- Email: [email protected]
Health policy and traditional medicine in Singapore
Cqrt$h!
0271-7123’81 ISO149-08SOL~‘O e 1981 Per~mnon Press Ltd
HEALTH POLICY AND TRADITIONAL MEDICINE IN SINGAPORE %-ELLAR. QUU Department of Sociology, National University of Singapore, Singapore Abstract-Singapore’s degree of government intervention into health policy can be seen as intermediate between the bureaucratic and market strategies which Alford delineates. In this approach, the govemment takes a quite tolerant if not directly encouraging approach to the several forms of traditional medicine of the several important ethnic groups in the country. To some extent this approach reflects a solution of sorts to the shortage of qualified medical personnel.
The
necessity
to
control
the
rapid
and
complex
growth of modem medicine has become an important issue today. The message in a 1971 book by a German scientist indicates that “health is too important to be entrusted only to doctors” [l]. That statement conveys clearly the feeling among many social scientists and policy analysts. Despite their differences in approaches, they seem to agree on the need for some type of government intervention in the provision and administration of health care services. Some examples of this common idea are the works of Berry [Z], Djukanovic [33 and Mechanic [4,5]. While industriahzed countries are busy trying to harness highly technical and expensive private medical services, the developing countries have a different concern. The latter have an urgent need to supply low-cost primary health care. Thus. one of the key topics of health services research in developing countries now is the utilization of traditional medicine services [6-S]. I intend to discuss in this paper the case of Singapore’s health policy as an instructive example of governmental management of health services in a society where both modem and traditional health care services are available. This paper is divided into three sections. The first section presents some relevant ideas from the literature on policy studies that serve as a guideline in the discussion. The second section deals with the major trends in health policy since 1965 when Singapore became an independent Rep& lit. The final section focuses on the link between health policy and the traditional practitioners of Chinese medicine. The term health policy used here falls well within Townsend’s definition of social policy. Townsend detines social policy as the underlying as well as professed rationale by which social institutions and groups are used or brought into being to ensure social preservation and development.. in other words, the institutionalized control of services, agencies and organizations to maintain or change social structure and values. Sometimes this control may be utterly conscious. and consciously expressed by Govemment spokesmen and others. Sometimes it may be un-
spoken and even unrecognized [9]. In the context of this paper the source of health policy is the State. Moreover. health policy per se involves
the reform, creation, administration, and distribution of health services. Health services refer to health or medical manpower, medical equipment, and medical products. The term traditional medicine represents the practitioners of Chinese medicine or Chinese physicians in this discussion. Although other types of traditional healers can also be found in Singapore, for example, Malay medicine practitioners known as “bomohs” and Indian healers of various styles [lo, 111, Chinese physicians are, in terms of their level of technical knowledge and internal organization, the best prepared among traditional healers for an eventual integration into the national health care system [12]. For this reason they form a more relevant group in the analysis of health policy.
SOME RELEVANT IDEAS FROM POLTCY STUDIES
Social science contributions to the study of health policy and to the analysis of health care systems around the world have increased considerably during the past 15 years. The work of Babson [13] and the comprehensive bibliographies prepared by Akhtar Cl43 and Delaney [lS] are examples of this trend. A persistent feature in most studies of health care systems and policies is the call to decision-makers to manage the scarce resources available as effectively as possible. Disagreement exists, however, with respect to what exactly is meant by “effective” management. This has resulted in the creation of various typologies of health policy. To follow too closely a given typology here would not do justice to the characteristics of Singapore’s health policy. It is more useful to analyse Singapore’s health policy in the light of two opposite typologies or approaches which have been aptly discussed by Mechanic [16] and Alford [17]. Mechanic criticizes the elitists’ and the pluralists’ approaches to health policy as extreme. He rightly notes that although, interest groups are constantly mvolved in health policy and limiting compromises are a common outcome, positive changes still do take place in the health system. If the choice of approach is between the imposition of standard procedures versus self-actualiza-
149
IS0
STELLA
tion, Mechanic takes an intermediate position: the solution
lies with an organizational conception that guidance and support to the practitioner, but also considerable opportunity for self-expression and innovaprovides
tion a model that views personal adaptation in relationship to organizational environments may be instructive
C181. Mechanic’s call for a right quota of both regulatory intervention and. RexibiEty actually reflects the Singapore situation. as will be seen later on in this analysis. On a similar line of thought. Alford [19] examines two opposite approaches to health care reform. These approaches are the market strategy which allows for free competition among providers of health care services, and the bureaucratic strategy characterized by firm governmental intervention in the creation and distribution of health care services. Alford sees the market strategy reformers as promulgating expansion of health facilities and personnel. competition between health care services, and expansion of health insurance. Three assumptions of the market strategy are, according to Alford, that the Government pays for the health care bills of the poor, the users of health services choose services as consumers, and the free competition induces better services. The bureaucratic reformers, on the other hand. direct their efforts to make the best use of limited available resources. Hospitals are used as the heart of health services. There is a strict division of labor among the different health care sectors and geographical zoning of health services distribution is implemented. The intended result is an equilibrium of demand and supply of health care produced by active bureaucratic intervention. The bureaucratic approach is partially supported by Heifienheimer, Heclo and Adams [ZO]. They believe that governmental regulation is necessary for an effective functioning of the health care system. They suggest that a strong party discipline may overcome the likely opposition by interest groups. Berry [Zl] agrees with Heidenheimer’s position and advocates the use of technical and economic rationality in health planning. Other experts are less optimistic about government intervention. For example, Djukanovic and Mach [223 say that there is excessive reliance on medical technology in developing countries while there is absence of clear goals in government health policies in these countries. The situation, they add, becomes more difficult when strong interest groups interfere in health decision-making. The negative role of interest groups against bureaucratic organization of health care is also identified by Rein [23] who sees these groups as a major obstacle to reform in the health care system. As for the market approach, its theme of compromise between interest groups is defended by Babson [24]. He believes that compromise is a must for the effective functioning of the health care system. Alford’s market and bureaucratic strategies together with the corresponding trends that Mechanic labels self-actualization and regulatory intervention will provide the background for the analysis of Singapore’s health policy. I turn now to Singapore’s health policy proper.
R. QUAH MAJOR TRENDS IN HEALTH POLICY IN SINGAPORE
Singapore initiated its development as an independent nation with its separation from the Federation of Malaysia in 1965. Real growth in the economic sector was nurtured by the establishment of a stable political climate under the political leadership of the People’s Action Party (PAP). The consolidation of the PAP Government since 1965 has gone hand in hand with an increase in the rate of economic growth from below eight percent prior to 1965 t-251 to a remarkable average of 14 per cent just before the world economic recession in 1975 [26]. The Singapore economy is again on its way to recovery foilowing the Government’s initiatives to stimulate economic growth [27]. The pattern of definite and systematic Government intervention in the economic system is also found in the health care system. Government intervention has produced results throughout the different phases of health policy since 1965. The initial task of the Ministry of Health after independence was one of reorganization. The focus of the reorganization in 1966 was public health services which required improvement “even though it [public health] is among the highest in Asia” [ZS]. This twofold awareness. i.e. that Singapore health services are among the best in the region and that there is need for constant improvement, has permeated health policy. Empirical indicators of quantitative adequacy, geographical distribution, and cost do indeed demonstrate the leading position of Singapore’s health services in the region, although it is a relatively wealthy country and this must be considered in judging its health system in relation to those of poorer nations [29]. Heidenheimer. Heclo, and Adams believe in the efficacy of a strong political leadership and party discipline to impose order in the health care system [30]. The accuracy of their ideas is clearly demonstrated by the Singapore experience. Health policy normally follows the guidelines imposed by the predominant goal of economic development and the implementation of health regulations is characteristically prompt and thorough. Two years after independence the Minister for Health declared that in his view “health would rank at the most fifth in order of priority” for public funds. The first four priorities would be national security and defense, creation of jobs, housing and education. in that order [31]. Indeed, as the first four priorities have received due governmental attention and formerly acute problems such as housing shortages and limited school facilities are solved. the development of health care services has received increasing attention and has attained higher levels of sophistication. Understandably, primary health care accompanied public health in the Ministry’s agenda for reorganization and development. Already in August 1964, a network of 26 government outpatient dispensaries was decentralised from the main General Hospital (formerly Outram Road General Hospital, and now called Singapore General Hospital). The reason for this move was to bring primary health care closer to the people [32]. This is an example of the dominant idea in the first years of independence, i.e. to control health care expenditures while maximizing the avail-
Traditional medicine in Singapore able resources. The Minister for Health iabeiied this attitude “an unusual but necessary policy of consolidation and non expansion.. which has produced the necessary results” [33]. The pace of development policy in health services, however, has gained momentum during the past 5 years. The emphasis now has been placed on quality “where the stress is on brain power skills and brain services” [34]. Accordingly, since 1973 health policy has been geared to build up Singapore as a health specialist center to serve the region. Such a goal involves a comprehensive plan of hospital development-including the construction of a new General Hospital and a teaching hospital--during a period of 10 years. The plans also include an increase in the public sector’s provision of health services [35]. The rationale for this move was that the private sector will not for a very long time be able to develop the very sophisticated specialities such as.. . radiotherapy, neurosurgery and cardiac-surgery which involve extremely high capital cost. This will still have to depend on the Government to be the sole provider.. Millions of dollars have already been spent [by the Government Medical Services] in buying sophisticated equipment and improving facilities to upgrade the various specialities 1361. Due to the overall expansion of economic deveiopment in Singapore, this heavy investment in specialized medical services has not altered significantly the health expenditure proportion of the gross national product. The percentage of GNP invested in health has only risen from 0.88% in 1972 to an estimated l.lS% in 1976 [37]. However, the emphasis on expansion is reflected by the increase in development expenditure from 2.97; to 14.0:; of the total health expenditure during the same period [38]. One negative aspect of this drive for expansion of specialized services is the increasing shortage of highly qualified manpower. This problem is iilustrated by the fact that, in 1976. 20.40,& of the professional posts in the Government Medical Services were vacant [39]. To remedy the situation the Ministry of Health has been working since 1973 on a scheme to tap the specialist talent in the private sector through consuitancy appointments on part-time or temporary bases [40]. Along with the phase of expansion. the Govemment Medical Services which already provide 89:~ of the total hospital beds available [41]. have also established a zoning of hospital catchment areas [42]. a Home Nursing Scheme to shorten the length of hospitalization [43], and the Nurse Practitioner scheme [44] to ease work pressure on outpatient clinics’ physicians. The latest phase in health policy is the emphasis .on preventive health. The danger of being trapped into a “Ministry of sickness” by exclusive concern with expensive curative services was pointed out in 1977 by the Minister for Health. He emphasized the importance of health policy based on cost-effectiveness, the need for awareness of the local situation. and ability to overcome pressures from interest groups for the sake of national goals [45]. Now, the preceding outline of governmental intervention may appear to the casual observer as fitting
151
nicely within Alford’s bureaucratic strategy. Yet such a conclusion would not be accurate. The dominant position of the Government in the provision and administration of health services has not precluded the development of the private medical sector. The Minister for Health has manifested that it is not the Government’s intention “to secure a monopoly” over the health care system [46]. Such a position may be based. among other things. on a realistic appraisal of the local manpower situation. Of the total 1705 registered physicians in December 1976, 57% were in private practice [47]. The government outpatient clinics are facing an increasing demand for primary health care [48], a fact which stresses the importance of private genera1 practitioners. As it is usually the case in other countries, the private sector. offering better work conditions and, more important, higher incomes. appears more attractive to the medical doctors than the government service. Hence, there is a flow of physicians from the public to the private sector [49]. The Ministry of Health has recently implemented a salary revision scheme aimed at containing this flow [SO]. The Government’s flexibility towards the private sector has been manifested in several ways. There are specific calls for the cooperation of the private sector, for example, encouraging it to build more private hospitals to supplement the Government’s efforts [Sl]. In March 1978 the Government approved a $32 million private hospital project [52]. Furthermore, in a special interview for a local newspaper the Minister for Health declared that In Singapore we have a system where health services are provided in part by the Government and in part by the private sector. This realistic system has served us well so far [53]. Another feature of Singapore’s health policv that sets it away from Alford‘s bureaucratic strategy-is the issue of payment of health care. The bureaucratic strategy implies that the Government pays the citizen’s health care bill through taxes [54]. In Singapore. on the contrary. the goal is to achieve a situation where our operating costs can be paid half by the patients and half by the Government over a period of time.. it should be our target at least.. it will help to restrain unnecessary usage of hospital facilities and check abuse [55]. Two points should be clear by now. First, Singapore’s health policy has passed through four major phases since the nation’s independence in 1965. These phases, not always delimited by specific time periods. are: reorganization of public health and primary health care services; expansion of primary health care services; provision of highly specialized. hospitalbased health services; and. most recently. emphasis on health education and other preventive services. Second. the concern of the decision-makers to keep their eyes firmly on reality has made them keenly aware of the local social. economic. and political variables involved. Such awareness has prevented the imposition of single-minded health policies and has highlighted the value of flexibility. I. therefore. believe that Singapore’s health policy can not be anaiysed in terms of a single approach. whether that be the mar-
152
STELLA
ket or the bureaucratic approach. It is more fruitful to see this policy as a result of a combination of features of both approaches, created to suit the national situation. This characteristic of Singapore’s health policy will become more evident in the discussion of traditional medicine. CHINESE
PHYSICIANS
AND HEALTH
POLICY
Singapore shares with most Asian countries the phenomenon of a dual health care system comprising modem or Western-style health services and traditional health services [56]. As I have indicated earlier, my concern here rests exclusively with the Chinese physicians. The assessment of the local Chinese medicine manpower can only be approximate. The difficulties involved in surveying traditional healers have been discussed elsewhere [57]. The only available record of manpower to date is the Chinese Physicians Association’s (CPA) Singapore Chung Hwa Free Clinic report, which presents the patient attendance to the three CPA-managed free clinics as well as an up-todate listing of the CPA membership. The Singapore List of Registered Societies includes several organizations involved in the practice of Chinese medicine. However, the CPA affirms that it is the only organization exclusively open to qualified Chinese physicians in Singapore [SS]. The aims of the CPA, as stated in the Rules of the Singapore Chinese Physicians Association are, among others: . to expound the principles of Chinese medicine men and Chinese medicine, to do research work in Singapore and Malaysian diseases, to assimilate the specialities of the w~tld’s medical science with a view to achieving perfection in the subject, to try to improve the effectiveness of prevention and curing of diseases.. [59]. Membership in the CPA is open to the graduates of the CPA’s Chinese Physicians Training School. Any other applicant must have at least 5 years of experience in the practice of Chinese medicine and must pass a special examination set up by the CPA. This examination covers both theoretical and practical tests of the applicants’ knowledge of Chinese medicine [60]. CPA’s membership increased from 387 in 1975 l-613 to 530 members in 1977 [62]. The proportion of members established in Singapore has remained at 94%. Most of the other members have their practices
R. QUAH
in Malaysia Only one member practices in Hong Kong and one in Indonesia [63]. The CPA’s three free clinics have played an active role, catering to the public demand for primary health care. There were 29!,748 patient visits to all the three clinics in 1977 [64]. That gives an average monthly attendance of 24,312 to all three clinics, or an average of 270 patients per day at each of the three CPA clinics. Yet, despite this heavy workload, CPA clinics cover only a small proportion of the demand for primary health care, compared to the contribution of Government outpatient services. Table 1 indicates that during the period 1972-1976 the CPA contribution has decreased slightly, from 13% in 1972 to 11.5% in 1976. The figures in Table 1 must be interpreted cautiously, considering that the total demand for both modem and traditional health care is difficult to assess. Such a task would require a complete record of visits to private general practitioners (modem health care services) as well as a record of patient visits to the private clinics of Chinese physicians (traditional health services). Neither type of records is available as yet. Estimating the overall demand for health care in Singapore is even more complex due to a third factor : the tendency to use both traditional and modem health services at different stages of an illness episode or for different health complaints. This tendency may be partly explained by a person’s perceived accessibility of traditional and modem health services [65]. The combined use of health services is commonly found in any society where the two types of health care are available [663. Nevertheless, the message conveyed by Table 1, i.e. that the bulk of the supply of primary health care services comes from modem health care, is very likely to be accurate. The President of the Society of General Practitioners has estimated that nine out of every ten persons seeking health care go to a general practitioner 167-J. The public’s increasing preference for modem health care over traditional health care has also been noted by the Prime Minister [68]. Furthermore, it is not unusual for modem health services to receive patients referred to them by Chinese physicians [69]. Currently there are not sufficient data to present an accurate profile of a typical Chinese physician. Partial
Table 1. Patient Attendance at Government Outpatient Dispensaries (GOPD) and CPA Clinics, 1972-76
Year
Patient attendance GOPD* CPAt
1972 :973 1974 1975 1976
1.919.199 2,058.397 1903,946 2143,652 2J46.713
287,075 269,033 263,117 280,052 278,817
Total attendance
CPA as y0 of total
2,206.274 2,327,430 2,167,063 2,423,704 2.425530
13.0 11.5 12.1 11.5 11.5
Midyear populationf 2,147,400 2,185,100 2,219,100 2.249900 2278.200
Attendance rate per 1000 population CPA GOPD 894 942 858 953 942
133 123 118 124 122
Sources:
* Ministry of Health. Annual Report 1976. Appendix 2, p. 46, 1977. t Chinese Physicians Association. Chung Hwa Free Clinic 1977. Singapore: CPA, p. 3, 1978. : Singapore Department of Statistics, Yearbook of Statistics Singapore 1976/77. National Printers. Table 2.1, p. 11. Singapore, 1977.
Traditional medicine in Singapore information suggests that most of them are part-time practitioners [70]. This is a common feature of traditional healers in other countries [71]. A few Chinese physicians are community leaders. The President of the CPA, for example, is the Chairman of his constituency’s Citizens’ Consultative Committee (CCC) [72]. There are at least two other constituencies which have Chinese physicians as members of their respective CCCs [73]. The community esteem for some Chinese physicians-reflected in the above examples-may be interpreted not only in ethnic terms (that is, as a result of traditional Chinese values) but also as a subproduct of the prestige awarded to the practice of medicine in general and to modem medical doctors in particular. Medical doctors themselves hold some formal leadership positions in Singapore as occurs in most industrialized nations. Illustrations of these cases are the President of the Republic, two Members of Parliament, one of whom is the Speaker of Parliament, and some members of CCCs. Turning now to the policy issues, my assumption is that the same policy guidelines of the modem health care services apply. in general, to the Chinese physicians. As mentioned earlier. these policy guidelines are a balanced combination of regulatory intervention and flexibility [74] and complementanty between the public and private sectors of health care services. Two general trends may be identified in the link between health policy and Chinese medicine services. First, the issues involved follow, to some extent, the phases undergone by the modem health care services since Independence. Second, Chinese physicians have normally been willing to accommodate to implicit or explicit governmental regulations. I will deal with each of these trends in some detail. Parallel issues In correspondence with their initial preoccupation. i.e. low-cost primary health care. policy-formulators were prompt and generous in acknowledging the contribution of free Chinese physicians’ clinics. The following is a good example: in early 1968. the Minister for Health declared-in his speech during a CPA official function-that
he appreciated
the outstanding voluntary services contributed by your [CPA] members in providing free treatment and medicines to hundreds of thousands in your Chung Hwa Free Clinics for the past 15 years.. In recognition and appreciation of your most commendable social and welfare work.. I have decided to seek Treasury’s agreement for a small token grant [to] your association [75]. The official recognition
of the services provided by Chinese physicians has been reiterated usually-but not exclusively-during annual functions of the Thong Chai Medical Institution [76], the Kwong Wai Siu Free Hospital [77]. and the CPA, by the invited Government officials. It must be noted that this official recognition stems from the policy pronouncement found in the Medical Registration Act. Section 28 of this Act states: Nothing in this Act shall be construed to prohibit or prevent the practice of systems of therapeutics according to Malay. Chinese or Indian method [78]. Chinese
physicians
have felt the impact
of a sub-
153
sequent phase of health policy, i.e. the provision of highly specialized health services and a corresponding emphasis on medical technology. More specifically, Chinese physicians have been reminded of the importance of experiments and tests of their techniques [79]. of the need to improve or modify herbal prescriptions. the need to assess public demand for their services, and the importance of coordinating the activities of the various groups of Chinese physicians in the Republic [80]. The most recent of the Govemment’s suggestions to the CPA is If Chinese physicians could use their techniques and experiences together with the scientific methods and equipment used by Western-trained doctors. they would definitely be able to raise their efficiency [813,
At different times during the past 12 years, Government suggestions have been followed by specific regulations. Two relevant examples are: the Medicines (Medical Advertisements) Regulations 1977 which came into operation on 1 February 1978 and seek to protect the consumer from “exaggerated, misleading and even false statements” about medicines and medical instruments [SZ]; and the registration requirement for all institutions teaching Chinese medicine [83]. It is opportune to mention here an illustration of the Government’s combination of regulatory intervention and flexibility. In November, 1975, Parliament approved the Medicines Act (No. 52 of 1975). Some time earlier, a Select Committee had been appointed to assess the problem of export and import of medicines, their production and marketing. and to pass recommendations to the Government. During the Select Committee’s research. Chinese physicians and traders dealing in Chinese medicines manifested their concern as they believed that a restriction on the production and sale of Chinese medicines would affect them directly. Accordingly, seventeen commercial firms dealing in Chinese medicines asked the Government to keep in mind the interest of “the traditional users of Chinese medicines” [84]. The same appeal was made by the CPA and four other organizations involving Chinese physicians, in a memorandum submitted through the Chinese Chamber of Commerce. This memorandum also requested that the definition of the term “practitioner” in the Act include not only medical doctors but also “practitioners in the traditional medicine of any ethnic community” [85-J. Sensitive to these pleas but at the same time conscious of the consumers’ safety, the Act approved in Parliament responded to the first but not the second of the above two appeals. That is. Section 8 of the Medicines Act exempts herbal remedies from the product licence requirement [86]. But under the definition of terms used in the Act, ‘*‘practitioner’ means a doctor, dentist or veterinary surgeon” [87-j. Willingness to adapt The ,;cond observable trend in the link between health policy and Chinese medicine practitioners is the latter’s responsiveness to implicit or explicit recommendations from the Government. The essence of these recommendations is the need to modernize the traditional health services. There are several indicators of the Chinese physicians’ willingness to modernize their services. The
STELLAR. QUAH
154
Thong Chai Medical Institution plans to set up a research institute “to raise the standards of Chinese medicine and physicians” [88]. The CPA has projects for the development of four research teams to work on acupuncture, bone-setting, locally-grown herbs and general Chinese medicine. after their %5 million fourstorey headquarters was completed in June, 1978 [89]. In addition, the CPA has manifested on several OCcasions its readiness to work together with medical doctors [90] and to incorporate electronic and scientific equipment in their practices if they can get the necessary training [91]. Further illustrations of the trend towards modemization are the opening of a mobile Chinese medicine clinic by the Kwan-In Welfare Society attended by quafified Chinese physicians from the CPA [92], and a multi-purpose Chinese drugstore. In addition to self-service sale of Chinese medicines, this drugstore includes the saIe of Chinese medicine equipment and books, a permanent exhibition to educate the public on important aspects of Chinese medicine, and a qualified Chinese physician (who is a CPA member) to assist the public in the selection of appropriate Chinese medicines [93]. The Chinese physicians’ responsiveness to the Government’s recommendation to modernize may be explained, tentatively, by two types of incentives. There is, on the one hand, the internalization of national goals; in this case the goal is not only to provide adequate health care for the local’ population but also to develop Singapore as a health care center for the region. Although this goal is normally identified with modem heafth care services, Singapore could satisfy the need for good Chinese medicine schools in neighboring countries. The membership Iist of the CPA gives some indications of this, albeit on a very modest scale. The other incentive for modernization of Chinese medicine services is the undeniable demand for better health care by an increasingly more educated and affluent population. This is simply a matter of professional competition and survival. What we have here then, is the beginning of a trend towards modernization of Chinese medicine. Such a trend, however, may not necessarily lead to integration with modem health care services. One of the many obstacles in the complex problem of integration is the ethicai structure of modem medicine. According to the Singapore Medical Association (SMA), a medical doctor is not allowed to share a patient with someone who is not a medical doctor. But SMA suggests that the door is open for mutual learning between medical doctors
and Chinese physicians
[94].
1 find Mechanic’s words very appropriate scribe the work of Singapore’s policy-makers:
to
de-
It requires considerable ingenuity to devise solutions that work and that also create minimal conflicts among interested persons and in relation to dominant values [SS]. Indeed, whenever reorganization and innovation occur it is nearly impossible to avoid confrontation between particular interests and public interests. Singapore has not been an exception. There are and there will always be problems to be soived in the health care system. One immediate problem, for example, is the shortage of qualified medical personnel. It is a challenge for health policy-makers to tap a11 availabie manpower resources without sacrificing the quality of health care. Fortunately for Singapore, the shortage of health care personnel is not as acute as that of other countries in the region (961 due, to a great extent, to the health policy characteristics discussed in this paper. Singapore’s efforts and achievements may be a usefui guide to countries with similar inputs of modem and traditional health care services. Acknowkdgemencs--I wish to thank Dr David C. M. Seah for his comments and assistance in arranging and translating my interview with Mr Neo Sai Hai, President, CPA. I am very grateful for the kind cooperation of Mr Neo and other CPA officers in providing the necessary information during my interviews with them.
REFERENCES 1. Dreitzei H. P. (Ed.) T!ie So&l Organization of He&h. Macmillan, New York. 1971. 2. Berry D. E. The transfer of oianninn theories to health planning practice. Policy Scl. 5, 343: 1974. 3. Diukanovic V. and Mach E. P. (Eds.) A/tern&L-e Abproaches to Meeting Basic He&h Needs in Develop ing Countries. WHO, Geneva, 1975. 4. Mechanic D. Polirics. Medicine and Social Science. Wiley. New York, 1974. 5. Mechanic D. (Ed.) The Growth of Bureaucratic Medicine. An lnqujry into the Dynamics of Parient Behavior and the Organization of Medical Care. Wiley, New
York, 1976. 6. Akhtar S. Low Cost Rural Health Care and Health Manpower Training. Vol. 1. IDRC, Ottawa, I975 7. Delaney F. M. Low Cost Ruraf Health Care and Health ‘Manpower Training, Vol. 2. IDRC, Ottawa, 1976. 8. Levin A. (Ed.) He&h Services. The Local Perspective. Academy of Political Science, New York, 1977. 9. Townsend P. Sociology and Social Policy, p. 6. Penguin, Middlesex. England. 1975 10. Babb L. A. Hindu mediumship in Singapore. S. East Asian J. Sot. Sci. 2, 29. 1914.
Ii. Quah S. R. Accessibility of modern and traditional CONCWSION
AIford’s bureaucratic and market strategies may be seen as ideal types marking the extremes of a continuum of degrees of government intervention. Singapore’s health policy can be interpreted as an intermediate case on this continuum, that is. a combination of regulatory intervention and flexibility where the play between regulation and laissez-faire is evident with respect to both modem and traditional systems of health care.
12.
13. 14. 15. 16. 17.
health services in Singapore. Sot. Sci. Med. 11. 333. 1977a Quab S. R. The Unplanned Dimensions of Health Care in Singapore: Traditional Healers and Self-medication. Department of Sociology, Sociology Working Paper No. 62. Singapore 1977b. Babson f. H. Health Care Zteliver): Systems: A Muirinarional Survey. Pitman, London. 1912. Akhtar, op. cit. Delaney, op. cit. Mechanic, op. cit.. 1976. Alford R. R. Health Care Politics, ~deo~ogicai and
Traditional medicine in Singapore
18. 19. 20.
21. 22. 23. 24. 25. 26 27 28, 29. 30. 31
32 33 34
35 36 37 38 39. 40. 41. 42. 43 44 45. 46. 47 48 49
50. 51
52
lnrerest Group Barriers to Reform. Univ. of Chicago Press. Chicago. 1975. Mechanic. op. cif.. p. 70. 1976. Alford. op. cit. Heidenheimer. A. J.. Heclo H. and Adams C. T. Cornparatioe P&fir Poficy. The Polities of Social Choice in Europe and Atnericn. St Martin’s Press, New York, 197.5. Berry, op. cit. Djukanovic and Mach. op. cit. Rein, M. Social Science and Public Policy. Penguin, Middlesex. England. 1976. Babson. op. cit. You P. S. and Lim C. Y. (Eds.) The Singapore Economy. Eastern Univ. Press. Singapore. 1971. Singapore Department of Statistics. Yeorboo~ of Starisrics Singapore 1976!77, a. 45. National Printers, Singapore. i977. Ministry of Culture. Singapore ‘76. p. 8. Publicity Division. Ministry of Culture. Singapore, 1977. See Singapore Government Press Statements. Ministry of Health. Answers to Partiament questions by Mr N. L. Yong. Minister for Health. 26 August t966. Quah. op. cir., 1977a. Heidenheimer et al.. op. cir. See speech by the Minister for Health, Mr N. L. Yang. at the opening of the WHO seminar on Health Planning in Urban Development, Singapore. 2! November 1967. See Singapore Government Press Statements. Ministry of Heaitd. Answers to Parliament questions by Mr K. L. Yone. Minister for Health. 26 August 1966. See speech by Minister for Health at %HO seminar r313. Speech b! Mr Chua Sian Chin. Minister for Health at the Macpherson Constituency’s National Day Dinner. 19 August 1972. Speech by Mr Chua Sian Chin. Minister for Realth and Home Affairs. at the Annual Medical Society Dinner, 20 January 1973. Speech by Mr Chua Sian Chin. Minister for Health and Home Agairs. at the Society of Private Practice Annual Dinner. 27 January 1973. Ministry of Health. Annual Reporr 19%. Table 5. p. 45. Singapore National Printers. Singapore. 1977. Ibid. Ibid.. p. 40.
See speech by Mr Chua Sian Chin [36]. Ministry of Culture, op. cif., p. 168. See Ministry of Health. Annual Reporr ‘75. p. 14. National Printers. Singapore. 1976; See also Srraifs Times report. 31 January 1975. Mmistrj of Health. op. cir.. p. 1. 1976. Ibid.. p. 7. See speech by Dr Toh Chin Chye, Minister for Health. at the 5th Commonwealth Medical Conference in Wellington. November 1977. Speech-by Dr Toh Chin Chye. Minister for Heaith. at the Singapore Medical Association 16th Annual Dinner. 24 April 1976. Calculated from figures given in Singapore Department of Statistics, op. cir., Table 15.2. p. 210. See Straits Times report. 10 August 1977 See also speech by Minister f&r Health 1463. Ministry of Health. h’afioual Surrey of Medical Pracrifioners 1975. p. 20. Mentor Printers. Singapore. 1976. See Srrairs Times report. 1 December 1977. p. 7. Speech bv Minister for National Development and Communications. Mr Lim Kim Sar?, at the 67th Anniversary Celebration of the Kwong Wai Shiu Free HOSpital. 4 September 1977. See Sunday Times report. p. 6. 26 March 1978.
155
53. See Wang Look Fang ‘Searching for the cure’. Neti N&on, 16 August. P. 10. 1977. 54. Alford. op. cit.. 55. See Wang Look Fang, op. cir. 56. Quah, op. cit.. 1977b. 57. Quah, op. fir.. 1977a. 58. Personal interviews with Mr Neo Sai Hai President. CPA. 22 March 1978, and Mr Ngoh Eng Kok, Secretary General. CPA, 8 April 1976. 59. Chinese Physicians Ass&iation. Rules of the Singapore Chinese Plrysicions Association CPA. p. 1. Singapore. no date. 60. Ibid., pp. 34. 61. Chinese Physicians Association. Chung Hwa Free Clinic 1975. p. 78. CPA. Singapore. 1976. 62. Chinese Physicians Association. Chung Hwa Free fiinic 1977. p. 86. CPA, Singapore. 1978. 63. Ibid.. pp. 71 and 81. 64. Ibid.. p. 3. 65. Quah, op. cif.. p. 338. 1977a. 66. See. for example. Landy D. (Ed.) Culture. Disease and pealing. Sudies in Medicaf Anthropology. pp. 46848 1, Macmillan, New York, 1977. 67. As auoted bv Dr Toh Chin Chve. Minister for Health [46j. . 68. See speech by Mr Lee Kuah Yew. Prime Minister. at the inauguration of the Thong Chai Medical Institution b&ding. 29 November 1576. 69. Personal interview with Ngoh Emt Kok. CPA Secretary General. 8 April 1976. See also Straits Times report. p. 16. 21 March 1978. 70. Quah. op. cit., p. 9, 1977b. See also Straits Times report. p. 8. 28 -Febru&y t977. 71. See Leslie C. M. Pluralism and inteeration in the Indian and Chinese medical systems. In-Landy. op. cit.. pp. 511-517. 72. Personal interview with Mr Nco Sai Hai, President. CPA. 12 March 1978. The Citizens’ Consultative Committees are “grass-roots” committees established by the ruhng PAP “in each district of the State to be run from the local communit> centre and to include influential people in the area”. See Chan Heng Chee. The D.vnamics oj OIW Party ~orni~~~ce. The PAP and the Grass-roars. p. 133. Singapore Univ. Press. Singapore.
1976. 73. Ghan. op. cit.. pp. 236-249. 74. Borrowing Mechanic’s terminoiogy in Mechanic. op. cir.. 1976. 75. See speech by Minister for Health. Mr N. L. Yong at the Swearing-in Ceremony of the 19th Batch of Office Bearers of the CPA. 16 February 1968. 76. The Thong Chai Medical Institution is an organization established in 1867 by some Chinese physicians for the purpose of giving free medical treatment and medicines to the poor in Singapore. See Thong Chai Medical Institution. Building Plans for the New Thong Chai Medical Insriturion. Shing Loonp Press. Singapore. no date. 77. The Kwong Wai Siu Free Hospital is the on13 one in Singapore that offers both Chinese medicine or modern medicine to patients. according to the patient’s choice. See New Narion report. I I March 1975. pi 7. 7%. See Republic of Singapore. Medical Regisirarion ACI. Chap. 218. Government Publications Bureau. Smgapore. 1970. 79. See speech by the Minister for Health. Mr Chua Sian Chin, at the Annual Swearing-in Ceremony of CPA officials. 30 January 1969. 80. Speech by Minister for Health. Dr Toh Chin Chye. at the 11th Graduation Ceremony of the Chinese Physicians Training School. 23 January 1977. 81. See speech by the Senior Minister of State for Edu-
156
82. 83. 84. 85. 86.
SITELLA
catIon, Mr Chai Chong Yii, at the 26th Installation Ceremony of CPA Officials, 18 March 1978. See Sr&s Times reports of p. 6, 4 January 1978; p. 24, 18 Januarv 1978 and D. 5. 1 February 1978. See speecd by Dr Toh Chin Chye [80]. Straits Times report. p. 6. 10 November 1975. ibid. See Republic of Singapore. The Medicines Act, 1975. Government Gazette Acts Supplement, p. 16. Singapore National Printers, Singapore, 23 January 1976.
K. @AH
87. 88. 89. 90. 91. 92. 93.
Ibid., p. 9. Straits Times report. p. 5, 14 April 1977. Straits Times reoort. D. 10. 13 Januarv 1978. Personal interviews vkh CPA offic& c58]. Straits Times report, p. 16, 21 March 1978. New Nation p. 3, 7 June 1977. Straits i”imes reports. p. 15, 1 October 1977 and p. 10, 10 October 1977. 94. Straits Times report, p. 10, 17 January 1978. 95. Mechanic, op. cit., p. 63, 1976. 96. Quah, op. cit., p. 334, 1977a
0271-7123’81 ISO149-08SOL~‘O e 1981 Per~mnon Press Ltd
HEALTH POLICY AND TRADITIONAL MEDICINE IN SINGAPORE %-ELLAR. QUU Department of Sociology, National University of Singapore, Singapore Abstract-Singapore’s degree of government intervention into health policy can be seen as intermediate between the bureaucratic and market strategies which Alford delineates. In this approach, the govemment takes a quite tolerant if not directly encouraging approach to the several forms of traditional medicine of the several important ethnic groups in the country. To some extent this approach reflects a solution of sorts to the shortage of qualified medical personnel.
The
necessity
to
control
the
rapid
and
complex
growth of modem medicine has become an important issue today. The message in a 1971 book by a German scientist indicates that “health is too important to be entrusted only to doctors” [l]. That statement conveys clearly the feeling among many social scientists and policy analysts. Despite their differences in approaches, they seem to agree on the need for some type of government intervention in the provision and administration of health care services. Some examples of this common idea are the works of Berry [Z], Djukanovic [33 and Mechanic [4,5]. While industriahzed countries are busy trying to harness highly technical and expensive private medical services, the developing countries have a different concern. The latter have an urgent need to supply low-cost primary health care. Thus. one of the key topics of health services research in developing countries now is the utilization of traditional medicine services [6-S]. I intend to discuss in this paper the case of Singapore’s health policy as an instructive example of governmental management of health services in a society where both modem and traditional health care services are available. This paper is divided into three sections. The first section presents some relevant ideas from the literature on policy studies that serve as a guideline in the discussion. The second section deals with the major trends in health policy since 1965 when Singapore became an independent Rep& lit. The final section focuses on the link between health policy and the traditional practitioners of Chinese medicine. The term health policy used here falls well within Townsend’s definition of social policy. Townsend detines social policy as the underlying as well as professed rationale by which social institutions and groups are used or brought into being to ensure social preservation and development.. in other words, the institutionalized control of services, agencies and organizations to maintain or change social structure and values. Sometimes this control may be utterly conscious. and consciously expressed by Govemment spokesmen and others. Sometimes it may be un-
spoken and even unrecognized [9]. In the context of this paper the source of health policy is the State. Moreover. health policy per se involves
the reform, creation, administration, and distribution of health services. Health services refer to health or medical manpower, medical equipment, and medical products. The term traditional medicine represents the practitioners of Chinese medicine or Chinese physicians in this discussion. Although other types of traditional healers can also be found in Singapore, for example, Malay medicine practitioners known as “bomohs” and Indian healers of various styles [lo, 111, Chinese physicians are, in terms of their level of technical knowledge and internal organization, the best prepared among traditional healers for an eventual integration into the national health care system [12]. For this reason they form a more relevant group in the analysis of health policy.
SOME RELEVANT IDEAS FROM POLTCY STUDIES
Social science contributions to the study of health policy and to the analysis of health care systems around the world have increased considerably during the past 15 years. The work of Babson [13] and the comprehensive bibliographies prepared by Akhtar Cl43 and Delaney [lS] are examples of this trend. A persistent feature in most studies of health care systems and policies is the call to decision-makers to manage the scarce resources available as effectively as possible. Disagreement exists, however, with respect to what exactly is meant by “effective” management. This has resulted in the creation of various typologies of health policy. To follow too closely a given typology here would not do justice to the characteristics of Singapore’s health policy. It is more useful to analyse Singapore’s health policy in the light of two opposite typologies or approaches which have been aptly discussed by Mechanic [16] and Alford [17]. Mechanic criticizes the elitists’ and the pluralists’ approaches to health policy as extreme. He rightly notes that although, interest groups are constantly mvolved in health policy and limiting compromises are a common outcome, positive changes still do take place in the health system. If the choice of approach is between the imposition of standard procedures versus self-actualiza-
149
IS0
STELLA
tion, Mechanic takes an intermediate position: the solution
lies with an organizational conception that guidance and support to the practitioner, but also considerable opportunity for self-expression and innovaprovides
tion a model that views personal adaptation in relationship to organizational environments may be instructive
C181. Mechanic’s call for a right quota of both regulatory intervention and. RexibiEty actually reflects the Singapore situation. as will be seen later on in this analysis. On a similar line of thought. Alford [19] examines two opposite approaches to health care reform. These approaches are the market strategy which allows for free competition among providers of health care services, and the bureaucratic strategy characterized by firm governmental intervention in the creation and distribution of health care services. Alford sees the market strategy reformers as promulgating expansion of health facilities and personnel. competition between health care services, and expansion of health insurance. Three assumptions of the market strategy are, according to Alford, that the Government pays for the health care bills of the poor, the users of health services choose services as consumers, and the free competition induces better services. The bureaucratic reformers, on the other hand. direct their efforts to make the best use of limited available resources. Hospitals are used as the heart of health services. There is a strict division of labor among the different health care sectors and geographical zoning of health services distribution is implemented. The intended result is an equilibrium of demand and supply of health care produced by active bureaucratic intervention. The bureaucratic approach is partially supported by Heifienheimer, Heclo and Adams [ZO]. They believe that governmental regulation is necessary for an effective functioning of the health care system. They suggest that a strong party discipline may overcome the likely opposition by interest groups. Berry [Zl] agrees with Heidenheimer’s position and advocates the use of technical and economic rationality in health planning. Other experts are less optimistic about government intervention. For example, Djukanovic and Mach [223 say that there is excessive reliance on medical technology in developing countries while there is absence of clear goals in government health policies in these countries. The situation, they add, becomes more difficult when strong interest groups interfere in health decision-making. The negative role of interest groups against bureaucratic organization of health care is also identified by Rein [23] who sees these groups as a major obstacle to reform in the health care system. As for the market approach, its theme of compromise between interest groups is defended by Babson [24]. He believes that compromise is a must for the effective functioning of the health care system. Alford’s market and bureaucratic strategies together with the corresponding trends that Mechanic labels self-actualization and regulatory intervention will provide the background for the analysis of Singapore’s health policy. I turn now to Singapore’s health policy proper.
R. QUAH MAJOR TRENDS IN HEALTH POLICY IN SINGAPORE
Singapore initiated its development as an independent nation with its separation from the Federation of Malaysia in 1965. Real growth in the economic sector was nurtured by the establishment of a stable political climate under the political leadership of the People’s Action Party (PAP). The consolidation of the PAP Government since 1965 has gone hand in hand with an increase in the rate of economic growth from below eight percent prior to 1965 t-251 to a remarkable average of 14 per cent just before the world economic recession in 1975 [26]. The Singapore economy is again on its way to recovery foilowing the Government’s initiatives to stimulate economic growth [27]. The pattern of definite and systematic Government intervention in the economic system is also found in the health care system. Government intervention has produced results throughout the different phases of health policy since 1965. The initial task of the Ministry of Health after independence was one of reorganization. The focus of the reorganization in 1966 was public health services which required improvement “even though it [public health] is among the highest in Asia” [ZS]. This twofold awareness. i.e. that Singapore health services are among the best in the region and that there is need for constant improvement, has permeated health policy. Empirical indicators of quantitative adequacy, geographical distribution, and cost do indeed demonstrate the leading position of Singapore’s health services in the region, although it is a relatively wealthy country and this must be considered in judging its health system in relation to those of poorer nations [29]. Heidenheimer. Heclo, and Adams believe in the efficacy of a strong political leadership and party discipline to impose order in the health care system [30]. The accuracy of their ideas is clearly demonstrated by the Singapore experience. Health policy normally follows the guidelines imposed by the predominant goal of economic development and the implementation of health regulations is characteristically prompt and thorough. Two years after independence the Minister for Health declared that in his view “health would rank at the most fifth in order of priority” for public funds. The first four priorities would be national security and defense, creation of jobs, housing and education. in that order [31]. Indeed, as the first four priorities have received due governmental attention and formerly acute problems such as housing shortages and limited school facilities are solved. the development of health care services has received increasing attention and has attained higher levels of sophistication. Understandably, primary health care accompanied public health in the Ministry’s agenda for reorganization and development. Already in August 1964, a network of 26 government outpatient dispensaries was decentralised from the main General Hospital (formerly Outram Road General Hospital, and now called Singapore General Hospital). The reason for this move was to bring primary health care closer to the people [32]. This is an example of the dominant idea in the first years of independence, i.e. to control health care expenditures while maximizing the avail-
Traditional medicine in Singapore able resources. The Minister for Health iabeiied this attitude “an unusual but necessary policy of consolidation and non expansion.. which has produced the necessary results” [33]. The pace of development policy in health services, however, has gained momentum during the past 5 years. The emphasis now has been placed on quality “where the stress is on brain power skills and brain services” [34]. Accordingly, since 1973 health policy has been geared to build up Singapore as a health specialist center to serve the region. Such a goal involves a comprehensive plan of hospital development-including the construction of a new General Hospital and a teaching hospital--during a period of 10 years. The plans also include an increase in the public sector’s provision of health services [35]. The rationale for this move was that the private sector will not for a very long time be able to develop the very sophisticated specialities such as.. . radiotherapy, neurosurgery and cardiac-surgery which involve extremely high capital cost. This will still have to depend on the Government to be the sole provider.. Millions of dollars have already been spent [by the Government Medical Services] in buying sophisticated equipment and improving facilities to upgrade the various specialities 1361. Due to the overall expansion of economic deveiopment in Singapore, this heavy investment in specialized medical services has not altered significantly the health expenditure proportion of the gross national product. The percentage of GNP invested in health has only risen from 0.88% in 1972 to an estimated l.lS% in 1976 [37]. However, the emphasis on expansion is reflected by the increase in development expenditure from 2.97; to 14.0:; of the total health expenditure during the same period [38]. One negative aspect of this drive for expansion of specialized services is the increasing shortage of highly qualified manpower. This problem is iilustrated by the fact that, in 1976. 20.40,& of the professional posts in the Government Medical Services were vacant [39]. To remedy the situation the Ministry of Health has been working since 1973 on a scheme to tap the specialist talent in the private sector through consuitancy appointments on part-time or temporary bases [40]. Along with the phase of expansion. the Govemment Medical Services which already provide 89:~ of the total hospital beds available [41]. have also established a zoning of hospital catchment areas [42]. a Home Nursing Scheme to shorten the length of hospitalization [43], and the Nurse Practitioner scheme [44] to ease work pressure on outpatient clinics’ physicians. The latest phase in health policy is the emphasis .on preventive health. The danger of being trapped into a “Ministry of sickness” by exclusive concern with expensive curative services was pointed out in 1977 by the Minister for Health. He emphasized the importance of health policy based on cost-effectiveness, the need for awareness of the local situation. and ability to overcome pressures from interest groups for the sake of national goals [45]. Now, the preceding outline of governmental intervention may appear to the casual observer as fitting
151
nicely within Alford’s bureaucratic strategy. Yet such a conclusion would not be accurate. The dominant position of the Government in the provision and administration of health services has not precluded the development of the private medical sector. The Minister for Health has manifested that it is not the Government’s intention “to secure a monopoly” over the health care system [46]. Such a position may be based. among other things. on a realistic appraisal of the local manpower situation. Of the total 1705 registered physicians in December 1976, 57% were in private practice [47]. The government outpatient clinics are facing an increasing demand for primary health care [48], a fact which stresses the importance of private genera1 practitioners. As it is usually the case in other countries, the private sector. offering better work conditions and, more important, higher incomes. appears more attractive to the medical doctors than the government service. Hence, there is a flow of physicians from the public to the private sector [49]. The Ministry of Health has recently implemented a salary revision scheme aimed at containing this flow [SO]. The Government’s flexibility towards the private sector has been manifested in several ways. There are specific calls for the cooperation of the private sector, for example, encouraging it to build more private hospitals to supplement the Government’s efforts [Sl]. In March 1978 the Government approved a $32 million private hospital project [52]. Furthermore, in a special interview for a local newspaper the Minister for Health declared that In Singapore we have a system where health services are provided in part by the Government and in part by the private sector. This realistic system has served us well so far [53]. Another feature of Singapore’s health policv that sets it away from Alford‘s bureaucratic strategy-is the issue of payment of health care. The bureaucratic strategy implies that the Government pays the citizen’s health care bill through taxes [54]. In Singapore. on the contrary. the goal is to achieve a situation where our operating costs can be paid half by the patients and half by the Government over a period of time.. it should be our target at least.. it will help to restrain unnecessary usage of hospital facilities and check abuse [55]. Two points should be clear by now. First, Singapore’s health policy has passed through four major phases since the nation’s independence in 1965. These phases, not always delimited by specific time periods. are: reorganization of public health and primary health care services; expansion of primary health care services; provision of highly specialized. hospitalbased health services; and. most recently. emphasis on health education and other preventive services. Second. the concern of the decision-makers to keep their eyes firmly on reality has made them keenly aware of the local social. economic. and political variables involved. Such awareness has prevented the imposition of single-minded health policies and has highlighted the value of flexibility. I. therefore. believe that Singapore’s health policy can not be anaiysed in terms of a single approach. whether that be the mar-
152
STELLA
ket or the bureaucratic approach. It is more fruitful to see this policy as a result of a combination of features of both approaches, created to suit the national situation. This characteristic of Singapore’s health policy will become more evident in the discussion of traditional medicine. CHINESE
PHYSICIANS
AND HEALTH
POLICY
Singapore shares with most Asian countries the phenomenon of a dual health care system comprising modem or Western-style health services and traditional health services [56]. As I have indicated earlier, my concern here rests exclusively with the Chinese physicians. The assessment of the local Chinese medicine manpower can only be approximate. The difficulties involved in surveying traditional healers have been discussed elsewhere [57]. The only available record of manpower to date is the Chinese Physicians Association’s (CPA) Singapore Chung Hwa Free Clinic report, which presents the patient attendance to the three CPA-managed free clinics as well as an up-todate listing of the CPA membership. The Singapore List of Registered Societies includes several organizations involved in the practice of Chinese medicine. However, the CPA affirms that it is the only organization exclusively open to qualified Chinese physicians in Singapore [SS]. The aims of the CPA, as stated in the Rules of the Singapore Chinese Physicians Association are, among others: . to expound the principles of Chinese medicine men and Chinese medicine, to do research work in Singapore and Malaysian diseases, to assimilate the specialities of the w~tld’s medical science with a view to achieving perfection in the subject, to try to improve the effectiveness of prevention and curing of diseases.. [59]. Membership in the CPA is open to the graduates of the CPA’s Chinese Physicians Training School. Any other applicant must have at least 5 years of experience in the practice of Chinese medicine and must pass a special examination set up by the CPA. This examination covers both theoretical and practical tests of the applicants’ knowledge of Chinese medicine [60]. CPA’s membership increased from 387 in 1975 l-613 to 530 members in 1977 [62]. The proportion of members established in Singapore has remained at 94%. Most of the other members have their practices
R. QUAH
in Malaysia Only one member practices in Hong Kong and one in Indonesia [63]. The CPA’s three free clinics have played an active role, catering to the public demand for primary health care. There were 29!,748 patient visits to all the three clinics in 1977 [64]. That gives an average monthly attendance of 24,312 to all three clinics, or an average of 270 patients per day at each of the three CPA clinics. Yet, despite this heavy workload, CPA clinics cover only a small proportion of the demand for primary health care, compared to the contribution of Government outpatient services. Table 1 indicates that during the period 1972-1976 the CPA contribution has decreased slightly, from 13% in 1972 to 11.5% in 1976. The figures in Table 1 must be interpreted cautiously, considering that the total demand for both modem and traditional health care is difficult to assess. Such a task would require a complete record of visits to private general practitioners (modem health care services) as well as a record of patient visits to the private clinics of Chinese physicians (traditional health services). Neither type of records is available as yet. Estimating the overall demand for health care in Singapore is even more complex due to a third factor : the tendency to use both traditional and modem health services at different stages of an illness episode or for different health complaints. This tendency may be partly explained by a person’s perceived accessibility of traditional and modem health services [65]. The combined use of health services is commonly found in any society where the two types of health care are available [663. Nevertheless, the message conveyed by Table 1, i.e. that the bulk of the supply of primary health care services comes from modem health care, is very likely to be accurate. The President of the Society of General Practitioners has estimated that nine out of every ten persons seeking health care go to a general practitioner 167-J. The public’s increasing preference for modem health care over traditional health care has also been noted by the Prime Minister [68]. Furthermore, it is not unusual for modem health services to receive patients referred to them by Chinese physicians [69]. Currently there are not sufficient data to present an accurate profile of a typical Chinese physician. Partial
Table 1. Patient Attendance at Government Outpatient Dispensaries (GOPD) and CPA Clinics, 1972-76
Year
Patient attendance GOPD* CPAt
1972 :973 1974 1975 1976
1.919.199 2,058.397 1903,946 2143,652 2J46.713
287,075 269,033 263,117 280,052 278,817
Total attendance
CPA as y0 of total
2,206.274 2,327,430 2,167,063 2,423,704 2.425530
13.0 11.5 12.1 11.5 11.5
Midyear populationf 2,147,400 2,185,100 2,219,100 2.249900 2278.200
Attendance rate per 1000 population CPA GOPD 894 942 858 953 942
133 123 118 124 122
Sources:
* Ministry of Health. Annual Report 1976. Appendix 2, p. 46, 1977. t Chinese Physicians Association. Chung Hwa Free Clinic 1977. Singapore: CPA, p. 3, 1978. : Singapore Department of Statistics, Yearbook of Statistics Singapore 1976/77. National Printers. Table 2.1, p. 11. Singapore, 1977.
Traditional medicine in Singapore information suggests that most of them are part-time practitioners [70]. This is a common feature of traditional healers in other countries [71]. A few Chinese physicians are community leaders. The President of the CPA, for example, is the Chairman of his constituency’s Citizens’ Consultative Committee (CCC) [72]. There are at least two other constituencies which have Chinese physicians as members of their respective CCCs [73]. The community esteem for some Chinese physicians-reflected in the above examples-may be interpreted not only in ethnic terms (that is, as a result of traditional Chinese values) but also as a subproduct of the prestige awarded to the practice of medicine in general and to modem medical doctors in particular. Medical doctors themselves hold some formal leadership positions in Singapore as occurs in most industrialized nations. Illustrations of these cases are the President of the Republic, two Members of Parliament, one of whom is the Speaker of Parliament, and some members of CCCs. Turning now to the policy issues, my assumption is that the same policy guidelines of the modem health care services apply. in general, to the Chinese physicians. As mentioned earlier. these policy guidelines are a balanced combination of regulatory intervention and flexibility [74] and complementanty between the public and private sectors of health care services. Two general trends may be identified in the link between health policy and Chinese medicine services. First, the issues involved follow, to some extent, the phases undergone by the modem health care services since Independence. Second, Chinese physicians have normally been willing to accommodate to implicit or explicit governmental regulations. I will deal with each of these trends in some detail. Parallel issues In correspondence with their initial preoccupation. i.e. low-cost primary health care. policy-formulators were prompt and generous in acknowledging the contribution of free Chinese physicians’ clinics. The following is a good example: in early 1968. the Minister for Health declared-in his speech during a CPA official function-that
he appreciated
the outstanding voluntary services contributed by your [CPA] members in providing free treatment and medicines to hundreds of thousands in your Chung Hwa Free Clinics for the past 15 years.. In recognition and appreciation of your most commendable social and welfare work.. I have decided to seek Treasury’s agreement for a small token grant [to] your association [75]. The official recognition
of the services provided by Chinese physicians has been reiterated usually-but not exclusively-during annual functions of the Thong Chai Medical Institution [76], the Kwong Wai Siu Free Hospital [77]. and the CPA, by the invited Government officials. It must be noted that this official recognition stems from the policy pronouncement found in the Medical Registration Act. Section 28 of this Act states: Nothing in this Act shall be construed to prohibit or prevent the practice of systems of therapeutics according to Malay. Chinese or Indian method [78]. Chinese
physicians
have felt the impact
of a sub-
153
sequent phase of health policy, i.e. the provision of highly specialized health services and a corresponding emphasis on medical technology. More specifically, Chinese physicians have been reminded of the importance of experiments and tests of their techniques [79]. of the need to improve or modify herbal prescriptions. the need to assess public demand for their services, and the importance of coordinating the activities of the various groups of Chinese physicians in the Republic [80]. The most recent of the Govemment’s suggestions to the CPA is If Chinese physicians could use their techniques and experiences together with the scientific methods and equipment used by Western-trained doctors. they would definitely be able to raise their efficiency [813,
At different times during the past 12 years, Government suggestions have been followed by specific regulations. Two relevant examples are: the Medicines (Medical Advertisements) Regulations 1977 which came into operation on 1 February 1978 and seek to protect the consumer from “exaggerated, misleading and even false statements” about medicines and medical instruments [SZ]; and the registration requirement for all institutions teaching Chinese medicine [83]. It is opportune to mention here an illustration of the Government’s combination of regulatory intervention and flexibility. In November, 1975, Parliament approved the Medicines Act (No. 52 of 1975). Some time earlier, a Select Committee had been appointed to assess the problem of export and import of medicines, their production and marketing. and to pass recommendations to the Government. During the Select Committee’s research. Chinese physicians and traders dealing in Chinese medicines manifested their concern as they believed that a restriction on the production and sale of Chinese medicines would affect them directly. Accordingly, seventeen commercial firms dealing in Chinese medicines asked the Government to keep in mind the interest of “the traditional users of Chinese medicines” [84]. The same appeal was made by the CPA and four other organizations involving Chinese physicians, in a memorandum submitted through the Chinese Chamber of Commerce. This memorandum also requested that the definition of the term “practitioner” in the Act include not only medical doctors but also “practitioners in the traditional medicine of any ethnic community” [85-J. Sensitive to these pleas but at the same time conscious of the consumers’ safety, the Act approved in Parliament responded to the first but not the second of the above two appeals. That is. Section 8 of the Medicines Act exempts herbal remedies from the product licence requirement [86]. But under the definition of terms used in the Act, ‘*‘practitioner’ means a doctor, dentist or veterinary surgeon” [87-j. Willingness to adapt The ,;cond observable trend in the link between health policy and Chinese medicine practitioners is the latter’s responsiveness to implicit or explicit recommendations from the Government. The essence of these recommendations is the need to modernize the traditional health services. There are several indicators of the Chinese physicians’ willingness to modernize their services. The
STELLAR. QUAH
154
Thong Chai Medical Institution plans to set up a research institute “to raise the standards of Chinese medicine and physicians” [88]. The CPA has projects for the development of four research teams to work on acupuncture, bone-setting, locally-grown herbs and general Chinese medicine. after their %5 million fourstorey headquarters was completed in June, 1978 [89]. In addition, the CPA has manifested on several OCcasions its readiness to work together with medical doctors [90] and to incorporate electronic and scientific equipment in their practices if they can get the necessary training [91]. Further illustrations of the trend towards modemization are the opening of a mobile Chinese medicine clinic by the Kwan-In Welfare Society attended by quafified Chinese physicians from the CPA [92], and a multi-purpose Chinese drugstore. In addition to self-service sale of Chinese medicines, this drugstore includes the saIe of Chinese medicine equipment and books, a permanent exhibition to educate the public on important aspects of Chinese medicine, and a qualified Chinese physician (who is a CPA member) to assist the public in the selection of appropriate Chinese medicines [93]. The Chinese physicians’ responsiveness to the Government’s recommendation to modernize may be explained, tentatively, by two types of incentives. There is, on the one hand, the internalization of national goals; in this case the goal is not only to provide adequate health care for the local’ population but also to develop Singapore as a health care center for the region. Although this goal is normally identified with modem heafth care services, Singapore could satisfy the need for good Chinese medicine schools in neighboring countries. The membership Iist of the CPA gives some indications of this, albeit on a very modest scale. The other incentive for modernization of Chinese medicine services is the undeniable demand for better health care by an increasingly more educated and affluent population. This is simply a matter of professional competition and survival. What we have here then, is the beginning of a trend towards modernization of Chinese medicine. Such a trend, however, may not necessarily lead to integration with modem health care services. One of the many obstacles in the complex problem of integration is the ethicai structure of modem medicine. According to the Singapore Medical Association (SMA), a medical doctor is not allowed to share a patient with someone who is not a medical doctor. But SMA suggests that the door is open for mutual learning between medical doctors
and Chinese physicians
[94].
1 find Mechanic’s words very appropriate scribe the work of Singapore’s policy-makers:
to
de-
It requires considerable ingenuity to devise solutions that work and that also create minimal conflicts among interested persons and in relation to dominant values [SS]. Indeed, whenever reorganization and innovation occur it is nearly impossible to avoid confrontation between particular interests and public interests. Singapore has not been an exception. There are and there will always be problems to be soived in the health care system. One immediate problem, for example, is the shortage of qualified medical personnel. It is a challenge for health policy-makers to tap a11 availabie manpower resources without sacrificing the quality of health care. Fortunately for Singapore, the shortage of health care personnel is not as acute as that of other countries in the region (961 due, to a great extent, to the health policy characteristics discussed in this paper. Singapore’s efforts and achievements may be a usefui guide to countries with similar inputs of modem and traditional health care services. Acknowkdgemencs--I wish to thank Dr David C. M. Seah for his comments and assistance in arranging and translating my interview with Mr Neo Sai Hai, President, CPA. I am very grateful for the kind cooperation of Mr Neo and other CPA officers in providing the necessary information during my interviews with them.
REFERENCES 1. Dreitzei H. P. (Ed.) T!ie So&l Organization of He&h. Macmillan, New York. 1971. 2. Berry D. E. The transfer of oianninn theories to health planning practice. Policy Scl. 5, 343: 1974. 3. Diukanovic V. and Mach E. P. (Eds.) A/tern&L-e Abproaches to Meeting Basic He&h Needs in Develop ing Countries. WHO, Geneva, 1975. 4. Mechanic D. Polirics. Medicine and Social Science. Wiley. New York, 1974. 5. Mechanic D. (Ed.) The Growth of Bureaucratic Medicine. An lnqujry into the Dynamics of Parient Behavior and the Organization of Medical Care. Wiley, New
York, 1976. 6. Akhtar S. Low Cost Rural Health Care and Health Manpower Training. Vol. 1. IDRC, Ottawa, I975 7. Delaney F. M. Low Cost Ruraf Health Care and Health ‘Manpower Training, Vol. 2. IDRC, Ottawa, 1976. 8. Levin A. (Ed.) He&h Services. The Local Perspective. Academy of Political Science, New York, 1977. 9. Townsend P. Sociology and Social Policy, p. 6. Penguin, Middlesex. England. 1975 10. Babb L. A. Hindu mediumship in Singapore. S. East Asian J. Sot. Sci. 2, 29. 1914.
Ii. Quah S. R. Accessibility of modern and traditional CONCWSION
AIford’s bureaucratic and market strategies may be seen as ideal types marking the extremes of a continuum of degrees of government intervention. Singapore’s health policy can be interpreted as an intermediate case on this continuum, that is. a combination of regulatory intervention and flexibility where the play between regulation and laissez-faire is evident with respect to both modem and traditional systems of health care.
12.
13. 14. 15. 16. 17.
health services in Singapore. Sot. Sci. Med. 11. 333. 1977a Quab S. R. The Unplanned Dimensions of Health Care in Singapore: Traditional Healers and Self-medication. Department of Sociology, Sociology Working Paper No. 62. Singapore 1977b. Babson f. H. Health Care Zteliver): Systems: A Muirinarional Survey. Pitman, London. 1912. Akhtar, op. cit. Delaney, op. cit. Mechanic, op. cit.. 1976. Alford R. R. Health Care Politics, ~deo~ogicai and
Traditional medicine in Singapore
18. 19. 20.
21. 22. 23. 24. 25. 26 27 28, 29. 30. 31
32 33 34
35 36 37 38 39. 40. 41. 42. 43 44 45. 46. 47 48 49
50. 51
52
lnrerest Group Barriers to Reform. Univ. of Chicago Press. Chicago. 1975. Mechanic. op. cif.. p. 70. 1976. Alford. op. cit. Heidenheimer. A. J.. Heclo H. and Adams C. T. Cornparatioe P&fir Poficy. The Polities of Social Choice in Europe and Atnericn. St Martin’s Press, New York, 197.5. Berry, op. cit. Djukanovic and Mach. op. cit. Rein, M. Social Science and Public Policy. Penguin, Middlesex. England. 1976. Babson. op. cit. You P. S. and Lim C. Y. (Eds.) The Singapore Economy. Eastern Univ. Press. Singapore. 1971. Singapore Department of Statistics. Yeorboo~ of Starisrics Singapore 1976!77, a. 45. National Printers, Singapore. i977. Ministry of Culture. Singapore ‘76. p. 8. Publicity Division. Ministry of Culture. Singapore, 1977. See Singapore Government Press Statements. Ministry of Health. Answers to Partiament questions by Mr N. L. Yong. Minister for Health. 26 August t966. Quah. op. cir., 1977a. Heidenheimer et al.. op. cir. See speech by the Minister for Health, Mr N. L. Yang. at the opening of the WHO seminar on Health Planning in Urban Development, Singapore. 2! November 1967. See Singapore Government Press Statements. Ministry of Heaitd. Answers to Parliament questions by Mr K. L. Yone. Minister for Health. 26 August 1966. See speech by Minister for Health at %HO seminar r313. Speech b! Mr Chua Sian Chin. Minister for Health at the Macpherson Constituency’s National Day Dinner. 19 August 1972. Speech by Mr Chua Sian Chin. Minister for Realth and Home Affairs. at the Annual Medical Society Dinner, 20 January 1973. Speech by Mr Chua Sian Chin. Minister for Health and Home Agairs. at the Society of Private Practice Annual Dinner. 27 January 1973. Ministry of Health. Annual Reporr 19%. Table 5. p. 45. Singapore National Printers. Singapore. 1977. Ibid. Ibid.. p. 40.
See speech by Mr Chua Sian Chin [36]. Ministry of Culture, op. cif., p. 168. See Ministry of Health. Annual Reporr ‘75. p. 14. National Printers. Singapore. 1976; See also Srraifs Times report. 31 January 1975. Mmistrj of Health. op. cir.. p. 1. 1976. Ibid.. p. 7. See speech by Dr Toh Chin Chye, Minister for Health. at the 5th Commonwealth Medical Conference in Wellington. November 1977. Speech-by Dr Toh Chin Chye. Minister for Heaith. at the Singapore Medical Association 16th Annual Dinner. 24 April 1976. Calculated from figures given in Singapore Department of Statistics, op. cir., Table 15.2. p. 210. See Straits Times report. 10 August 1977 See also speech by Minister f&r Health 1463. Ministry of Health. h’afioual Surrey of Medical Pracrifioners 1975. p. 20. Mentor Printers. Singapore. 1976. See Srrairs Times report. 1 December 1977. p. 7. Speech bv Minister for National Development and Communications. Mr Lim Kim Sar?, at the 67th Anniversary Celebration of the Kwong Wai Shiu Free HOSpital. 4 September 1977. See Sunday Times report. p. 6. 26 March 1978.
155
53. See Wang Look Fang ‘Searching for the cure’. Neti N&on, 16 August. P. 10. 1977. 54. Alford. op. cit.. 55. See Wang Look Fang, op. cir. 56. Quah, op. cit.. 1977b. 57. Quah, op. fir.. 1977a. 58. Personal interviews with Mr Neo Sai Hai President. CPA. 22 March 1978, and Mr Ngoh Eng Kok, Secretary General. CPA, 8 April 1976. 59. Chinese Physicians Ass&iation. Rules of the Singapore Chinese Plrysicions Association CPA. p. 1. Singapore. no date. 60. Ibid., pp. 34. 61. Chinese Physicians Association. Chung Hwa Free Clinic 1975. p. 78. CPA. Singapore. 1976. 62. Chinese Physicians Association. Chung Hwa Free fiinic 1977. p. 86. CPA, Singapore. 1978. 63. Ibid.. pp. 71 and 81. 64. Ibid.. p. 3. 65. Quah, op. cif.. p. 338. 1977a. 66. See. for example. Landy D. (Ed.) Culture. Disease and pealing. Sudies in Medicaf Anthropology. pp. 46848 1, Macmillan, New York, 1977. 67. As auoted bv Dr Toh Chin Chve. Minister for Health [46j. . 68. See speech by Mr Lee Kuah Yew. Prime Minister. at the inauguration of the Thong Chai Medical Institution b&ding. 29 November 1576. 69. Personal interview with Ngoh Emt Kok. CPA Secretary General. 8 April 1976. See also Straits Times report. p. 16. 21 March 1978. 70. Quah. op. cit., p. 9, 1977b. See also Straits Times report. p. 8. 28 -Febru&y t977. 71. See Leslie C. M. Pluralism and inteeration in the Indian and Chinese medical systems. In-Landy. op. cit.. pp. 511-517. 72. Personal interview with Mr Nco Sai Hai, President. CPA. 12 March 1978. The Citizens’ Consultative Committees are “grass-roots” committees established by the ruhng PAP “in each district of the State to be run from the local communit> centre and to include influential people in the area”. See Chan Heng Chee. The D.vnamics oj OIW Party ~orni~~~ce. The PAP and the Grass-roars. p. 133. Singapore Univ. Press. Singapore.
1976. 73. Ghan. op. cit.. pp. 236-249. 74. Borrowing Mechanic’s terminoiogy in Mechanic. op. cir.. 1976. 75. See speech by Minister for Health. Mr N. L. Yong at the Swearing-in Ceremony of the 19th Batch of Office Bearers of the CPA. 16 February 1968. 76. The Thong Chai Medical Institution is an organization established in 1867 by some Chinese physicians for the purpose of giving free medical treatment and medicines to the poor in Singapore. See Thong Chai Medical Institution. Building Plans for the New Thong Chai Medical Insriturion. Shing Loonp Press. Singapore. no date. 77. The Kwong Wai Siu Free Hospital is the on13 one in Singapore that offers both Chinese medicine or modern medicine to patients. according to the patient’s choice. See New Narion report. I I March 1975. pi 7. 7%. See Republic of Singapore. Medical Regisirarion ACI. Chap. 218. Government Publications Bureau. Smgapore. 1970. 79. See speech by the Minister for Health. Mr Chua Sian Chin, at the Annual Swearing-in Ceremony of CPA officials. 30 January 1969. 80. Speech by Minister for Health. Dr Toh Chin Chye. at the 11th Graduation Ceremony of the Chinese Physicians Training School. 23 January 1977. 81. See speech by the Senior Minister of State for Edu-
156
82. 83. 84. 85. 86.
SITELLA
catIon, Mr Chai Chong Yii, at the 26th Installation Ceremony of CPA Officials, 18 March 1978. See Sr&s Times reports of p. 6, 4 January 1978; p. 24, 18 Januarv 1978 and D. 5. 1 February 1978. See speecd by Dr Toh Chin Chye [80]. Straits Times report. p. 6. 10 November 1975. ibid. See Republic of Singapore. The Medicines Act, 1975. Government Gazette Acts Supplement, p. 16. Singapore National Printers, Singapore, 23 January 1976.
K. @AH
87. 88. 89. 90. 91. 92. 93.
Ibid., p. 9. Straits Times report. p. 5, 14 April 1977. Straits Times reoort. D. 10. 13 Januarv 1978. Personal interviews vkh CPA offic& c58]. Straits Times report, p. 16, 21 March 1978. New Nation p. 3, 7 June 1977. Straits i”imes reports. p. 15, 1 October 1977 and p. 10, 10 October 1977. 94. Straits Times report, p. 10, 17 January 1978. 95. Mechanic, op. cit., p. 63, 1976. 96. Quah, op. cit., p. 334, 1977a