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How is Palliative Care Paid for in Singapore?

How is Palliative Care Paid for in Singapore?. Kai Hong Phua Yong Loo Lin School of Medicine and Lee Kuan Yew School of Public Policy. Overview. Introduction Health Care Financing in Singapore Palliative Care in Singapore Policy Issues and Implications Conclusion.

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How is Palliative Care Paid for in Singapore?

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  1. How is Palliative Care Paid for in Singapore? Kai Hong Phua Yong Loo Lin School of Medicine and Lee Kuan Yew School of Public Policy

  2. Overview • Introduction • Health Care Financing in Singapore • Palliative Care in Singapore • Policy Issues and Implications • Conclusion

  3. Singapore Health Statistics - Past and Present 1980 2005 • Life expectancy 70 years 80 years • Infant mortality 12/`000 2/`000 • Aged/total population 5 % 11 % • Public hospital mix 85 % 80 % • Health expenditure/GDP 3 % 4 % • Health expenditure/ 6 % 7 % government budget • User fees recovered / 3 % 60% public expenditure

  4. Population Ageing in Singapore by 2030

  5. Health Expenditures and Ageing 14 United States 12 Canada France 10 Switzerland Finland Russia Australia Germany Norway Italy Sweden Health Expenditure as % of GDP 8 New Zealand Belgium Spain Japan Portugal United Kingdom Ireland Korea Taiwan Czechoslovakia Denmark 6 Greece Poland Hong Kong Mexico Argentina 4 Turkey Singapore Singapore’s health expenditure projected to rise to between 6-8 % of GDP by 2030 2 0 4 8 12 16 20 24 28 Aged Dependency Ratio (>65/Aged 15-64)

  6. Comparative Health Expenditurein Asian Countries - WHO Report 2000 Health$/capita (Int $) Public/Total %GNP %Pop>60 DALE Japan 2373 (1759) 80.2 7.1 22.6 74.5 Singapore 843 (750) 35.8 3.1 10.3 69.3 Korea 700 (862) 37.8 6.7 10.2 65.0 Brunei - (857) 40.6 5.4 5.0 64.4 Malaysia 110 (202) 57.6 2.4 6.5 61.4 China 20 (74) 24.9 2.7 10.0 62.3 India 23 (84) 13.0 5.2 7.5 53.2 Thailand 133 (327) 33.0 5.7 8.5 60.2 Philippines 40 (100) 48.5 3.4 5.6 58.9 Indonesia 18 (56) 36.8 1.7 7.3 59.7 Vietnam 17 (65) 20.0 4.8 7.5 58.2 Myanmar 100 (78) 12.6 2.6 7.4 51.6 Cambodia 21 (73) 9.4 7.2 4.8 45.7 Laos 13 (53) 62.7 3.6 5.2 46.1

  7. Healthcare Financing Strategies in Singapore Instill personal and family responsibility(Cost-sharing)+Ensure future sustainability with ageing(Savings)+Enhance risk-pooling and social protection (Insurance)+Target subsidy and equitable distribution(Taxation)

  8. Health Care Financing in Singapore Financing Method Taxes PUBLIC HEALTH SERVICES Private Payment PRIMARY CARE Medisave Compulsory Savings ACUTE CARE Medishield Social/Private Insurance CATASTROPHIC (LONG TERM CARE) (Eldershield) Medifund (Eldercare fund) PUBLIC SUBSIDIES Source: Dr. Phua Kai Hong

  9. Government Subsidy Policy

  10. Sources of Healthcare Financingin Singapore Medisave 8% Government subsidies 25% Medishield 2% Private Insurance 5% Out of pocket 25% Employer Benefits 35%

  11. Ministry of Health Annual Sectoral Budget

  12. The Unfinished Agenda - Health Care Financing Reforms • Blue Paper - National Health Plan • 1984 Medisave • 1990 Medishield • 1993 Medifund • 1993 White Paper - Affordable Health Care • 2000 Eldercare Fund • Eldershield • Enhanced Medishield/Private Insurance • ? Enhanced Eldershield/Private Insurance

  13. FINANCING METHOD Personal savings Compulsory savings Catastrophic insurance Disability insurance Endowment Taxation 3-M SYSTEM + 2E MEDISAVE (1984) MEDISHIELD (1990) + ELDERSHIELD(2002) MEDIFUND (1992) + ELDERCARE FUND (2000) Health and Long Term Care Financing in Singapore

  14. Palliative Care in Singapore • Introduction of geriatrics training of doctors at the Medical School (Dr Anne Merriman) in mid-1980’s • Founding of Gerontological Society of Singapore and Hospice Care Association • Promotion of palliative care in hospitals, homes and community settings • Rapid growth of voluntary hospices – Dover Hospice, Assisi, St Luke’s (Christian) Ren Ci Hospital (Buddhist) Kwong Wai Siu Hospital (Local Charity) Ang Mo Kio Community Hospital (Government)

  15. Past Financing for Long Term Care Community care / long term care • Direct payment by individuals and families • Community assistance Voluntary Welfare Organizations` fund-raising (Up to 50% or more of recurrent expenditure) • Government funding Grants-in-aid or subventions - Capital funding (up to 90%) - Recurrent funding (up to 50% of cost norms; 75% for public assistance cases)

  16. Community Care Model in Singapore • Involvement of voluntary welfare organizations • Co-financing from government of 3:1 ratio, based on piece-rate and program funding • Step-down care paid by a mix of Eldershield (severe disability insurance) and subsidies • Within grassroots structure of local government - Community Development Councils (CDC)

  17. Policy Implications -Financing the Levels of Care • Family support for home care • Personal savings and community services for primary health care • Compulsory savings for hospitalization and acute care • Insurance and institutional support for catastrophic and long term care • Taxation and state welfare as safety net

  18. Policy Implications – Towards Cost-effective Care • Avoid hospitalization and institutions • Provide substitutes and alternatives eg. day care, home nursing, hospice, etc • Develop community-based services • Strengthen family support and home care • Improve housing and living arrangements

  19. Health & Social Care in Singapore The `many helping hands` approach: • Public, Private & People (3P) Partnerships • Joint responsibilities of the individual and family, community and the state • Shift from state welfarism to more cost-sharing by a more diversified mix of financing methods, e.g. prepayment, savings, insurance, annuities and targeted subsidies (means-test)

  20. Socio-Cultural & Gender Issues in Asia and Singapore • Most caregivers are women • Lower rates of pay and employment among women • Women earn less but live longer

  21. Gender Issues in Health and Social Care Financing • Most caregivers are women - Who cares for the elderly women? • Women lose out in earnings - Who pays for care of elderly women? • Women also lose out in savings - Who saves for financial security and medical expenditure of elderly women?

  22. Special Conditions in Asiaand Singapore • Fastest pace of socio-economic transition • Highest rates of population ageing and population growth • Great propensity for savings and sharing • Strong traditional social support systems Health and social care policies must contend with such considerations

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