Singapore - The Limits of a Technocratic Approach to Healthcare

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Singapore: The Limits of a Technocratic Approach to

Health CareMichael D. Barr a

a School of Political and International Studies, Flinders University, Adelaide,

Australia

Online Publication Date: 01 August 2008

To cite this Article: Barr, Michael D. (2008) 'Singapore: The Limits of a

Technocratic Approach to Health Care', Journal of Contemporary Asia, 38:3, 395

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Singapore: The Limits of a TechnocraticApproach to Health Care

MICHAEL D. BARRSchool of Political and International Studies, Flinders University, Adelaide, Australia

ABSTRACT Being a tiny, easily managed polity run by Western-educated technocrats, Singa-pore is an ideal laboratory for those who believe that there is a ‘‘logical’’ answer to the problemof health-care funding in economically advanced societies. Certainly the ruling elite in this not-very-democratic country is convinced that Singapore is the epitome of a rational, technocraticstate in which rule is based on supposedly impartial, objective criteria. The government’s achieve-ments in the delivery of health care are at the forefront of its showcase of technocratic achieve-ments. This article uses the Singapore government’s innovations in health-care funding as a casestudy to explore and test the limitations of trying to apply purist technocratic premises and meth-odologies to governance. The limitations it uncovers raise the question of whether a technocraticapproach to governance can ever deliver the promised results and suggests that the attraction of‘‘technocracy’’ is a chimera.

KEY WORDS: Singapore, health-care policy, health-care financing, technocracy, MedicalSavings Accounts, governance

In 1982 Singapore’s then-Health Minister Goh Chok Tong declared that his

country’s British-style health system was among the ‘‘best in the world.’’ This was

a brave boast, but there was more to come. In the same speech he foreshadowed a

complete overhaul of the system in a quixotic quest for efficiency: ‘‘We should not

rest on our laurels, looking down from Mount Everest. In organisational efficiency,

in the pursuit of quality and excellence, there can be no highest peak,’’ he declared

(Goh, 1982). The key words in this passage were ‘‘efficiency,’’ ‘‘quality’’ and

‘‘excellence.’’ The resultant reforms turned the Singapore health system into a

multi-generational ‘‘work in progress’’ in which ‘‘organisational efficiency’’ and

‘‘quality and excellence’’ were identified as the primary benchmarks of success. The

original vision enunciated by Goh Chok Tong in 1982 has provided the essential

organisational culture for the Singapore health service, but, in February 2004 the

current Health Minister, Khaw Boon Wan, raised the bar for hyperbole when he

defined his ideal as a health-care system that has no patients (The Sunday

Times, 29 February 2004). A month later he declared his satisfaction that

Correspondence Address: Michael D. Barr, School of Political and International Studies, Flinders

University, GPO Box 2100, Adelaide SA 5001, Australia. Email: [email protected]

Journal of Contemporary Asia

Vol. 38, No. 3, August 2008, pp. 395–416

ISSN 0047-2336 Print/1752-7554 Online/08/030395-22 Ó 2008 Journal of Contemporary Asia

DOI: 10.1080/00472330802078485

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Singapore’s health-care financing system was ‘‘probably’’ the best in the world

(Khaw, 2004).

By its own bold claims, the Singapore government has consciously set itself up as a

test case of the effectiveness of the relentless pursuit of organisational efficiency,

excellence and quality as the drivers for solving the problem of the cost of delivering

health care in a modern, capitalist society. In doing so it is also putting to the test a

much broader element of its legitimating rationale: its claim that despite the fact that

its style of governance can often appear to be hard-hearted and overbearing, it

should be accepted because it is in fact the application of dispassionate and

disinterested reason and is the key to and basis of Singapore’s success and

prosperity.1

As one of the least democratic of any of the world’s advanced capitalist

societies, and being a tiny, easily managed polity run by Western-educated

technocrats, Singapore is an ideal laboratory for those who believe that there is a

‘‘logical’’ answer to the problems of government, including those of providing

universal, comprehensive and affordable health care in economically advanced

societies. The ruling elite of this small country is convinced beyond all doubt that

it has achieved these ambitions in all or most aspects of governance, and that it is

the epitome of rational rule. As Prime Minister Lee Hsien Loong (2005)

announced proudly in March 2005, the Singapore government has ‘‘shielded civil

servants from political interference . . . [giving them] the space to work out

rational, effective solutions for our problems’’ so they can ‘‘practise public

administration in almost laboratory conditions.’’ This vision that Lee was claiming

to have achieved is, in fact, the ideal of the technocracy: a Utopian vision of

governance that presumes that the system is able to rise above subjective

considerations of politics, ideology and sectional interests by relying on impartial

reason and the technical skills of modern, highly trained professionals. To borrow

the words of sociologist Luigi Pellizzoni (which foreshadow those of Lee Hsien

Loong to a remarkable degree), in a technocracy ‘‘the elite is suitably ‘protected’

against the rest of society and is able to perform its tasks efficiently’’ (Pellizzoni,

2001: 64). Rule in a technocracy is based on supposed impartial, objective criteria

derived directly or indirectly from disciplines such as economics, management, law,

medicine and engineering.2 In the Singapore example, systems engineers have been

given a particular place of honour at the upper executive level of this schema. A

team of systems engineers was even entrusted to reform the education system at

the end of the 1970s to make it efficient and to cut ‘‘wastage’’ (Goh et al., 1979:

3-1; Hochstadt, 1993).3

The government’s achievements in the efficient delivery of health care are at the

very forefront of its showcase of technocratic achievements, which explains why

government ministers are so pleased that their health system is providing a loose

model for health care reforms in both China (Dong, 2006) and the USA (US

Department of Treasury, 2006; US Office of Personnel Management, 2006). The

system generating this pride was built upon the 1984 introduction of medical savings

accounts (Medisave). These medical savings accounts were later supplemented by

catastrophic illness insurance (MediShield) and various supplementary welfare

measures (such as MediFund, ElderShield and the Comprehensive Chronic Care

Programme [CCCP]) (Barr, 2005). The entire system is referred to routinely in a

396 M. D. Barr

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semi-official way as the ‘‘3Ms’’, referring to the central role of Medisave, MediShield

and MediFund.

This is not the place to engage in a comprehensive description of this system, but

since the intention is to explore the implications of applying purist technocratic

premises and methodologies to the provision of health care, a brief overview at least

of the substance of the system is necessary. After this overview, the article will

outline the established reasons to doubt some of the more extravagant claims about

the achievements of the system before interrogating the implications and limitations

of the technocratic ethos behind Singapore’s health system.

The Singapore System in Outline4

Since Goh Chok Tong’s reforms of the mid-1980s, the Singapore government has

been developing an increasingly complex system of health-care financing based on

the principles of personal-cum-family responsibility for costs, enforced by cost-based

rationing and high levels of micro-management in matters of health-care delivery

(even using draconian measures to restrict the number of doctors being trained), but

also subsidised by significant levels of government subsidy. In its original conception

it was to have no insurance component at all. Insurance was identified as a driver in

health-care consumption because it increased the ‘‘moral hazard.’’ Avoiding this

‘‘moral hazard’’ has since been identified by Toh Mun Heng and Linda Low (1991:

9) as the main philosophical driver of the 3Ms system:

A moral hazard problem is encountered when payment of medical expenses is

borne by a third party, either an insurance company or the government,

affecting the individual’s own behaviour. It may lead the individual to

overconsume medical services and his doctor to overtreat. It has nothing to

do with morality but represents a misallocation of resources by a particular

method of finance. Since the third party, be it the government or the insurance

company pays the full cost, the individual bears no financial burden or faces a

zero price for medical care. Consequently, consumption is greater following the

law of demand.

Today the government runs several interconnected health funding schemes. The

core scheme is Medisave, which is effectively a special savings account to which those

in the paid workforce, including the self-employed, must contribute up to 6-8% of

wages or salaried income. Those on very high incomes can cap their contributions,

and those whose Medisave accounts have reached an internal cap (at the time of

writing, $S32,500) can divert their contributions to other approved purposes

(Ministry of Health, 2006a). Members build savings to fund patient co-payments (at

least 19% of cost) in the event of hospitalisation. To protect accounts from being run

down – since Medisave operates without any insurance component – there is a strict

fees schedule for medical services and Medisave will not pay above this. Under this

regime many high-cost services that are routinely funded in other developed

countries are excluded (see below).

Originally access to government hospitals was intended to be facilitated by

Medisave alone. The government discovered, however, that Medisave provided

Singapore’s Technocratic Approach to Health Care 397

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patients with grossly insufficient coverage, so in 1990 it decided to supplement it with

an insurance scheme after all – but only catastrophic illness insurance, not general

medical insurance. This scheme, called MediShield, draws premiums from a person’s

Medisave account and is designed to cover most of the expenses of treating many

major or prolonged illnesses and conditions up to pre-determined caps – but only

after the member has paid a very high ‘‘deductible’’ or ‘‘co-payment’’ from their

Medisave account, their personal savings, or a combination of both (depending on

the rules governing payment for treatment of the particular illness). MediShield

covers about 89% of the population, giving it a slightly better coverage than the

American health insurance rate of 84% (The Straits Times, 4 February 2005).

MediShield initially covered members to age 75, but this was increased to 80 in 2001

and then to 85 in 2005 (Channel NewsAsia, 25 September 2005).

Next came MediFund, a central endowment fund that provides charity-style relief

to those too poor to meet any costs. Interest from the fund is distributed to public

hospitals and charities that allocate assistance on a case-by-case basis. These

facilities are now supplemented by a growing number of targeted insurance and

welfare schemes, such as ElderShield and the CCCP. None of these latter schemes,

however, is designed to provide comprehensive cover. ElderShield, for instance, is an

insurance plan that provides a modest fixed sum per month for up to 60 months to

beneficiaries who suffer severe disability in their old age, while the CCCP piggy-

backs on government polyclinics to provide subsidised long-term health care to those

suffering from three specific chronic conditions: diabetes, high blood pressure and

high cholesterol. It should also be noted that charitable organisations are also an

institutional part of the health financing structure. Voluntary Welfare Organisations,

as they are called, receive government aid and MediFund-based financing to assist

them as they care for many who require long-term institutionalised care.

An anomaly of the system is that nearly one-third of the population is effectively

outside the 3Ms because they are covered by generous employer schemes negotiated

before the current systems were put in place (Hanvoravongchai, 2002).

According to the Singapore Ministry of Health (2004), the financing philosophy of

this complex health-care delivery system is based explicitly on:

. . . individual responsibility, coupled with Government subsidies to keep basic

health care affordable. Patients are expected to pay part of the cost of medical

services which they use, and pay more when they demand a higher level of

services. The principle of co-payment applies even to the most heavily

subsidised wards to avoid the pitfalls of providing ‘‘free’’ medical services.

The ‘‘Singapore system’’ is a continually evolving effort to reconcile the Singapore

government’s aversion to welfare with the reality that, for both economic and

political reasons, it must ensure the provision of health services to the whole

population, including low-income earners and the poor. In fact, the Singapore

system developed as an explicit reaction to the perceived failures of ‘‘social and

health welfare’’ in Europe and the USA – a perception premised more on ideological

preconceptions than on empirical data. In November 1981, on the eve of the move to

introduce medical savings accounts, then Prime Minister Lee Kuan Yew (1981: 8)

told a meeting of government MPs:

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Subsidies on consumption are wrong and ruinous . . . for however wealthy a

nation, it cannot carry health, unemployment and pension benefits without

massive taxation and overloading the system, reducing the incentives to work

and to save and care for one’s family – when all can look to the state for welfare.

. . . Social and health welfare are like opium or heroin. People get addicted, and

withdrawal of welfare benefits is very painful.

It is of some importance to realise that Medisave was not a ‘‘progressive’’ attempt

to ameliorate the effects of a laissez-faire health system, but a bold attempt to

introduce market forces into government-funded health care. Under the previous

system hospital care was free and government clinics were subsidised directly.

Furthermore, there was no immediate funding problem with the old system.

Although per capita costs in simple dollar terms had been increasing by 11% per

annum (Hsiao, 1995), health costs as a proportion of GDP had been falling steadily

since 1960 (Toh and Low, 1991: 26). Even the government’s share of overall health

costs had dropped slightly by the early 1980s, being 68% in 1980; down from 70.1%

in 1970 (Blank and Burau, 2004: 26). This reading suggests that the government’s

introduction of Medisave and hospital fees, along with the use of the rhetoric of self-

help and personal responsibility, was an attempt to both meet and restrict rising

middle-class expectations by replacing government regulation with the archetypal

middle-class mechanisms of financial constraint and self-regulation. If it worked,

then managed self-regulation would provide a sustainable basis for curtailing health

costs into the long term.

The rhetoric of self-help and personal responsibility that permeates public

discussion of the 3Ms suggests that these systems are self-sustaining. In fact, none of

them could function without government micro-management and subsidies. The

government continues to subsidise hospital wards (up to 81% of costs) even after it

ensures that public hospital charges are kept down. Furthermore the entire system of

polyclinics operates on direct government subsidies without drawing on the 3Ms

at all.

The most expensive section of any modern health-care system is hospitals, so it

should not be surprising that the core of the 1984 reforms is found in this sector. The

reforms were foreshadowed as early as the May 1981 announcement that the

government intended to reduce ‘‘subsidies’’ to hospitals and polyclinics (The Straits

Times, 11 May 1981). This initiative was followed by overt government efforts to

encourage the establishment of private hospitals (The Straits Times, 10 April 1982,

24 December 1982), and across-the-board increases in hospital fees (The Straits

Times, 17 December 1982). The expansion of expensive private hospitals at the

expense of subsidised public hospital wards seems to have been an attempt to take

advantage of the perception that Singaporeans had turned a socio-economic corner,

and had become a bourgeois-cum-wealthy society; though the advent of parallel

‘‘privatisation’’ moves in the school sector in the pursuit of ‘‘excellence’’ in the late

1980s suggests that the ‘‘privatisation’’ of health was merely one aspect of a much

broader push that wilfully saw generic benefits in the private sphere.

Regardless of motivation, these moves reached their logical conclusion when the

government announced, in May 1984, that government hospitals would move

towards privatisation, not in the sense that ownership would change, but they would

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be run as private enterprises: collecting fees for services, relying less on government

‘‘subsidies,’’ competing for business, balancing their budgets and relying in part on

profitable private patients (who pay their full treatment and accommodations costs)

to provide income to subsidise public patients. The trailblazer in this new enterprise

was to be the National University Hospital (NUH), which was restructured in 1987,

followed by the National Skin Centre in 1988 and the Singapore General Hospital in

1989 (Toh and Low, 1991: 30-1). American consultants were duly engaged and the

‘‘privatisation’’/‘‘restructuring’’ programme continued into the 1990s, although it

stopped a long way short of including all government hospitals. The NUH provided

the model for the ‘‘restructured’’ hospitals. It was broken down into 50 cost centres

that had to pay their own way. One interpretation of NUH’s experience was

provided by Toh Mun Heng and Linda Low in 1991, who began by observing that:

The ‘‘privatisation’’ exercise at NUH is said to have provided new and more

personalised services, promoted staff motivation, deployed nurses more

effectively, and enabled greater financial accountability, among other advan-

tages. . . . Doctors are made more circumspect when requesting certain tests

which indirectly keeps the cost to patients under control, too.

Yet this rosy view was balanced by some strong criticisms that questioned the value

of the entire enterprise:

On the other hand, charges in the NUH have increased . . . . Government

subsidies have not remained at the same level over the years. . . . There is no

concerted effort to contain costs with measures aimed at the supply side, such as

physicians’ earnings and mode of practice.

These authors continued, observing that the ‘‘benefits of ‘privatisation’ of the NUH

are difficult to prove or refute given the paucity of information and financial data

[released by the government and NUH]’’ (Toh and Low, 1991: 32).

One could add that, in terms of public accountability, nothing much has changed

since this assessment and there is still no reliable basis for judging the strengths and

weaknesses of the overall ‘‘privatisation’’ programme.

In 1999, the government restructured public hospitals into two regional clusters,

the National Healthcare Group and Singapore Health Services. Each comprises one

of Singapore’s two major tertiary hospitals, as well as general hospitals, a number of

specialist centres and institutes (such as the National Cancer Centre), and

government polyclinics. The government believes that by micro-managing both

demand and supply, it can make the system efficient and cost-effective, minimising

waste and maximising service delivery.

Implicit in government control of inputs and the introduction of ‘‘business’’

principles to health management is the principle of rationing health services based on

wealth. The 1993 White Paper on Health stated this without voicing the criteria of

wealth:

We cannot avoid rationing medical care, implicitly or explicitly. Funding for

health care will always be finite. There will always be competing demands for

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resources, whether the resources come from the State or the individual citizens.

Using the latest in medical technology is expensive. Trade-offs among different

areas of medical treatments, equipment, training and research are unavoidable

(Ministerial Committee on Health Policies, 1993: 17).

The ‘‘Singapore system’’ is thus a continually evolving effort to reconcile the

conflicting demands in the Singapore government’s ideological, economic and

political agendas. Regardless of any other criticisms that might tarnish its record, it

should be acknowledged that as a result of this system, Singapore runs a

modern, effective health system that absorbs only 3.63% of GDP (Ministry of

Manpower, 2004) and 7.4% of government expenditure (Ministry of Finance,

2004). The government and many others attribute its success primarily to the

3Ms, with perhaps the strongest claim coming from the current Minister for

Health who told Parliament in 2004 that ‘‘our 3M framework is far from perfect,

but it is probably the best healthcare financing model in the world today’’ (Khaw,

2004).

Routine Scrutiny

With such an imprudent record of boasts from successive Health Ministers, it seems

only proper that the system be brought under critical scrutiny. Yet this is not as

straightforward as one might expect. Even the simple claim of having kept health

expenditure low is difficult to verify because the Singapore government does not

follow Organization for Economic Co-operation and Development (OECD)

standards in measuring health expenditure. This makes international comparisons

extremely difficult. Furthermore, the government is highly secretive about the

detailed operation of its system, and has made neither the data source nor method of

its calculations available to anyone outside those in the civil service and the

government who need to know. So, although one can say safely that expenditure is

low by Western standards, it may well be higher than the government’s published

figures suggest.

The extensive list of exclusions from the 3Ms system also makes it difficult to

establish a meaningful standard of international comparison. To make a very explicit

comparison, the MediShield list of exclusions includes most of the services that have

been identified as major drains on hospital budgets in the Australian health system at

the end of the 1990s: cardiovascular disease, control of cancer, care involving

dialysis, and care related to the treatment of HIV, mental health and diabetes. The

basis of this comparison is spelt out in Barr (2005), but essentially a comparison is

being made between the Singapore system and Australia’s list of National Health

Priority Areas (NHPA). The NHPA was an initiative of Australia’s nine

commonwealth, state and territory governments, and focuses on ‘‘diseases and

other conditions that contribute most significantly to Australia’s burden of illness

and for which there is potential for the burden to be significantly reduced’’

(Australian Institute of Health and Welfare, 1999: 93). The NHPA list accounted for

40% of total hospital patient days in Australia in 1998-99. In Singapore, when it

comes to outpatient renal dialysis, radiotherapy, chemotherapy, and AZT treatment,

patients have not only been forbidden from using MediShield funds, they have also

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been forbidden from committing their future Medisave funds, as is allowed for the

treatment of many other conditions.

The burden on the Singapore health system has also been lightened drastically by

the extraordinary youth of the society5 – an advantage that is now acknowledged by

the government in the context of discussions about future challenges (The Straits

Times, 15 November 2006). In 1991, 6.2% of Singapore’s population was aged 65 or

over, as opposed to proportions between 10.9% and 15.4% for the USA, Canada,

UK, Australia, New Zealand and West Germany (Ministerial Committee on Health

Policies, 1993: Appendix B). In 1988, the Ministry of Health estimated that by 2030,

52% of the population would be 60 years or older, though later figures suggest that

this trend may have slowed (Low, 1998). This is a serious concern for the

government when it is realised that in 1996, the aged of Singapore (65 and over) were

admitted to hospital at 2.8 times the frequency of their younger counterparts, and

stayed in hospital an average of 1.66 times as long. They were also higher consumers

of the two most heavily subsided classes of ward (Prescott, 1998: 43). Thus, an

increase in the proportion of the aged will inevitably increase demand for health

services.

A further factor contributing to the low expenditure on health is the anomaly of

Traditional Chinese Medicine (TCM). It is commonplace among Singaporeans to

rely on a mixture of Western and traditional medicines, or even to turn to Western

medicine only as a last resort. The Ministry of Health estimates that about 12% of

daily outpatient users also visit TCM practitioners (Ministry of Health, 1995), and

even though TCM has been regulated by the Ministry of Health since November

2000 (Ministry of Health, 2006b), it is excluded from national health expenditure

figures, thus artificially depressing expenditure figures.

Despite the government’s avowed intention to reduce health expenditure, and its

routine claims to have contained costs, it seems that the introduction of Medisave in

1984 did not reduce or even contain health expenditure. In fact, immediately

following the introduction of Medisave in 1984, the rate of increase in health

expenditure per capita jumped from 11% to 13% per annum (Hsiao, 1995). The

share of GDP absorbed by health expenditure also increased in the immediate post-

Medisave period, due largely to a sudden increase in expenditure on doctors’ fees

and the purchase of new technology as hospitals competed with each other for

business and reputation in the new fee-paying environment (Toh and Low, 1991).

It should also be realised that while the Singapore health system has delivered

impressive statistics in terms of some major health indicators, notably longevity and

infant mortality. Even so, in 2000, the World Health Organisation ranked Singapore

only thirtieth in the world for the overall health of its population, using measures

such as the average age of the onset of disability and the rate of incidence of illnesses

that seriously affect not only life expectancy, but also quality of life (King, 2006:

353). On this ranking, health systems from countries such as Japan and Australia are

far superior in maintaining a healthy population than is the Singapore system.

A further dampener is placed on the more extravagant claims of the Singapore

government when one compares the outcomes of the Singapore health system with

those of societies that are, in various ways, more comparable than are Western

countries, such as the UK, USA and Australia. Japan, South Korea, Taiwan and

Hong Kong, for instance, have somewhat similar societies to that of Singapore, all

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being economically advanced East Asian societies, but they have very different

health systems that nevertheless produce results comparable to – and, in some cases,

significantly better than – those of Singapore in areas such as longevity and infant

mortality (Gauld 2005; Gauld et al., 2006: 326-27). Furthermore, with the exception

of Japan, their total health expenditure per capita (in US dollars at Purchasing

Power Parity) is actually less than Singapore’s (Gauld et al., 2006: 326). In the case of

Taiwan, it is 22% less (on 2002 figures).

Effectiveness Through Efficiency

These well-established critiques make it clear that the more extravagant claims made

by Singapore’s leadership must be dismissed, but this does not mean that the system

is not worthy of attention. The Singapore health system remains, on the face of it, an

impressive system. And when one thinks of the endemic crises and shortcomings that

beset many other health systems in advanced democratic societies – crises that seem

to be routine in the various states of Australia, for example – one could be forgiven

for thinking that perhaps the Singapore system is still an exemplar of technocratic

methodology after all.

This thinking becomes all the more reasonable when it is acknowledged that the

technocratic methodology does not guarantee absolute perfection, but just a striving

towards perfection based on the constant application of rationality and logic.

Singapore’s current Prime Minister, Lee Hsien Loong, encapsulated the spirit of this

ethos in April 2004 when he told an audience of tertiary students that they must not

be content to inherit and enjoy the Singapore built by their parents and

grandparents. Instead he asked them to ‘‘change it, improve it and build on it’’

(The Straits Times, 6 April 2004). Several months later he delivered a similar message

at the National Day Rally:

We can never afford to be satisfied with the status quo, even if we are still okay,

even if our policies are still working. People say, ‘‘If it ain’t broke, don’t fix it’’. I

say, if it ain’t broke, better maintain it, lubricate it, replace it, upgrade it, try

something better and make it work better than before (Lee, 2004).

Between them Lee’s speeches encapsulate the spirit of Singapore’s technocratic rule

in a general way, but to identify the application of this spirit in the administration of

the health system, in particular, calls for a return to Goh Chok Tong’s 1982 speech,

with which this article opened. The two sentences quoted above from Goh’s 1982

speech fail to convey the full import of his message, so a fuller quotation is

reproduced here:

We have a hospital service that we can be proud of. It stands up to comparison

with the best in the world. But having said that, I hasten to add that we should

not rest on our laurels, looking down from Mount Everest. In organisational

efficiency, in the pursuit of quality and excellence, there can be no highest peak.

It is not like Mount Everest which you can climb and plant a flag and proclaim

you have reached the peak. Of course, climbing Mount Everest is in itself a great

achievement, as only a few can reach that height. But this organisational

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mountain of ours is even higher than Mount Everest. It is so high that even at

20,000 feet you cannot see the peak, even on a clear day (Goh, 1982).

The imaginative analogy with mountain climbing is wont to distract attention from

Goh’s central message – which perhaps accounts for the academic neglect of this

pivotal speech. It is clear that Goh was foreshadowing a major restructure of the

Singapore health system – and indeed a radical new system of health care and

hospital funding was introduced two years later. It is also indicated from the

hyperbole that this reform was going to be an ongoing quixotic quest for perfection –

and indeed the system has, since 1982, been a continually evolving project in which

the ‘‘summit’’ of perfection always seems to be just out of sight even though it is

always said to be getting closer. Yet the core sentence contains a radical proposition

that has not been given serious attention. It reads, ‘‘In organisational efficiency, in

the pursuit of quality and excellence, there can be no highest peak.’’ The goals

identified by Goh were unambiguously ‘‘efficiency’’ and ‘‘quality and excellence,’’

but the relationship between them is less clear. The sentence can perhaps be read as

calling for ‘‘efficiency’’ and ‘‘quality and excellence’’ equally, but, if so, then it was an

uncharacteristically sloppy piece of speechwriting. These two ideals potentially and

routinely stand in opposition to each other in health care, as in most aspects of life

and business. Alternatively, this sentence can be reasonably read as defining ‘‘quality

and excellence’’ in terms of ‘‘organisational efficiency.’’

On this reading, ‘‘organisational efficiency’’ is the master concept that provides the

conceptual parameters by which the system is to be judged, and the prioritisation of

‘‘organisational efficiency’’ was, in fact, the deliberate message of Goh’s speech, with

his reforms following these principles to the letter. They turned the Singapore health

system into a multi-generational ‘‘work in progress,’’ in which the unending quest for

‘‘organisational efficiency’’ was identified as the primary goal, and ‘‘quality’’ and

‘‘excellence’’ were conceptually and actually subservient: they were, in fact, regarded

primarily as outcomes of ‘‘efficiency’’ and defined in terms of ‘‘efficiency.’’ This focus

on organisational efficiency (which quickly came to subsume the objective of

minimising government expenditure on health) has shaped the Singapore health

system in both positive and negative ways. On the one hand, it has led to the

production of an impressive infrastructure that delivers high quality health care to

most of the population most of the time. On the other hand, the emphasis on

systemic perfection breeds an element of blinding hubris that tends to make the

system prone to rather spectacular failings.

It is the proposition here that the quest for efficient systems has led the Singapore

health system to crisis point, potentially putting lives and health at risk. With

‘‘efficiency’’ as a starting point, the government measures ‘‘effectiveness’’ by

averages, metrics and the degree to which the wastage of resources is minimised

(Khaw, 2004). Hence the government is inordinately proud to announce health

achievements such as Singapore’s ranking as the most cost-effective health care

system in ASEAN (Channel NewsAsia, 22 October 2004) and that its rate of

health expenditure is drastically lower than those in countries such as the UK and

the USA (Khaw, 2007). These objectives are, of course, worthy in themselves, and

the system should be credited with achieving good scores on these measures, but this

mindset is prone to create a tunnel vision focused on throughput and average

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outcomes, which shifts focus from the health system’s core business of patient care

and public health.

Impurities in ‘‘Technocratic’’ Approach

There is concrete evidence that this type of problem is endemic at the level of health

administration, and that it operates in ways that impact negatively on the quality of

health service, but, before considering this evidence, it is important to make the point

that there are good grounds for believing that the supposedly value-free, rational

technocratic approach of the Singapore government to health policy is compromised

severely by the operation of a priori assumptions and prejudices based on socio-

economic class and gender (to name just two areas), and by the surprisingly strong

impact of public opinion in matters of health care. These distorting influences can be

demonstrated as being at the core of the thinking of the designers of the system.

A priori assumptions and prejudices. First, although the efficiency-driven approach

being studied here is justified as the outcome of technocratic discipline, it would be

truer to say that the idolisation of efficiency is one a priori assumption among many

that have actively contributed to the character of the health system. The ideological

rejection of ‘‘welfare-ism’’ that originated with Lee Kuan Yew has already been

referred to. This was presented as a logical if unpleasant application of logic, but an

alternate reading is that the Singapore government, dominated by middle-class

politicians and technocrats, was transforming the health system into one that

reflected their class’ expectations by introducing the archetypal middle-class

mechanisms of tight financial responsibility, self-regulation, rationing access to

services on the basis of wealth, and turning public goods into commercial enterprises.

This observation might be accepted as being merely a viable alternative to the

government’s explanation, except that it can be demonstrated that this reform of the

health system was part of a broader pattern of the embourgeoisement of the public

services, and reforms in housing and industrial relations that reveal explicitly middle-

class societal views and prejudices.

The other public good that was transformed in this way during the mid-1980s was

the education system. Then-Education Minister Tony Tan took for granted that the

best students would excel academically in Singapore schools, but according to

Eugene Wijeysingha, a civil servant who took instructions directly from Tan,6 he

wanted schools that would build their character and turn them into ‘‘gentlemen.’’7

To this end he engaged in what was effectively a programme of the gentrification of

elite education to parallel the privileging of elite education per se. Tan’s first step was

taken in 1986 when he commissioned a group of 12 secondary school principals,

including Wijeysingha, to tour a collection of elite schools in the UK and the USA,

apparently to find the best way to implement privatisation initiatives that had been

publicly urged by Prime Minister Goh Chok Tong the previous year. The result was

a 76-page report titled Towards Excellence in Schools, which was substantially

implemented over the next few years. The principals recommended that selected

schools be effectively privatised and given both considerable autonomy and extra

resources to enable them to offer a better study environment and school experience.

In the full spirit of this ‘‘privatisation,’’ the Independent schools were given

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government grants of $S1 million each to launch their endowment funds (The Straits

Times, 1 September 1987) and began charging fees that have progressively moved

from being nominal in the 1980s to very substantial in the 2000s (Business Times, 3

November 1989; The Straits Times, 11 August 1990, 29 November 2005).

Unsurprisingly, these newly created ‘‘independent’’ schools quickly came to be

dominated by the children of middle-class and professional parents (Goh et al., 1987;

Tan, 1993: 245-6).

It stretches credulity to assert that the almost-simultaneous embourgeoisement of

both the health and the education systems could have been a coincidence or the

result of the independent application of objective ‘‘reason,’’ but, in any case, the

reader is not being asked to accept these two pieces of evidence in isolation. Even

before these initiatives had manifested themselves in health and education, the

government had already taken measures in the areas of housing and industrial

relations that should remove all doubt about the operation of a middle-class bias in

its approach to governance. In the area of housing, it took steps in 1980 to ensure

that each housing block (in the government-run housing estates in which 67% of the

population lived at that time (The Straits Times, 1 October 1980)) had a number of

middle-class professionals as residents. There is no need to speculate on whether

there were middle-class presumptions motivating this move because Lee Kuan Yew

stated explicitly that the reason for this initiative was to ensure that ordinary people

could benefit from the ‘‘quality community leadership’’ that would be provided by

these ‘‘better education people’’ (The Sunday Times, 30 November 1980). A similar

set of middle-class presumptions were operating in the field of industrial relations in

the same period. From the mid-1970s onwards the trade unions were subjected to a

parallel incursion of well-educated, middle-class ‘‘talent,’’ whereby professionals

(university-trained engineers, etc.) were parachuted into leadership roles in the union

movement, coming to dominate the leadership of the National Trades Union

Congress and most trade unions during the early 1980s (Barr, 2000a). In 1980, Lee

Kuan Yew justified this programme on the grounds that ‘‘the unions must have their

quota of talent’’ (Barr, 2000b: 116). Moreover the field of industrial relations also

saw the introduction of a 12-hour shift for factory workers in the mid-1980s, an

initiative that pleased employers unreservedly but showed contemptuous disregard

for the health and family lives of factory workers (Koh, 2007). These examples are

not the only pieces of evidence that indicate the presence of a middle-class agenda at

the core of the government’s reform programmes in the early to mid-1980s, but they

are sufficient to leave no room to doubt that it was the case. The significance of this

for our consideration of Singapore’s system of health-care financing is that the

government was supposed, according to its own logic, to be completely free of such

biases, but this was clearly not so.

Beyond these class-based factors, further evidence of the distortion of reason and

logic in the operation of the Ministry of Health’s basic premises is found in the

restrictive cap on the number of female candidates allowed into the local medical

school. This cap was imposed in 1979 and was lifted only at the end of 2002 (Business

Times, 6 December 2002). It was justified by the assumption that women would

withdraw from their profession either partially or completely after marriage and

starting a family (Kong et al., 2000: 515-16). Its effect on the operation of the health

system is minor compared to the impact of the class-based distortions described

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above, but it is mentioned because its continued operation into the early years of the

twenty-first century demonstrates how far the Ministry of Health is from being the

rational, logical, sophisticated and modern creature that it claims to be.

Public opinion and politics. The second set of grounds for doubting the purity of the

Singapore government’s technocratic approach to health care is a consideration of

the potent operation of public opinion in this field. Although the government is the

only proactive driver in health-care policy, the end result is a compromise between

the ‘‘efficiency’’-driven, technocratic assumptions of government, and strong

reactions from the public. It is an understatement to say that public opinion is not

generally a powerful factor in Singapore governance because the government is such

a strong and overbearing player in politics, but – probably because health issues

affect the lives of Singaporeans so intimately – it has nevertheless been a significant

contributor to shaping health policy. According to the ideology of technocracy, such

impacts are an irrational impediment to the quest for efficiency, but it is argued that

they account for much of the positive outcomes for which the government takes

credit. The key health issues raised routinely in newspaper articles and features, in

the ‘‘forum’’ pages of newspapers, by opposition political parties and by government

backbench MPs (reflecting in turn the concerns raised in their ‘‘Meet-the People’’

sessions in their constituencies), revolve around the access of the poor and the lower

middle classes to affordable health care.

The vulnerability of the poor and the elderly was highlighted in 2005 when the

government closed the evening service offered by the government polyclinics at

the same time that it was inadvertently focusing public attention on the plight of the

middle class by threatening to end their access to the cheap C Class wards in

government hospitals. Such is the expense of being sick in Singapore that even the

middle class are scared of the cost of the high ‘‘co-payments’’ and the large gaps

between the amount covered by Medisave and MediShield and the actual bills

received from the hospital. These problems moved to the front of the government’s

mind, not because of any efficiency-driven review conducted by its technocrats, but

because public discontent threatened the government in the 2006 elections. The most

spectacular eruption of the issue was the unprecedented spectacle of Health Minister

Khaw being berated for a quarter of an hour by an aged constituent, but the more

serious threat came from the opposition Workers’ Party, which campaigned strongly

on the issue (Channel NewsAsia, 4, 14 May 2006). The unambiguous result of this

engagement was Khaw’s mid-campaign announcement that he was deferring

indefinitely the introduction of a means test for access to the highly subsidised C

Class wards (Channel NewsAsia, 2, 3, 4 May 2006). Not since the late 1980s had the

government engaged in such a spectacular volte face – and significantly on that

occasion the issue was also about access to C Class wards, and it was brought about

by the most vehement expressions of concern by government backbenchers passing

on the concerns of their constituents.8 The government presents the history of

incremental change in the health system since the original introduction of Medisave

in 1984 as a triumph of reason and efficiency, directed towards the noble end of

providing affordable health care for all, but without the input of ordinary politics it

is doubtful that the regime and its mandarins would have seen any pressing need to

engage in this masterpiece of micro-management. Granted that Medisave was

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originally intended as the final word in health-care financing, and taking into

account the middle-class preconceptions from which the government was and is

operating, the gradual watering down of the original drive against ‘‘moral hazard’’ is

evidence that the operation of politics is the key dynamic in the evolution of the

system, and insofar as the Singapore health system is a showcase, Singapore’s

vestiges of democracy deserve at least as much credit as does its technocratic ethos.

Today, when the Health Minister focuses seriously and systematically on ways to

reduce costs to the consumer and plugging the myriad gaps in 3Ms coverage that he

admits often leave people with huge medical bills (Channel NewsAsia, 14 August

2006; The Straits Times, 19 October 2006), he is giving witness to the impact of even

a modest degree of democratic forms, rather than the brilliance of his technocrats.

Separate Problems?

The remainder of this article focuses on some faults in the Singapore health system

and argues that they are all the result of a common systemic failing. In essence, it is

argued that the most basic publicly stated premise on which the Singapore

health system has been built – the premise of striving for technocratic efficiency –

is responsible for its most spectacular and serious failings, rather than its

achievements.

Spectacular Failures

When considering the Singapore health system’s record of public failures, it should

be noted that given the right setting and provocation, Singapore’s leaders are willing

to concede that their health system’s record of achievement is less perfect than they

claim in moments of bravado. A number of examples can be cited. First, there was

the government’s delayed response to the SARS epidemic in 2003. For the first five

weeks of the SARS outbreak (13 March-20 April, 2003) there were no protocols or

contingency plans to deal with an epidemic that had infected 65 people in its first

fortnight (The Straits Times, 25 March 2003). The responses, such as they were, were

ad hoc and reactive. The public marker of the ending of this rudderless period was

the effective removal of the SARS response from the hands of then-Health Minister

Lim Hng Kiang – who in March had asked the public to accept some deaths as

inevitable (see The Straits Times, 25 March 2003) – and the creation of two

ministerial committees to handle the crisis (The Sunday Times, 20 April 2003). It was

five weeks (13 March-17 April) before the government began supplying free

ambulances to take suspected SARS cases to hospital (Ministry of Health, 2004).

Until then, suspected SARS cases generally made their own way to hospital by taxi

or public transport, as was recommended by official bodies, such as the Office of

Student Affairs at the National University of Singapore.9 As the current Head of the

Civil Service, Peter Ho, has since acknowledged: ‘‘We were surprised by SARS. We

were surprised by its epidemiology. We were unprepared for it. But we should have

been prepared. It was not a fundamental surprise, because we knew that the risk of a

highly infectious epidemic existed’’ (Ho, 2005: 3).

The truly frightening aspect of this episode is that it was only because SARS

threatened the family of the then Senior Minister Lee Kuan Yew at the five-week

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mark, when his wife was rushed to hospital with a suspected case of SARS, that

Cabinet finally began to take SARS seriously (The Straits Times, 26 April 2003) –

and even then it took the direct intervention of SM Lee himself to galvanise

Cabinet into action. This is not the sign of an efficient or far-sighted health system,

but one that requires the most severe shocks to overcome a culture of

complacency.

Of more serious political consequence for the government was its failure to

adequately oversee the National Kidney Foundation (NKF). The NKF is notionally

an independent charity but is, in fact, an integral part of the health system as the

main provider of kidney dialysis. Suffice to say that it is only thanks to the operation

of the NKF that the government can afford to exclude dialysis and kidney-related

treatments from the 3Ms (and even when it was operating properly, as in the mid-

1990s, the death rate from lack of access to dialysis was averaging not less than 30

per year [The Straits Times, 3 September 1997]). Yet, in 2005, the NKF was exposed

as a corrupt institution that was grossly abusing public trust as well as public money.

In its official report on the gross mismanagement of the NKF, auditing firm KPMG

was scathing:

Power was centred around one man, and was exercised in an ad hoc manner

through [CEO] Mr [T.T.] Durai and his coterie of long-serving assistants.

. . . The NKF appeared to run and operate, and in fact did run and operate, on

the ideas, whims and caprice of the chief executive (comments drawn from

Today, 20 December 2005 and Reuters, 19 December 2005).

Not that any government instrumentality or personnel can take credit for uncovering

the NKF abuses. That honour goes to a humble plumber who was scandalised when

contracted to install gold-plated taps and a luxurious toilet seat in the NKF

executive office (Today, 26 December 2005). On this occasion the government was

saved from facing serious consequences by the ineptness of its domestic political

opponents – the Opposition Singapore Democratic Party (SDP) made the strategic

error of questioning the integrity of the government rather than its competence. By

questioning the government’s integrity, the SDP invited a libel action that made it

impossible for the NKF issue to be raised during the 2006 General Election

campaign (The Straits Times, 26 April 2006; The Business Times, 11 May 2006). Yet,

even so, as a direct result of this fiasco the Health Minister apologised to the public,

conceding that he had been made to look ‘‘silly’’ (The New Paper, 23 December

2005), and the government conducted a major review of dialysis access, instituted

audits of all Voluntary Welfare Organisations and overhauled its own procedures for

overseeing these critical areas of health and welfare policy.

It could be argued that the NKF and SARS are not a fair basis on which to

judge the Singapore health system because they are both outside the 3Ms and so

off the main stage of the health system. There are two answers to this objection.

Regarding the consideration of the NKF, there can be no reasonable basis for not

including dialysis treatment as part of mainstream health care. Regarding SARS,

any health system must be judged as much by its capacity to cope with crises as it

does with routine demands. That expectation is intrinsic to the nature of health

care.

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Systemic Failures

It is more difficult to interrogate the systemic core of the health system at the

more mundane level of day-to-day practice because the government maintains

close control over the relevant information, and it is generally successful in

ensuring that only flattering information is released. Yet there are a few clear and

public signs that the ethos of so-called efficiency-driven management of health

care is driving down the standard of health care. These centre around a critical

shortage of both hospital beds and doctors, both of which are putting lives at

risk on a daily basis.

First, the current shortage of hospital beds should be considered. Singapore’s ratio

of hospital beds to population stood at 1: 348 in 2004 (Ministry of Health, 2004).

The most recent figures available show that after a year of intensive expansion this

figure had improved to 1: 278 by 2005 (Ministry of Health, 2007). This is a

commendable improvement, but, to put it in perspective, it needs to be realised that

in 1960 (one year out from full colonial rule), the ratio of hospital beds to population

was 1: 229 (Lim, 1989: 174), making the 2004 figure a deterioration of 52% in 44

years and the 2005 figure ‘‘only’’ a deterioration of 21% in 45 years. In fact, the 2005

figure is still worse than that of 1985 (in the first year after the reforms of 1984) when

the hospital bed-to-population ratio stood at 1: 259 (Lim, 1989: 174). Oddly enough,

the government regards this as an achievement. In his Budget Speech on 17 March

2004, Health Minister Khaw Boon Wan made it clear that the focus on efficiency and

cost savings provides the core of the Singaporean health-care philosophy and he

stated explicitly that he considers less consumption of public health services to be a

positive outcome in its own right, and conclusive proof that the Singapore health

philosophy of personal responsibility and self-help is among the world’s best practice

(Ministry of Health, 2004).10 Yet, in his less boastful moments, he admits that the

shortage of beds is a problem that needs to be addressed because it is adversely

affecting the delivery of health care: hence, his strenuous efforts to increase the

number of beds over the last year and his lamentation that these initiatives are

several years too late to address the crisis (Today, 11 July 2006). Minister Khaw now

admits that the shortage of beds is ‘‘stressing’’ doctors and patients: ‘‘Stressful,’’ he

says, ‘‘in the sense that, every day, our doctors have to go down to beg the patients

[to be discharged]’’ (Today, 25 May 2007). Yet, despite the obvious seriousness of the

problem, his belated announcement of the opening of 200 beds by 2009 reveal the

continuing presence of the mentality that led to the shortfall in the first place. He

lamented that since public hospitals are heavily subsidised, ‘‘the more beds I add, I

know tomorrow they will be filled up’’ (Today, 11 July 2006), by which he seemed to

imply that it is the availability of subsidised beds, rather than illness, that drives

people to hospital, ignoring the more likely explanation that there are currently

people sick at home who should be in hospital.

Yet, even the hospital-to-population ratio cited above ignores the recent

phenomenon of international medical tourists who have also been placing increasing

demands on the Singapore health system. According to Khaw, medical tourism

attracted 200,000 international patients in 2002, 374,000 in 2005 and is increasing at

a rate of 20% per annum, with a target of one million patients per year by 2012

(Ministry of Health, 2007; Australian Doctor, 23 March 2007), leaving one to wonder

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how many Singaporeans have benefited from the recent and planned improvement in

the hospital bed-to-population ratio.

With such statistics as a background, it should come as no surprise to learn that

Singapore also has, according to Yong Ying I, Permanent Secretary in the Ministry

of Health, the worst doctor-to-patient ratio in the developed world – 1: 652 in 2007,

up from 1: 640 in 2005 (Agence France Presse, 21 February 2007; Ministry of Health,

2007). The low doctor-to-patient ratio is regarded in the Ministry as a serious

problem and teams have been sent to Australia and London to recruit as many as

they can from outside normal channels. In the longer term the Ministry intends to

nearly treble its output of locally trained doctors from over 200 to about 600 per

annum (Agence France Presse, 21 February 2007).

Doctor shortages have multiple effects on patient care, the most obvious being

that it increases waiting times and deters people from seeking routine medical

services, but it also places stress on doctors and gives them incentives to push

patients through as quickly and as routinely as possible, leading to mistakes and the

premature discharge of patients. Yet, this phenomenon also contributes directly to

the high throughput of patients of which the government boasts as evidence of the

efficiency of its hospitals (The Straits Times, 8 March 2007). Yong Ying I

understated the situation when she said that ‘‘We have very efficient doctors and they

work very hard. But somewhere along the way we also don’t have enough’’ (Agence

France Presse, 21 February 2007).

Both these shortages – of doctors and hospital beds – are the direct result of

government policy described earlier that deliberately restricted the supply of doctors

and hospital beds to avoid increased consumption of health care. By the

government’s own logic of the dangers of ‘‘moral hazard,’’ the doctor and hospital

bed shortages are at the heart of Singapore’s ultra-efficient health-care system and

are major contributing factors that have contributed to that reputed efficiency, yet

now both are admitted to be serious problems, undermining the capacity of the

health system to service its own population. This is part of the problem with running

a system whose goals are all fashioned in terms of ‘‘organisational efficiency.’’

The emphasis on ‘‘organisational efficiency’’ has had yet another deleterious effect.

It is not ‘‘efficient’’ to build in a capacity to meet infrequent or unlikely scenarios,

so the whole system – right down to the pattern of coverage and limitations by the

3Ms – is based upon an assumption that dealing with averages and common patterns

is best practice because it is an ‘‘efficient’’ way to produce good measurable (average)

outcomes. This ethos is becoming increasingly problematic for the government

because the ‘‘unexpected’’ seems to be arising with increasing frequency, possibly

because Singapore has positioned itself so successfully as a regional cross-road and

so is open to every bug that is floating around the region. Yet, for whatever reason,

2006 proved to be yet another crisis year for the Singapore health system, with

government polyclinics reporting that queues were so long and staff members so

overworked that lives were being put at risk, with one death due to mistaken

prescription already recorded (Ministry of Health, 2006c). In the same period the

public hospitals struggled to cope with an increase in the number of patients, largely

due to outbreaks of dengue fever and influenza (Ministry of Health, 2006c) and, as

Health Minister Khaw has admitted implicitly, the failure of Ministry of Health

planners to provide enough beds to cover peak demand (Today, 11 July 2006). Yet,

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such is the power of the drive to achieve efficiency and eliminate the ‘‘moral hazard’’

that hospital beds are provided only reluctantly, even to cater for an influenza

epidemic.

The explicit admissions of failures by the Health Minister and his Permanent

Secretary reveal that it is at the very ordinary level of affordability and availability

that the system is facing the most strain. This problem is of particular interest

because it is thoroughly systemic: it affects the poor (especially the female elderly

poor – see Chia and Tsui (2005)), the middle class and anyone with a serious chronic

illness. This is a reach that makes everyone except the very wealthy and those lucky

enough to be on generous employer-sponsored schemes – which the government is

phasing out in any case (Hanvoravongchai, 2002) – feel a considerable level of

vulnerability (Prescott, 1998: 2).

The issue has driven the Health Minister to focus seriously and systematically on

ways to reduce costs to the consumer and plug the myriad gaps in 3Ms coverage

(Channel NewsAsia, 14 August 2006; The Straits Times, 19 October 2006), and to

highlight the success of the 3Ms in offering adequate cover to most patients most of

the time (see, for instance, The Straits Times, 23 August 2006). Talk of incremental

modifications to the 3Ms have therefore come thick and fast, including a proposed

extension of MediShield coverage to include some congenital disabilities in exchange

for higher premiums (Channel NewsAsia, 27 October 2006), and extending Medisave

to cover GPs’ bills in relation to some chronic illnesses, including diabetes, high

blood pressure and stroke (The Straits Times, 29 August 2006), with the possibility

of including the treatment of asthma and mental illness (Channel News Asia, 3

November 2006).

Creeping Ordinariness

Of more significance for those who particularly admire the medical savings element

of the Singapore schemes, Khaw has also been quietly but systematically moving the

Singapore health funding model away from its intense focus on medical savings and

giving medical insurance a more central role. He has foreshadowed higher premiums,

broader coverage, lower deductibles and higher caps (The Straits Times Interactive,

12 August 2004; The Straits Times, 17 June, 19 October 2006). Specifically, Khaw

has so far announced that the government plans to reduce the standard MediShield

deductible of $S3000 by about $S500, and to halve the ‘‘gap’’ left by MediShield

coverage of large hospital bills from 40% to 20% (Channel NewsAsia, 21, 22 January

2007). Such moves are radical in Singapore and are being rushed out to meet

pressing political needs, but they are not exactly new or impromptu. They were

broadly foreshadowed by Khaw’s predecessor, Lim Hng Kiang, as far back as 2001

(Channel NewsAsia, 23 September 2001), showing that they are emerging system-

atically from the Ministry of Health’s guided evolution of the health system. Yet,

Khaw has gone further than anyone could have expected and has stated openly that

he is looking at alternative health models, presumably from the West (Channel News

Asia, 17 March 2004).

From the point of view of this consideration of the Singapore health system as

a case study of the application of technocratic approaches to governance, its

significance lies in the fact that if it does prove to be the case that these

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developments mark the beginning of a new pattern of insurance-based health-care

funding, then the Singapore system will increasingly resemble a particularly

parsimonious version of Western health-care systems. It will most definitely not

have the mystique of a cutting-edge pioneering venture developed by brilliant

technocratic minds because brilliant technocratic governments do not normally

take two decades of radical experimentation just to arrive at the point very near

where they started.

Efficient to the Core

Yet, at this stage, the actual changes being implemented and planned (as opposed to

merely mooted) are intended to introduce only incremental changes that will leave

the system intact, with the mantra of ‘‘organisational efficiency’’ as the central

objective and methodology. Consider the following report, taken directly from a

Channel NewsAsia report from 3 November 2006:

Health Minister Khaw Boon Wan says his key priority is to fine-tune and

strengthen the 3M framework of Medisave, MediShield and MediFund – to

make sure quality healthcare is available and affordable to all. One way to

improve healthcare delivery is greater integration across primary, acute and

step-down care between private, public and people sectors. . . . To keep them

out of hospitals, family doctors will play a bigger role. They will help

manage common illnesses like diabetes, high blood pressure and stroke, so

patients will not have to go to hospitals for expensive specialist outpatient

treatment.

The quest for efficiency and cost-effectiveness is commendable, and there can be

no doubt that some of the Singaporean initiatives are very imaginative, but it is of

concern when the health system seems to be devoted to efficiency rather than patient

care. This dichotomy also raises questions about the government’s motivation in its

current campaign to promote Advanced Medical Directives (‘‘living wills’’) onto a

population that is clearly unwilling to embrace them (Channel NewsAsia, 29 October,

6 November 2006).

Conclusion

Where does this leave the supposed miracle of the Singapore health system? It is

touted by the Singapore government as world’s best practice, and regarded by some

as a model for advanced capitalist democracies, but one is left wondering if the key

to the system is merely the government’s monopoly of information and its

authoritarian control of political discourses. It seems to be highly likely that if one

could examine the Singapore health system from the inside, one would find a fairly

ordinary health system with some strong points and many weaknesses – much like

health systems all over the developed world. It is probable that there are aspects of

the system worthy of emulation, but the image of a near-perfect system driven by a

technocratic imperative for efficiency is likely to be revealed as little more than

the result of government spin and tight control of information and, in so far as the

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quest for efficiency is a driving force, it seems likely to be as much a negative as a

positive.

The limitations of the Singapore health system raise the question of whether a

technocratic approach to governance can ever deliver the promised results. The

showcase product of Singapore’s technocratic system of governance has been

examined and a health system beset by contradictions and shortcomings uncovered,

and one which is creeping closer and closer to becoming a ‘‘typical’’ health system.

But should one be surprised? The image of the coldly rational and objective

technocrat was a chimera in any case. The health-care experiment that started in

1984 was indeed bold and innovative, but from the start it was the product of

prejudices and a priori judgements that find their origins in, among other biases,

socio-economic class and gender, which then had to contend with the vital

component of public opinion.

The truly interesting conclusion that can be drawn from this study is not the

positive role of technocracy (which is marginal at best), but the pivotal role of

democracy in providing some level of protection from the ruthlessness of aloof

political leaders and anonymous bureaucrats. Even the tokenistic version of

democracy served up in Singapore has been sufficient to ameliorate the worst

excesses of Singapore’s drive for ‘‘organisational efficiency’’ and to insist that

politicians become a little less aloof. Perhaps if Singapore had a little more

democracy and a little less ‘‘efficiency,’’ it might have an even better health system

than it has now.

Acknowledgement

The author wants to thank the journal’s two anonymous reviewers for their critical and invaluable

input.

Notes

1 There is no shortage of evidence to support the contention that the Singapore government projects

itself as being ‘‘hard’’ but worthy of support because it follows correct prescriptions. For a small

sample of contemporary evidence see Today, 2 and 5 May 2007, which report speeches delivered by two

different government ministers over a period of three days. Headlines of these stories are respectively,

‘‘What’s right, not what’s popular; Buoyant economy, record job creation the result of hard work,

sound policies: PM’’, and ‘‘Why S’pore went the hard way.’’2 The pre-eminent profession in a particular technocracy and in theories of technocracy varies

considerably (see, in particular, Winner (1977: 144-65)).3 This account of Singapore as a ‘‘technocracy’’ is drawn from Barr (2006).4 This overview of the Singapore health funding system is based on Barr (2001, 2005). More detailed

information can be found in these works.5 In 1996, industrialised countries’ per capita health-care expenditure on the aged was up to five times

that of the expenditure on under-65s (in Japan) and rarely less than twice the figure. The Netherlands,

the USA, Australia, Switzerland, Finland, the UK and New Zealand all spent approximately four

times more on the aged than they did on the younger section of the population (Prescott, 1998: 13).6 Eugene Wijeysingha was a former Deputy Director of Education who was posted as principal of Raffles

Institution in 1986 to turn the school ‘‘Independent’’ (The Straits Times, 9 October 1986).7 Interview with Eugene Wijeysingha, Singapore, 11 April 2003.8 The government had been gradually reducing the number of C Class beds in hospitals since the

introduction of Medisave in 1984, but pressure from government backbenchers forced the Ministry of

Health to back down at the end of the 1980s (Toh and Low, 1991).

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9 The author has a copy of an official notice issued by the NUS Office of Student Affairs, dated 1 April

2003, which recommended that people with SARS-like symptoms ‘‘go immediately to the Accident and

Emergency Dept of TTSH [Tan Tock Seng Hospital] by taxi or public transport.’’10 Khaw Boon Wan said: ‘‘Last week, my Ministry published a paper comparing the utilization of

medical services in Singapore with several developed countries. Singapore has done well. We have

lower hospital admissions per capita. Our patients generally do not overstay’’ (Ministry of Health,

2004).

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