Some musings at the end of the year, after 6 months back in the public sector following a short 2-year stint in the private sector as an infectious diseases physician. This series will probably be (infrequently) updated and extended over time. My experience is primarily with acute hospital-based care, largely through the lens of the infectious diseases specialty.

Singapore’s healthcare system is unique, but as with healthcare in other countries, it is probably best viewed as only one healthcare system and not separate public, private and traditional/alternative medical sectors. What affects the public sector will have ramifications for the private sector, and vice versa. Real experts have described and discussed Singapore’s healthcare system in greater detail, for those who are interested. There are even two contemporary books (if you discount the Ministry of Health’s official SG50 commemorative book) available on Amazon here and here – you can also buy them at Kinokuniya. In brief, more than 80% of acute care hospital beds in Singapore are in public sector hospitals. There is a system of “subsidisation” (a clever framing) in public sector hospitals, where the “subsidy” rate depends on income and ward class (with various levels of comfort, privacy and amenities as shown) – a co-pay system with tiers to reduce moral hazard. The dominant perception is that medical care is of good quality regardless of ward class or “subsidy” in the public sector hospitals.

Ward class and subsidy rate at public sector hospitals in Singapore (screen capture from the MOH website).

Most of the doctors in the public sector hospitals are either employees of the hospitals or the parent holding company (MOH Holdings). In the private sector, the majority of the doctors are independent operators that are licensed to practice at the various private sector acute care hospitals. The exception is Raffles Hospital, which operates similar to public sector hospitals (i.e. most of the doctors practising at Raffles Hospital are employees of Raffles Medical Group – the few independent operators are mainly in specialties or sub-specialties not covered by an existing Raffles employee).

Moving to the private sector as a specialist is popularly likened to “joining the Dark Side” (a holdover from the original Star Wars). The old narrative is that the specialist has traded in public service for great financial gain, since he/she no longer provides medical care for the poor and the needy, but instead only attends to those wealthy enough to seek treatment in private sector hospitals and clinics. This is no longer true, if it ever was. While many of the pioneer specialists that provided private medical care did become immensely wealthy, higher operating costs in the private sector coupled with higher public sector compensation have narrowed the income gap between private and public sector specialists considerably. Few specialists nowadays leave the public sector in the pursuit of great wealth – push or personal factors resulting in such decisions are the norm in my limited experience.

Is there a difference between care in private or public sector hospitals? Unfortunately, in the strictest sense (i.e. in terms of medical outcomes, cost-effectiveness, and/or even patient wellbeing), this has not been rigorously studied. There is comparably greater inefficiency and delay in the public sector hospitals, even if one was to stay in a premium medical suite. This is in some sense inevitable because public sector hospitals are also training hospitals for students and specialist-wannabes, and also because public sector hospitals generally handle a far higher patient load (there are only so many operating theatres, endoscopy suites or radiology instruments in each hospital) compared to private hospitals.

Clinical care is probably more consistently uniform in public sector hospitals. Take antibiotics: virtually all public sector hospitals I know have some form of antibiotic guidelines. Community-acquired pneumonia, nosocomial pneumonia, urinary tract infection, intra-abdominal infection, etc. – there is a good chance that each of these will have been covered in the hospital guidelines and a reasonable chance that the public sector hospitals’ doctors will adhere to them. Nowadays, in many public sector hospitals, there are even antibiotic stewardship teams (the antibiotic police!) – supported by the hospitals’ management – that will audit how broad-spectrum antibiotics are prescribed and provide advice if the clinical rationale is inappropriate. In private sector hospitals (with the exception of Raffles Hospital), doctors are independent operators and each is generally free to prescribe antibiotics as he or she pleases. Both hospitals and doctors have little incentive to come up with antibiotic guidelines, much less try to get most of the doctors to adhere to these guidelines (until the next Joint Commission International inspection for JCI-accredited hospitals).

More at a later date…