Upon independence in 1965, the tiny city-state of Singapore was not what it is today: One of the world’s richest economies, where its citizens enjoy one of the highest standards of living in the world — and excellent, affordable public healthcare.
But unlike other Southeast Asian nations, the country’s leaders had a plan, and implemented to the last detail with astonishing success. Singapore now spends less than 1 percent of its gross domestic product on health, much less than India where public health services are poor, and even less than the United States where outcomes are way below the average of OECD countries.
So what happened?
We asked U.S. biologist, entrepreneur and philanthropist Dr. William Haseltine, also chairman and CEO of ACCESS Health International, an international nonprofit that advocates for worldwide high-quality healthcare. Singapore, according to Dr. Haseltine, is an excellent example for the developing world because its leaders had the vision to initially adopt a system they could afford, and later on expand it as the nation grew and grew until becoming the Asian economic powerhouse it is today.
Doing it right
“Singapore has done something right,” said Dr. Haseltine. “[And] the lesson learned for emerging countries is that Singapore didn’t start out rich.”
When the former British colony was expelled from the Federation of Malaysia in 1965, the Singaporean government led by strongman Lee Kuan Yew decided to start from the bottom and work its way up on healthcare. First they invested in basic healthcare and low-cost clinics, with special attention to childcare, maternal health, vaccines and sanitation, most of them totally free.
“The first lesson lesson is [that] you do what you can afford at the time you can afford it, but think through the long-term implications of your first steps, because how you begin is pretty much how you develop over time,” said Dr. Haseltine, who compared this mentality with that of neighboring countries that at the same time adopted systems they could not pay for, like the Philippines.
He also stressed that implementation was systematic: The government didn’t set up a first-class system from the beginning because “they knew they couldn’t afford it.”
Two decades later, as Singapore became a middle-income economy, and always spending within the state coffers’ limits, the government reformed the system and started focusing more on the quality of the services, which slowly progressed into today’s model.
In the early 1980s, the Singaporean government already saw the future problems of public health systems like the United States, where most people can’t afford healthcare, or Europe, where the states are running out of money to pay for universal free coverage.
That’s when the government “sought a balance between individual and collective responsibility” that led to today’s success, said Dr. Haseltine. Now the government spends about 1 percent of GDP, private citizens 3 percent and the rest comes from a pool of savings funds, state insurance schemes and incentives such as copays in a transparent sector with open competition between the public and private sectors, well-trained local professionals and state-of-the-art hospitals — all in such demand that medical tourism has turned into an economic driver for Singapore.
“It’s extraordinary [because] it’s an excellent system at an affordable cost,” added the expert, who called on political leaders in other developing countries to have the same vision.
Singapore’s government took the lead on health services from the beginning, but in most developing countries the public sector has proven to be corrupt and inefficient. But that doesn’t mean that governments should be excluded from healthcare reform in the developing world, according to Dr. Haseltine.
“Government policies, if they are well formulated, can make a huge difference, and Singapore is an example,” he said.
In many of these countries, foreign and local NGOs end up filling the void of the weak public sector. Dr. Haseltine noted aid groups of course should have an important role, but more to develop functional models and best practices rather than deliver the services, which is the responsibility of governments.
Public health NGOs, he warned, have “a dangerous philosophy of anti-government” and a tendency to support the private sector on health. These organizations, however, can and do good work on public health when they develop models that can be implemented by governments or other NGOs when necessary.
“In any case, denying government a role is a mistake,” stressed Dr. Haseltine.
Known for his groundbreaking work on HIV/AIDS and the human genome, the chairman and CEO of ACCESS Health International recently published “Affordable Excellence: The Singapore Health System.”
Michael Igoe is a Global Development Reporter for Devex. Based in Washington, he covers US foreign aid and emerging trends in international development and humanitarian policy. Michael draws on his experience as both a journalist and international development practitioner in Central Asia to develop stories from an insider's perspective.