Getting the Healthcare Resource Balance Right – Speech by Jamus Lim on the Healthcare Motion

Mr Speaker, I will speak about steps we can take, as a nation, toward moving to a better balance in our expenditure on healthcare resources. I will share some details on why I think we can increase the carrying capacity of our healthcare system—perhaps to some detriment in efficiency and some marginal pressure in costs—that will pay off in terms of greater long-term resilience. 

As others in this House have shared—and as well understood by this government—our impending public expenditures on medical care will be substantially greater than what we have currently allocated for spending today. This is due, predominantly, to societal aging, and the greater healthcare needs associated with a more elderly population.

Our impending healthcare needs

But my point is more fundamental. It is that, even at present, our healthcare spending falls short of what we might reasonably expect from an economy at our stage of development.

Now, I am not suggesting that our current system is fundamentally flawed, nor am I saying that it should be completely overhauled. Indeed, I believe we can justifiably be proud of the quality of care delivered by our existing system, which blends public and private components, and has proven to be remarkably cost-effective in doing so. While I would certainly prefer the balance to be tilted more toward a larger public share—a matter that I had spoken about before, in the context of the debate on the amendments to the Healthcare Services Act in March this year—that is not the focus of my concerns today.

Engineers versus economists

Rather, I wish to highlight one glaring shortcoming that was raised by the COVID-19 episode: Because we run our systems so lean, it has become fragile in the face of large, unanticipated (but fully predictable) shocks, such as a pandemic.

Here, a little theoretical digression is in order. The bread and butter of function of economists is to maximize a given objective, subject to constraints. This generally means that we are constantly looking for optimal solutions to resource allocation problems, and we are very happy when we find such solutions. My wife often makes fun of how I gain enormous satisfaction by planning my visit to the grocery store along with all my other errands—pumping gas, drawing cash, tapao dinner—so that I make one smooth, continuous trip (in this regard, economists are easily satisfied creatures).

But there is another, equally tenable worldview, and that is one often held by engineers. Engineers don’t look to wholly strip systems of inefficiencies. They recognize that redundancies are important, because while under normal conditions, such underutilized elements may seem wasteful, they are mission-critical and can prevent the entire failure of the system during times of undue stress. Accordingly, they build bridges that can bear far more weight than one might expect with normal traffic, and then add a little more. They design planes that can run with one engine, even when the other stops. They design power plants that possess multiple failsafes, so that the can keep the whole thing running while a compromised part is being repaired.

Hospital beds are often above target capacity

Sir, the number of ICU beds in Singapore, per 100,000 of our population, is 5.7. The average in the OECD, an association of industrialized nations, is a dozen, twice our number. Of the 4 economies that have lower coverage than we do, only one—Japan—has a significantly larger elderly share in its population.

More generally, our hospital bed count is also low. We maintain a little more than two beds per thousand of our population, a fraction of that of other East Asian economies, like Japan and South Korea (which have around a dozen), China (at around 5), and other advanced economies like Denmark, the Netherlands, Israel, and the United States (which is closer to 3).

To be clear, this low bed count is not prima facie evidence that there is a problem with the present system. We need to look at the occupancy of said beds, and one could even make the argument that efficient recovery means that we are able to sustain a lower carrying capacity.

In a response to a PQ filed last year by my honorable friend Mr Leon Perera, SMS Janil Puthucheary shared that the targeted bed occupancy rate over the next five years was around 80 percent, which he added was generally recommended by academic communities and healthcare authorities. And in a statement to this House the year prior, he also explained that we have been able to ramp up ICU quickly, as we did during the pandemic.

But in that statement, he also acknowledged the need to ramp up ICU bed capacity, although he qualified this by pointing out that this process was nontrivial, being limited by the need to increase the medical personnel required to staff such beds. Moreover, recent data on bed occupancy rates at our major hospitals reveal that this 80 percent is systematically breached, and over the past month, the rate has routinely exceeded even 90 percent in Tan Tock Seng, Ng Teng Fong, and Koo Teck Puat. And that is under nonpandemic conditions.

Taken together, these suggest that the government is both aware that running our medical infrastructure too lean can come back to bite us during periods of stress, and that we have yet to fully address this problem even though we are back in normal times. 

MOH has shared that it plans to roll out a new health campus in Woodlands, as well as another in Bedok, but the remaining projects are all expansions of current facilities. Will the Minister be willing to share if these will be sufficient to cater to not just anticipated increases in demand due to an aging population, but also relieve some of the existing capacity constraints faced? Or will they be mainly focused on matching resources with new demand, leaving current capacity unaltered?

Doctors and nurses

This brings us to what appears to be the key constraint: medical manpower. At present, we also have a comparatively low coverage of doctors and nurses. As of 2021, Singapore has 2.7 physicians per 1,000 people, around two-thirds the OECD average of 3.8.

Unsurprisingly, this has led to burnout, stress, and high turnover among our medical professionals, which others in this House have articulated. The solution appears straightforward and is uncontentious: we need to increase our supply of medical personnel. The government has stressed the same, that ramping up medically-trained staff is a priority. The question is how.

There is a global nurse shortage, which the WHO estimates may be close to 6 million, and the International Council of Nurses places at a larger number, of 13 million. Given this context, increasing supply calls for us to attract and retain global talent in the short term, while looking for ways to expand domestically-trained workers in the longer term.

Wait times

The practical manifestation of our limited beds and doctors is that wait times for admission to a ward has remained elevated at many facilities. This has been most chronic at Koo Teck Puat, although we’ve seen spikes at Ng Teng Fong as well as Sengkang General, located in the ward I represent. On certain days, this could lead to waits exceeding 24 hours. 

The question we should ask ourselves is: Are we willing to accept the status quo, where our patients may occasionally need to wait for more than a day to be admitted into hospital? Perhaps we think this is a reasonable tradeoff, to keep overall medical costs down. Or we may use this fact as symptomatic of a need to increase the carrying capacity of our healthcare system.

Increasing resources

In my earlier speech, I offered some medium-term suggestions for how could relieve some of the existing pressure on our system. We could consider increasing the number of recognized universities for basic medical degrees, up from the present 100. For experienced doctors, who have a long track record of working in other jurisdictions, we can simplify the application and accreditation process, perhaps with designated processors based at MOH that seek out such doctors and encourage them to apply.

As we compete for global nursing talent with other advanced economies—many of whom are facing their own nursing shortages—it also makes sense to train more of our homegrown workforce to take this on. We could offer more generous terms for trainees: we could fully waive course fees—which to be fair are already relatively modest—on condition that these trainees work as nurses in Singapore for a certain duration after graduation. This would also apply to those who may consider a mid-career switch; can we ensure that SkillsFuture funds fully cover conversion courses, and perhaps provide more credit for prior training (for example, early childhood educators and teachers surely would satisfy courses in communications, critical thinking, data analysis, and behavioral science)?

Easing the supply pressure will require that we go beyond policies on the quantity dimension; we should also work on price. At its simplest, it means that salaries in the field must rise. One existing limitation to more sustained increases in wages is that costs are already high; this, in turn, seems to be led by commercial rental rates for private hospitals, which can spill over to public pricing. And high rent is a function of, you guessed it, elevated land pricing.

But it isn’t simply about higher wages, if these are simultaneously accompanied by longer hours; if anything, it would be better to increase the total number of doctors and nurses, while keeping hours sane. The total wage bill will remain the same, but quality of care is likely to improve.

We could also increase the number of tiers within the nursing—these number as many as 5 or 6 in other countries—from our present three, of enrolled, registered, and advanced practice nurses. This offers additional upward mobility pathways, making the profession more attractive for those contemplating entry.


Sir, as I explained at the outset, our healthcare system capacity does not appear to be fundamentally flawed, but it is facing increasing pressure, and it is wise to adjust and adapt to impending needs—at a time of relative calm—rather than feel the need to kelam kabut to make up for these during a future pandemic scenario.