Singapore Health Care Case Study

Journal of Contemporary Asia O RoutledgeVol. 38, No. 3, August 2008, pp. 395-416 ^^ T.>.„..™nc„o™

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 hiscountry's British-style health system was among the "best in the world." This wasa brave boast, but there was more to come. In the same speech he foreshadowed acomplete overhaul of the system in a quixotic quest for efficiency: "We should notrest 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 amulti-generational "work in progress" in which "organisational efficiency" and"quality and excellence" were identified as the primary benchmarks of success. Theoriginal vision enunciated by Goh Chok Tong in 1982 has provided the essentialorganisational culture for the Singapore health service, but, in February 2004 thecurrent Health Minister, Khaw Boon Wan, raised the bar for hyperbole when hedefined his ideal as a health-care system that has no patients (The SundayTimes, 29 February 2004). A month later he declared his satisfaction that

Correspondence Address: Michael D. Barr, School of Political and International Studies, FlindersUniversity, GPO Box 2100, Adelaide SA 5001, Australia. Email: [email protected]

ISSN 0047-2336 Print/1752-7554 Online/08/030395-22 © 2008 Journal of Contemporary AsiaDOI: 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 atest 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 deliveringhealth care in a modern, capitalist society. In doing so it is also putting to the test amuch broader element of its legitimating rationale: its claim that despite the fact thatits style of governance can often appear to be hard-hearted and overbearing, itshould be accepted because it is in fact the application of dispassionate anddisinterested reason and is the key to and basis of Singapore's success andprosperity.'

As one of the least democratic of any of the world's advanced capitalistsocieties, and being a tiny, easily managed polity run by Western-educatedtechnocrats, Singapore is an ideal laboratory for those who believe that there is a"logical" answer to the problems of government, including those of providinguniversal, comprehensive and affordable health care in economically advancedsocieties. The ruling elite of this small country is convinced beyond all doubt thatit has achieved these ambitions in all or most aspects of governance, and that it isthe epitome of rational rule. As Prime Minister Lee Hsien Loong (2005)announced proudly in March 2005, the Singapore government has "shielded civilservants from political interference . . . [giving them] the space to work outrational, effective solutions for our problems" so they can "practise publicadministration in almost laboratory conditions." This vision that Lee was claimingto have achieved is, in fact, the ideal of the technocracy: a Utopian vision ofgovernance that presumes that the system is able to rise above subjectiveconsiderations of politics, ideology and sectional interests by relying on impartialreason and the technical skills of modern, highly trained professionals. To borrowthe words of sociologist Luigi Pellizzoni (which foreshadow those of Lee HsienLoong 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 criteriaderived directly or indirectly from disciphnes such as economics, management, law,medicine and engineering.'^ In the Singapore example, systems engineers have beengiven a particular place of honour at the upper executive level of this schema. Ateam of systems engineers was even entrusted to reform the education system atthe end of the 1970s to make it efficient and to cut "wastage" (Goh et al., 1979:3-1; Hochstadt, 1993).^

The government's achievements in the efficient delivery of health care are at thevery forefront of its showcase of technocratic achievements, which explains whygovernment ministers are so pleased that their health system is providing a loosemodel for health care reforms in both China (Dong, 2006) and the USA (USDepartment of Treasury, 2006; US Office of Personnel Management, 2006). Thesystem generating this pride was built upon the 1984 introduction of medical savingsaccounts (Medisave). These medical savings accounts were later supplemented bycatastrophic illness insurance (Medi Shield) and various supplementary welfaremeasures (such as MediFund, ElderShield and the Comprehensive Chronic CareProgramme [CCCP]) (Barr, 2005). The entire system is referred to routinely in a

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semi-official way as the "3Ms", referring to the central role of Medisave, MediShieldand MediFund.

This is not the place to engage in a comprehensive description of this system, butsince the intention is to explore the implications of applying purist technocraticpremises and methodologies to the provision of health care, a brief overview at leastof the substance of the system is necessary. After this overview, the article willoutline the established reasons to doubt some of the more extravagant claims aboutthe achievements of the system before interrogating the implications and limitationsof the technocratic ethos behind Singapore's health system.

The Singapore System in Outline"*

Since Goh Chok Tong's reforms of the mid-1980s, the Singapore government hasbeen developing an increasingly complex system of health-care financing based onthe principles of personal-cum-family responsibility for costs, enforced by cost-basedrationing and high levels of micro-management in matters of health-care delivery(even using draconian measures to restrict the number of doctors being trained), butalso subsidised by significant levels of government subsidy. In its original conceptionit was to have no insurance component at all. Insurance was identified as a driver inhealth-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 isborne by a third party, either an insurance company or the government,affecting the individual's own behaviour. It may lead the individual tooverconsume medical services and his doctor to overtreat. It has nothing todo with morality but represents a misallocation of resources by a particularmethod of finance. Since the third party, be it the government or the insurancecompany pays the full cost, the individual bears no financial burden or faces azero price for medical care. Consequently, consumption is greater following thelaw of demand.

Today the government runs several interconnected health funding schemes. Thecore scheme is Medisave, which is effectively a special savings account to which thosein the paid workforce, including the self-employed, must contribute up to 6-8% ofwages 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 ofwriting, $S32,500) can divert their contributions to other approved purposes(Ministry of Health, 2006a). Members build savings to fund patient co-payments (atleast 19% of cost) in the event of hospitalisation. To protect accounts from being rundown - since Medisave operates without any insurance component - there is a strictfees schedule for medical services and Medisave will not pay above this. Under thisregime many high-cost services that are routinely funded in other developedcountries are excluded (see below).

Originally access to government hospitals was intended to be facilitated byMedisave alone. The government discovered, however, that Medisave provided

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patients with grossly insufficient coverage, so in 1990 it decided to supplement it withan insurance scheme after all - but only catastrophic illness insurance, not generalmedical insurance. This scheme, called MediShield, draws premiums from a person'sMedisave account arid is designed to cover most of the expenses of treating manymajor or prolonged illnesses and conditions up to pre-determined caps - but onlyafter the member has paid a very high "deductible" or "co-payment" from theirMedisave account, their personal savings, or a combination of both (depending onthe rules governing payment for treatment of the particular illness). MediShieldcovers about 89% of the population, giving it a slightly better coverage than theAmerican 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 2001and then to 85 in 2005 {Channel NewsAsia, 25 September 2005).

Next came MediFund, a central endowment fund that provides charity-style reliefto those too poor to meet any costs. Interest from the fund is distributed to publichospitals and charities that allocate assistance on a case-by-case basis. Thesefacilities are now supplemented by a growing number of targeted insurance andwelfare schemes, such as ElderShield and the CCCP. None of these latter schemes,however, is designed to provide comprehensive cover. ElderShield, for instance, is aninsurance plan that provides a modest fixed sum per month for up to 60 months tobeneficiaries who suffer severe disability in their old age, while the CCCP piggy-backs on government polyclinics to provide subsidised long-term health care to thosesuffering from three specific chronic conditions: diabetes, high blood pressure andhigh cholesterol. It should also be noted that charitable organisations are also aninstitutional part of the health financing structure. Voluntary Welfare Organisations,as they are called, receive government aid and MediFund-based financing to assistthem 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 effectivelyoutside the 3Ms because they are covered by generous employer schemes negotiatedbefore the current systems were put in place (Hanvoravongchai, 2002).

According to the Singapore Ministry of Health (2004), the financing philosophy ofthis complex health-care delivery system is based explicitly on:

. . . individual responsibility, coupled with Government subsidies to keep basichealth care affordable. Patients are expected to pay part of the cost of medicalservices which they use, and pay more when they demand a higher level ofservices. The principle of co-payment applies even to the most heavilysubsidised wards to avoid the pitfalls of providing "free" medical services.

The "Singapore system" is a continually evolving effort to reconcile the Singaporegovernment's aversion to welfare with the reality that, for both economic andpolitical reasons, it must ensure the provision of health services to the wholepopulation, including low-income earners and the poor. In fact, the Singaporesystem developed as an explicit reaction to the perceived failures of "social andhealth welfare" in Europe and the USA - a perception premised more on ideologicalpreconceptions than on empirical data. In November 1981, on the eve of the move tointroduce medical savings accounts, then Prime Minister Lee Kuan Yew (1981: 8)told a meeting of government MPs:


Subsidies on consumption are wrong and ruinous . . . for however wealthy anation, it cannot carry health, unemployment and pension benefits withoutmassive taxation and overloading the system, reducing the incentives to workand 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, andwithdrawal of welfare benefits is very painful.

It is of some importance to realise that Medisave was not a "progressive" attemptto ameliorate the effects of a laissez-faire health system, but a bold attempt tointroduce market forces into government-funded health care. Under the previoussystem 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 % perannum (Hsiao, 1995), health costs as a proportion of GDP had been falling steadilysince 1960 (Toh and Low, 1991: 26). Even the government's share of overall healthcosts 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'sintroduction 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 archetypalmiddle-class mechanisms of financial constraint and self-regulation. If it worked,then managed self-regulation would provide a sustainable basis for curtailing healthcosts into the long term.

The rhetoric of self-help and personal responsibility that permeates publicdiscussion of the 3Ms suggests that these systems are self-sustaining. In fact, none ofthem could function without government micro-management and subsidies. Thegovernment continues to subsidise hospital wards (up to 81% of costs) even after itensures that public hospital charges are kept down. Furthermore the entire system ofpolyclinics operates on direct government subsidies without drawing on the 3Msat all.

The most expensive section of any modern health-care system is hospitals, so itshould not be surprising that the core of the 1984 reforms is found in this sector. Thereforms were foreshadowed as early as the May 1981 announcement that thegovernment intended to reduce "subsidies" to hospitals and polyclinics {The StraitsTimes, 11 May 1981). This initiative was followed by overt government efforts toencourage the establishment of private hospitals {The Straits Times, 10 April 1982,24 December 1982), and across-the-board increases in hospital fees {The StraitsTimes, 17 December 1982). The expansion of expensive private hospitals at theexpense of subsidised public hospital wards seems to have been an attempt to takeadvantage 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 late1980s suggests that the "privatisation" of health was merely one aspect ofa muchbroader push that wilfully saw generic benefits in the private sphere.

Regardless of motivation, these moves reached their logical conclusion when thegovernment announced, in May 1984, that government hospitals would movetowards 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 onprofitable private patients (who pay their full treatment and accommodations costs)to provide income to subsidise public patients. The trailblazer in this new enterprisewas 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 in1989 (Toh and Low, 1991: 30-1). American consultants were duly engaged and the"privatisation"/"restructuring" programme continued into the 1990s, although itstopped a long way short of including all government hospitals. The NUH providedthe model for the "restructured" hospitals. It was broken down into 50 cost centresthat had to pay their own way. One interpretation of NUH's experience wasprovided 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 morepersonalised services, promoted staff motivation, deployed nurses moreeffectively, and enabled greater financial accountability, among other advan-tages. . . . Doctors are made more circumspect when requesting certain testswhich indirectly keeps the cost to patients under control, too.

Yet this rosy view was balanced by some strong criticisms that questioned the valueof the entire enterprise:

On the other hand, charges in the NUH have increased Governmentsubsidies have not remained at the same level over the years. . . . There is noconcerted effort to contain costs with measures aimed at the supply side, such asphysicians' earnings and mode of practice.

These authors continued, observing that the "benefits of 'privatisation' of the NUHare 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 changedsince this assessment and there is still no reliable basis for judging the strengths andweaknesses 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 oneof Singapore's two major tertiary hospitals, as well as general hospitals, a number ofspecialist centres and institutes (such as the National Cancer Centre), andgovernment polyclinics. The government believes that by micro-managing bothdemand and supply, it can make the system efficient and cost-effective, minimisingwaste 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 onwealth. The 1993 White Paper on Health stated this without voicing the criteria ofwealth:

We cannot avoid rationing medical care, implicitly or explicitly. Funding forhealth care will always be finite. There will always be competing demands for


resources, whether the resources come from the State or the individual citizens.Using the latest in medical technology is expensive. Trade-offs among differentareas 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 theconflicting demands in the Singapore government's ideological, economic andpolitical agendas. Regardless of any other criticisms that might tarnish its record, itshould be acknowledged that as a result of this system, Singapore runs amodern, effective health system that absorbs only 3.63% of GDP (Ministry ofManpower, 2004) and 7.4% of government expenditure (Ministry of Finance,2004). The government and many others attribute its success primarily to the3Ms, with perhaps the strongest claim coming from the current Minister forHealth 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 seemsonly proper that the system be brought under critical scrutiny. Yet this is not asstraightforward as one might expect. Even the simple claim of having kept healthexpenditure low is difficult to verify because the Singapore government does notfollow Organization for Economic Co-operation and Development (OECD)standards in measuring health expenditure. This makes international comparisonsextremely difficult. Furthermore, the government is highly secretive about thedetailed operation of its system, and has made neither the data source nor method ofits calculations available to anyone outside those in the civil service and thegovernment who need to know. So, although one can say safely that expenditure islow by Western standards, it may well be higher than the government's publishedfigures suggest.

The extensive list of exclusions from the 3Ms system also makes it difficult toestablish a meaningful standard of international comparison. To make a very explicitcomparison, the MediShield list of exclusions includes most of the services that havebeen identified as major drains on hospital budgets in the Australian health system atthe end of the 1990s: cardiovascular disease, control of cancer, care involvingdialysis, and care related to the treatment of HIV, mental health and diabetes. Thebasis of this comparison is spelt out in Barr (2005), but essentially a comparison isbeing made between the Singapore system and Australia's list of National HealthPriority Areas (NHPA). The NHPA was an initiative of Australia's ninecommonwealth, state and territory governments, and focuses on "diseases andother conditions that contribute most significantly to Australia's burden of illnessand for which there is potential for the burden to be significantly reduced"(Australian Institute of Health and Welfare, 1999: 93). The NHPA list accounted for40% of total hospital patient days in Australia in 1998-99. In Singapore, when itcomes 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 thetreatment of many other conditions.

The burden on the Singapore health system has also been lightened drastically bythe extraordinary youth of the society^ - an advantage that is now acknowledged bythe government in the context of discussions about future challenges {The StraitsTimes, 15 November 2006). In 1991, 6.2% of Singapore's population was aged 65 orover, as opposed to proportions between 10.9% and 15.4% for the USA, Canada,UK, Australia, New Zealand and West Germany (Ministerial Committee on HealthPolicies, 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 thatthis trend may have slowed (Low, 1998). This is a serious concern for thegovernment when it is realised that in 1996, the aged of Singapore (65 and over) wereadmitted to hospital at 2.8 times the frequency of their younger counterparts, andstayed in hospital an average of 1.66 times as long. They were also higher consumersof the two most heavily subsided classes of ward (Prescott, 1998: 43). Thus, anincrease in the proportion of the aged will inevitably increase demand for healthservices.

A further factor contributing to the low expenditure on health is the anomaly ofTraditional Chinese Medicine (TCM). It is commonplace among Singaporeans torely on a mixture of Western and traditional medicines, or even to turn to Westernmedicine only as a last resort. The Ministry of Health estimates that about 12% ofdaily outpatient users also visit TCM practitioners (Ministry of Health, 1995), andeven though TCM has been regulated by the Ministry of Health since November2000 (Ministry of Health, 2006b), it is excluded from national health expenditurefigures, thus artificially depressing expenditure figures.

Despite the government's avowed intention to reduce health expenditure, and itsroutine claims to have contained costs, it seems that the introduction of Medisave in1984 did not reduce or even contain health expenditure. In fact, immediatelyfollowing the introduction of Medisave in 1984, the rate of increase in healthexpenditure per capita jumped from 11% to 13% per annum (Hsiao, 1995). Theshare of GDP absorbed by health expenditure also increased in the immediate post-Medisave period, due largely to a sudden increase in expenditure on doctors' feesand the purchase of new technology as hospitals competed with each other forbusiness and reputation in the new fee-paying environment (Toh and Low, 1991).

It should also be realised that while the Singapore health system has deliveredimpressive statistics in terms of some major health indicators, notably longevity andinfant mortality. Even so, in 2000, the World Health Organisation ranked Singaporeonly thirtieth in the world for the overall health of its population, using measuressuch as the average age of the onset of disability and the rate of incidence of illnessesthat 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 arefar superior in maintaining a healthy population than is the Singapore system.

A further dampener is placed on the more extravagant claims of the Singaporegovernment when one compares the outcomes of the Singapore health system withthose of societies that are, in various ways, more comparable than are Westerncountries, such as the UK, USA and Australia. Japan, South Korea, Taiwan andHong Kong, for instance, have somewhat similar societies to that of Singapore, all


being economically advanced East Asian societies, but they have very differenthealth systems that nevertheless produce results comparable to - and, in some cases,significantly better than - those of Singapore in areas such as longevity and infantmortality (Gauld 2005; Gauld et al., 2006: 326-27). Furthermore, with the exceptionof Japan, their total health expenditure per capita (in US dollars at PurchasingPower Parity) is actually less than Singapore's (Gauld et al., 2006: 326). In the case ofTaiwan, it is 22% less (on 2002 figures).

Effectiveness Through Efficiency

These well-established critiques make it clear that the more extravagant claims madeby Singapore's leadership must be dismissed, but this does not mean that the systemis not worthy of attention. The Singapore health system remains, on the face of it, animpressive system. And when one thinks of the endemic crises and shortcomings thatbeset many other health systems in advanced democratic societies - crises that seemto be routine in the various states of Australia, for example - one could be forgivenfor thinking that perhaps the Singapore system is still an exemplar of technocraticmethodology after all.

This thinking becomes all the more reasonable when it is acknowledged that thetechnocratic methodology does not guarantee absolute perfection, but just a strivingtowards perfection based on the constant application of rationality and logic.Singapore's current Prime Minister, Lee Hsien Loong, encapsulated the spirit of thisethos in April 2004 when he told an audience of tertiary students that they must notbe content to inherit and enjoy the Singapore built by their parents andgrandparents. 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 messageat 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". Isay, if it ain't broke, better maintain it, lubricate it, replace it, upgrade it, trysomething better and make it work better than before (Lee, 2004).

Between them Lee's speeches encapsulate the spirit of Singapore's technocratic rulein a general way, but to identify the application of this spirit in the administration ofthe 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 1982speech fail to convey the full import of his message, so a fuller quotation isreproduced here:

We have a hospital service that we can be proud of. It stands up to comparisonwith 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 organisationalefficiency, 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 fiag and proclaimyou have reached the peak. Of course, climbing Mount Everest is in itself a greatachievement, 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 at20,000 feet you cannot see the peak, even on a clear day (Goh, 1982).

The imaginative analogy with mountain climbing is wont to distract attention fromGoh's central message - which perhaps accounts for the academic neglect of thispivotal speech. It is clear that Goh was foreshadowing a major restructure of theSingapore health system - and indeed a radical new system of health care andhospital funding was introduced two years later. It is also indicated from thehyperbole 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 whichthe "summit" of perfection always seems to be just out of sight even though it isalways said to be getting closer. Yet the core sentence contains a radical propositionthat has not been given serious attention. It reads, "In organisational efficiency, inthe pursuit of quality and excellence, there can be no highest peak." The goalsidentified by Goh were unambiguously "efficiency" and "quality and excellence,"but the relationship between them is less clear. The sentence can perhaps be read ascalling for "efficiency" and "quality and excellence" equally, but, if so, then it was anuncharacteristically sloppy piece of speechwriting. These two ideals potentially androutinely stand in opposition to each other in health care, as in most aspects of lifeand business. Alternatively, this sentence can be reasonably read as defining "qualityand excellence" in terms of "organisational efficiency."

On this reading, "organisational efficiency" is the master concept that provides theconceptual 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, withhis reforms following these principles to the letter. They turned the Singapore healthsystem 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, regardedprimarily as outcomes of "efficiency" and defined in terms of "efficiency." This focuson organisational efficiency (which quickly came to subsume the objective ofminimising government expenditure on health) has shaped the Singapore healthsystem in both positive and negative ways. On the one hand, it has led to theproduction of an impressive infrastructure that delivers high quality health care tomost of the population most of the time. On the other hand, the emphasis onsystemic perfection breeds an element of blinding hubris that tends to make thesystem prone to rather spectacular failings.

It is the proposition here that the quest for efficient systems has led the Singaporehealth system to crisis point, potentially putting lives and health at risk. With"efficiency" as a starting point, the government measures "effectiveness" byaverages, metrics and the degree to which the wastage of resources is minimised(Khaw, 2004). Hence the government is inordinately proud to announce healthachievements such as Singapore's ranking as the most cost-effective health caresystem in ASEAN {Channel NewsAsia, 22 October 2004) and that its rate ofhealth expenditure is drastically lower than those in countries such as the UK andthe USA (Khaw, 2007). These objectives are, of course, worthy in themselves, andthe system should be credited with achieving good scores on these measures, but thismindset is prone to create a tunnel vision focused on throughput and average


outcomes, which shifts focus from the health system's core business of patient careand public health.

Impurities in "Technocratic" Approach

There is concrete evidence that this type of problem is endemic at the level of healthadministration, and that it operates in ways that impact negatively on the quality ofhealth service, but, before considering this evidence, it is important to make the pointthat there are good grounds for believing that the supposedly value-free, rationaltechnocratic approach of the Singapore government to health policy is compromisedseverely 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 strongimpact of public opinion in matters of health care. These distorting influences can bedemonstrated as being at the core of the thinking of the designers of the system.

A priori assumptions and prejudices. First, although the efficiency-driven approachbeing studied here is justified as the outcome of technocratic discipline, it would betruer to say that the idolisation of efficiency is one a priori assumption among manythat have actively contributed to the character of the health system. The ideologicalrejection of "welfare-ism" that originated with Lee Kuan Yew has already beenreferred to. This was presented as a logical if unpleasant application of logic, but analternate reading is that the Singapore government, dominated by middle-classpoliticians and technocrats, was transforming the health system into one thatreflected their class' expectations by introducing the archetypal middle-classmechanisms of tight financial responsibility, self-regulation, rationing access toservices on the basis of wealth, and turning public goods into commercial enterprises.This observation might be accepted as being merely a viable alternative to thegovernment's explanation, except that it can be demonstrated that this reform of thehealth system was part of a broader pattern of the embourgeoisement of the publicservices, 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 wasthe education system. Then-Education Minister Tony Tan took for granted that thebest students would excel academically in Singapore schools, but according toEugene Wijeysingha, a civil servant who took instructions directly from Tan,^ hewanted schools that would build their character and turn them into "gentlemen."'To this end he engaged in what was eff'ectively a programme of the gentriflcation ofelite education to parallel the privileging of elite education per se. Tan's first step wastaken 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 beenpublicly urged by Prime Minister Goh Chok Tong the previous year. The result wasa 76-page report titled Towards Excellence in Schools, which was substantiallyimplemented over the next few years. The principals recommended that selectedschools be eff'ectively privatised and given both considerable autonomy and extraresources 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 StraitsTimes, 1 September 1987) and began charging fees that have progressively movedfrom being nominal in the 1980s to very substantial in the 2000s {Business Times, 3November 1989; The Straits Times, 11 August 1990, 29 November 2005).Unsurprisingly, these newly created "independent" schools quickly came to bedominated 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 ofboth the health and the education systems could have been a coincidence or theresult of the independent application of objective "reason," but, in any case, thereader is not being asked to accept these two pieces of evidence in isolation. Evenbefore these initiatives had manifested themselves in health and education, thegovernment had already taken measures in the areas of housing and industrialrelations that should remove all doubt about the operation of a middle-class bias inits approach to governance. In the area of housing, it took steps in 1980 to ensurethat each housing block (in the government-run housing estates in which 67% of thepopulation lived at that time {The Straits Times, 1 October 1980)) had a number ofmiddle-class professionals as residents. There is no need to speculate on whetherthere were middle-class presumptions motivating this move because Lee Kuan Yewstated explicitly that the reason for this initiative was to ensure that ordinary peoplecould benefit from the "quaUty community leadership" that would be provided bythese "better education people" {The Sunday Times, 30 November 1980). A similarset of middle-class presumptions were operating in the field of industrial relations inthe same period. From the mid-1970s onwards the trade unions were subjected to aparallel incursion of well-educated, middle-class "talent," whereby professionals(university-trained engineers, etc.) were parachuted into leadership roles in the unionmovement, coming to dominate the leadership of the National Trades UnionCongress and most trade unions during the early 1980s (Barr, 2000a). In 1980, LeeKuan Yew justified this programme on the grounds that "the unions must have theirquota of talent" (Barr, 2000b: 116). Moreover the field of industrial relations alsosaw the introduction of a 12-hour shift for factory workers in the mid-1980s, aninitiative that pleased employers unreservedly but showed contemptuous disregardfor the health and family lives of factory workers (Koh, 2007). These examples arenot the only pieces of evidence that indicate the presence of a middle-class agenda atthe core of the government's reform programmes in the early to mid-1980s, but theyare sufficient to leave no room to doubt that it was the case. The significance of thisfor our consideration of Singapore's system of health-care financing is that thegovernment was supposed, according to its own logic, to be completely free of suchbiases, but this was clearly not so.

Beyond these class-based factors, further evidence of the distortion of reason andlogic in the operation of the Ministry of Health's basic premises is found in therestrictive cap on the number of female candidates allowed into the local medicalschool. This cap was imposed in 1979 and was Hfted only at the end of 2002 {BusinessTimes, 6 December 2002). It was justified by the assumption that women wouldwithdraw from their profession either partially or completely after marriage andstarting a family (Kong et al., 2000: 515-16). Its effect on the operation of the healthsystem is minor compared to the impact of the class-based distortions described


above, but it is mentioned because its continued operation into the early years of thetwenty-first century demonstrates how far the Ministry of Health is from being therational, logical, sophisticated and modern creature that it claims to be.

Public opinion and politics. The second set of grounds for doubting the purity of theSingapore government's technocratic approach to health care is a consideration ofthe potent operation of public opinion in this field. Although the government is theonly proactive driver in health-care policy, the end result is a compromise betweenthe "efficiency"-driven, technocratic assumptions of government, and strongreactions from the public. It is an understatement to say that public opinion is notgenerally a powerful factor in Singapore governance because the government is sucha strong and overbearing player in politics, but - probably because health issuesaffect the lives of Singaporeans so intimately - it has nevertheless been a significantcontributor to shaping health policy. According to the ideology of technocracy, suchimpacts are an irrational impediment to the quest for efficiency, but it is argued thatthey account for much of the positive outcomes for which the government takescredit. The key health issues raised routinely in newspaper articles and features, inthe "forum" pages of newspapers, by opposition political parties and by governmentbackbench MPs (reñecting in turn the concerns raised in their "Meet-the People"sessions in their constituencies), revolve around the access of the poor and the lowermiddle classes to affordable health care.

The vulnerability of the poor and the elderly was highlighted in 2005 when thegovernment closed the evening service offered by the government polyclinics atthe same time that it was inadvertently focusing public attention on the plight of themiddle class by threatening to end their access to the cheap C Class wards ingovernment hospitals. Such is the expense of being sick in Singapore that even themiddle class are scared of the cost of the high "co-payments" and the large gapsbetween the amount covered by Medisave and MediShield and the actual billsreceived from the hospital. These problems moved to the front of the government'smind, not because of any efficiency-driven review conducted by its technocrats, butbecause public discontent threatened the government in the 2006 elections. The mostspectacular eruption of the issue was the unprecedented spectacle of Health MinisterKhaw being berated for a quarter of an hour by an aged constituent, but the moreserious threat came from the opposition Workers' Party, which campaigned stronglyon the issue (Channel News Asia, 4, 14 May 2006). The unambiguous result of thisengagement was Khaw's mid-campaign announcement that he was deferringindefinitely the introduction of a means test for access to the highly subsidised CClass wards (Channel News Asia, 2, 3, 4 May 2006). Not since the late 1980s had thegovernment engaged in such a spectacular volte face - and significantly on thatoccasion the issue was also about access to C Class wards, and it was brought aboutby the most vehement expressions of concern by government backbenchers passingon the concerns of their constituents.^ The government presents the history ofincremental change in the health system since the original introduction of Medisavein 1984 as a triumph of reason and efficiency, directed towards the noble end ofproviding affordable health care for all, but without the input of ordinary politics itis doubtful that the regime and its mandarins would have seen any pressing need toengage in this masterpiece of micro-management. Granted that Medisave was

408 M. D. Barr

originally intended as the final word in health-care financing, and taking intoaccount the middle-class preconceptions from which the government was and isoperating, the gradual watering down of the original drive against "moral hazard" isevidence that the operation of politics is the key dynamic in the evolution of thesystem, and insofar as the Singapore health system is a showcase, Singapore'svestiges of democracy deserve at least as much credit as does its technocratic ethos.Today, when the Health Minister focuses seriously and systematically on ways toreduce costs to the consumer and plugging the myriad gaps in 3Ms coverage that headmits often leave people with huge medical bills {Channel NewsAsia, 14 August2006; The Straits Times, 19 October 2006), he is giving witness to the impact of evena 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 systemand argues that they are all the result of a common systemic failing. In essence, it isargued that the most basic publicly stated premise on which the Singaporehealth system has been built - the premise of striving for technocratic eificiency -is responsible for its most spectacular and serious failings, rather than itsachievements.

Spectacular Failures

When considering the Singapore health system's record of public failures, it shouldbe noted that given the right setting and provocation, Singapore's leaders are willingto concede that their health system's record of achievement is less perfect than theyclaim in moments of bravado. A number of examples can be cited. First, there wasthe government's delayed response to the SARS epidemic in 2003. For the first fiveweeks of the SARS outbreak (13 March-20 April, 2003) there were no protocols orcontingency plans to deal with an epidemic that had infected 65 people in its firstfortnight {The Straits Times, 25 March 2003). The responses, such as they were, weread hoc and reactive. The public marker of the ending of this rudderless period wasthe effective removal of the SARS response from the hands of then-Health MinisterLim Hng Kiang - who in March had asked the public to accept some deaths asinevitable (see The Straits Times, 25 March 2003) - and the creation of twoministerial committees to handle the crisis {The Sunday Times, 20 April 2003). It wasfive weeks (13 March-17 April) before the government began supplying freeambulances to take suspected SARS cases to hospital (Ministry of Health, 2004).Until then, suspected SARS cases generally made their own way to hospital by taxior public transport, as was recommended by official bodies, such as the Office ofStudent Affairs at the National University of Singapore.^ As the current Head of theCivil Service, Peter Ho, has since acknowledged: "We were surprised by SARS. Wewere surprised by its epidemiology. We were unprepared for it. But we should havebeen prepared. It was not a fundamental surprise, because we knew that the risk of ahighly infectious epidemic existed" (Ho, 2005: 3).

The truly frightening aspect of this episode is that it was only because SARSthreatened the family of the then Senior Minister Lee Kuan Yew at the five-week


mark, when his wife was rushed to hospital with a suspected case of SARS, thatCabinet 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 galvaniseCabinet 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 ofcomplacency.

Of more serious political consequence for the government was its failure toadequately oversee the National Kidney Foundation (NKF). The NKF is notionallyan independent charity but is, in fact, an integral part of the health system as themain provider of kidney dialysis. Suffice to say that it is only thanks to the operationof the NKF that the government can afford to exclude dialysis and kidney-relatedtreatments 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 30per year [The Straits Times, 3 September 1997]). Yet, in 2005, the NKF was exposedas 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 KPMGwas scathing:

Power was centred around one man, and was exercised in an ad hoc mannerthrough [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, onthe ideas, whims and caprice of the chief executive (comments drawn fromToday, 20 December 2005 and Reuters, 19 December 2005).

Not that any government instrumentality or personnel can take credit for uncoveringthe NKF abuses. That honour goes to a humble plumber who was scandalised whencontracted to install gold-plated taps and a luxurious toilet seat in the NKFexecutive office (Today, 26 December 2005). On this occasion the government wassaved from facing serious consequences by the ineptness of its domestic politicalopponents - the Opposition Singapore Democratic Party (SDP) made the strategicerror of questioning the integrity of the government rather than its competence. Byquestioning the government's integrity, the SDP invited a libel action that made itimpossible for the NKF issue to be raised during the 2006 General Electioncampaign (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 December2005), and the government conducted a major review of dialysis access, institutedaudits of all Voluntary Welfare Organisations and overhauled its own procedures foroverseeing these critical areas of health and welfare policy.

It could be argued that the NKF and SARS are not a fair basis on which tojudge the Singapore health system because they are both outside the 3Ms and sooff 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 notincluding 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 itdoes with routine demands. That expectation is intrinsic to the nature of healthcare.

410 M. D. Barr

Systemic Failures

It is more difficult to interrogate the systemic core of the health system at themore mundane level of day-to-day practice because the government maintainsclose control over the relevant information, and it is generally successful inensuring that only flattering information is released. Yet there are a few clear andpublic signs that the ethos of so-called efficiency-driven management of healthcare is driving down the standard of health care. These centre around a criticalshortage of both hospital beds and doctors, both of which are putting lives atrisk on a daily basis.

First, the current shortage of hospital beds should be considered. Singapore's ratioof 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 thisfigure had improved to 1: 278 by 2005 (Ministry of Health, 2007). This is acommendable improvement, but, to put it in perspective, it needs to be realised thatin 1960 (one year out from full colonial rule), the ratio of hospital beds to populationwas 1: 229 (Lim, 1989: 174), making the 2004 figure a deterioration of 52% in 44years and the 2005 figure "only" a deterioration of 21% in 45 years. In fact, the 2005figure is still worse than that of 1985 (in the first year after the reforms of 1984) whenthe 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 March2004, Health Minister Khaw Boon Wan made it clear that the focus on efficiency andcost savings provides the core of the Singaporean health-care philosophy and hestated explicitly that he considers less consumption of public health services to be apositive outcome in its own right, and conclusive proof that the Singapore healthphilosophy of personal responsibility and self-help is among the world's best practice(Ministry of Health, 2004).'" Yet, in his less boastful moments, he admits that theshortage of beds is a problem that needs to be addressed because it is adverselyaffecting the delivery of health care: hence, his strenuous efforts to increase thenumber of beds over the last year and his lamentation that these initiatives areseveral years too late to address the crisis {Today, 11 July 2006). Minister Khaw nowadmits that the shortage of beds is "stressing" doctors and patients: "Stressful," hesays, "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 theproblem, his belated announcement of the opening of 200 beds by 2009 reveal thecontinuing presence of the mentality that led to the shortfall in the first place. Helamented that since public hospitals are heavily subsidised, "the more beds I add, Iknow tomorrow they will be filled up" {Today, 11 July 2006), by which he seemed toimply that it is the availability of subsidised beds, rather than illness, that drivespeople to hospital, ignoring the more likely explanation that there are currentlypeople sick at home who should be in hospital.

Yet, even the hospital-to-population ratio cited above ignores the recentphenomenon of international medical tourists who have also been placing increasingdemands on the Singapore health system. According to Khaw, medical tourismattracted 200,000 international patients in 2002, 374,000 in 2005 and is increasing ata 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


how many Singaporeans have benefited from the recent and planned improvement inthe hospital bed-to-population ratio.

With such statistics as a background, it should come as no surprise to learn thatSingapore also has, according to Yong Ying I, Permanent Secretary in the Ministryof 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 seriousproblem and teams have been sent to Australia and London to recruit as many asthey can from outside normal channels. In the longer term the Ministry intends tonearly treble its output of locally trained doctors from over 200 to about 600 perannum (Agence Prance Presse, 21 February 2007).

Doctor shortages have multiple effects on patient care, the most obvious beingthat it increases waiting times and deters people from seeking routine medicalservices, but it also places stress on doctors and gives them incentives to pushpatients through as quickly and as routinely as possible, leading to mistakes and thepremature discharge of patients. Yet, this phenomenon also contributes directly tothe high throughput of patients of which the government boasts as evidence of theefficiency of its hospitals (The Straits Times, 8 March 2007). Yong Ying Iunderstated the situation when she said that "We have very efficient doctors and theywork very hard. But somewhere along the way we also don't have enough" (AgencePrance Presse, 21 February 2007).

Both these shortages - of doctors and hospital beds - are the direct result ofgovernment policy described earlier that deliberately restricted the supply of doctorsand hospital beds to avoid increased consumption of health care. By thegovernment's own logic of the dangers of "moral hazard," the doctor and hospitalbed shortages are at the heart of Singapore's ultra-efficient health-care system andare major contributing factors that have contributed to that reputed efficiency, yetnow both are admitted to be serious problems, undermining the capacity of thehealth system to service its own population. This is part of the problem with runninga 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 the3Ms - is based upon an assumption that dealing with averages and common patternsis best practice because it is an "efficient" way to produce good measurable (average)outcomes. This ethos is becoming increasingly problematic for the governmentbecause the "unexpected" seems to be arising with increasing frequency, possiblybecause Singapore has positioned itself so successfully as a regional cross-road andso 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, withgovernment polyclinics reporting that queues were so long and staff members sooverworked that lives were being put at risk, with one death due to mistakenprescription already recorded (Ministry of Health, 2006c). In the same period thepublic hospitals struggled to cope with an increase in the number of patients, largelydue to outbreaks of dengue fever and influenza (Ministry of Health, 2006c) and, asHealth Minister Khaw has admitted implicitly, the failure of Ministry of Healthplanners to provide enough beds to cover peak demand (Today, 11 July 2006). Yet,

412 M. D. Barr

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 influenzaepidemic.

The explicit admissions of failures by the Health Minister and his PermanentSecretary reveal that it is at the very ordinary level of affordability and availabilitythat the system is facing the most strain. This problem is of particular interestbecause it is thoroughly systemic: it affects the poor (especially the female elderlypoor - see Chia and Tsui (2005)), the middle class and anyone with a serious chronicillness. This is a reach that makes everyone except the very wealthy and those luckyenough to be on generous employer-sponsored schemes - which the government isphasing out in any case (Hanvoravongchai, 2002) - feel a considerable level ofvulnerability (Prescott, 1998: 2).

The issue has driven the Health Minister to focus seriously and systematically onways 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 tohighlight the success of the 3Ms in offering adequate cover to most patients most ofthe time (see, for instance. The Straits Times, 23 August 2006). Talk of incrementalmodifications to the 3Ms have therefore come thick and fast, including a proposedextension of MediShield coverage to include some congenital disabilities in exchangefor higher premiums {Channel NewsAsia, 27 October 2006), and extending Medisaveto cover GPs' bills in relation to some chronic illnesses, including diabetes, highblood pressure and stroke {The Straits Times, 29 August 2006), with the possibilityof including the treatment of asthma and mental illness {Channel News Asia, 3November 2006).

Creeping Ordinariness

Of more significance for those who particularly admire the medical savings elementof the Singapore schemes, Khaw has also been quietly but systematically moving theSingapore health funding model away from its intense focus on medical savings andgiving medical insurance a more central role. He has foreshadowed higher premiums,broader coverage, lower déductibles and higher caps {The Straits Times Interactive,12 August 2004; The Straits Times, 17 June, 19 October 2006). Specifically, Khawhas so far announced that the government plans to reduce the standard MediShielddeductible of $S3000 by about $S500, and to halve the "gap" left by MediShieldcoverage of large hospital bills from 40% to 20% {Channel NewsAsia, 21, 22 January2007). Such moves are radical in Singapore and are being rushed out to meetpressing political needs, but they are not exactly new or impromptu. They werebroadly 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 thathe is looking at alternative health models, presumably from the West {Channel NewsAsia, 17 March 2004).

From the point of view of this consideration of the Singapore health system asa case study of the application of technocratic approaches to governance, itssignificance lies in the fact that if it does prove to be the case that these


developments mark the beginning of a new pattern of insurance-based health-carefunding, then the Singapore system will increasingly resemble a particularlyparsimonious version of Western health-care systems. It will most definitely nothave the mystique of a cutting-edge pioneering venture developed by brillianttechnocratic minds because brilliant technocratic governments do not normallytake two decades of radical experimentation just to arrive at the point very nearwhere they started.

Efficient to the Core

Yet, at this stage, the actual changes being implemented and planned (as opposed tomerely mooted) are intended to introduce only incremental changes that will leavethe system intact, with the mantra of "organisational efficiency" as the centralobjective and methodology. Consider the following report, taken directly from aChannel NewsAsia report from 3 November 2006:

Health Minister Khaw Boon Wan says his key priority is to fine-tune andstrengthen the 3M framework of Medisave, MediShield and MediFund - tomake sure quality healthcare is available and affordable to all. One way toimprove healthcare delivery is greater integration across primary, acute andstep-down care between private, public and people sectors. . . . To keep themout of hospitals, family doctors will play a bigger role. They will helpmanage common illnesses like diabetes, high blood pressure and stroke, sopatients will not have to go to hospitals for expensive specialist outpatienttreatment.

The quest for efficiency and cost-effectiveness is commendable, and there can beno doubt that some of the Singaporean initiatives are very imaginative, but it is ofconcern when the health system seems to be devoted to efficiency rather than patientcare. This dichotomy also raises questions about the government's motivation in itscurrent campaign to promote Advanced Medical Directives ("living wills") onto apopulation 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? Tt istouted by the Singapore government as world's best practice, and regarded by someas a model for advanced capitalist democracies, but one is left wondering if the keyto the system is merely the government's monopoly of information and itsauthoritarian control of political discourses. It seems to be highly likely that if onecould examine the Singapore health system from the inside, one would find a fairlyordinary health system with some strong points and many weaknesses - much likehealth systems all over the developed world. It is probable that there are aspects ofthe system worthy of emulation, but the image of a near-perfect system driven by atechnocratic imperative for efficiency is likely to be revealed as little more thanthe result of government spin and tight control of information and, in so far as the

414 M. D. Barr

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

The limitations of the Singapore health system raise the question of whether atechnocratic approach to governance can ever deliver the promised results. Theshowcase product of Singapore's technocratic system of governance has beenexamined 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 objectivetechnocrat was a chimera in any case. The health-care experiment that started in1984 was indeed bold and innovative, but from the start it was the product ofprejudices and a priori judgements that find their origins in, among other biases,socio-economic class and gender, which then had to contend with the vitalcomponent of public opinion.

The truly interesting conclusion that can be drawn from this study is not thepositive role of technocracy (which is marginal at best), but the pivotal role ofdemocracy in providing some level of protection from the ruthlessness of aloofpolitical leaders and anonymous bureaucrats. Even the tokenistic version ofdemocracy served up in Singapore has been sufficient to ameliorate the worstexcesses of Singapore's drive for "organisational efficiency" and to insist thatpoliticians become a little less aloof. Perhaps if Singapore had a little moredemocracy and a little less "efficiency," it might have an even better health systemthan it has now.

Acknowledgement

The author wants to thank the journal's two anonymous reviewers for their critical and invaluableinput.

Notes

' There is no shortage of evidence to support the contention that the Singapore government projectsitself as being "hard" but worthy of support because it follows correct prescriptions. For a smallsample of contemporary evidence see Today, 2 and 5 May 2007, which report speeches delivered by twodifferent 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."

^ The pre-eminent profession in a particular technocracy and in theories of technocracy variesconsiderably (see, in particular. Winner (1977: 144-65)).

' This account of Singapore as a "technocracy" is drawn from Barr (2006).* This overview of the Singapore health funding system is based on Barr (2001, 2005). More detailed

information can be found in these works.' 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 fourtimes more on the aged than they did on the younger section of the population (Prescott, 1998: 13).

' Eugene Wijeysingha was a former Deputy Director of Education who was posted as principal of RafflesInstitution in 1986 to turn the school "Independent" {The Slraits Times, 9 October 1986).

' Interview with Eugene Wijeysingha, Singapore, 11 April 2003.* 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 ofHealth to back down at the end of the 1980s (Toh and Low, 1991).


The author has a copy of an official notice issued by the NUS Office of Student Affairs, dated I April2003, which recommended that people with SARS-like symptoms "go immediately to the Accident andEmergency Dept of TTSH [Tan Tock Seng Hospital] by taxi or public transport."Khaw Boon Wan said: "Last week, my Ministry published a paper comparing the utilization ofmedical services in Singapore with several developed countries. Singapore has done well. We havelower hospital admissions per capita. Our patients generally do not overstay" (Ministry of Health,2004).

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Singapore Health Care Case Study