What US Health Agencies Can Learn From Singapore

The public is losing confidence in the US’s health agencies. US health agencies have been criticized for their poor leadership and sclerotic cultures, not only for their handling of COVID-19 but also for earlier failures. We rely on our health agencies to finance care for more than 100 million people, deliver health care to millions of veterans, fund biomedical innovation, and keep us safe during public health crises. If Americans lose faith in their health agencies, they will not listen to public health recommendations and will increasingly doubt the safety of vaccines. Without functioning health agencies, public spending will be wasted, and health outcomes, including life expectancy, will continue to deteriorate.

We suggest policy makers seeking to improve the functioning of US health care agencies might usefully consider Singapore’s example. Skepticism about the relevance of Singapore to the US is understandable. After all, Singapore is an island nation of just 5.7 million people with a single-party government, not a continent-spanning 330-million-person democracy. More importantly, it is not possible to “lift and shift” a health system to another country with a different history, structure, financing arrangement, and delivery system. Despite these differences, there are important management practices from Singapore that can be usefully implemented without comprehensive system reform to improve the culture and functioning of US health agencies including the Centers for Medicare and Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), National Institutes of Health, Department of Veterans Affairs (VA), and state health departments.

Singapore’s Health System

Singapore has achieved low-cost, universal health care coverage with a system very different than in the US. Although considered a bastion of capitalism, Singapore’s system is a unique mix of patient financial responsibility and intense government controls. The financing of the system is based on the “3 Ms”:

• Medishield Life: All Singaporeans are enrolled in Medishield Life, the government’s basic health insurance program. Coverage is generally limited to catastrophic expenses such as hospital bills and requires up to 10 percent copayments. Singaporeans are expected to pay for outpatient visits and most prescription drugs with supplementary private insurance or from their own savings.
• Medisave: Given this responsibility, all Singaporeans are required to save about 9 percent of their income into Medisave, the national medical savings program. These savings are invested by the government, accrue interest, and can be used to pay for insurance premiums and medical expenses. Individuals can give their savings to a beneficiary when they die or can fully cash out their savings if they permanently emigrate.
• Medifund: For individuals who cannot afford medical expenses, the government provides subsidies via Medifund and other safety-net programs. The government does not publish transparent income-eligibility rules for Medifund. Instead, hospital systems have the discretion to make individualized grants to applicants based on their income, savings, medical bill, and health circumstances.

The government also plays an active role owning and operating hospitals and clinics. About 70 percent of hospital beds are public, and the government runs 18 polyclinics, like federally qualified health centers in the US, to provide primary and chronic care to low-income patients.

Singapore’s health care system is often ranked as one of the world’s best. Health care spending is just 4 percent of gross domestic product in Singapore compared to nearly 20 percent in the United States. Singapore achieves outcomes comparable or better than the US. The infant mortality rate in the US is triple Singapore’s rate. Singapore has a higher childhood vaccination rate, a lower smoking rate, a comparable rate of hypertension under control, and fewer deaths per capita from COVID-19 than the US, but a lower five-year cancer survival rate for most common sites of cancer.

One important reason for Singapore’s success is its highly capable Ministry of Health (MoH) stewarding the system. Although Singapore is a market-driven economy, government service is a high-status job and their nation’s founder, Lee Kuan Yew, instilled a belief in hiring the most talented people as civil servants. The World Bank ranks Singapore number one in the world for government effectiveness. The US ranks 28th.

Even though Singapore’s health system is so different from the US’s, their public administration is a root cause for their success, which suggests that parts of their model can readily be adapted to the US without major institutional changes.

We highlight four critical lessons from Singapore that can be adapted to federal and state health agencies to improve their functioning, Americans’ health outcomes, and public confidence.

Measurable Agency Outcomes

First, the MoH in Singapore explicitly identifies success in terms of transparent, publicly announced, measurable health outcomes. The MoH annual budget publishes a scorecard of 18 metrics across 4 categories: health outcomes, quality, accessibility, and affordability. Each metric has a quantifiable target for the next year. The Singaporean legislature uses these metrics to evaluate the MoH’s performance and the Minister of Health’s individual performance. Indeed, the Minister earns a financial bonus that is partly based on hitting these 18 targets. Program leaders can generally articulate how their work drives at least one metric. For example, the finance leader managing the government’s health insurance program could easily cite the statistics on affordability she is responsible for. Even for programs in which the agencywide metrics do not apply, Singaporean policy makers are still generally accountable to targets. This use of metrics makes the agency more focused in its mission and more accountable for results.

Federal agencies are required to create five-year strategic plans each presidential term. But the goals set by US health agencies tend to be nonspecific or process oriented. For example, CMS’s strategic plan has six key pillars including health equity and engaging partners. These are worthy goals, but the agency does not define specific, measurable outcomes to assess whether the goals, such as reducing disparities, are achieved. There is an irony in that CMS administers the Star Rating systems that provide outcomes-based scores for hospitals, Medicare Advantage plans, and nursing homes but does not have a way of ranking its own performance on critical outcomes.

The Department of Health and Human Services (HHS) also publishes a strategic plan with an accompanying annual performance plan with about 80 performance metrics and targets—many even outcomes-based. But the selected metrics are scattershot and fail to provide a comprehensive picture of how HHS is advancing its mission. The report satisfies a legal requirement, but it is unclear if HHS managers know how their jobs are connected to these performance plan metrics as is the case with Singapore program leaders.

Lesson 1

We propose that each US health agency should publicly delineate a total of no more than 20 specific quantifiable goals across health outcomes, quality, accessibility, affordability, equity, and innovation. These outcome-based goals should have five-year targets set as part of each agency’s strategic planning process that occurs each presidential term. Then, agencies should report their progress annually. For instance, on quality, CMS might propose achieving a national 30-day hospital readmission rate in line with targets set for hospitals in its value-based purchasing program. On health outcomes, CMS might target increasing hypertension control to 50 percent of the population with no disparities between Black and White populations. On innovation, the FDA should set targets to reduce the total development time from preclinical trials through new drug approval while holding constant measures of safety. The VA and CDC’s strategic plans already include some outcomes-based targets. The CDC, for example, aims to reduce adolescent tobacco use to less than 14 percent by 2023. But even where US health agencies have published some quantified goals, they should further strive to build a comprehensive outcomes-based scorecard that motivates agency employees and enables public accountability.

Exhibit 1: Goal setting in US health agency strategic plans

Source: Authors’ analysis of US health agency strategic plans.

Collaboration Across Agencies

Second, Singapore explicitly builds effective collaboration across agencies, including both health agencies and other governmental agencies that impact health outcomes. Workers with experience across different government agencies are highly valued. Thus the current MoH minister previously served as the minister for transport and education—two areas known to be linked to health outcomes. This kind of experience is common among top leadership and further down in the MoH. For example, the finance director in charge of reimbursement and insurance policy previously worked in the labor ministry and for an agency responsible for promoting racial harmony.

Singapore has a Public Service Leadership Program that rotates top recruits across agencies as they build their careers. The prime minister and agency heads frequently convene Strategic Issue Groups (SIGs) in which a cross-agency team presents a recommendation on government strategy. For example, a recent SIG on aging brought together the health, labor, economic, transportation, and housing agencies because they all have an impact of healthy aging. Success in complex projects is important for career advancement because the MoH believes it is necessary to learn how to collaborate across agencies.

Health care services contribute only about 20 percent to health outcomes for a population. Diet, housing, education, environment, and other factors contribute much more. This recognition is now embodied in CMS rule changes that allow Medicare Advantage plans to provide to their members non-health services that improve health outcomes. Similarly, many provider groups are trying to address social determinants of health by more effectively linking beneficiaries with social services, such as Supplemental Nutrition Assistance Program (SNAP).

To improve health outcomes, the government must better integrate services across departments and agencies. For example, at the federal level, CMS and US Department of Agriculture (USDA) use different definitions of income (modified adjusted gross income versus gross income) for Medicaid and SNAP applications, making eligibility harder to determine. And at the state level, if Medicaid officials had work experience at SNAP and housing agencies, they could better align the application processes for Medicaid, nutrition assistance, and housing vouchers. Just 28 states allow for unified Medicaid and SNAP applications, and even then only in certain cases, despite the Affordable Care Act’s decade-old requirements to update eligibility systems. Even fewer states coordinate Medicaid and SNAP applications with housing vouchers. These enrollment barriers mean fewer low-income families receive the help they need, adversely impacting their health.

Building multi-agency enrollment systems is challenging and slow for states because officials from different departments do not regularly collaborate. If officials had greater shared work experience—such as a CMS official with years of experience in the Department of Housing and Urban Development—they would have a deeper sense of a joint mission, a more interconnected professional network, the common policy knowledge needed to work together, and could be held jointly accountable. Greater collaboration across health care, housing, food, labor, and tax agencies at both the federal and state level is needed to tackle the social determinants of health more effectively.

Lesson 2

The US should create a rotational program equivalent to Singapore’s Public Service Leadership Program for career civil servants to build experience for health policy work that requires experience across different governmental departments. Existing government rotational programs must be overhauled, scaled up, and made more prestigious with General Schedule promotion opportunities. Talented young recruits in the rotational program should expect to lead cross-agency strategy projects and make recommendations to HHS leadership, like Singapore’s SIGs. Similar rotational programs could be adopted within state governments. If rotational programs are not feasible, then US health agencies should promote collaboration by developing cross-trainings for health policy makers to meet and learn from colleagues in other agencies relevant to health.

Developing And Retaining Talent

Third, Singapore’s government emphasizes developing and retaining talent. Many of the nation’s brightest high school students are provided university scholarships in exchange for five or more years of public service. Civil servants are then encouraged to remain in government with near market-rate salaries, financial bonuses for good performance, and an assessment tool called Currently Estimated Potential that counsels young officers on their potential career path to higher leadership. Singapore’s MoH prioritizes retention because effective policy making requires understanding a complex health system, political landscape, and regulatory process. Higher retention gives employees time to climb a steep learning curve and gives the agency more work history to make promotion decisions. Singapore almost exclusively promotes from within rather than hiring externally to fill open positions. In fact, only one job at the top of the MoH is a political appointee. As a result, the agency has greater stability and leadership commands greater respect from staff because they had to rise through the ranks.

Because the MoH relies on promotions, the government needs to develop its staff and invests to help them learn new skills. Singapore’s Civil Service College (CSC) is a government-run college for public service officers. The CSC provides classes on skills such as data analysis and partners with departments to develop new courses such as design thinking for the health finance group. The CSC is also responsible for monitoring the leadership development of civil servants as they proceed through rotational programs across the government.

The US has more of a revolving door between the public and private sectors. Indeed, the turnover rate for government employees has increased significantly in recent years. This exchange brings fresh ideas to government, but low retention likely impedes employee performance because it takes time to understand how an agency works and how to be an effective civil servant. HHS’s talent development resources include limited online learning options and fall far short of the resources of Singapore’s CSC. But colleges for training government employees are not foreign to the US. The Department of Defense’s Naval War College and the National War College make significant investments in training the military’s next generation of leaders.

Lesson 3

US health agencies should reform management practices to increase retention. Although general increases in pay may not be politically feasible, we recommend other practices to boost retention, such as reforming feedback systems, fully using federal retention bonus programs, and inspiring career goals with a system like Singapore’s Currently Estimated Potential.

The US should also create the equivalent of the National War College for training health agency leadership. This school could be created in collaboration with an existing university and would award master’s level degrees to prepare students to lead health agencies. The courses would teach hard skills such as data analysis and operations as well as softer skills such as leadership and public communication.

Learning From Other Countries

Fourth, Singapore’s MoH studies and adapts successful models from other countries. We conducted recent interviews that demonstrated MoH officials’ deep familiarity with other nations’ policies and health systems. For every significant payment innovation or initiative launched by the MoH Office for Healthcare Transformation, Singaporean policy makers learn from the world’s centers of excellence. The MoH invites academics from the US to serve as expert advisers on value-based care and brings hospital leaders from Cedar-Sinai to Singapore to advise on delivery innovation. We learned in interviews that the MoH even funds international trips for its officials; for example, policy makers traveled to Kaiser Permanente to learn about care coordination. As further evidence of openness, the National University of Singapore and Duke University partnered to establish one of Singapore’s three medical schools in 2005.

The US is often hesitant to publicly admit it is not number one. Like Singapore, the US should study and adapt what works in other countries. The US could reduce its uninsurance rate by adopting simplified auto-enrollment practices like in the UK, Norway, or Switzerland. Or state insurance regulators aiming to reduce the burden of selecting among dozens of complex insurance options in the individual exchanges could learn from how the Netherlands streamlines this kind of decision with more uniform options.

Lesson 4

US health agencies should establish working partnerships with other countries’ health agencies and fund trips for policy makers to study centers of excellence. Furthermore, HHS’s Office of the Assistant Secretary for Planning and Evaluation should create an office responsible for studying innovation in health policy and delivery outside of the US. This office should make recommendations for how to improve the US health care system and advise Medicare and Medicaid agencies on how to adapt successes from other countries.

There are limitations to studying Singapore’s system to improve the US’s health system. But these four specific, actionable lessons from Singapore can and should be adopted in the US. We must continue to press for a well administered government and study what works in other countries. The nation’s health depends on it.

Authors’ Note

Jeremy Rubel is an employee of the Boston Consulting Group, which provides consultancy services to entities described in the article. Dr Emanuel reports personal fees and speaker fees from Optum Labs and travel reimbursement, personal fees from Goldman Sachs and travel reimbursement, personal and speaker fees from Brown University and travel reimbursement, personal fees from The Atlantic and travel reimbursement, personal fees and speaker fees from McKay Lab, personal fees and speaker fees from American Society for Surgery of the Hand, personal fees and speaker fees from Association of American Medical Colleges and travel reimbursement, personal fees and speaker fees from America’s Essential Hospitals and travel reimbursement, personal fees and speaker fees from Optum and travel reimbursement, personal fees and speaker fees from Johns Hopkins University and travel reimbursement, personal fees from National Resident Matching Program and travel reimbursement, personal fees and speaking fees from Shore Memorial Health System and travel reimbursement, personal fees and speaker fees from Tulane University and travel reimbursement, personal fees and speaker fees from Oregon Health & Science University and travel reimbursement, personal fees and speaker fees from United Health Group and travel reimbursement, personal fees and speaker fees from Blue Cross Blue Shield Speaker and travel reimbursement, personal fees and speaker fees from CBI/Informa, personal fees and speaker fees from Rise Health, personal fees and speaker fees from Galien Foundation, personal fees and speaker fees from Wellsky, personal fees and speaker fees from Rightway, personal fees and speaker fees from Signature, personal fees and speaker fees from Healthcare Leaders of New York and travel reimbursement, personal fees and speaker fees from Medimpact, non-financial support from University of Sydney, personal fees and speaker fees from Massachusetts Association of Health Plans, non-financial support from American Philosophical Society Speaker, personal fees and speaker fees from Princeton University Speaker and travel reimbursement, personal fees and speaker fees from Philadelphia Committee on Foreign Relations. Dr. Emanuel is an unpaid board member for Village MD, an unpaid board member for Oncology Analytics, an unpaid board member for Cellares, an unpaid member of the board of advisers for Notable, unpaid advisory board member of HIEx Health Innovation Exchange partnership sponsored by UN Geneva, and an advisory board member for the Peterson Center on Healthcare. He is a venture partner at Oak HC/FT Venture Partner, a partner at Embedded Healthcare Partner, and an LLC Partner at COVID-19 Recovery LLC.