Singapore: #10 in the 2022 World Index of Healthcare Innovation
Singapore, a model of consumer-driven health care, has continued rapid spending growth that further endangers its health care system.
By Gregg Girvan, Grant Rigney, and Avik Roy
Introduction
Singapore ranks 10th in the 2022 World Index of Health Care Innovation, up from 12th in 2021 and down from 7th in 2020. Singapore’s overall performance was driven by high scores for Choice (12th) as well as strong research universities and top-notch digital health care.
Singapore’s fiscal performance, however, sits around the median, ranking 16th for Fiscal Sustainability due in part to politically-driven “top-ups” in public health care spending. While the overall cost of health care in Singapore remains remarkably low, its edge over the rest of the industrialized world is shrinking.
Background
The Singaporean health care system does not fit neatly into Western categories like single-payer or universal private insurance. Instead, compared to the U.S. system, Singaporean health care leans both further to the left and further to the right. To the left, it features a single-payer program for catastrophic insurance, called Medishield. But, to the right, it offers patients a system of universal Health Savings Accounts, known as Medisave. These accounts allow Singaporeans to shop for the everyday care they need without resorting to a third-party payer.
In a manner somewhat like the U.S. Social Security system, Singapore takes mandatory deductions from workers’ paychecks — around 20 percent of wages — and deposits a portion of them into health savings accounts called Medisave. In 2021, Medisave contributions were capped at $7,560, although additional voluntary contributions can be made yearly. Medisave accounts are used mostly for inpatient expenses, but also some outpatient ones. Singaporeans are expected to pay most of their outpatient expenses with non-Medisave cash.
This HSA-based system encourages providers to compete on price and value. In addition, it rewards Singaporeans for looking after their own health and for not overutilizing the health care system.
Notably, prescription drug pricing is unregulated. Drugs on a standard list maintained by the Ministry of Health are subsidized; drugs off the list are unsubsidized and obtainable via out-of-pocket spending. This gives Singaporeans complete freedom of choice, while still keeping costs in check.
Quality
Singapore ranks 13th for Quality. Singapore struggles most to prevent hospitalizations, especially for asthma, COPD, and diabetes. However, Singapore ranks third in the Index in mitigating COVID-19, behind only the United Arab Emirates and Taiwan. Its strong GDP growth, moreover, fuels investment in health care resources. Singapore boasts a rank of 5th in patient-centered care — up from 29th in 2021 — due to improvements in patient safety, transparency, and wait times to see a doctor.
Choice
At 12th, Singapore does better than average in offering choices for their health care. While affordable access to new treatments (30th) lags due to the government-controlled drug formulary, the defining feature of its health care system are health savings accounts. The system keeps health insurance costs extremely low (affordability: 3rd) while giving patients maximum control of their health care dollars. Singapore’s free and open choice of providers (14th) further strengthens the system despite it single payer structure.
Science & Technology
Singapore ranks 15th in Science and Technology, hampered by a lack of medical technology development (22nd). Besides Singapore’s providers universally embracing health digitization, Singapore’s research capabilities (10th) are widely recognized as being on par with many European academic centers.
Fiscal Sustainability
Singapore, however, faces looming challenges for Fiscal Sustainability (16th). Though its public health spending is among the lowest of any country in the Index at 2.7% of GDP (5th), Singapore’s national solvency (28th) is in question with a debt-to-GDP ratio over 155%, a 25-percentage point increase from last year primarily due to increased spending during the COVID-19 pandemic. In addition, public health spending growth (28th) is putting additional pressure on an already stretched national budget.
