Office for Healthcare Transformation, Ministry of Health, Singapore; Department of Medicine, National University of Singapore, Singapore.
National Heart Centre Singapore, Singapore; Duke-NUS Cardiovascular Academic Clinical Program, Duke-NUS Medical School, Singapore; Department of Cardiology, University Medical Center Groningen, Groningen, Netherlands.
Lancet. 2021 Sep 18;398(10305):1091-1104. doi: 10.1016/S0140-6736(21)00252-X. Epub 2021 Sep 2.
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.
自 1965 年新加坡成为独立国家以来，其医疗保健系统的发展一直强调个人对健康的责任，并通过有针对性的补贴积极干预政府，以确保可及性和负担能力，并降低不必要的成本。新加坡实现了良好的健康结果，2016 年总卫生支出占国内生产总值的 4.47%。然而，医疗保健系统正面临着越来越大的压力，这反映在所谓的痛点上，这些痛点引起了公众的关注，包括急性医院病床和中短期护理（ILTC）服务短缺，以及高额自付费用。这些挑战的主要驱动因素是慢性病患病率的上升和人口老龄化的迅速加快、初级保健和 ILTC 的提供和组织方面的限制，以及可能无意中阻碍医疗保健整合的财务激励措施。为了解决这些挑战，新加坡卫生部在其 2020 年医疗保健总计划下于 2012 年实施了一系列全面改革。这些改革大大增加了公立医院病床和社区中 ILTC 服务的容量，扩大了对初级保健和长期护理的补贴，并推出了一系列融资医疗保健改革措施，以加强财务保护和覆盖范围。然而，很明显，这些措施单独实施并不能从长期上解决系统压力的根本驱动因素。相反，该系统需要并正在对其方法进行更根本的改变。2016 年，卫生部用所谓的“三个超越”来概括所需的转变——即超越医疗保健至健康，超越医院至社区，以及超越质量至价值。
