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Singapore: Status of cancer pain and palliative care
Vol. 8 No. 6 Augusl1993
Singapore is a small island republic of 633 square kilometers situated at the tip of the riValayPeninsula, strategically straddiing major air and shipping routes in southeast Asia. It has an almost entirely urban population of 3 million, comprising 78% Chinese, 34% Malays, and 7% Indian<.’ Though Singapore spends only 3.1% of its gross national product on health, a reasonable standard of health care is accessible to practically the entire population. The average life expectancy at birth in 1991 was 75.7 yr and the infant mortality rate was 5.5 pel’ thousand live births. Care is provided by 37’79 registered medicat practitioners, of whom 52% are in the public sector, giving a popuiation-doctor ratio of 731 persons per doctor in 1991. The total number of public and private hospitals is 22 with a bed capacity of 9081 and a bed-population ratio of 3.5 per 1000. The government also provides 19 maternal and child health clinics and 22 outpatient clinics offering primary health care at nominal rates.* While mortality from all causes has remained fairly stable at about 5.2 per 1000 during 1983-1987 and the age-standardized mean annual cancer death rates decreased marginally over that period from 147 to 144 per 100,000, cancer as a cause of deatb has been increasing in importance.3 In 1992, cancer overtook coronary heart disease as the most common cause of death, with 3440 cancer deaths and 15,~~s hospital admissions that year.
Care 2&m&x The present palliative care services in Singapore derive from the hospice movement, which had its origins in 1985 when 16 beds AddressW,LF+Z’ quests lo: Cynthia R. Cob, MRCP (UK), Hospice care Association, 26 Dunearn Road. Singapore 1130. Q U.S. Cancer Pain Relief Committee, 1993 Published by Elsetier, New York, New York
were set aside for hospice care in St. Joseph’s Home, a home for the aged run by the Catholic Canossian Sisters and funded by charity. From there, a group of volunteers in 1987 started the Hospice Care Group, which provided hospice home care by volunteers under the auspices of the Singapore Cancer Society. In 1988, the first full-time hospice staff member, a nurse coordinator, wzs employed for this service. Also in 1988, the 5O-bed Assisi Home for the chronically sick, run by the Catholic Francisca;r Sisters of the Divine Motherhood, decided to set aside I2 beds for the terminally ill. In 1989, the Hospice Care Association was formed from the volunteers of *zhe Hospice Care Group, which has continued to provide a hospice home care service funded by charity through the Community Chest of Singapore.
Hospice
HOTWCare
Two organizations provide hospice home care. The Singapore Cancer Society employs one nurse coordinator and one doctor to maintain its home care service, which cared fol 137 patients in 1992. The Hospice Care Association currently employs one full-time medical director, one part-time doctor, four nurses, and one social worker to run its home care service, which cares for 90-100 patients at any one time. This service is undergoing rapid expansion. It provided care for 500 patients in 1992, double the number in 1990. Both services are supported by a large corps of volunteers. The services are funded almost entirely out of public donations, though the Hospice Care Association rents premises from the Ministry of Health, which gives it an annual grant of US $30,500 to cover 80% of the rental.
08853924/93/$6.00
432
Inpatient Hospices Two organizations provide inpatient hospice beds. St. joseph’s home has 16 beds and is planning in 1993 to move into new premises ;Lw w
Future Plans A long-term aim of the hospice movement is to obtain recognition of palliative medicine as part of mainstream medicine and to be accepted as part of the basic health care package that the government provides for the population. Progress towdrd these goals has been made recently. As part of its plan to encourage voluntary welfare organizations to provide the bulk of the welfare services for the less fortunate in society, such as the disabled, the chronic sick, and the elderly, the government has agreed to provide 80% of developmental costs and 50% of operating costs for such facilities. In 1992, the Ministty of Health has recognized hospice as a category of nursing home, covered by the new Private Hospitals and Medical Clinics Act (1991). It has formed a committee to look into space norms and staffing norms for inpatient hospices, which will form the basis for govern-
Goh
Vat. 8 No. 6 Augud
1993
ment funding and licensing. A purpose-built inpatient hospice, Dover Park Hospice, is being planned and will be operational by 1995. This will be run by a charitable organization with no religious affiliation and will be eligible for government funding of SO% of the develop mental costs and 50% of operating costs. Hospice home care is at present not eligible for government funding, but the Ministry of Health is currently preparing a paper to justify such funding on the basis of the cost benefits of home care in its prevention of unnecessary hospitalization, It seems likely that hospice home care will also acquire government funding of 80% of the developmental costs and 50% of operating costs. Attempts are still being made to introduce palliative care into hospitals and into the medical curriculum, but local politics have thus far thwarted all such efforts. It is hoped that. these goals will eventually be achieved.
In Singapore, cancer pain relief and palliative care have not met with problems of drug availability, Morphine for cancer pain relief has been freely available. The pioneers of the hospice movement have early on received support from pharmacists and the drug administration division, who have made oral morphine preparations available for cancer pain relief. Funding through charitable donations for hospice services has also not been a problem. The public shows great appreciation and support for such projects. Government funding, however, has not been forthcoming and palliative care has not been and still is not a priority in health care provision or planning. The government has only recently begun to look into recognizing it for funding, and it has yet to be incorporated into a national plan for dedling -6;“1 cancer. Personnel provision for palliative care presents some difficulties. There is a lack of medical personnel, previously because the specialty was entirely unknown. More recently, some of the younger doctors have shown an interest in going into the specialty, but trained medical personnel are very scarce. Nursing personnel are a problem in that Singapore currently suffers a national shortage of 1000 nurses for all sewices. However, palliative care is an attractive field for nurses, and it is encouraging that more and
Vol. 8 No. 6 August 1993
more muses with the requisite experience expressing an interest to work in the field.
Singapore
are
In 1992, it is estimated that only I’7% of the 3440 patients who died of cancer received some sort of palliative care, either at home or in a hospice. Nospice home care services need to be greatly expanded because they seem to be necessary and well accepted by the community. About 60% of patients receiving hospice home care die at home, which compares favorably with 35% of deaths from ail causes occurring at home. It is estimated that Singapore needs I50 palliative care beds for its 3 million population, of which perhaps 50 could be provided in hospitals and 100 in inpatient hospices. By 1995, it is estimated that there will be S5 functional inpatient hospice beds with another
433
35 in the pipeline. It is hoped that hospital palliative care services would also be started by then.
1. Lau KE. Singapore knsus of population 1990. Demographic characteristics. Singapore: Census of Population Office, Department of Statistics, 1992. 2. Health facts Singapore 91. Singapore: Research and Ewluation Department, Ministry of He&h, Republic of Singapore, 1992. 3. ice HP, Chia KS, Shanmugaratnam K. Cancer incidence in Singapore 1983-1987: Singapore cancer registry report 3. Singapore Cancer Registry, 1992.
Singapore is a small island republic of 633 square kilometers situated at the tip of the riValayPeninsula, strategically straddiing major air and shipping routes in southeast Asia. It has an almost entirely urban population of 3 million, comprising 78% Chinese, 34% Malays, and 7% Indian<.’ Though Singapore spends only 3.1% of its gross national product on health, a reasonable standard of health care is accessible to practically the entire population. The average life expectancy at birth in 1991 was 75.7 yr and the infant mortality rate was 5.5 pel’ thousand live births. Care is provided by 37’79 registered medicat practitioners, of whom 52% are in the public sector, giving a popuiation-doctor ratio of 731 persons per doctor in 1991. The total number of public and private hospitals is 22 with a bed capacity of 9081 and a bed-population ratio of 3.5 per 1000. The government also provides 19 maternal and child health clinics and 22 outpatient clinics offering primary health care at nominal rates.* While mortality from all causes has remained fairly stable at about 5.2 per 1000 during 1983-1987 and the age-standardized mean annual cancer death rates decreased marginally over that period from 147 to 144 per 100,000, cancer as a cause of deatb has been increasing in importance.3 In 1992, cancer overtook coronary heart disease as the most common cause of death, with 3440 cancer deaths and 15,~~s hospital admissions that year.
Care 2&m&x The present palliative care services in Singapore derive from the hospice movement, which had its origins in 1985 when 16 beds AddressW,LF+Z’ quests lo: Cynthia R. Cob, MRCP (UK), Hospice care Association, 26 Dunearn Road. Singapore 1130. Q U.S. Cancer Pain Relief Committee, 1993 Published by Elsetier, New York, New York
were set aside for hospice care in St. Joseph’s Home, a home for the aged run by the Catholic Canossian Sisters and funded by charity. From there, a group of volunteers in 1987 started the Hospice Care Group, which provided hospice home care by volunteers under the auspices of the Singapore Cancer Society. In 1988, the first full-time hospice staff member, a nurse coordinator, wzs employed for this service. Also in 1988, the 5O-bed Assisi Home for the chronically sick, run by the Catholic Francisca;r Sisters of the Divine Motherhood, decided to set aside I2 beds for the terminally ill. In 1989, the Hospice Care Association was formed from the volunteers of *zhe Hospice Care Group, which has continued to provide a hospice home care service funded by charity through the Community Chest of Singapore.
Hospice
HOTWCare
Two organizations provide hospice home care. The Singapore Cancer Society employs one nurse coordinator and one doctor to maintain its home care service, which cared fol 137 patients in 1992. The Hospice Care Association currently employs one full-time medical director, one part-time doctor, four nurses, and one social worker to run its home care service, which cares for 90-100 patients at any one time. This service is undergoing rapid expansion. It provided care for 500 patients in 1992, double the number in 1990. Both services are supported by a large corps of volunteers. The services are funded almost entirely out of public donations, though the Hospice Care Association rents premises from the Ministry of Health, which gives it an annual grant of US $30,500 to cover 80% of the rental.
08853924/93/$6.00
432
Inpatient Hospices Two organizations provide inpatient hospice beds. St. joseph’s home has 16 beds and is planning in 1993 to move into new premises ;Lw w
Future Plans A long-term aim of the hospice movement is to obtain recognition of palliative medicine as part of mainstream medicine and to be accepted as part of the basic health care package that the government provides for the population. Progress towdrd these goals has been made recently. As part of its plan to encourage voluntary welfare organizations to provide the bulk of the welfare services for the less fortunate in society, such as the disabled, the chronic sick, and the elderly, the government has agreed to provide 80% of developmental costs and 50% of operating costs for such facilities. In 1992, the Ministty of Health has recognized hospice as a category of nursing home, covered by the new Private Hospitals and Medical Clinics Act (1991). It has formed a committee to look into space norms and staffing norms for inpatient hospices, which will form the basis for govern-
Goh
Vat. 8 No. 6 Augud
1993
ment funding and licensing. A purpose-built inpatient hospice, Dover Park Hospice, is being planned and will be operational by 1995. This will be run by a charitable organization with no religious affiliation and will be eligible for government funding of SO% of the develop mental costs and 50% of operating costs. Hospice home care is at present not eligible for government funding, but the Ministry of Health is currently preparing a paper to justify such funding on the basis of the cost benefits of home care in its prevention of unnecessary hospitalization, It seems likely that hospice home care will also acquire government funding of 80% of the developmental costs and 50% of operating costs. Attempts are still being made to introduce palliative care into hospitals and into the medical curriculum, but local politics have thus far thwarted all such efforts. It is hoped that. these goals will eventually be achieved.
In Singapore, cancer pain relief and palliative care have not met with problems of drug availability, Morphine for cancer pain relief has been freely available. The pioneers of the hospice movement have early on received support from pharmacists and the drug administration division, who have made oral morphine preparations available for cancer pain relief. Funding through charitable donations for hospice services has also not been a problem. The public shows great appreciation and support for such projects. Government funding, however, has not been forthcoming and palliative care has not been and still is not a priority in health care provision or planning. The government has only recently begun to look into recognizing it for funding, and it has yet to be incorporated into a national plan for dedling -6;“1 cancer. Personnel provision for palliative care presents some difficulties. There is a lack of medical personnel, previously because the specialty was entirely unknown. More recently, some of the younger doctors have shown an interest in going into the specialty, but trained medical personnel are very scarce. Nursing personnel are a problem in that Singapore currently suffers a national shortage of 1000 nurses for all sewices. However, palliative care is an attractive field for nurses, and it is encouraging that more and
Vol. 8 No. 6 August 1993
more muses with the requisite experience expressing an interest to work in the field.
Singapore
are
In 1992, it is estimated that only I’7% of the 3440 patients who died of cancer received some sort of palliative care, either at home or in a hospice. Nospice home care services need to be greatly expanded because they seem to be necessary and well accepted by the community. About 60% of patients receiving hospice home care die at home, which compares favorably with 35% of deaths from ail causes occurring at home. It is estimated that Singapore needs I50 palliative care beds for its 3 million population, of which perhaps 50 could be provided in hospitals and 100 in inpatient hospices. By 1995, it is estimated that there will be S5 functional inpatient hospice beds with another
433
35 in the pipeline. It is hoped that hospital palliative care services would also be started by then.
1. Lau KE. Singapore knsus of population 1990. Demographic characteristics. Singapore: Census of Population Office, Department of Statistics, 1992. 2. Health facts Singapore 91. Singapore: Research and Ewluation Department, Ministry of He&h, Republic of Singapore, 1992. 3. ice HP, Chia KS, Shanmugaratnam K. Cancer incidence in Singapore 1983-1987: Singapore cancer registry report 3. Singapore Cancer Registry, 1992.