Elsevier

Health Policy

Volume 122, Issue 4, April 2018, Pages 431-443
Health Policy

Health systems reforms in Singapore: A qualitative study of key stakeholders

https://doi.org/10.1016/j.healthpol.2018.02.005Get rights and content

Highlights

  • The RHS is a national-level move towards caring for the patient holistically across the care continuum.

  • The RHS’s key principles are integration, innovation, and people-centeredness.

  • Strengths of the RHS include a shared understanding of the RHS’s goals and objectives and strong leadership.

  • Some challenges to RHS implementation are alignment of actors, healthcare financing, evaluation, and manpower.

Abstract

In response to a growing chronic disease burden and ageing population, Singapore implemented Regional Health Systems (RHS) in 2008. In January 2017, the MOH announced that the six RHS clusters would be reorganised into three in 2018. This qualitative study sought to identify the health system challenges, opportunities, and ways forward for the implementation of the RHS. We conducted semi-structured interviews with 35 key informants from RHS clusters, government, academia, and private and voluntary sectors. Integration, innovation, and people-centeredness were identified as the key principles of the RHS. The RHS was described as an opportunity to holistically care for a person across the care continuum, address social determinants of health, develop new models of care, and work with social and community partners. Challenges to RHS implementation included difficulties aligning the goals, values, and priorities of multiple actors, the need for better integration across clusters, differing care capabilities and capacities across partners, healthcare financing structures that may not reflect RHS goals, scalability and evaluation of pilot programmes, and disease-centricity, provider-centricity, and medicalisation in health and healthcare. Suggested ways forward included building relationships between actors to facilitate integration; exploring innovative new models of care; clear long-term/scale-up plans for successful pilots; healthcare financing reforms to meet changing patient and population needs; and developing evaluation systems reflective of RHS principles and priorities.

Introduction

Singapore is a high-income, densely-populated Southeast Asian island city-state. Between the nation’s inception in 1965 and today, Singapore’s health system has seen the expansion and consolidation of healthcare services into a network of government health clinics, public hospitals, tertiary-care specialist centres, primary care providers, private hospitals, and non-government entities [1]. Singapore’s public hospitals have been ‘restructured’ to operate as government-owned corporations [2]; meanwhile, much of primary care and intermediate and long-term care (ILTC) is delivered by the private and non-profit sectors [1]. Singapore’s public healthcare system is staffed by a body of healthcare professionals that includes 12,459 doctors, of which 7909 are in the public sector and 4788 are specialists; 39,005 nurses and midwives, of which 24,000 are in the public sector; and a smaller group of allied health professionals (967 occupational therapists, 1550 physiotherapists, 474 speech therapists) [3]. The Ministry of Health (MOH) takes a health systems design, development, and stewardship role across system design and governance, national healthcare services planning, structuring healthcare financing, and healthcare regulation. Singapore’s health expenditure as a total percentage of GDP rose from 3.93 per cent in 2011–4.92 per cent in 2014 [4], but this remains low relative to the Organisation for Economic Co-operation and Development (OECD) average of 9 per cent in 2015 [5].

Healthcare financing in Singapore rests on the twin philosophies of affordability of basic healthcare services for all and individual responsibility [6]. A proportion of public sector healthcare costs are covered by the government, and remaining co-payments in the public and private sectors come from other sources, including statutory financing schemes, opt-out public schemes, private voluntary health insurance, employer medical benefits, and out-of-pocket (OOP) payments. The OOP health expenditure as a percentage of total expenditure on health was 54.83 per cent in 2014 [7], which is high in comparison to the OECD average of 13.6 per cent in 2014 [8].

Singapore’s healthcare system uses a multi-payer financing framework comprising government subsidies and the 3 M Framework. The 3 M Framework comprises Medisave, a national medical savings account which combines savings from payroll deductions to help meet future personal or immediate family members’ hospitalisation, day surgery, and certain outpatient expenses [9]; Medishield Life, a universal, mandatory coverage plan which was grown out of its predecessor, Medishield, and is designed to help pay for large hospitalisation bills and selected costly outpatient treatments [10]; and Medifund, a government-established endowment fund to help those who cannot afford subsidised medical bill charges. Other support schemes are available, including Medifund Silver, which assists needy, elderly patients [1]; the Community Health Assist Scheme (CHAS), a portable subsidy scheme that subsidises medical and dental care for lower- and middle-income at participating providers [10]; and Pioneer Generation benefits to assist with the lifetime healthcare costs of those aged 16 and above in 1965 and obtained citizenship on or before 31 December 1986 [11].

In 2000, the Ministry of Health (MOH) organised its restructured hospitals and polyclinics into two clusters in order to facilitate referrals, coordinate chronic disease care for patients post-hospital discharge, and encourage competition between clusters towards better care provision at a lower cost [12]. In 2007–2008, the MOH saw an opportunity to restructure healthcare institutions with the promise of working with providers in the region to provide patient-centred care. This resulted in the formation of six public healthcare clusters named the Regional Health Systems (RHS). In January 2017, the MOH announced that the six clusters would be reorganised into three integrated clusters by early 2018. These three new clusters would offer a more comprehensive suite of healthcare services, encompassing acute hospital care, primary care, and community care [13].

While there is a body of academic literature addressing Singapore’s health systems reform and looking at specific areas of interest within the Singapore health system (e.g. health services and utilisation) [[14], [15], [16], [17], [18], [19]], at time of writing, there was no qualitative study on Singapore’s most recent health systems reform. This study fills a gap in this body of research by addressing Singapore’s health system reforms and how they develop at the nexus of complex social, political, and economic interactions.

The study aimed to identify the health system challenges, opportunities, and ways forward for the implementation of the RHS in Singapore. The objectives of this study were to identify the contextual factors that influence the design and implementation of the RHS; to explore the perspectives and positions of the actors involved in introducing and implementing the RHS; to describe the content of the RHS’s principles, arrangements, and policies; to describe the processes that led to the initiation and implementation of the RHS; to identify health system barriers and facilitators to RHS implementation (including health systems hardware and software); and to identify possible ways forward. This paper is important and timely in the context of re-clustering, as its findings will help inform and guide the reorganisation process.

Section snippets

Conceptual framework

This study is grounded in an expanded version of Walt and Gilson’s Triangle Framework [20], which was adapted according to analysis of interviewees’ responses. It incorporates elements of Sheikh et al’s concept of health systems hardware and software [21]. It is underpinned by the understanding that the RHS is policy, based on policy as “decision-making processes at all levels of the health system and the wider influences that underpin the prioritisation of policy issues, the formulation of

Sampling

We undertook a qualitative study of 35 semi-structured key informant interviews with stakeholders throughout Singapore’s health system, including representatives from all six RHS clusters, government agencies, and the private and voluntary welfare sectors. The study used two methods to sample key informants. Purposive sampling was used to identify informants in key roles across sectors relevant to the RHS. Informants were selected based on their expertise and their position within the RHS, with

Structural and cultural factors: the ageing population, Singapore’s demographic transition, and changing family conventions

It was reported that the ageing population influences the evolution of the healthcare system. The young population of Singapore’s earlier years gave rise to the development of a healthcare system more focused on looking after diseases. However, over the last decade, the system has seen symptoms of strain, including longer hospitalisation periods and higher admission rates for the elderly, and longer wait times in emergency departments.

While it was acknowledged that the government had done

Summary of findings

The Singapore RHS was introduced to cope with the challenges of an ageing population, a demographic transition, changing family and care conventions, and a historically acute tertiary-focused, somewhat siloed health system. The RHS was described as an evolution of the health system where restructured public hospitals would care for patients within their geographical regions, integrate care between hospital and other care providers, and that the RHS’s strategic vision was focused on

Conclusion

The current RHS reorganisation appears to be an opportunity to redefine the perceptions, practices, and priorities of health and healthcare in Singapore. The RHS was widely understood to be a national-level, concerted attempt to move towards caring for the patient/person holistically across the care continuum, address social determinants of health, and provide care alongside partners from the social and community care sectors. Alongside, the key challenge to RHS implementation that arose from

Funding sources

This research received funding from Helena Legido-Quigley’s Start-up Grant granted by the Ministry of Education (WBS Number R-608-000-130-133).

Conflicts of interest

We are not aware of any relationships or support which might be perceived as conflict of interest.

Acknowledgment

We thank all interviewees for their participation in this study.

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