Commentary: Values and Health Policy: The Case of Singapore

Health care systems do not develop in isolation. They are products of the societies in which they are embedded and of the values held to be important in those societies. There could be no better illustration of this truth than the comparison between Sweden and the United States. The commitment in Sweden to equity and to the belief in that country in the benefits of action by the state has resulted in the development of a universal, tax-funded health service in which the emphasis is on ensuring access to health care for all. In contrast, the commitment in the United States to individual freedom and the aversion to government intervention has led to the development of a market-based health care system in which choice is highly valued and inequities in access tolerated.

The case of Singapore described by Michael Barr is a further illustration of the influence of social embeddedness and values in health care. A former British colony that gained independence in 1965, Singapore has attracted attention mainly because of the success of its economy. Rapid economic growth since independence has created a city-state of 3 million people in which per capita incomes are among the highest in the world. Singapore is a paradigm case of the tiger economies and has come through the economic downturn in Southeast Asia relatively unscathed. In recent times, the country's health care system has also attracted interest because of its ability to deliver good health outcomes at what appears to be a remarkably low cost (only 3 percent of GDP, according to government figures). Singapore's economic success is of course a major factor contributing to the health outcomes achieved, but its adoption of a middle way between a laissez-faire system and a government-owned national health service has acted as a magnet for policy analysts searching for new thinking on health care reform. Its attractions will only increase following the ranking of Singapore as sixth in the World Health Organization's assessment of health systems performance (WHO 2000).

As Barr shows, Singapore has developed a health care system involving a mix of public and private funding and provision. Equally important, the system combines a commitment to personal responsibility and government regulation. In primary care, most services are delivered by private practitioners operating on a fee-for-service basis and paid for directly by patients. These services are supplemented by government polyclinics offering subsidized (but not free) care to patients who prefer polyclinics to the private sector. Similarly, public hospitals coexist with private hospitals, and patients can choose different standards and costs of care. The government subsidizes public hospitals, but patients there also have to bear part of the cost even in the lowest standard of accommodation. The role of the state is not to provide services from the cradle to the grave along the lines aspired to by western European governments, but to offer a minimum level of support and to encourage individuals to supplement this.

The feature of health care that has attracted most interest in Singapore is the use of medical savings accounts (MSAs). These accounts are mandated by government and require those who are employed to pay a proportion of their income into a personal savings scheme. Contributions are matched by employers and are drawn on to meet the costs of hospital care. Unlike in Western European social insurance schemes, there is no risk pooling and savings accounts have been established on the basis that each generation should meet its own needs rather than build up reserves or commitments for future generations. This principle of intragenerational accountability rather than intergenerational solidarity reflects the values on which the Singapore system is based and the emphasis placed on personal responsibility (Ham 1996).

In seeking to analyze Singapore's system, it is important to understand the context in which the country gained...