HEALTHCARE THAT WORKS FOR ALL

During a week in which India has lost countless lives, I count my blessings. Can some aspects of Singapore’s continued commitment to safety and its model of healthcare offer pointers for India?

This week the upper crust of India discovered that the virus could not be shot down by a phalanx of security guards at the gate of their apartment complex. “Now the rich sit alongside the poor, facing a reckoning that had only ever plagued the vulnerable in India,” writes Vidya Krishnan in a piece in The Atlantic that denounces the willful disregard of the affluent people of India towards “the ricketiness of our health-care system”.

The bad news from India has been relentless. Our friend in Delhi’s Gurgaon is on oxygen 24x7 at a hospital. At least seven people in my sister-in-law’s apartment complex in Chennai have tested positive. How must others in the complex stay safe when patients use the same lift in order to be taken to the hospital for tests? In Singapore, two sisters lost their dynamic sibling, a respected dance guru in Delhi. A friend I met last January in Hyderabad and her sister lost their father in a Delhi hospital three days ago; the sister, Barkha Dutt—who has been reporting daily from India’s killing fields since Covid assaults began last year—became the news herself as she ferried her father in a make-shift ambulance, lost him to the disease and then partook in the despair of pyre shortage at the burning ghat. 

The consequences of the negligence of the privileged have finally come home to roost. Now while discovering that I too have been part of the problem, I’m reading the reports out of India with guilt and shame. On social media, I see how those of us who used our money once to buy our family members special medical care are now trying to pump money back to the system. But it’s too late. “The collective well-being of our nation depends on us showing solidarity with and compassion toward one another,” writes Vidya Krishnan. “No one is safe until everyone is.”  

In Singapore, this week is posing new concerns.  At the time of this writing, the country has 16 new cases of locally transmitted COVID-19 infection. These numbers have been zero—or in the single digits—during the four months I’ve been here. Still, the country isn’t letting its guard down—or tossing the mask aside. Vaccinations continue alongside adherence to mask wearing and contact tracing. We continue to keep a distance of at least one meter from other individuals or groups of up to eight persons in public places (excluding in vehicles or public transport facilities).

In almost every area of nation-building, Singapore has fashioned itself from the successes and failures of other countries. I learned that the Singapore’s health care model emerged from the experiences under colonial rule. “The growth of the welfare state in Britain in the 1970s, while well-intentioned, had been associated with an eroding work ethic, a deteriorating fiscal position and a growing entitlement mentality,” writes the team in “Governance”, a publication by Straits Times Press. In contrast, Singapore wanted its people to be self-reliant. There were going to be no doles.

From what I can see, the people here work well past the retirement age of 63 years. For the last 120 days, except on Sundays, I’ve been greeting an old man in our building—he must be at least 80—who wipes down the gates and handrails every day. He is very slow but he works daily, always offering me a few canned greetings in English. I also see a sweeper in the lobby whose head is now bent, as if all he has done from birth is sweep. Then there are all those gentlemen who insist on taking our temperature at the cafeteria and ensure that we comply with contact tracing as we enter the premises. All of them must be in their seventies. A friend of mine, Lakshmy, agreed that a lot of older people in this country do continue to work for a living.

Many of the elderly work, I’m told, not because Singapore’s system forced them to work until their dying day. “It’s true that the government pushes people to stand on their own two feet,” Lakshmy said, “but for many of the old it’s also about wanting to socialize and belonging to a community.”  She told me about her hair dresser who had freelanced until she was about 75.

Seniors really don’t have to work in Singapore. Besides their own insurance, many of them can also be helped by their children’s insurance. In a country that expects children to be responsible for their parents who can sue them for negligence—read about Singapore’s Maintenance of Parents Act—a child may use his medical savings (see more on MediSave below) for his parent’s medical treatment. Prior to this statute, there was no legal requirement for an adult child to support the parents, no matter how needy the parents were or how affluent the children were.

Health care in Singapore is offered as a combination of both public and private initiatives. It’s a government-run publicly funded universal healthcare system supervised by its Ministry of Health. I’d written about public housing in a previous post pointing out how the Central Provident Fund (CPF) is Singapore’s lifeline. CPF is also the conduit for health, it turns out.

Singaporeans are mandated to stash away a part of their monthly pay in the CPF for the purposes of health, housing and retirement. MediSave is a basic program fed by the CPF in which the employee sets aside 17% of his wages and the employer contributes 20% until the amount reaches a Government stipulated max (changes every couple of years but it’s currently set at $63, 000). There is another account called MediShield that kicks in when someone has a serious illness that requires hospitalization. A friend, Vasant, explained that MediShield is an insurance coverage that the government buys for which the premium is paid from the MediSave account. A large number of people subscribe also to an employer based medical insurance and Vasant, who found himself needing heart treatment, bought himself a private health insurance so that he could opt for privatized care. The financing of healthcare also involves cost sharing through copays, deductibles, and coinsurance. In addition, the government also offers many subsidies; depending on what people choose, the government can absorb up to 80 percent of the cost of treatment.

A 2017 story in The New York Times analyzed Singapore’s health care to see why it was so cheap. The section of the piece that interested me most, however, were the comments that trailed it. It’s obvious that the health care system in Singapore is still skewed favorably towards the wealthier segments of the populace. End-of-life care and hospice also need to improve, according to some of the comments, although I’ve been reading about many long-term care services provided by voluntary welfare organizations to those who are discharged from a hospital.  

Within the public system, patients can choose their class of care, too, depending on the size of their wallets. Public hospitals offer subsidized wards as well as unsubsidized ones for those who want and can afford better service. They sound like a grade point average and reap you benefits accordingly: they are A, B1, B2+, B2 and C.

“A” gets you a private room, your choice of doctor, attached bath room, toiletries, television, telephone, fully automated electric bed, choice of food and a sleeper unit for an accompanying adult at an extra charge. At the other end of the spectrum, a standard ward in C which is heavily subsidized by the government may have  up to 8 beds in a room, a shared bathroom and a doctor who is assigned to the ward. Note that opting for “C” means that the government pays up to 80 percent of the costs.  

A friend of ours, a Chinese Singaporean in his mid-eighties, just returned home from a public hospital two days ago. He is a red wine connoisseur and hence he will be RWC for the purposes of this post. He had wanted a private room in one hospital but was offered only a non-AC room. He ended up enrolling at another public hospital, instead, and opted for a ward with five patients. For RWC, who is sharp, funny and active, it was an experience that taught him to appreciate his privilege and his independence. Just the previous weekend he had walked some five hours on a trail at the Gardens by the Bay. He was candid about why he chose his option for this hospitalization. “It's not only the huge government subsidies for senior citizens that swayed my decision, but also the unique experience of learning how the less privileged are being treated in real life. For sure there is some loss of comfort and privacy by staying in a B Class ward, but overall I think it's a fair exchange.” Even though the waiting period for non-emergency treatments can be long at public hospitals, the facilities themselves, I’m told, are top of the line and RWC assured me that emergencies are attended to promptly.

A white paper on affordable healthcare in Singapore published in 1993 outlines the country’s underlying philosophy with respect to health. Two of the five fundamental objectives have to do with people and their attitudes: To nurture a healthy nation by promoting good health; to promote personal accountability and avoid over-reliance on state welfare and medical insurance.

It reminded me of the premise of our health care provider in the San Francisco Bay Area that, above all, one of the responsibilities of a decent health care system is also to enforce individual accountability in the people it serves. When you belong to Kaiser Permanente, you subscribe to Kaiser’s health “management” philosophy. Its follow-through can feel excessive at times but I’m not going to complain. I like it.

In our experience in the last four years, we’ve found that Kaiser rarely give its patients a chance to slip up. It plays the role of a hovering parent, much like Singapore’s Ministry of Health, believing, not erroneously perhaps, that most humans will be careless about their health and that most of their health problems can be staved off simply by following a system of regular checks and balances. A small country’s health solutions cannot, however, address another country’s problems but there’s so much for India to learn from Singapore about investing in a robust public health care system.

Unfortunately, India’s population of 1.4 billion people—with many hundred million living in multidimensional poverty—puts it in a different category altogether for how to effectively deliver health to vast swathes of the population. But there’s a lot to learn—even about clear and efficient communication—from Singapore’s approach to quarantine and I’ve written about our experiences after we landed here in mid-December.

This country’s health mandates have taught me one thing that when it comes to public health, the consistency of messaging from a place of authority, a systematic approach to care and, of course, the compliance of a population are paramount. With Covid-19, Singapore has shown that a scrupulous health management system—and, of course, a population that will follow the country’s diktats—may be the only way to come out of a health crisis alive.