Singapore: health policy and programming in historical perspective and social, political and economic context MeNg - KIN LIM

Along with other more populous and economically dynamic countries in the Asia-­Pacific­region,­ the­ tiny­ island­city-­state­of­Singapore­ (land­area:­710­km2; population­five­million)­ completed­ its­ epidemiologic­ transition­ in­ a­ very­ short­ time.­Whereas­tuberculosis­and­pneumonia­were­the­two­leading­causes­of­death­ in­ the­ 1950s­ and­ 1960s,­ chronic,­ non-­communicable­ diseases­ (NCDs)­ like­ cancer,­ heart­ disease­ and­ stroke­ are­ now­ the­ leading­ causes­ of­morbidity­ and­ mortality.­To­appreciate­how­far­Singapore­has­come,­one­has­only­to­note­that­ average­life­expectancy­has­risen­to­81.4­years­in­2010,­from­62­years­in­1957­ (the­earliest­ that­such­a­statistic­was­published),­and­infant­mortality­ is­2.2­per­ 1,000­live­births,­down­from­an­appalling­82­per­1,000­live­births­in­1950­(Ministry­ of­ Health­ 2010a).­ The­ World­ Health­ Statistics­ 2010­ ranked­ Singapore­ second­lowest­for­infant­mortality­and­ninth­highest­for­life­expectancy­at­birth­ (World­Health­Organization­2010:­48). Its inhabitants enjoy universal access1­ to­ a­ high­ standard­ of­ health­ care­ at­ affordable­costs.­Remarkably,­national­health­expenditure­has­remained­between­ 3­and­4­per­cent­of­GDP­in­the­past­four­decades­(compared­to­OECD­countries­ which­averaged­9­per­cent­of­GDP­(OECD­Health­Data­2009).­The­WHO­2000­ Report­gave­Singapore’s­health­care­system­high­marks,­ranking­it­sixth­best­in­ the­world­ for­ overall­ efficiency­ (World­Health­Report­ 2000).­ It­ is­ fair­ to­ say,­ however,­ that­ it­was­ not­ improved­ health­ care­ per­ se­ that­was­ responsible­ for­ Singapore’s­impressive­health­status­improvements;­rather,­the­credit­must­go­to­ the improved housing, sanitation, nutrition, education and environment that accompanied­Singapore’s­rapid­rise­as­one­of­Asia’s­economic­miracles:­it­now­ boasts­a­per­capita­GDP­of­US$57,200­(purchasing­power­parity,­2010),­surpassing­ even­ that­ of­ most­ of­ the­ OECD­ countries­ (Central­ Intelligence­ Agency­ 2010). Paradoxically, the dramatic declines in mortality and its new-rich status – good­news­surely­–­have­combined­ to­generate­a­ fresh­set­of­problems­known­ only­too­well­to­developed­countries:­that­rich­citizens­live­longer­but­have­fewer­ children.­ In­ 2009­ the­ total­ fertility­ rate­ was­ 1.22­ (Ministry­ of­ Health­ 2010a).­ True,­the­population­is­relatively­young­by­any­standards­–­in­2009,­only­8­per­

cent­were­65­years­or­older­–­but­assuming­the­present­trajectory­holds,­20­per­ cent­of­the­population­will­be­65­years­or­older­in­2030­(Ministry­of­Community­ Development­ 1999).­ The­ old­ age­ dependency­ ratio,­ which­ in­ 1994­ was­ one­ elderly­ dependant­ to­ seven­ working­ adults,­ will­ be­ one­ to­ two­ in­ 2030,­ with­ serious­ implications­ for­ a­ whole­ range­ of­ issues:­ workforce,­ social­ security,­ housing­and­health,­to­name­a­few. ­ Since­health­and­disease­are­the­result­of­complex­interactions­of­social­determinants­in­addition­to­genetic­factors,­ it­goes­without­saying­that­they­are­profoundly­ shaped­ by­ the­ broader­ context­ of­ economic­ and­ social­ development­ (World­Health­Organization­2008).­This­chapter­reviews­the­health­policies­and­ prevention­and­control­initiatives­of­Singapore­from­a­historical­perspective­and­ in­the­context­of­social,­political­and­economic­developments.