Singapore's health-care system: key features, challenges, and shifts

Since Singapore became an independent nation in 1965, the development of its health-care system has been underpinned by an emphasis on personal responsibility for health, and active government intervention to ensure access and affordability through targeted subsidies and to reduce unnecessary costs. Singapore is achieving good health outcomes, with a total health expenditure of 4·47% of gross domestic product in 2016. However, the health-care system is contending with increased stress, as reflected in so-called pain points that have led to public concern, including shortages in acute hospital beds and intermediate and long-term care (ILTC) services, and high out-of-pocket payments. The main drivers of these challenges are the rising prevalence of non-communicable diseases and rapid population ageing, limitations in the delivery and organisation of primary care and ILTC, and financial incentives that might inadvertently impede care integration. To address these challenges, Singapore's Ministry of Health implemented a comprehensive set of reforms in 2012 under its Healthcare 2020 Masterplan. These reforms substantially increased the capacity of public hospital beds and ILTC services in the community, expanded subsidies for primary care and long-term care, and introduced a series of financing health-care reforms to strengthen financial protection and coverage. However, it became clear that these measures alone would not address the underlying drivers of system stress in the long term. Instead, the system requires, and is making, much more fundamental changes to its approach. In 2016, the Ministry of Health encapsulated the required shifts in terms of the so-called Three Beyonds-namely, beyond health care to health, beyond hospital to community, and beyond quality to value.

Non-small cell lung cancer presenting with neoplastic fever at diagnosis and relapse

Fever occurs frequently in cancer patients, and neoplastic fever is a well-described paraneoplastic phenomenon in patients with lymphoma, acute leukemias, and renal cell carcinoma. It is also more commonly encountered in metastatic disease. Treatment options include disease-specific therapy, non-steroidal anti-inflammatory drugs (NSAIDs), and steroids. Lung cancer is one of the most common cancers, yet fever as a manifestation of this malignancy has not been emphasized. In this report, we describe an unusual case of non-metastatic non-small cell lung cancer (NSCLC) presenting with neoplastic fever at both diagnosis and relapse, responding on each occasion to disease-specific treatment, and provide a review of the management of neoplastic fever.

Patient and disease characteristics, and outcome of treatment defaulters from the Singapore TB control unit--a one-year retrospective survey

SETTING

The Singapore Tuberculosis Control Unit.

OBJECTIVES

1) To identify any demographic, social, disease or treatment-related characteristics which may be predictive of patients defaulting from treatment; 2) to assess the effectiveness of home visits as a means of defaulter recall; 3) to ascertain outcome in these patients.

DESIGN

A retrospective, case-controlled study of TB treatment defaulters, defined as patients who missed their scheduled appointments and required a home visit to recall for treatment. Controls were randomly selected, non-defaulting patients who started treatment on the same dates as the defaulters.

RESULTS

Forty-four patients required home visits in 1996. Compared to controls, defaulters were more likely to be non-Chinese, and to live on their own or with friends. There was no significant association of defaulting with age, sex, marital or employment status, disease characteristics, or treatment-related factors. Seventy per cent defaulted during the continuation phase of treatment. Home visits did not result in contact with the patient (or any other person) 41% of the time. Although 48% of the defaulters remained lost to follow-up at the time of the survey, all but one of the sputum-positive patients had bacteriologically converted by the time of default.

CONCLUSION

Non-Chinese ethnicity and lack of family support were found to be factors strongly predictive of default. Age, sex, marital and employment status, treatment-related factors and disease characteristics were not significant in distinguishing those at risk for defaulting.