This article is part of New Naratif’s coverage of the Singapore General election 2020. For more, please visit our Singapore General Election 2020 portal. It was written before the ongoing novel coronavirus crisis.
In 1982, Singapore’s then-Health Minister Goh Chok Tong bravely boasted that his country’s health system was among the “best in the world”. At the same time, he foreshadowed its complete overhaul: “We should not rest on our laurels, looking down from Mount Everest. In organisational efficiency, in the pursuit of quality and excellence, there can be no highest peak.” In February 2004, then-Health Minister Khaw Boon Wan raised the bar for hyperbole, defining his ideal as a healthcare system that has no patients. A month later, he declared his satisfaction that Singapore’s healthcare financing system was “probably” the best in the world.
By its own bold claims, the Singapore government has consciously set itself up as a test case: can the relentless pursuit of “organisational efficiency”, “excellence and quality” solve the problem of the cost of delivering healthcare in a modern capitalist society? This question also goes to a much broader element of the government’s legitimating rationale: its claim that its at times seemingly hard-hearted and overbearing governance reflects the application of dispassionate and disinterested reason, and is the basis of Singapore’s success and prosperity.
Singapore is one of the least democratic of the world’s advanced capitalist societies, a tiny, easily-managed polity run by Western-educated technocrats. This makes it an ideal laboratory for those who believe there is a “logical” answer to the problems of government, including those of providing universal, comprehensive and affordable healthcare in economically advanced societies. Singapore’s ruling elite is wholly convinced that it has achieved these ambitions in all or most aspects of governance, and that it is the epitome of rational rule.
Can the relentless pursuit of “organisational efficiency”, “excellence and quality” solve the problem of the cost of delivering healthcare in a modern capitalist society?
As Prime Minister Lee Hsien Loong announced proudly in March 2005, the government has “shielded civil servants from political interference . . . [giving them] the space to work out rational, effective solutions for our problems” so they can “practise public administration in almost laboratory conditions”. This is the ideal of the technocracy: a Utopian vision of governance that presumes that the system can rise above subjective considerations of politics, ideology and sectional interests, by relying on impartial reason and the technical skills of modern, highly trained professionals. To borrow the prescient words of sociologist Luigi Pellizzoni, in a technocracy “the elite is suitably ‘protected’ against the rest of society and is able to perform its tasks efficiently”. Rule in a technocracy is based on supposed impartial, objective criteria, derived directly or indirectly from disciplines such as economics, management, law, medicine and engineering. In Singapore, systems engineers have a particular place of honour at the upper executive level: a team of them was even entrusted to reform the education system at the end of the 1970s to make it efficient.
Healthcare is at the forefront of the Singapore government’s showcase of technocratic achievements, with ministers pleased that their health system provided a loose inspiration for attempts at healthcare reforms in both China and the USA in past decades. This system was built upon the 1984 introduction of medical savings accounts (MediSave), later supplemented by catastrophic illness insurance (MediShield, replaced in 2015 by MediShield Life) and various additional welfare measures (such as MediFund, ElderShield, the Community Health Assist Scheme (CHAS) and Chronic Disease Management Programme (CDMP)). The entire system is referred to routinely in a semi-official way as the “3Ms”, referring to the central role of Medisave, MediShield and MediFund. In recent years, the government has also announced one-time funding packages (the “Pioneer Generation Package” and “Merdeka Generation Package”) which provide additional funding and subsidies for specific cohorts of older persons only.
This article will: (i) give a brief overview of the substance of the system, (ii) outline the established reasons to doubt some of the more extravagant claims about its achievements; and (iii) interrogate the implications and limitations of the technocratic ethos behind Singapore’s health system.
The Singapore System in Outline
Since Goh Chok Tong’s mid-1980s reforms, the Singapore government has developed an increasingly complex system of healthcare financing. It is based on the principles of personal-plus-family responsibility for costs, enforced by cost-based rationing and high levels of micro-management in healthcare delivery (including draconian measures to restrict the number of doctors trained). There is also a significant level of government subsidy.
Initially, Singapore’s healthcare system was to have no insurance component at all. Insurance was identified as a driver in healthcare consumption, because it increased the “moral hazard”. Avoiding this “moral hazard” has since been identified by Toh Mun Heng and Linda Low as the main philosophical driver of the 3Ms system:
A moral hazard problem is encountered when payment of medical expenses is borne by a third party, either an insurance company or the government, affecting the individual’s own behaviour. It may lead the individual to overconsume medical services and his doctor to overtreat. It has nothing to do with morality but represents a misallocation of resources by a particular method of finance. Since the third party, be it the government or the insurance company pays the full cost, the individual bears no financial burden or faces a zero price for medical care. Consequently, consumption is greater following the law of demand.
A moral hazard problem is encountered when payment of medical expenses is borne by a third party, either an insurance company or the government, affecting the individual’s own behaviour….It has nothing to do with morality but represents a misallocation of resources by a particular method of finance.
Today, the government runs several interconnected health funding schemes. The core is MediSave. Those in the paid workforce, including the self-employed, must contribute up to 6-8% of wages or salaried income to a special savings account. Those whose accounts have reached an internal cap (from 1 January 2019, S$57,200) can divert their contributions to other special savings accounts (used to fund housing purchases and/or retirement). Members build savings to pay for their own or family members’ health insurance premiums; inpatient and outpatient care; and certain costs associated with long-term care. To protect accounts from being run down, there is a strict schedule of permissible fee payments for medical services and MediSave will not pay above this. This regime excludes many high-cost services that are routinely funded in other developed countries.
Originally, access to government hospitals was to be facilitated by MediSave alone. The government discovered, however, that this provided patients with grossly insufficient coverage. So in 1990 it supplemented MediSave with an insurance scheme after all – but only catastrophic illness insurance, not general medical insurance. This scheme, first called MediShield and replaced in 2015 by MediShield Life, draws premiums from a person’s MediSave account and is designed to cover most of the expenses of treating many major or prolonged illnesses and conditions, up to predetermined caps. Under MediShield (and to a lesser extent MediShield Life), the member had to also pay a very high “deductible” or “co-payment” from their MediSave account, their personal savings, or a combination of both (depending on the rules governing payment for treatment of the particular illness). In 2005, MediShield covered about 89% of the population; now, MediShield Life is mandatory and intended to cover all Singaporeans. MediShield initially covered members to age 75, but this was increased to 80 in 2001 and then to 85 in 2005; finally, in 2015, with MediShield Life, the maximum age was removed altogether.
Next came MediFund, a central endowment fund providing charity-style relief to those too poor to meet any costs. Interest is distributed to public hospitals and charities that allocate assistance on a case-by-case basis. This is supplemented by a growing number of targeted insurance and welfare schemes, such as ElderShield, CHAS and CDMP. None of these is designed to provide comprehensive cover. ElderShield is an insurance plan that provides a modest fixed sum per month for up to 60 months to beneficiaries who suffer severe disability in old age, while the CDMP piggybacks on government polyclinics to provide subsidised long-term healthcare and expanded MediSave access to those suffering from one of 20 specific chronic conditions. CHAS subsidises lower- and middle-income households to access general practitioner and dental care. Charitable organisations are also an institutional part of the health financing structure. Voluntary Welfare Organisations (VWOs), as they are called, receive government aid and MediFund-based financing to assist them, as they care for many who require long-term institutionalised care.
In 2004, the Ministry of Health stated that the financing philosophy of this complex healthcare delivery system is based explicitly on:
. . . individual responsibility, coupled with Government subsidies to keep basic healthcare affordable. Patients are expected to pay part of the cost of medical services which they use, and pay more when they demand a higher level of services. The principle of co-payment applies even to the most heavily subsidised wards to avoid the pitfalls of providing “free” medical services.
The “Singapore system” is a continually evolving effort to reconcile the government’s aversion to welfare with the reality that, for both economic and political reasons, it must ensure the provision of health services to the whole population, including low-income earners and the poor. In fact, the system developed as an explicit reaction to the perceived failures of “social and health welfare” in Europe and the USA – a perception premised more on ideological preconceptions than on empirical data. In November 1981, on the eve of the move to introduce medical savings accounts, then Prime Minister Lee Kuan Yew told a meeting of government MPs:
Subsidies on consumption are wrong and ruinous . . . for however wealthy a nation, it cannot carry health, unemployment and pension benefits without massive taxation and overloading the system, reducing the incentives to work and to save and care for one’s family – when all can look to the state for welfare. . . . Social and health welfare are like opium or heroin. People get addicted, and withdrawal of welfare benefits is very painful.
Thus, Medisave was not a “progressive” attempt to ameliorate the effects of a laissez-faire health system, but a bold attempt to introduce market forces into government-funded healthcare. Under the previous system, hospital care was nearly free and government clinics were subsidised directly. Furthermore, there was no immediate funding problem with the old system. Although per capita costs in simple dollar terms had been increasing by 11% per annum, health costs as a proportion of GDP had been falling steadily since 1960. Even the government’s share of overall health costs had dropped slightly by the early 1980s, being 68% in 1980; down from 70.1% in 1970. This suggests that the introduction of MediSave and hospital fees, along with the use of the rhetoric of self-help and personal responsibility, was an attempt to both meet and restrict rising middle-class expectations, by replacing government regulation with the archetypal middle-class mechanisms of financial constraint and self-regulation. If it worked, then managed self-regulation would provide a sustainable basis for curtailing health costs into the long term.
The “Singapore system” is a continually evolving effort to reconcile the government’s aversion to welfare with the reality that, for both economic and political reasons, it must ensure the provision of health services to the whole population, including low-income earners and the poor.
The rhetoric of self-help and personal responsibility that permeates public discussion suggests that these systems are self-sustaining. Yet in fact, none of them could function without government micro-management and subsidies. The government continues to subsidise hospital wards (up to 81% of costs) even after it ensures that public hospital charges are kept down. Furthermore the entire system of polyclinics operates on direct government subsidies without drawing on the 3Ms at all.
The most expensive section of any modern healthcare system is hospitals, so the core of the 1984 reforms is found in this sector. As early as May 1981, the government announcement that it intended to reduce “subsidies” to hospitals and polyclinics. This was followed by overt government efforts to encourage the establishment of private hospitals, and across-the-board increases in hospital fees. The expansion of expensive private hospitals at the expense of subsidised public hospital wards seems to have been an attempt to take advantage of the perception that Singaporeans had turned a socio-economic corner, and become a wealthy, bourgeois society. At the same time, parallel “privatisation” moves in the school sector in the late 1980s, in the pursuit of “excellence”, suggests that the “privatisation” of health was merely one aspect of a much broader push.
Regardless of motivation, these moves reached their logical conclusion in May 1984, when the government announced that government hospitals would move towards privatisation. Ownership would not change, but they would be run as private enterprises: collecting fees for services, relying less on government “subsidies”, competing for business, balancing their budgets and relying in part on profitable private patients (who pay their full treatment and accommodations costs) to provide income to subsidise public patients. The National University Hospital (NUH) was restructured in 1987, followed by the National Skin Centre in 1988 and the Singapore General Hospital in 1989. American consultants were duly engaged and the “privatisation”/”restructuring” programme continued into the 1990s, although it stopped a long way short of including all government hospitals.
The NUH provided the model: it was broken down into 50 cost centres that had to pay their own way. Toh Mun Heng and Linda Low in 1991 observed that:
The “privatisation” exercise at NUH is said to have provided new and more personalised services, promoted staff motivation, deployed nurses more effectively, and enabled greater financial accountability, among other advantages. . . . Doctors are made more circumspect when requesting certain tests which indirectly keeps the cost to patients under control, too.
Yet this rosy view was balanced by some strong criticisms that questioned the value of the entire enterprise:
On the other hand, charges in the NUH have increased …. Government subsidies have not remained at the same level over the years. . . . There is no concerted effort to contain costs with measures aimed at the supply side, such as physicians’ earnings and mode of practice.
These authors observed that the “benefits of ‘privatisation’ of the NUH are difficult to prove or refute given the paucity of information and financial data [released by the government and NUH]”. In terms of public accountability, nothing much has changed since this assessment. There is still no reliable basis for judging the strengths and weaknesses of the overall “privatisation” programme.
On the other hand, charges in the NUH have increased …. Government subsidies have not remained at the same level over the years. . . . There is no concerted effort to contain costs with measures aimed at the supply side, such as physicians’ earnings and mode of practice.
In 1999, the government restructured public hospitals into two regional clusters, the National Healthcare Group and Singapore Health Services. Each comprised one of Singapore’s two major tertiary hospitals, as well as general hospitals, a number of specialist centres and institutes (such as the National Cancer Centre), and government polyclinics. In 2015, all public hospitals and polyclinics were reorganised as six regional clusters, and in 2017 came the announcement that those six would be further reorganised into three. The government believes that by micro-managing both demand and supply, it can make the system efficient and cost-effective, minimising waste and maximising service delivery.
Implicit in government control of inputs and the introduction of “business” principles to health management is the principle of rationing health services based on wealth. The 1993 White Paper on Health stated this without voicing the criteria of wealth:
We cannot avoid rationing medical care, implicitly or explicitly. Funding for healthcare will always be finite. There will always be competing demands for resources, whether the resources come from the State or the individual citizens. Using the latest in medical technology is expensive. Trade-offs among different areas of medical treatments, equipment, training and research are unavoidable.
The “Singapore system” is thus a continually evolving effort to reconcile the conflicting demands in the government’s ideological, economic and political agendas. Regardless of any other criticisms, it should be acknowledged that Singapore runs a modern, effective health system that in 2004 absorbed only 3.63% of GDP and 7.4% of government expenditure. The government and many others attribute its success primarily to the 3Ms, with perhaps the strongest claim coming from the previous Minister for Health Khaw Boon Wan, who told Parliament in 2004 that “our 3M framework is far from perfect, but it is probably the best healthcare financing model in the world today.”
Established criticisms of the 3M system
Critical scrutiny of this system is not as straightforward as one might expect. Even the simple claim of having kept health expenditure low is difficult to verify, because the Singapore government does not follow Organization for Economic Co-operation and Development (OECD) standards in measuring health expenditure, making international comparisons extremely difficult. Furthermore, the government is highly secretive about the detailed operation of its system, and has made neither the data source nor method of its calculations available outside the civil service and the government. So, although one can say safely that expenditure is low by Western standards, it may well be higher than the government’s published figures suggest.
The varying exclusions from the 3Ms system also makes it difficult to establish a meaningful standard of international comparison. By way of comparison, MediShield excluded most of the services identified as major drains on hospital budgets in the Australian health system at the end of the 1990s: cardiovascular disease, control of cancer, care involving dialysis, and care related to the treatment of HIV, mental health and diabetes. The insurance coverage of the 3Ms has since been expanded in incremental steps, though it still avoids many of the commitments of the Australian and other Western health systems.
The government is highly secretive about the detailed operation of its system, and has made neither the data source nor method of its calculations available outside the civil service and the government.
The burden on the Singapore health system was also initially lightened drastically by the extraordinary youth of the society. The government now acknowledges this in the context of discussions about future challenges. In 1991, 6.2% of Singapore’s population was aged 65 or over, as opposed to proportions between 10.9% and 15.4% for the USA, Canada, UK, Australia, New Zealand and West Germany. As of June 2018, official government statistics put the percentage of the population aged 65 and above at 15.2%. This is a serious concern for the government: in 1996, the aged of Singapore (65 and over) were admitted to hospital at 2.8 times the frequency of their younger counterparts, and stayed in hospital an average of 1.66 times as long. They were also higher consumers of the two most heavily subsidised classes of ward.Thus, an increase in the proportion of the aged will inevitably increase demand for health services.
Despite the government’s avowed intention to reduce health expenditure, and its routine claims to have contained costs, it seems that the introduction of Medisave in 1984 did not reduce or even contain health expenditure. In fact, immediately following this introduction, the rate of increase in health expenditure per capita jumped from 11% to 13% per annum. The share of GDP absorbed by health expenditure also increased in the immediate post-MediSave period, due largely to a sudden increase in expenditure on doctors’ fees and the purchase of new technology as hospitals competed with each other for business and reputation in the new fee-paying environment.
Certainly, the Singapore health system has delivered impressive statistics in terms of some major health indicators, notably longevity and infant mortality. The World Health Organisation has ranked Singapore as number one in the world in for Healthy Life Expectancy – meaning that the days of its demographic advantage are coming to an end and it will struggle to keep costs under control. There can be no doubt that Singapore has succeeded in delivering world class health services, but its problem now is that the cost of delivery is no longer so low that it stands out from its peers. In 2016 its cost per person (in US$) was catching up with the average in the European Union ($3,211.40 for the EU; $2,462.39 for Singapore). It is only in comparison with very high expenditure countries like the US and Australia that Singapore’s health expenditure now looks impressively low.
Singapore’s healthcare as a test case for technocracy
These well-established critiques make it clear that the more extravagant claims made by Singapore’s leadership must be treated with a healthy dose of scepticism. Nevertheless, the system remains, on the face of it, impressive. Endemic crises and shortcomings do beset other health systems in advanced democratic societies – crises that seem to be routine in the various states of Australia, for example. One could be forgiven for thinking that perhaps the Singapore system is still an exemplar of technocratic methodology, despite some exaggerations by its advocates.
After all, the technocratic methodology does not guarantee absolute perfection, but just a striving towards perfection based on the constant application of rationality and logic. The Prime Minister encapsulated this in April 2004, when he told an audience of tertiary students that they must not be content to inherit and enjoy the Singapore built by their parents and grandparents. Instead he asked them to “change it, improve it and build on it”. Several months later he delivered a similar message at the National Day Rally:
We can never afford to be satisfied with the status quo, even if we are still okay, even if our policies are still working. People say, “If it ain’t broke, don’t fix it”. I say, if it ain’t broke, better maintain it, lubricate it, replace it, upgrade it, try something better and make it work better than before.
To see this spirit in the administration of the health system, in particular, calls for a return to Goh Chok Tong’s 1982 speech:
We have a hospital service that we can be proud of. It stands up to comparison with the best in the world. But having said that, I hasten to add that we should not rest on our laurels, looking down from Mount Everest. In organisational efficiency, in the pursuit of quality and excellence, there can be no highest peak. It is not like Mount Everest which you can climb and plant a flag and proclaim you have reached the peak. Of course, climbing Mount Everest is in itself a great achievement, as only a few can reach that height. But this organisational mountain of ours is even higher than Mount Everest. It is so high that even at 20,000 feet you cannot see the peak, even on a clear day.
People say, “If it ain’t broke, don’t fix it”. I say, if it ain’t broke, better maintain it, lubricate it, replace it, upgrade it, try something better and make it work better than before
Goh indicated with this hyperbole that the subsequent reform was going to be an ongoing quixotic quest for perfection – and indeed the system has, since 1982, been a continually evolving project in which the “summit” of perfection always seems to be just out of sight even though it is always said to be getting closer.
What was the relationship between “organisational efficiency” and “quality and excellence” in this speech? Goh might have been calling for “efficiency” and “quality and excellence” equally, but these two ideals potentially and routinely stand in opposition to each other in healthcare, as in most aspects of life and business. Alternatively, this sentence can be reasonably read as defining “quality and excellence” in terms of “organisational efficiency”. On this reading, “organisational efficiency” is the master concept by which the system is to be judged.
Prioritising this was, in fact, the deliberate message of Goh’s speech. His reforms, following these principles, turned the Singapore health system into a multi-generational “work in progress”, in which the unending quest for “organisational efficiency” was identified as the primary goal. “Quality” and “excellence” were conceptually and actually subservient: they were, in fact, regarded primarily as outcomes of “efficiency”. This focus on organisational efficiency quickly came to subsume the objective of minimising government expenditure on health. It has shaped the Singapore health system in both positive and negative ways. On the one hand, it has produced an impressive infrastructure that delivers high quality healthcare to most of the population most of the time. On the other hand, the emphasis on systemic perfection breeds an element of blinding hubris that tends to make the system prone to rather spectacular failings.
Further below I argue that the quest for efficient systems has led the Singapore health system to crisis point, potentially putting lives and health at risk. With “efficiency” as a starting point, the government measures “effectiveness” by averages, metrics and the degree to which the wastage of resources is minimised. Hence the government has been inordinately proud of achievements such as Singapore’s ranking as the most cost-effective healthcare system in ASEAN and that its rate of health expenditure is drastically lower than those in countries such as the UK and the USA. These objectives are, of course, worthy in themselves, and the system should be credited with achieving good scores on these measures, but this mindset is prone to create a tunnel vision focused on throughput and average outcomes, which shifts focus from the health system’s core business of patient care and public health.
Impurities in “Technocratic” Approach
Before we consider the negative impact of this approach on health administration and outcomes, it is worth questioning whether the system genuinely exemplifies the claimed technocratic ideal of value-free rationality. In reality, health policy in Singapore is compromised severely by the operation of unevidenced assumptions and prejudices based on socioeconomic class and gender (to name just two areas). It is also affected to a surprising degree by public opinion. These distorting influences are demonstrably at the core of the thinking of the designers of the system.
Assumptions and prejudices. First, why is efficiency prized? It has been suggested that this is due to rational, technocratic discipline. It would, however, be truer to say that the idolisation of efficiency is one unevidenced assumption among many that have actively contributed to the character of the health system. The ideological rejection of “welfare-ism” that originated with Lee Kuan Yew is presented as logical, if unpleasant. But an alternate reading is that the Singapore government, dominated by middle-class politicians and technocrats, was transforming the health system into one that reflected their class’ expectations, by introducing the archetypal middle-class mechanisms of tight financial responsibility, self-regulation, rationing access to services on the basis of wealth, and turning public goods into commercial enterprises. This observation is not merely a viable alternative to the government’s explanation: it can be demonstrated that this reform of the health system was part of a broader pattern of the embourgeoisement of the public services, and reforms in housing and industrial relations that reveal explicitly middle-class societal views and prejudices.
The other public good transformed in this way during the mid-1980s was the education system. Then-Education Minister Tony Tan took for granted that the best students would excel academically in Singapore schools, but according to Eugene Wijeysingha, a civil servant who took instructions directly from Tan, he wanted schools that would build their character and turn them into “gentlemen”. To this end he engaged in what was effectively the gentrification of elite education to parallel the privileging of elite education per se. In 1986, he commissioned a group of 12 secondary school principals, including Wijeysingha, to tour a collection of elite schools in the UK and the USA, apparently to find the best way to implement privatisation initiatives publicly urged by Deputy Prime Minister Goh Chok Tong the previous year. The result was a 76-page report titled ‘Towards Excellence in Schools’, which was substantially implemented over the next few years.
The principals recommended that selected schools be effectively privatised and given both considerable autonomy and extra resources to enable them to offer a better study environment and school experience. The Independent schools were given government grants of S$1 million each to launch their endowment funds and began charging fees that have progressively moved from being nominal in the 1980s to very substantial in the 2000s. Unsurprisingly, these newly created “independent” schools quickly came to be dominated by the children of middle-class and professional parents.
In 1980, it (the government) took steps to ensure that each housing block (in the government-run housing estates in which 67% of the population lived at that time) had a number of middle-class professionals as residents. Lee Kuan Yew stated explicitly that this was so that ordinary people could benefit from “quality community leadership” by these “better education people”.
It stretches credulity to assert that the almost-simultaneous embourgeoisement of both the health and the education systems could have been a coincidence or the result of the independent application of objective “reason”. But these examples are not isolated. Prior to these reforms, the government had already taken other measures that reveal a middle-class bias in its approach to governance. For example, in 1980, it took steps to ensure that each housing block (in the government-run housing estates in which 67% of the population lived at that time) had a number of middle-class professionals as residents. Lee Kuan Yew stated explicitly that this was so that ordinary people could benefit from “quality community leadership” by these “better education people”.
In the field of industrial relations, from the mid-1970s onwards, the trade unions were subject to a parallel incursion of well-educated, middle-class “talent”, whereby professionals (university-trained engineers, etc.) were parachuted into leadership roles in the union movement, coming to dominate the leadership of the National Trades Union Congress and most trade unions during the early 1980s. In 1980, Lee Kuan Yew justified this on the grounds that “the unions must have their quota of talent”. Moreover, the field of industrial relations also saw the introduction of a 12-hour shift for factory workers in the mid-1980s, an initiative that pleased employers unreservedly but showed contemptuous disregard for the health and family lives of factory workers.
Beyond these class-based factors, further evidence of the distortion of reason and logic in the Ministry of Health could be found in the restrictive cap on the number of female candidates allowed into the local medical school. This was imposed in 1979 and lifted only at the end of 2002. It was justified by the assumption that women would withdraw from their profession either partially or completely after marriage and starting a family. Its effect on the health system is minor compared to the class-based distortions described above, but its continued operation into the early years of the twenty-first century demonstrates the gap between the Ministry of Health and the rational, logical, sophisticated and modern creature that it claims to be.
Public opinion and politics. The second reason for doubting the purity of the government’s technocratic approach to healthcare is the potent operation of public opinion in this field. Although the government is the only proactive driver in healthcare policy, the end result is a compromise between the “efficiency”-driven, technocratic assumptions of government, and strong reactions from the public. Public opinion is not generally a powerful factor in Singapore governance, but – probably because health affects the lives of Singaporeans so intimately – it has nevertheless been a significant contributor to shaping health policy. According to the ideology of technocracy, such impacts are an irrational impediment to the quest for efficiency, but arguably they account for much of the positive outcomes for which the government takes credit. The key health issues raised routinely in newspaper articles and features, in the “forum” pages of newspapers, by opposition political parties and by government backbenchers (reflecting in turn the concerns raised in their “Meet-the People” sessions in their constituencies), revolve around the access of the poor and the lower middle classes to affordable healthcare.
In 2005, when the government closed the evening service offered by the government polyclinics, affecting the poor and elderly. At the same time, it threatened to end access by the middle class to cheap C-Class wards in government hospitals. Such is the expense of being sick in Singapore that even the middle class were scared of the high “co-payments”, and the large gaps between the amounts covered by MediSave and MediShield (as it then was) and the actual hospital bills.
These problems were highlighted, not because of any efficiency-driven review conducted by technocrats, but because public discontent threatened in the 2006 elections. Beyond the unprecedented spectacle of Health Minister Khaw being berated for a quarter of an hour by an aged constituent, the opposition Workers’ Party campaigned strongly on the issue. The unambiguous result was Khaw’s mid-campaign announcement that he was deferring indefinitely the introduction of a means test for access to the highly subsidised C-Class wards. Not since the late 1980s had the government engaged in such a spectacular volte face – and significantly on that occasion the issue was also about access to C-Class wards, and it was brought about by the most vehement expressions of concern by government backbenchers passing on the concerns of their constituents. Not until 2009 did the government finally achieve its goal of placing a means test on access to C-Class wards.
The government presents the history of incremental change in the health system since 1984 as a triumph of reason and efficiency, directed towards the noble end of affordable healthcare for all. But without the input of ordinary politics it is doubtful that the regime and its mandarins would have seen any pressing need to engage in this masterpiece of micro-management. MediSave was originally intended as the final word in healthcare financing, yet the gradual watering down of the original drive against “moral hazard” is evidence that the operation of politics is the key dynamic in the evolution of the system. Insofar as the Singapore health system is a showcase, Singapore’s vestiges of democracy deserve at least as much credit as does its technocratic ethos. In 2006, when the then Health Minister was focusing seriously and systematically on ways to reduce costs to the consumer and plugging the myriad gaps in 3Ms coverage that he admits often leave people with huge medical bills, he was giving witness to the impact of even a modest degree of democratic forms, rather than the brilliance of his technocrats. The 2015 upgrading of MediShield to MediShield Life has arguably confirmed this analysis. It is a compulsory health insurance scheme that is much more substantial than anything offered under the old MediShield, responding to the political reality that adherence to the purist principles of the 3Ms was unsustainable. MediShield Life is, in fact, rather close to the comprehensive and compulsory universal health coverage sometimes found in Western democracies, which Lee Kuan Yew would have derided as welfare.
The government presents the history of incremental change in the health system since 1984 as a triumph of reason and efficiency, directed towards the noble end of affordable healthcare for all. But without the input of ordinary politics it is doubtful that the regime and its mandarins would have seen any pressing need to engage in this masterpiece of micro-management.
There are, nevertheless, two fundamental differences between MediShield Life and fully comprehensive universal health insurance. The first is that the Singapore version still shies away from providing intergenerational subsidies. That is to say, MediShield provides no relief for the elderly. Clearly, in the short-to-medium term, the government intends to relieve the health burdens on the elderly by other mechanisms of direct subsidy that, ironically, harken even more overtly to welfare. It also hopes that by the time the current working generations of Singaporeans have reached old age, the provisions they are ‘banking’ now as savings and early-purchased insurance in the 3Ms will be enough to provide for their own insurance needs.
The second difference with the West goes to the nature of the Singapore state-and-society: the Singapore government is able to reach so deeply and deftly into the bowels of the health bureaucracy that it can contain costs and create efficiency-driven pathways that are indisputably cheap and mostly avoid double handling. As Dr Wong Chiang Yin wrote in the Singapore Medical Association newsletter when he was advocating the scheme: MediShield Life differs from regular health insurance in that the government not only controls the premiums and the payout, but also the actual costs.
It remains to be seen whether the 3Ms survives in any recognisable form once the Singapore population has properly ‘greyed’ and the country’s demographic is more typical of capitalist societies. In the struggle to balance low health costs with public expectations of high quality healthcare, the government already seems to be edging towards the more expensive models that it derides – and its own costs are creeping up as a consequence.
Systemic failings from striving for efficiency
Finally, the rest of this article argues that the most basic publicly stated premise of the Singapore health system – that of striving for technocratic efficiency – is responsible for its most spectacular and serious failings, rather than its achievements.
Given the right setting and provocation, Singapore’s leaders are willing to concede that their health system’s record of achievement is less perfect than they claim in moments of bravado. A number of examples can be cited.
First, there was the government’s delayed response to the SARS epidemic in 2003. For the first five weeks of the SARS outbreak (13 March-20 April 2003), there were no protocols or contingency plans to deal with an epidemic that had infected 65 people in its first fortnight. The responses, such as they were, were ad hoc and reactive. The public marker of the ending of this rudderless period was the effective removal of the SARS response from the hands of then-Health Minister Lim Hng Kiang – who in March had asked the public to accept some deaths as inevitable – and the creation of two ministerial committees to handle the crisis. It was five weeks (13 March-17 April) before the government began supplying free ambulances to take suspected SARS cases to hospital. Until then, suspected SARS cases generally made their own way to hospital by taxi or public transport, as was recommended by official bodies, such as the Office of Student Affairs at the National University of Singapore. As the former Head of the Civil Service, Peter Ho, has since acknowledged: “We were surprised by SARS. We were surprised by its epidemiology. We were unprepared for it. But we should have been prepared. It was not a fundamental surprise, because we knew that the risk of a highly infectious epidemic existed.”
The truly frightening aspect of this episode is that it was only because SARS threatened the family of the then-Senior Minister Lee Kuan Yew at the five-week mark, when his wife was rushed to hospital with a suspected case of SARS, that Cabinet finally began to take SARS seriously. Even then it took the direct intervention of SM Lee himself to galvanise Cabinet into action. This is not the sign of an efficient or far-sighted health system, but one that requires the most severe shocks to overcome a culture of complacency.
“We were surprised by SARS. We were surprised by its epidemiology. We were unprepared for it. But we should have been prepared. It was not a fundamental surprise, because we knew that the risk of a highly infectious epidemic existed.”
Of more serious political consequence for the government was its failure to adequately oversee the National Kidney Foundation (NKF). The NKF is notionally an independent charity but is, in fact, an integral part of the health system, as the main provider of kidney dialysis. Suffice to say that it is only thanks to the operation of the NKF that the government could for some time afford to exclude dialysis and kidney-related treatments from the 3Ms. Indeed, even when the NKF was operating properly, as in the mid-1990s, the death rate from lack of access to dialysis was averaging not less than 30 per year. Yet, in 2005, the NKF was exposed as a corrupt institution that was grossly abusing public trust as well as public money. In its official report on the gross mismanagement of the NKF, auditing firm KPMG was scathing:
Power was centred around one man, and was exercised in an ad hoc manner through [CEO] Mr [T.T.] Durai and his coterie of long-serving assistants. . . . The NKF appeared to run and operate, and in fact did run and operate, on the ideas, whims and caprice of the chief executive.
No government instrumentality or personnel can take credit for uncovering the NKF abuses. That honour goes to a humble plumber who was scandalised when contracted to install gold-plated taps and a luxurious toilet seat in the NKF executive office. On this occasion the government was saved from facing serious consequences by the ineptness of its domestic political opponents – the opposition Singapore Democratic Party (SDP) made the strategic error of questioning the integrity of the government rather than its competence. In so doing, the SDP invited a libel action that made it impossible for the NKF issue to be raised during the 2006 General Election campaign. Yet, even so, as a direct result of this fiasco the Health Minister apologised to the public, conceding that he had been made to look “silly”, and the government conducted a major review of dialysis access, instituted audits of all VWOs and overhauled its own procedures for overseeing these critical areas of health and welfare policy.
During the 2015 election campaign, the government took a much more direct approach to smothering a fatal outbreak of Hepatitis C in Singapore General Hospital: there was never a whisper of the outbreak until weeks after the election. When it did become public, the relevant ministers claimed that they were not told and that they knew nothing!
The subsequent 2019 data leak of health records from the Ministry of Health was also revealed to the public after months of delay, and when it was finally revealed there was really nowhere for the Minister to hide. Unlike in the case of the Hep-C outbreak, he had to publicly apologise.
See: Political Agenda — Privacy Breaches in a “Smart Nation” for a discussion on these leak of health records.
Are failures such as these a fair basis on which to judge the Singapore health system? They are all outside the 3Ms, and so off the main stage of the health system. Yet there can be no reasonable basis for not including dialysis treatment as part of mainstream healthcare. Regarding SARS, any health system must be judged as much by its capacity to cope with crises as it does with routine demands. That expectation is intrinsic to the nature of healthcare. And can we really remove catastrophic failures in Singapore’s main hospital and in the security of health data from a judgement of the technocratic competence of the system as a whole? I argue not. Furthermore, the experience of the NKF scandal, the Hep-C outbreak and the long delay in coming clean about the data breaches points to another reason to be sceptical about claims of technocratic success per se: each came to public light only after a substantial delay that reflects well on the government’s capacity to manage information and poorly on the government’s transparency. This raises questions about the capacity of any observer to properly judge the government’s successes, even when the headline big-picture data looks impressive.
It is more difficult to interrogate the systemic core of the health system at the more mundane level of day-to-day practice. The government maintains close control over the relevant information, and it is generally successful in ensuring that only flattering information is released. Yet there are a few clear and public signs that the ethos of so-called efficiency-driven management of healthcare is driving down the standard of healthcare. These centre around a critical shortage of both hospital beds and doctors, both of which are putting lives at risk on a daily basis.
First, there has been a long-standing shortage of hospital beds. The ratio of hospital beds to population declined significantly over the decades, from 1:229 (one year out from full colonial rule) to 1:259 (in the first year after the reforms of 1984).  By 2004 this had deteriorated to 1:348, before a year of expansive expansion improved it to 1:278. At the time the government, oddly, regarded this low ratio as an achievement. In his Budget Speech on 17 March 2004, Health Minister Khaw Boon Wan made it clear that the focus on efficiency and cost savings provides the core of the Singaporean healthcare philosophy, stating explicitly that he considers less consumption of public health services to be a positive outcome in its own right, and conclusive proof that the Singapore health philosophy of personal responsibility and self-help is among the world’s best practice.
Yet, in less boastful moments, he admitted that the shortage of beds was a problem because it adversely affects the delivery of healthcare: hence, strenuous efforts to increase the number of beds in 2005 and his lamentation that these initiatives are several years too late to address the crisis. Eventually he admitted that the shortage of beds was “stressing” doctors and patients: “Every day, our doctors have to go down to beg the patients [to be discharged]” . Yet, despite the obvious seriousness of the problem, his belated announcement of the opening of 200 beds by 2009 revealed the continuing presence of the mentality that led to the shortfall in the first place. He lamented that since public hospitals are heavily subsidised, “the more beds I add, I know tomorrow they will be filled up” , by which he seemed to imply that the availability of subsidised beds, rather than illness, drives people to hospital. The more likely explanation that there are currently people sick at home who should be in hospital. In the 2000s and 2010s, “bed crunches” have continued to make headlines, with hospitals resorting to housing patients in tents and corridors.
Yet, even the hospital-to-population ratio cited above ignores the recent phenomenon of international medical tourists who have also been placing increasing demands on the Singapore health system. Medical tourism has grown substantially over the last two decades, bringing in S$1.1 billion, $832 million and $994 million respectively in 2012, 2013 and 2015. (The Singapore Tourism Board has not released data for subsequent years.) That being so, how many Singaporeans have benefited from any improvements in the hospital bed-to-population ratio?
With such statistics as a background, it should come as no surprise to learn that Singapore has had, according to Yong Ying I, Permanent Secretary in the Ministry of Health, one of the worst doctor-to-patient ratios in the developed world – 1: 652 in 2007, up from 1: 640 in 2005. Over a decade ago, this was regarded in the Ministry as a serious problem and teams were sent to Australia and London to recruit as many as they can from outside normal channels. By 2016 the ratio had improved to 1:444, but this continues to compare unfavourably to other OECD countries. In 2016, Health Minister Gan Kim Yong identified a need to increase the ranks of healthcare workers by 30,000 within the next four years.
Doctor shortages obviously increase waiting times and deter people from seeking routine medical services. They also places stress on doctors and gives them incentives to push patients through as quickly and as routinely as possible, leading to mistakes and premature discharge. Yet this phenomenon also contributes directly to the high throughput of patients of which the government has boasted as evidence of the efficiency of its hospitals. Yong Ying I understated the situation when she said that “We have very efficient doctors and they work very hard. But somewhere along the way we also don’t have enough.” The problem she identified has persisted clearly ten years later, with Singapore’s healthcare system ranking well for “efficiency” but poorly for “access”.
Singapore has had, according to Yong Ying I, Permanent Secretary in the Ministry of Health, one of the worst doctor-to-patient ratios in the developed world – 1: 652 in 2007, up from 1: 640 in 2005.
Both shortages – of doctors and hospital beds – directly result from government policy that deliberately restricted the supply of doctors and hospital beds to avoid increased consumption of healthcare. By the government’s own logic regarding “moral hazard,” these shortages are at the heart of Singapore’s ultra-efficient healthcare system, and are major contributing factors that have contributed to that reputed efficiency. Yet now both are admitted to be serious problems, undermining the capacity of the health system to service its own population. This is part of the problem with running a system whose goals are all fashioned in terms of “organisational efficiency”.
The emphasis on “organisational efficiency” has had yet another deleterious effect. It is not “efficient” to build in a capacity to meet infrequent or unlikely scenarios. Thus the whole system – right down to the pattern of coverage and limitations by the 3Ms – is based upon an assumption that dealing with averages and common patterns is best practice, because it is an “efficient” way to produce good measurable (average) outcomes. Yet the “unexpected” seems to arise with increasing frequency, possibly because Singapore has positioned itself successfully as a regional cross-road and so is open to every bug that is floating around the region.
For instance, 2006 was a crisis year for the Singapore health system, with government polyclinics reporting that queues were so long and staff members so overworked that lives were being put at risk, with one death due to mistaken prescription already recorded. In the same period the public hospitals struggled to cope with an increase in the number of patients, largely due to outbreaks of dengue fever and influenza  and, as Health Minister Khaw has admitted implicitly, the failure of Ministry of Health planners to provide enough beds to cover peak demand. Yet, such is the power of the drive to achieve efficiency and eliminate the “moral hazard” that hospital beds are provided only reluctantly, even to cater for an influenza epidemic.
It is at the very ordinary level of affordability and availability that the system is facing the most strain. This affects the poor (especially the female elderly poor), the middle class and anyone with a serious chronic illness, meaning that everyone except the very wealthy and those lucky enough to be on generous employer-sponsored schemes (which the government is phasing out in any case feels considerable vulnerability. The issue has driven the Health Minister to focus seriously and systematically on ways to reduce costs to the consumer and plug the myriad gaps in 3Ms coverage, and to highlight the success of the 3Ms in offering adequate cover to most patients most of the time. This has likely accounted for, for example,the expansion of MediSave access for some chronic illnesses under the CDMP.
Of more significance for those who particularly admire the medical savings element of the Singapore schemes, the Singapore health funding model has increasingly moved away from its intense focus on medical savings, giving medical insurance a more central role. The introduction of MediShield Life in 2015 meant higher premiums, broader coverage, lower deductibles and higher caps. This move was radical in Singapore and began with changes to MediShield rushed out to meet pressing political needs, but it is not exactly new or impromptu. Khaw’s predecessor, Lim Hng Kiang, foreshadowed such moves as far back as 2001, showing that they are emerging systematically from the Ministry of Health’s guided evolution of the health system.
As a result of this move, the Singapore system increasingly resembles a particularly parsimonious version of Western healthcare systems. It most definitely does not have the mystique of a cutting-edge pioneering venture developed by brilliant technocratic minds, because brilliant technocratic governments do not normally take two decades of radical experimentation just to arrive at the point very near where they started.
Efficient to the Core
Yet, at this stage, the mantra of “organisational efficiency” remains the central objective and methodology. Consider the following report, taken directly from a Channel NewsAsia report from 3 November 2006:
Health Minister Khaw Boon Wan says his key priority is to fine-tune and strengthen the 3M framework of Medisave, MediShield and MediFund – to make sure quality healthcare is available and affordable to all. One way to improve healthcare delivery is greater integration across primary, acute and step-down care between private, public and people sectors. . . . To keep them out of hospitals, family doctors will play a bigger role. They will help manage common illnesses like diabetes, high blood pressure and stroke, so patients will not have to go to hospitals for expensive specialist outpatient treatment.
The quest for efficiency and cost-effectiveness is commendable, and there can be no doubt that some of the Singaporean initiatives are very imaginative, but it is of concern when the health system seems to be devoted to efficiency rather than patient care. This dichotomy also raises questions about the government’s motivation in its campaigns to promote Advanced Medical Directives (“living wills”) onto a population that is clearly unwilling to embrace them.
Where does this leave the supposed miracle of the Singapore health system? It is touted by the Singapore government as world’s best practice, and regarded by some as a model for advanced capitalist democracies. But one is left wondering if the key to the system is merely the government’s monopoly of information and its authoritarian control of political discourses. It seems highly likely that if one could examine the Singapore health system from the inside, one would find a fairly ordinary health system with some strong points and many weaknesses – much like health systems all over the developed world. Probably some aspects of the system worthy of emulation, but the image of a near-perfect system driven by a technocratic imperative for efficiency is likely little more than government spin and tight control of information, As far as the quest for efficiency is a driving force, it seems likely to be as much a negative as a positive.
One is left wondering if the key to the system is merely the government’s monopoly of information and its authoritarian control of political discourses.
Can, therefore, a technocratic approach to governance ever deliver the promised results? Singapore’s showcase product, on examination, is a health system beset by contradictions and shortcomings, and creeping closer and closer to becoming a “typical” health system. But should one be surprised? The image of the coldly rational and objective technocrat was a chimera in any case. The healthcare experiment that started in 1984 was indeed bold and innovative, but from the start it was the product of prejudices and a priori judgements that find their origins in, among other biases, socio-economic class and gender, which then had to contend with the vital component of public opinion.
The truly interesting conclusion here is not the positive role of technocracy (marginal at best), but the pivotal role of democracy in providing some level of protection from the ruthlessness of aloof political leaders and anonymous bureaucrats. Even the tokenistic version of democracy served up in Singapore has ameliorated the worst excesses of Singapore’s drive for “organisational efficiency” and forced politicians to become a little less aloof.
The author wishes to thank Jolene Tan both for her assiduous editing and for the extra research she has contributed in order to bring this article up to date.
 Goh Chok Tong (1982) ‘‘Singapore Government Press Release. Speech by Mr Goh Chok Tong, Minister for Health and Second Minister for Defence, at the Singapore General Hospital (SGH), Nite 1982,’’ 6 March 1982, National Archives of Singapore, http://www.museum.org.sg/NAS/nas.shtml/ (downloaded 10 May 2004).
 Khaw Boon Wan (2004) ‘‘Ministry of Health Budget Speech on Wednesday, 17 March 2004 by Mr Khaw Boon Wan, Acting Minister for Health,’’ http://www.moh.gov.sg/ (downloaded 30 April 2004).
 There is no shortage of evidence to support the contention that the Singapore government projects itself as being ‘‘hard’’ but worthy of support because it follows correct prescriptions. For a small sample of contemporary evidence see Today, 2 and 5 May 2007, which report speeches delivered by two different government ministers over a period of three days. Headlines of these stories are respectively, ‘‘What’s right, not what’s popular; Buoyant economy, record job creation the result of hard work, sound policies: PM’’, and ‘‘Why S’pore went the hard way.’’
 Lee Hsien Loong (2005) ‘‘Speech by Prime Minister Lee Hsien Loong at the 2005 Administrative Service Dinner, 24 March 2005,’’ Sprinter [Singapore Government news service] http://www.sprinter.gov.sg/ (downloaded 30 March 2005).
 Pellizzoni, Luigi (2001) ‘‘The Myth of the Best Argument: Power, Deliberation and Reason,’’ British Journal of Sociology, 52, 1, pp. 59-86.
 The pre-eminent profession in a particular technocracy and in theories of technocracy varies considerably (see, in particular, Winner, Langdon (1977) Autonomous Technology: Technics-out-of-Control as a Theme in Political Thought, Cambridge: The MIT Press).
 This account of Singapore as a ‘‘technocracy’’ is drawn from Barr, Michael D. (2006) ‘‘Beyond Technocracy: The Culture of Elite Governance in Lee Hsien Loong’s Singapore,’’ Asian Studies Review, 30, 1, pp. 1-17. See also Goh Keng Swee and The Education Study Team (1979) Report on the Ministry of Education 1978, Singapore: Ministry of Education and Hochstadt, Herman (1993) ‘‘Interview with Herman Hochstadt,’’ Singapore, 7 January 1993, by Mr Daniel Chew on behalf of the Oral History Centre, National Archives of Singapore.
 Barr, Michael D. (2005) ‘‘Singapore,’’ in Robin Gauld (ed.), Comparative Health Policy in the Asia-Pacific, Maidenhead: Open University Press, pp. 146-73.
 This overview of the Singapore health funding system is based on Barr, Michael D. (2001) ‘‘Medical Savings Accounts in Singapore: A Critical Inquiry,’’ Journal of Health Politics, Policy and Law, 26, 3, pp. 707-24, and Barr (2005). More detailed information can be found in these works.
 Toh Mun Heng and Linda Low (1991) Health Care Economics, Policies and Issues in Singapore, Singapore: Times Academic Press for the Centre for Advanced Studies, National University of Singapore.
 Ministry of Health (2004), Ministry of Health website, http://www.moh.gov.sg/ (downloaded 30 April 2004).
 Lee Kuan Yew (1981) ‘‘Full Steam Ahead—Each Citizen Its Own Home,’’ Petir, 11, December, pp. 4-15.
 Lee Chien Earn and K. Satku, ‘The Transformation of the Health of Our People: An Overview’, in Lee Chien Earn and K. Satku (eds), Singapore’s Health Care System: What 50 years have achieved, Singapore: World Scientific, 2016, pp. 1-32. Parliamentarian Toh Chin Chye (previously of the Health Ministry) also referred, during Parliamentary debates on the National Health Plan, to 24% of Ministry income deriving from patient fees.
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 In 1996, industrialised countries’ per capita health-care expenditure on the aged was up to five times that of the expenditure on under-65s (in Japan) and rarely less than twice the figure. The Netherlands, the USA, Australia, Switzerland, Finland, the UK and New Zealand all spent approximately four times more on the aged than they did on the younger section of the population. See Prescott, Nicholas (ed.), (1998) Choices in Financing Health Care and Old Age Security: Proceedings of a Conference Sponsored by the Institute of Policy Studies, Singapore, and the World Bank, November 8, 1997, Washington, D.C., International Bank for Reconstruction and Development.
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 Lee Hsien Loong (2004) ‘‘Prime Minister Lee Hsien Loong’s National Day Rally 2004 Speech, Sunday 22 August 2004, at the University Cultural Centre, National University of Singapore,’’ Sprinter [Singapore Government news service] http://www.sprinter.gov.sg/ (downloaded 9 November 2004).
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 Eugene Wijeysingha was a former Deputy Director of Education who was posted as principal of Raffles Institution in 1986 to turn the school ‘‘Independent’’ (The Straits Times, 9 October 1986).
 Interview with Eugene Wijeysingha, Singapore, 11 April 2003.
 Goh Chi Lan and the principals of the Study Team (1987) Towards Excellence in Schools: A Report to the Minister for Education February 1987, Singapore: Ministry of Education, and Tan, Jason (1993) ‘‘Independent Schools in Singapore: Implications for Social and Educational Inequalities,’’ International Journal of Educational Development, 13, 3, pp. 239-51.
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 The government had been gradually reducing the number of C Class beds in hospitals since the introduction of Medisave in 1984, but pressure from government backbenchers forced the Ministry of Health to back down at the end of the 1980s (Toh and Low, 1991).
 Wong Chian Yin (2014), “MediShield Life: A Brief Introduction”, Singapore Medical Association, https://www.sma.org.sg/UploadedImg/files/Publications%20-%20SMA%20News/4608/Insight.pdf
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 The author has a copy of an official notice issued by the NUS Office of Student Affairs, dated 1 April 2003, which recommended that people with SARS-like symptoms ‘‘go immediately to the Accident and Emergency Dept of TTSH [Tan Tock Seng Hospital] by taxi or public transport.’’
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 Linette Lai (2017), “”,Singapore tops for medical tourism, but rivals catching up quickly”, The Straits Times, https://www.straitstimes.com/singapore/health/spore-tops-for-medical-tourism-but-rivals-catching-up-quickly
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 Wong Pei Ting (2018), “S’pore’s healthcare system best in value and satisfaction, but falls behind in providing access: Study“, TODAYonline, https://www.todayonline.com/singapore/spores-healthcare-system-best-value-and-satisfaction-falls-behind-providing-access-study
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 Chia Ngee-Choon and Albert K.C. Tsui (2005) ‘‘Medical Savings Accounts in Singapore: How Much is Adequate?,’’ Journal of Health Economics, 24, pp. 855-75.
 Hanvoravongchai, Piya (2002) Medical Savings Accounts: Lessons Learned from International Experience, EIP.HFS/PHF Discussion Paper No. 52, World Health Organisation, http://www3.who.int/whosis/ discussion_papers/pdf/paper52.pdf (downloaded 30 November 2006).
 Prescott, 1998.