute sector beds by the total Singapore population, we find a 1 bed-to-10,000-population ratio of about 20. Other developed countries have similar numbers, but Japan stands out with an extraordinary 140 beds. For Singapore, these numbers are derived from taking the total number of beds, including Community Hospital and Chronic Sick Hospital beds, and dividing by the resident population of Singapore, resulting in a 1 bed-to-10,000-population ratio of about 30.
Table 2.4
Table 2.5
Singapore is home to over 9,000 doctors according to the Singapore Medical Council, scoring a physician density rate of just over 18—higher than China, Malaysia, Thailand, and most other countries in the region, but behind the US and other high-income economies (see Table 2.6).
The number of physicians and hospital beds in the Singapore system is purposely kept in check to avoid oversupply and the too-easy availability of doctors or of