Friday, July 8, 2016
Singapore - Health equity in Singapore: A plan for action
Averages often disguise or at least underestimate health equity gaps, especially in countries with large economic disparities. In Singapore, we have a much lauded health system but we do not have a full appreciation of how well benefits of the system have been shared across the entire population. What, then, should we do?
A complete picture can be obtained by examining the factors that contribute to good health, the infrastructure available to lower-income Singaporeans when ill, and finally, the outcomes after disease.
We commonly misjudge a country’s health system and look only at the number of fancy hospitals, state-of-the-art technologies and well-trained doctors and nurses. All these are of course important but convey only an incomplete appreciation of what contributes to an individual’s and a nation’s health.
Public health professionals describe the “social determinants of health” — one’s health is shaped not just by personal motivation and genetic make-up. The environment we live in and the people we interact with all exert profound influence on our health. In the first part of this series, I highlighted how lower-income households have higher rates of obesity in Singapore. A ruthless meritocratic perspective would put the blame on the patients, citing a lack of drive and discipline leading to both low salaries and poor health status.
Today, we know better. While personal factors undoubtedly are important, extrinsic factors also matter. The poor are doubly hit in nutrition: A lack of grocery stores, farmers’ markets, and healthy (and higher priced) food providers in their communities is often coupled with easy access to convenience stores offering cheap, processed, sugar-laden and fatty food.
Healthy, nutritious food is often the privilege of the affluent. The same dynamics play out in physical activity. In many countries, the elite have beautiful parks and gyms in safe neighbourhoods while inner-city residents stay indoors for safety reasons. Unsurprisingly, while obesity rates among white children in America have levelled off, they continue to rise among children of colour.
The situation in Singapore is much better, of course, but social determinants matter too. Are all Singaporeans at the same starting point in the race for health?
Research has found that only 38 per cent of uninsured American women undergo mammograms compared with 70 per cent of those with insurance. In Australia, researchers analysing data from almost 400,000 cancer patients found that “13.4 per cent of deaths attributable to a diagnosis of cancer could have been postponed if socioeconomic disparity was eliminated”.
The international research points in one direction: Inequities span the entire spectrum of health, from risk factors to access to outcomes. In Singapore, where data is scarce, what should we do?
IMPROVING HEALTH EQUITY IN SINGAPORE
The old adage “What gets measured gets managed” is a good starting point. Singapore already has national registries for major diseases such as cancer, heart disease, kidney failure and stroke. Let’s begin to systematically analyse the data through an equity lens. We can segment data by income, housing type or other proxies for socioeconomic status and ferret out disparities. At the public-hospital level, we have a mixed system of full-fee-paying private and subsidised patients and it is important to evaluate how much this affects equity.
Singapore has two of the highest-ranked universities in Asia. Let’s challenge ourselves to develop a basket of metrics and establish a health equity index. These metrics should encompass the social determinants of health as well as measures for accessibility to health services, their affordability, and the outcomes.
When differences are discovered, as inevitably they will be, allocate resources preferentially to remove barriers and level up health outcomes.
We already do so in fiscal policy. Our tax system is highly progressive, with the top 20 per cent of households paying 55 per cent of all taxes and receiving only 12 per cent of benefits while the lowest 20 per cent of households pay 9 per cent of all taxes and receive 27 per cent of all benefits. Non-governmental agencies are already starting to do their part — the Singapore Cancer Society offers mammographic free screening for low- and middle-income women at its health facilities.
The Brexit saga has amply demonstrated the dangers of disenfranchising segments of society and under-estimating rich-poor divides. Even before the referendum, England had been sharply polarised over service cuts to the National Health Service and efforts to privatise it, with deep concerns over access and affordability.
In Singapore, the fault lines are there, even if not discussed openly. Health and health care should not exacerbate the tensions, and equity can be a powerful force to rally and unite the country. What matters gets measured and managed. Health equity matters.