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Myth Or Magic - The Singapore Healthcare System
This book provides a comprehensive look at the political philosophy that has shaped Singapore's healthcare system over the last five decades, and the financing and delivery of healthcare in Singapore. It delves into different aspects of the Singapore healthcare landscape, including pharmaceutical cost management, medical tourism, doctors' remuneration, medical education, rules and regulations, workforce planning and health promotion. It suggests lessons that the Singapore healthcare story holds for healthcare policy makers and reformers and the challenges that the future holds.
360 pages, Paperback
First published January 1, 2013
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Displaying 1 - 14 of 14 reviews
October 30, 2016
Having done stints in the health ministry and the private health sector in Singapore, and now finding myself a bit of a fish out of water in the public health sector - for me, this book served as fascinating context on the whys and wherefores of local public health policy which I heretofore merely dimly grasped but never quite understood. There are plenty of gems and insights to be gleaned, though I had to try very hard not to roll my eyes too much at the self-laudatory content. The author has a somewhat perverse obsession with international rankings and acclaim as a barometer of success, but his fixation would be better spent mulling over the fact that our health system is still a work in progress, and that luck (as opposed to the superior management of our forefathers) may have had as much a hand in the final cards we've been dealt.
March 25, 2018
Would recommend this book to anyone looking to learn more about the Singapore healthcare system, in any context. Lim is fair in both his praise and criticism as he traces the decisions and ideologies that have brought the healthcare system to its present form (acknowledging that significant parts of Singapore's success, e.g. the emphasis on "social determinants" of health like sanitation and housing instead of acute, specialised, hospital-based care, were likely as much incidental as they were deliberate), analyses its workings and failings in today's context, and makes recommendations for the future. While he doesn't shy away from in-depth discussions of policy implementation and outcomes (and there's no avoiding it—complexity is the name of the game here), I appreciated that he frequently goes back to first principles, whether in the original intent of certain policy directions or the more fundamental question of what the State owes its citizens.
It's not a book for the casual reader but as long as you're inclined to pick up a book with a title like this one you're good—it's written more with the generalist policymaker or interested citizen in mind rather than academics or medical professionals with specialist knowledge. I came into it almost completely ignorant of healthcare systems and found it both informative and easy to follow.
It is perhaps to the Singapore Government's credit that while this book was published only 5 years ago, some parts (e.g. the exclusion of the very old and those with pre-existing conditions from MediShield coverage) already come across as dated. That being said, it cannot be stressed enough that there is still much, much more to go, and this book provides a solid foundation for reflecting on the question of building a "less imperfect" healthcare system.
It's not a book for the casual reader but as long as you're inclined to pick up a book with a title like this one you're good—it's written more with the generalist policymaker or interested citizen in mind rather than academics or medical professionals with specialist knowledge. I came into it almost completely ignorant of healthcare systems and found it both informative and easy to follow.
It is perhaps to the Singapore Government's credit that while this book was published only 5 years ago, some parts (e.g. the exclusion of the very old and those with pre-existing conditions from MediShield coverage) already come across as dated. That being said, it cannot be stressed enough that there is still much, much more to go, and this book provides a solid foundation for reflecting on the question of building a "less imperfect" healthcare system.
October 1, 2013
The Singapore Health Care system has been consistently ranked as amongst the best in the world. That's an amazing feat given that 50 years ago the country had very basic health care. This well researched book described how the Singapore government actively managed the system to make it one of the best in the world. It describes the challenges Singapore is facing, and makes insightful if somewhat controversial solutions. A must read for everyone who has a stake in Singapore health care, and people who want to understand how Singapore did it.
February 14, 2021
Valuable unobtuse resource on policy and a good introduction to Singapore’s healthcare system and its considerations.
November 9, 2013
The book I read to research this post was Myth Or Magic The Singapore Healthcare System by Jeremy Lim which is one of the most interesting books on health I have ever read and which I bought from kindle. Jeremy is a doctor who has studied healthcare systems around the world and in particular the one in Singapore. According to Bloomberg it's the healthiest country in the world and according to the U N's World Health Organisation the 6th best health service in the world. This is despite the fact they spend 4% of their G D P on healthcare as compared to the U S A that spends around 17% and has a shocking healthcare system where 50 million people are uninsured. The Singapore model called Medicare was introduced in 1984 and very old people and those with pre existing conditions were exempt. Basically people are given a kind of bank account which gives 4% interest per annum and the government gives contributions to the account but in most cases they have to contribute as well but any medical treatment is paid for from the account. When they reach 65 the surplus above a certain amount they are allowed to spend. Their contributions in any given year towards treatment are capped at 2,000 Singapore dollars and the government increases contributions from it if they are over 65 or have a long term illness. The doctor's training course in Singapore is recognised by the B M A in Britain as a qualified doctor's qualification, so they are trained to a high standard. If someone needs treatment competition is encouraged by treatment providers. There has been controversy over some people who were close to 65 in 1984 when it was introduced and also those requiring long term treatment not having enough contributions from the government. Also the government has had to set aside money for health costs in the recession for several years ahead. With the economic downturn the government is encouraging foreigners to have private treatment in Singapore & people with private health insurance are given large contributions towards it equal to what their medishield amounts would be. Companies are also encouraged to take up private health insurance for their employees. I really enjoyed this book and thought it is an interesting perspective on what is probably a controversial subject.
May 4, 2015
Clear and insightful. Although slightly dated, this should be on the reading list for anyone who wants to understand healthcare system in Singapore.
April 1, 2018
Jeremy Lin does a brilliant job breaking down the Singapore healthcare system - the philosophy and values that underpin it, the considerations and trends that have shaped its evolution over the past half a century, and the challenges it must grapple with today.
The "magic" of the Singapore healthcare system is that in 50 years, Singapore has achieved stellar population health measures although government spending on healthcare, as a percentage of GDP, is a fraction of what other countries with comparable outcomes (or poorer outcomes, e.g. the US) spend. The "myth" is that the system is perfect and Lim elaborates in his book why cracks are starting to show in the Singapore model and the pressures it is coming under.
So what is the philosophy and the values underpinning the Singapore healthcare system? First, copayments to mitigate moral hazard. Second, subsidies are potentially ruinous. Third, a fundamental belief in economic theory and the power of markets to drive efficiency and deliver the greatest value to society. Fourth, the primacy of the state (as orchestrator).
And what are some of the factors behind the magic? First, good public health measures. To a large extent, Singapore's stellar population health outcomes are less a reflection of our healthcare system than the fact that we have excellent sanitation, clean air, access to healthy foods, etc. In the early days, Singapore's government focussed on public health measures (e.g. cleaning up the Singapore River, improving sanitation, vaccination) and we are reaping the benefits of these investments today. Second, the range of policy options available in the Singaporean policymaker's "armamentarium". Although the government directly funds only about a third of national healthcare expenditure, it exerts a much larger influence on financing e.g. decisions on Medisave and MediShield utilisation, regulatory oversight on health insurance, the drugs it opts to subsidise. Third, the government's ability to make swift policy changes (including about turns) when necessary e.g. dramatically increasing the size of the healthcare workforce after years of restricting supply.
But the Singapore system is far from perfect. There is the suspicion as to whether the healthcare financing system is structured simply to "reduce the government's financing burden", what with the Medisave scheme, the sense that the government subsidises based on the market price, not cost price, of drugs, and given that MediShield premiums collected by the government are far in excess of what the government pays out, among other things. (Although this is less of an issue with the introduction of MediShield Life.) Second, Singapore's current healthcare system was designed to deliver episodic care through hospitals efficiently and effectively. But if the emphasis is on enabling people lead healthy lives, then the government needs to look beyond acute and ambulatory care, and look at other parts of the ecosystem, e.g. primary care and the ILTC sector (which Lim points out the government 'divested' its involvement in to the private sector, which weakened its understanding of the sectors and its relationships with key leaders in the sectors as a consequence). Third, the incentives and financing structures don't always incentivise the right behaviours. If a significant proportion of hospital revenues are derived from patient and patient related revenues, for instance, where is the incentive to "right site" care if this results in a loss of revenue? If the financing model in primary care is primarily a fee for service one, which privileges treatment of lifestyle conditions like acne, what is the incentive for GPs to engage in activities like counselling patients on their diets, exercise, smoking cessation, etc? There is also perhaps a sense that policymakers did not understand the systems implications of some of their policy initiatives, e.g. the push to develop Singapore as a biomedical hub with clinician-scientists. Lim points out that although the initial target of 200 clinician scientists seemed modest, "clinical research worked on a pyramidal model..whilst there may be only a small number of clinician-scientists, this small cadre would need a much larger next echelon of clinician-investigators...every doctor in an academic institution needed to be familiar with research and supportive enough to refer patients to clinician-scientists and enrol patients into trials". This exacerbated the manpower shortages in the healthcare sector.
Still, notwithstanding the system's flaws, Lim concludes that the "Singapore model of healthcare delivery...rightly merits accolades. Even in Singapore, there is little unhappiness with the actual delivery of services other than complaints about waiting times and congested facilities. It is in healthcare financing that Singapore falters." Overall, Lim is cautiously optimistic about the system's ability to change for the better, what with major initiatives such as MediShield Life underway, which address some of the key criticisms.
The "magic" of the Singapore healthcare system is that in 50 years, Singapore has achieved stellar population health measures although government spending on healthcare, as a percentage of GDP, is a fraction of what other countries with comparable outcomes (or poorer outcomes, e.g. the US) spend. The "myth" is that the system is perfect and Lim elaborates in his book why cracks are starting to show in the Singapore model and the pressures it is coming under.
So what is the philosophy and the values underpinning the Singapore healthcare system? First, copayments to mitigate moral hazard. Second, subsidies are potentially ruinous. Third, a fundamental belief in economic theory and the power of markets to drive efficiency and deliver the greatest value to society. Fourth, the primacy of the state (as orchestrator).
And what are some of the factors behind the magic? First, good public health measures. To a large extent, Singapore's stellar population health outcomes are less a reflection of our healthcare system than the fact that we have excellent sanitation, clean air, access to healthy foods, etc. In the early days, Singapore's government focussed on public health measures (e.g. cleaning up the Singapore River, improving sanitation, vaccination) and we are reaping the benefits of these investments today. Second, the range of policy options available in the Singaporean policymaker's "armamentarium". Although the government directly funds only about a third of national healthcare expenditure, it exerts a much larger influence on financing e.g. decisions on Medisave and MediShield utilisation, regulatory oversight on health insurance, the drugs it opts to subsidise. Third, the government's ability to make swift policy changes (including about turns) when necessary e.g. dramatically increasing the size of the healthcare workforce after years of restricting supply.
But the Singapore system is far from perfect. There is the suspicion as to whether the healthcare financing system is structured simply to "reduce the government's financing burden", what with the Medisave scheme, the sense that the government subsidises based on the market price, not cost price, of drugs, and given that MediShield premiums collected by the government are far in excess of what the government pays out, among other things. (Although this is less of an issue with the introduction of MediShield Life.) Second, Singapore's current healthcare system was designed to deliver episodic care through hospitals efficiently and effectively. But if the emphasis is on enabling people lead healthy lives, then the government needs to look beyond acute and ambulatory care, and look at other parts of the ecosystem, e.g. primary care and the ILTC sector (which Lim points out the government 'divested' its involvement in to the private sector, which weakened its understanding of the sectors and its relationships with key leaders in the sectors as a consequence). Third, the incentives and financing structures don't always incentivise the right behaviours. If a significant proportion of hospital revenues are derived from patient and patient related revenues, for instance, where is the incentive to "right site" care if this results in a loss of revenue? If the financing model in primary care is primarily a fee for service one, which privileges treatment of lifestyle conditions like acne, what is the incentive for GPs to engage in activities like counselling patients on their diets, exercise, smoking cessation, etc? There is also perhaps a sense that policymakers did not understand the systems implications of some of their policy initiatives, e.g. the push to develop Singapore as a biomedical hub with clinician-scientists. Lim points out that although the initial target of 200 clinician scientists seemed modest, "clinical research worked on a pyramidal model..whilst there may be only a small number of clinician-scientists, this small cadre would need a much larger next echelon of clinician-investigators...every doctor in an academic institution needed to be familiar with research and supportive enough to refer patients to clinician-scientists and enrol patients into trials". This exacerbated the manpower shortages in the healthcare sector.
Still, notwithstanding the system's flaws, Lim concludes that the "Singapore model of healthcare delivery...rightly merits accolades. Even in Singapore, there is little unhappiness with the actual delivery of services other than complaints about waiting times and congested facilities. It is in healthcare financing that Singapore falters." Overall, Lim is cautiously optimistic about the system's ability to change for the better, what with major initiatives such as MediShield Life underway, which address some of the key criticisms.
July 22, 2020
Slightly dated, but an immensely valuable introduction to healthcare policy in Singapore by an experienced physician-cum-business consultant and former public policy-maker, with a detailed overview of the design of healthcare system financing and delivery, and a primer on key debates within the sector and possible areas for improvement.
June 4, 2021
This is a really nice book, and it clearly explains how Singapore's healthcare system is designed. It provides clear insight into the perspective that Singapore's policymakers viewed healthcare from.
September 23, 2022
The info kind of glossed over my head.
October 22, 2022
Actually insightful and interesting ngl
July 14, 2019
"Public sector salaries should keep pace with the market but not attempt the lead. Minister-in-charge of the Civil Service Mr Teo Chee Hean explains: " We don't want pay to be the reason for people to join us. But we also don't want pay to be the reason for them not to join us, or to leave after joining us." "
"A wise physician turned politician once shared that "(h)ealthcare was firstly about politics, then about economics and only thirdly about health." "
"A wise physician turned politician once shared that "(h)ealthcare was firstly about politics, then about economics and only thirdly about health." "
June 19, 2016
This book was not written for the general public. I found it extremely helpful for a project underway concerning comparative health systems. I can recommend it for anyone who seriously wants to learn about the achievements and challenges to Singapore’s health care system, which has been lauded by many professional analysts as being among the finest in the world.
Dr. Lim is knowledgeable as a physician, policy official, and scholar. He is not in any way apologetic about the authoritarian nature of his government. While the administration is somewhat sensitive to public pressure, it is not the primary motivator for formulation of policy, which has been based on their political philosophy. If I can summarize that philosophy (and apologies to Dr. Lim if I misconstrue it), a regulated market is better than strong central planning, not because it is morally superior, nor because of individual rights, but because of the market’s utility as the most efficient method to bring goods and services to the public. Individual responsibility for one’s own health care is paramount, not free and equal care for all. Health care is universal but tiered, with subsidies for the less fortunate.
I found it very interesting that Dr. Lim admires the vague manner in which regulation is written, and the opacity with which it is executed, which gives maximum leverage to the administration.
As a physician myself (and the same specialty as the author) I was intrigued by his description of their educational system and their mechanisms to deal with competitive conflict (i.e., turf wars). His observations on what he views of the deficiencies of the system and his recommendations for the future were insightful.
No country’s system can be grafted entirely onto another because of differences in culture and the realities of geography and economics. This is particularly true of Singapore and the U.S. Yet, there is much we can learn from each other—from both our successes and failures.
Dr. Lim is knowledgeable as a physician, policy official, and scholar. He is not in any way apologetic about the authoritarian nature of his government. While the administration is somewhat sensitive to public pressure, it is not the primary motivator for formulation of policy, which has been based on their political philosophy. If I can summarize that philosophy (and apologies to Dr. Lim if I misconstrue it), a regulated market is better than strong central planning, not because it is morally superior, nor because of individual rights, but because of the market’s utility as the most efficient method to bring goods and services to the public. Individual responsibility for one’s own health care is paramount, not free and equal care for all. Health care is universal but tiered, with subsidies for the less fortunate.
I found it very interesting that Dr. Lim admires the vague manner in which regulation is written, and the opacity with which it is executed, which gives maximum leverage to the administration.
As a physician myself (and the same specialty as the author) I was intrigued by his description of their educational system and their mechanisms to deal with competitive conflict (i.e., turf wars). His observations on what he views of the deficiencies of the system and his recommendations for the future were insightful.
No country’s system can be grafted entirely onto another because of differences in culture and the realities of geography and economics. This is particularly true of Singapore and the U.S. Yet, there is much we can learn from each other—from both our successes and failures.
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August 31, 2013This is on pre-sale. I can get autographed copies if you'd like.
Displaying 1 - 14 of 14 reviews