Health care: What Brazil, Thailand are doing right

Jeremy Lim's book Myth Or Magic, is a lucid, highly readable, frank and balanced treatise on the Singapore health-care system. In it, he devotes 10 pages to a discussion of an important issue: What lessons does the Singapore experience offer to the world?

This is an important question. But it is also important to turn the question on its head and ask: What lessons can the world offer Singapore?

This is an important issue because, in addition to the current state of the Singapore health system, Dr Lim is very concerned about future challenges.

In the book, he asks how Singapore should change. Four recommendations are given: MediShield reform, tweaking co-payments for maximum benefit to society, more attractive incentives for providers and the need to transform the health-care delivery model.

I would like to suggest two further recommendations based on the experiences of other countries.

First, the Singapore health-care system needs to be more inclusive, transparent and accountable in decision-making and policy formulation. It should pay particular attention to increased social participation and empowerment of the recipients of health-care services. In this respect, the experiences of Brazil and Thailand, which have successfully achieved universal health coverage, may contain valuable lessons.

In Brazil, strong social participation is achieved through national health councils and conferences convened at the national, provincial and municipal levels.

These bodies meet every four years to assess the health situation and propose policy directives. Significantly, they are not informal consultative platforms but permanent bodies institutionalised in the country's Constitution and legislature. Half of the council membership are users of health-care services. The other half is made up of health workers, managers and providers.

In Thailand, a united front of 11 Thai non-governmental organisations were closely involved in the development and successful implementation of the country's universal health coverage system, often known as the "30 baht" policy. The NGOs were instrumental in the advocacy and awareness campaigns for universal coverage.

Five NGO representatives were part of the policy formulation body which ultimately established the National Health Security Act of 2008. Together with political commitment and a sound knowledge base, social mobilisation was deemed the third critical element in the Thai success story.

My second suggestion is that Singapore needs to be more knowledge-driven and evidence-informed in the development and implementation of health policies. This should be done by establishing and building strong institutions which can provide high-quality, independent, objective and transparent advice on interventions, strategies and policies that work and are cost-effective. Such institutions will become more important in the future due to rising health-care costs and increased demands from the population for transparency and accountability on how policy decisions are made.

In Mexico, the roll-out of Seguro Popular, a national social health insurance scheme, was done as a rigorously designed, randomised controlled trial by Mexican health system researchers. As a result of this evidence-driven implementation process, data was obtained which indicated that the scheme would actually work. The process also identified challenges to implementation, which helped inform future policy reviews.

In Thailand, the Health Intervention and Technology Assessment Programme (Hitap), modelled on Britain's National Institute for Clinical Excellence (Nice), not only evaluates existing interventions but also carries out research and observational studies.

When a relatively costly new vaccine against the human papilloma virus became available, the Thai government was under considerable pressure to introduce the vaccine into the public health-care delivery system. When it turned to Hitap for guidance, the agency did a study which indicated that the vaccine was simply not cost-effective compared to existing procedures such as the traditional Pap smear. Based on this evidence, the government decided not to introduce the vaccine.

In addition to Hitap, Thailand has the Institute for Health Policy & Practice, which similarly places strong emphasis on evidence-informed policy development.

So when the Singapore Government is considering building four more hospitals and 12 more polyclinics by 2030, or increasing the share of government spending from 30 per cent to 40 per cent, would it not be prudent to adopt such an evidence-based approach during implementation in order to evaluate their effectiveness?

The time is clearly ripe for Singapore to invest in strong institutions which can perform these critical assessment, evaluation and research tasks. Investments in these institutions would require only a fraction of the billions of dollars invested in the A*Star programmes and institutions to support the biomedical sciences.

Currently, however, both the capacity for and commitment to such high-quality implementation research are woefully inadequate. This is perhaps a consequence of the disproportionate support given to biomedical research and the development of "commercially viable" products, rather than the less glamorous, but no less important, research to improve health-care delivery to the people.

Singapore is struggling to close the gap between what the Government envisions (the "magic") and what the people want (the "myth"). It is also striving to balance "participation" with "pragmatism", and "social justice and equity" with "market forces". In so doing, it would be wise to take note of the experiences of other countries to effect positive change. In this way, Singapore will become part of a collective global learning enterprise.

The writer is a Visiting Professor at the Lee Kuan Yew School of Public Policy and was director of research policy and cooperation at the World Health Organisation in Geneva.

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