The Centre for Biomedical Ethics (CBmE) of the Yong Loo Lin School of Medicine (NUS Medicine) is the first collaborating centre for bioethics to be designated within Asia by the World Health Organisation (WHO) in March 2014. Since then, CBmE has supported WHO and its partners (including the Asian Development Bank, the World Bank and UNICEF) in advancing universal health coverage (UHC) across Asia and the Pacific. In this paper, UHC as an equitable enterprise is discussed in terms of the past contributions of CBmE and future challenges ahead.
Universal Health Coverage
Broadly speaking, UHC is concerned with equitable access to quality health services (including medicines and health products) without undue financial hardship, and it was first adopted by all member states of the WHO in 2005.1 With the launch of the Sustainable Development Goals (SDGs) by the United Nations in 2016 as a roadmap for investments in development over the next 15 years, UHC remains a central concern and is identified as a specific target. At its very core, UHC is a bioethical enterprise with a clear focus on equity and for its emphasis that no one should be left behind in the realisation of the SDGs. However, there are many challenges confronting health systems. These include known and emerging infectious diseases, a growing number of high cost interventions and an increasing prevalence of non-communicable diseases faced by a number of countries. This includes Singapore, with a rapidly ageing population. How health systems meet these challenges will depend on the extent that equity is conceptualised and applied.
Conceptualising Equity
Equity is difficult to define simply, but it is regarded as a cornerstone not only of policy decisions, but also of ethically legitimate social institutions. In the context of the healthcare financing aspect of UHC, the CBmE has been involved in explicating a notion of equity (taken to be synonymous with fairness) in two reports of the WHO.2
In working towards UHC, equitable policies should be optimal both from the perspectives of fairness and benefit maximisation. Drawing from an essentially Rawlsian framework of distributive justice, fairness gives emphasis to pro-poor policies, in terms of both distribution and contribution. Fair distribution requires coverage and
use of services to be based on need, and priority should be given to policies benefitting the worst off groups. In contrast, fair contributions to the health system should be based on ability to pay, and not by need. Fair distribution and fair contribution, along with cost-effectiveness, are identified as three concrete guiding considerations for making policy decisions on the path to UHC. Within such a framework, certain trade-offs could be assessed to be ethically more defensible than others.3
Health insurance schemes constitute a crucial component to UHC in ensuring that people most in need of healthcare, especially the poor, are not left behind. Schemes that prioritise advantaged groups (basically those who are able to pay) or otherwise impose a heavy burden on groups already disadvantaged by need (such as a pre-existing medical condition) were identified as a barrier to UHC. Important policy changes have since been made by countries that are committed to UHC, including Singapore.
Universal Health Coverage in Singapore
On 29 January 2015, Singapore’s Parliament passed a law that introduced (from November that year) universal lifelong health insurance coverage in the form of MediShield Life. With this change, the benefits package has been enhanced in terms of an increase in pay-out in order to reduce out-of-pocket payment. Coverage would be for life in order to allay concerns over healthcare affordability, especially for the elderly, and applies to all Singaporeans and eligible permanent residents, including those who are living overseas.
Higher claim limits have also been established while co-payments have been lowered. For a large number of patients receiving inpatient care for serious illnesses, they will not be expected to pay more than S$3,000 a year. Co-payment has been reduced from between 10% and 20%, to a lower level of between 3% and 10%. In order to keep premiums affordable, co-payment has not been completely removed, and no change has been proposed to deductibles, which currently range from S$1,500 to S$3,000. The annual claim limit has been raised from S$70,000 to S$100,000, and the lifetime limit on medical claims of S$300,000 has been removed, so that there is no limit to medical claims over the lifetime of an insured person.
In addition, coverage has been widened to cover the medical claims of an insured person throughout the entire course of her or his life (but subject to an annual limit). A critical inclusion has been the extension of MediShield Life coverage to HIV carriers and AIDS patients. These individuals may be unable to get insurance coverage, while those already insured fear that their insurance policies will be voided if they make a claim.
Premiums are comparatively high among the insured who are young and healthy, as part of the contributions is intended to offset the even higher premiums that they will need to pay when they get older. However, this increase is considered to be affordable, as premiums are fully payable within Medisave withdrawal limits and contributions. In other words, no additional cash outlay should be necessary for most insured households. The financial cost of including those with pre-existing conditions (including HIV carriers) into MediShield Life is higher, as these individuals are likely to make claims from the moment they enter the insurance plan. Consequently, it has been deemed fair for these insured to pay a higher premium. However, their increased contributions is not enough to cover what they will cost to the insurance scheme in claims. At the present time, different cost-sharing arrangements and government subsidies are relied on to keep premiums affordable. For the insured who are 65 to 79 years of age in 2014 (the “Pioneer Generation”), public subsidy for their premiums has been provided, regardless of their income levels.
Advancing and Sustaining Equity
The introduction of MediShield Life is a crucial step forward for Singapore in its progress towards UHC. Expectedly, pay-out in claims under MediShield Life has increased by 66 per cent after about a year since it came into operation, given the scheme’s increased coverage and enhanced benefits package.4 Annual healthcare expenditure is also expected to grow from around S$4 billion in 2011 to S$13 billion in 20205. These development makes clear that equity remains central to MediShield Life in at least two respects: in the distribution of responsibilities and in balancing between benefits and premiums. Continuous monitoring, evaluation, deliberation and dialogue
are necessary to ensure that the scheme remains viable for Singaporeans, through guarding against inadvertent over-consumption or over-provision of healthcare services, and through the articulation of ethically-grounded roles and responsibilities of the different stakeholders involved.
However, reliable and timely information that is needed to support equitable decision-making and actions may not be readily available, whether in Singapore or elsewhere. For many health systems in Asia and the Pacific, there is as yet inadequate information on whether coverage meets the healthcare needs of their populations, and how they ensure that patients receive appropriate services at affordable costs. There are challenges in obtaining data for some of the new health issues included in the SDGs (particularly a number of non-communicable diseases) and disaggregated information is especially sparse. In addition, there are difficulties in obtaining data for health system inputs and outputs, as very limited data exist to measure availability and readiness, quality and people-centredness of health facilities.6
Advancing and sustaining equity through UHC will require health systems to step up on a range of surveillance and related activities. A WHO guidance on the ethical underpinnings of such activities has been a recent project which involved the CBmE.7 Further investments in health management information systems are necessary to obtain information that is needed to refine policies and programmes that could help reduce inequities in service access, coverage and delivery. To be sure, building capacity for equity-focused analysis of information is not confined to the level of health systems, but must be an intricate part of the training and continuing education of the health workforce. In this respect, the Yong Loo Lin School of Medicine will have a crucial role to play in the foreseeable future. Under a whole-of-society approach, UHC must be an initiative that every individual should take ownership of in terms of their health and well-being. Reflecting on Singapore’s experience, its capacity to achieve UHC could perhaps be attributed to its focus on wider social determinants that have no direct link to health.8 Early national priorities were on political unity, developing a prosperous economy and an efficient and corruption-free government, although equity has been a central value to them all.
References
1. World Health Assembly Resolution 58.33. 2005. Geneva: WorldHealth Organization. http://www.who.int/health_financing/documents/cov-wharesolution5833/en/
2. World Health Organization, Making fair choices on the path touniversal health coverage: Final report of the WHO ConsultativeGroup on Equity and Universal Health Coverage. Geneva: WorldHealth Organization, 2014, at 7; World Health Organization, Medicines in Health Systems. Geneva: World HealthOrganization and Alliance for Health Policy and Systems Research, 2014.
3. Ibid, at 37-41.
4. Neo Chai Chin, ‘One year on, MediShield Life sees 66% more payouts than previous scheme’, Today Online, 1 November 2016. http://www.todayonline.com/singapore/ medishield-life-sees-66-more-payouts-previous-scheme
5. Valerie Koh, ‘Govt Spending on healthcare set to go up in 3 to 5 years: Heng’, Today Online, 6 December 2017. http://www.todayonline.com/singapore/govt-spendinghealthcare-set-go-3-5-years-heng
6. Asian Development Bank and World Health Organization. Monitoring Universal Health Coverage in the Western Pacific: Framework, Indicators, and Dashboard. Manila: Asian Development Bank, 2016.
7. World Health Organization, WHO guidelines on ethical issues in public health surveillance. Geneva: World Health
Organisation, 2017.
8. Lincoln C Chen and Kai-Hong Phua, Transferring lessons from Singapore: an art or a science? The Lancet (2013) 382:930-931.