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.
Jeremy
Lim
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