Spotlight on Singapore

22 Oct 12
The city-state of Singapore is not only a gateway to Asia and bridge between East and West. It is also frequently cited as a world-class urban environment — and with good reason. Its modern infrastructure, high quality of life and forward looking approach has won many admirers around the world. Here, we talk to two senior city leaders to find out about its health care system and managing HR change in the public sector

By the editorial team, Ernst & Young | 22 October 2012

The city-state of Singapore is not only a gateway to Asia and bridge between East and West. It is also frequently cited as a world-class urban environment — and with good reason. Its modern infrastructure, high quality of life and forward looking approach has won many admirers around the world. Here, we talk to two senior city leaders to find out about its health care system and managing HR change in the public sector

Healthcare in Singapore

How does Singapore spend a fraction of its GDP on health care and yet still manage to offer universal coverage with world-leading outcomes such as low infant mortality rates and high life expectancies from birth? It’s a puzzle that has frustrated many a health care practitioner from

around the world, plenty of whom have descended on the city to investigate this seeming anomaly for themselves.

Over the years, Goh Aik Guan, Managing Director of Singapore’s MOH Holdings (MOHH), the holding company of Singapore’s public health care institutions, has welcomed many a foreign delegation to Singapore, all of whom have been keen — understandably so — to uncover the

secrets of their success. Singapore’s young population is key, it transpires. “One key factor is that up until now the Singapore population has been very young,” he says. “This gives us breathing space. In the absence of the pressures of excessive demand and long queues, we have been able to tweak and evolve our policies and delivery systems with good outcomes.”

Payment rendered

Under the Singapore system, its Government ensures affordability through a system of government subsidies, compulsory savings by individuals, a national insurance plan covering large inpatient bills and when all fails, an ultimate safety net to take care of the truly poor who have trouble paying their hospital bills. This combination is absolutely critical to the success of healthcare in Singapore, says Goh.

“It was a stroke of genius that we started the compulsory savings system for medical care because, even though it means everyone has to pay, they pay a relatively small amount each time, making the deductions that take place in the background almost imperceptible. And by the time people actually need it — say in their 50s and 60s — they will have built up a significant nest egg that goes toward reducing the burden of out-of-pocket cash.

The underlying principle is that individuals need to play their part and take personal responsibility for their health. So it’s like a quid pro quo — people accept that they have to take responsibility for their health and pay their share, and Government will pay its share, depending on the needs of each individual.”

Within the scheme, each citizen builds up funds that are individually tracked, and can be used within and across their family. These funds can then be tapped whenever a resident of Singapore needs to receive inpatient treatment at one of the city-state’s 13 private hospitals or 10 public hospitals.

“There is always a co-payment component as part of our fundamental policy philosophy of individual responsibility,” continues Goh. “There is no first-dollar subsidy or insurance coverage under the national insurance scheme. This helps to shape behavior and moderate demand, because people will question spending that dollar from their own pockets unless it is really necessary.”

Beyond borders?

The key question for foreign observers, then, is whether Singapore’s system could be successfully implemented in other countries and localities. Unfortunately, Goh has his doubts.

“It’s not that straightforward,” he admits. “Lots of people have asked us. We have reasons to be grateful to the British for leaving us many valuable legacies, one of which was the Central Provident Fund, which provided the mechanism where a very small fraction of someone’s salary is automatically put aside for retirement needs. It provided the basis on which we could carve out and ring fence a proportion of this retirement fund for future health care needs. Any other

country wishing to implement our system of compulsory savings for health care would have to start from scratch. I am not sure if that is politically doable!”

Another quirk of the Singapore system is that the public sector takes 80% of the in patient market. “This is one of the unusual aspects about Singapore that is not easy to replicate elsewhere,” says Goh. “In many other countries, the private sector provides the quality level of care and, therefore, the market share is reversed. For us, it’s the other way around. But because we are so big and because we own and control the bulk of the inpatient market, there is no disjoint between the ‘payor’ and the ‘provider’ that is often seen elsewhere. We are aligned in our quest to provide good, appropriate levels of care and at the same time manage costs so that the good, appropriate care is also affordable.”

Integration nation

Integrated care — even in somewhere as advanced as Singapore — remains a challenge, however. “It’s easier to integrate when ‘we’re in the same family’ but it’s still complicated,” says Goh, who is keen to stress that their integration is not just about paper trails but instead relates patients and care delivery — from one setting to another.

“We’ve coined the term ‘right-siting.’ We need to put the patient — whatever their condition — at the right site for their necessary care. So if they do not need care in an acute hospital — which is very expensive — they should be cared for say in a sub-acute setting, which is more cost-effective. So we’re really looking at this, examining how we can involve care providers out in the community — GPs, community hospitals, nursing homes, rehab centers etc. We want to bring everyone together to provide the whole spectrum of care settings needed by patients with different conditions, of different severity.”

A key hurdle has been IT, he continues. How do you enable key information to follow the patient? To address this challenge in, April 2011, the Government rolled out what was called the National

Electronic Health Record (NEHR). “It pulls information from all systems in one go,” explains Goh. “The NEHR is the critical enabler for the delivery of well-integrated care, using IT to ensure continuity of care during care transitions and improve care coordination of patients across the entire spectrum of health care. It also contributes to the cost-effectiveness of health care delivery, giving doctors quick access to key clinical information, including test results, of patients. Patients save time and money with the avoidance of multiple, repeat tests.”

Can this be done elsewhere? “It can be done elsewhere but it will be a challenge,” contends Goh. “Even in Singapore, where we are the main player, we had difficulties with data sets, standards, different workflows, legacy systems and so on. So you can imagine if it was a disparate set of players, strewn across a large country, all with different interests — consensus would be even harder to build. Plus, in Singapore it helped that we are small and fully wired up. So in a sense, we were lucky that the stars were aligned in our favor.”

Looking ahead

Like many health care leaders around the world, Goh pinpoints breaking down silos as a key priority going forward. “The medical profession — not only here but worldwide — is a very proud profession. Rightfully so, for theirs is a noble calling. But it is also a very individualistic profession,” he says. “From an administrator’s point of view, it is common sense to standardize, but the medical profession often tells us that every patient is different. So it is an ongoing conversation — and will, I suspect, always be an ongoing conversation. There will always be opportunities to standardize — there is no way non-doctors can step in and say ‘this is how it should be done.’ But pushing the envelope means there will always be a conversation.”

And of course, Goh and his colleagues are very much focused on pending demographic changes such as rising age expectancy. “We have the NEHR — this is a key enabler — and we are building more hospitals,” he says. “Each region will have roughly one acute hospital, one or two community hospitals, a network of nursing homes, and a broader network of GPs to serve the whole community. It’s still a work in progress but this is the vision and ambition. The key enabler is IT because it all comes down to information.”

Reforms in focus

At first glance, you’d never guess that Rupert Gwee recently retired as a senior officer in the Singapore armed forces. His positive, good-humored and open approach seems out of kilter with the stereotypical image of a senior serviceman.

Nonetheless it’s been only a few short months since he stepped down as a colonel working in the headquarters of Singapore’s Ministry of Defence. And it transpires he has no regrets about entering civilian life. “I don’t miss wearing the uniform — because I have done it successfully in the past, I still have the clout that it used to bring,” he says. “And anyway, sometimes it’s better to be on the outside — a prophet is never recognized in his home town!”

Driving big HR and administrative change

Gwee is now serving as Director of HR Transformation for Singapore’s Ministry of Home Affairs (MHA), where he is seeking to deploy the skills and experience accumulated over a long period working in and around human resources. It’s a far from straightforward task.

“Generally, it’s the guys on the ground who suffer because ground HR and admin can’t get the policy people to understand why their problems are so important,” he says. “For the policy people, it is always tempting to say ‘our plates are full and we don’t have time to focus on administrative stuff.’ If you look at the public sector, it has very tight resources to run its business and I have found that, to execute a needed change and the resources to do it, you have to go all the way to the top to make sure that everyone pays attention. This is because ground staff don’t have the power to change things without tweaking how policy gets interpreted. What you need is a highly empowered team with policy people embedded into it.”

So does this mean that you have to be highly skilled in the art of persuasion? Yes, and no, replies Gwee. “To put it bluntly, you need to ‘scare’ the leadership. You need to reframe the problem so they can’t ignore it, even if they have been scarred by previous attempts to fix issues in the past. So you need a different approach. I try to monetarize the size of the problem. This shows the bosses the value you are bringing to them. So you deliver an outcome and increase your team’s value and get that credibility, which is important as you go up the levels to clean up the problem.”

To illustrate his point, he uses the example of the Singapore Armed Forces, where demographic changes are poised to impact the size of this force significantly in the years ahead. “The population is aging and the birthrate has dropped. This means that smaller numbers are joining. Leveraging on technology for the warfighting part is part of the answer but in the end, deep headcount cuts in ‘tail’ areas like HR and Admin are inevitable,” he says. “So we reframe the problem; new resource coming in is dropping. So we asked the question: ‘How is HR and Admin going to operate with a reduction in numbers of 20% or more?’ You frame it at a sufficiently high-level enough meeting where they will ask for options. Very quickly they will say they need to start thinking about it, and when there is an operational lull, they will take that chance to fix the roof before it starts raining. So you need to create awareness and buy-in from the top.”

Avoiding the pitfalls

When asked to pinpoint common challenges in HR in the public sector — both in Singapore and overseas — Gwee identifies several. The first challenge is that HR projects often take several years to complete, at the same time as the other business of the department continues, which means that there is a high risk that project fatigue will set in. Secondly, such projects can often be the first time the people involved have worked at bringing about large-scale change and doing it while learning on the fly. “It can be still frightening for the team, even when you tell them that they will be mostly following well-trodden development steps,” he says.

Thirdly, change management is made all the more difficult as HR transformation often involves bringing together people across various departments who do not report to the project team and who are more often than not concerned how their jobs and roles are going to be affected by the end result. “You’re asking a turkey to vote for Thanksgiving sometimes,” he admits. “So you have to reframe it. We give them examples — they need to professionalize themselves because their new skills are not that hard to learn and the knowledge is transferrable. Otherwise they will belong to the other IBM: I’ve Been Moved! We use acronyms with a bit of humor so it’s easily understandable and lessens the anxiety.”

Clearly, then, communication is key, and Gwee adds that he always seeks to spotlight success stories. “You need to understand how to make it easy to say yes and how to make it difficult to say no,” he says. “You need to understand the emotional landscape and what the hot buttons are. Think about how to present it — an entrepreneurial approach is key, as you need to understand how people will react.”

Future trajectory

Just three months into his new role at the MHA, Gwee is relishing the opportunity to get stuck into the challenge of working in a new department.

“We have come up with four organizing concepts and five workstreams already,” he says. “We have made good progress on knowing what needs fixing and how to get it done at a brisk pace. The key, to note is that it’s not about a direct transplant of what we did in Ministry of Defence. The idea is to borrow yet adapt ideas into the new environment where resources are much leaner. There is a very strong operational ethos at the MHA. We will borrow best practice from anywhere and typically even improve on it. Change is always painful even if it is for good intentions. But we’re lucky. We have strong leadership. Our senior leaders are very focused — they think with their heads and execute with their hearts.”

This article first appeared in the October issue of Citizen today

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