Total Quality Management in Practice: A Singapore Healthcare Study - Page 2


In today's highly competitive healthcare environment, competition is likely to be aggressive with survival of only the fittest. The ageing of the population, coupled with rising affluence and greater consumer education has changed consumers' needs and bargaining power. At the same time, the increasing sophistication of medical technologies will change the delivery of services even as it changes the way medicine is practised. These developments in the healthcare industry are not specific to Singapore alone. Many developed countries, like the United States and the United Kingdom, are facing similar challenges. In the face of uncertainties, healthcare organisations are urgently looking for solutions to help them to improve their quality and cost effectiveness. Even though there is no specific solution, some authors have argued that the application of TQM may offer a partial solution (Geber, 1992; Anderson, 1992; Fried, 1992; Lawrence and Early, 1992; Bergman, 1994). This is because TQM is a process which embraces the conscious striving for zero defects in all aspects of an organisation's activities or management with workforce co-operating in the processes, developing, producing and marketing quality goods and services which satisfy customers' needs and expectations first time and every subsequent time (Haigh and Morris, 1993). Hence, many Singapore hospitals are jumping onto the bandwagon to implement TQM as a means of obtaining and maintaining a competitive advantage. However, it is surprising that there is a lack of research on quality management in the healthcare industry of Singapore. Thus, the specific objective of this paper is to present the findings of an empirical study on TQM practices of Singapore hospitals. It includes establishing the principal elements of TQM for a hospital setting, general information about Singapore, her healthcare delivery and financing system, future developments and challenges.

General Information

Singapore is a small country with a total land area of 647.8 sq. km. The total population is about 3.8 million with a resident population of 3.1 million (Singapore, Department of Statistics, 1997). Singapore has a relatively young population with only 10% of the population above 60 years of age. However, the percentage of population over 60 years is projected to increase to 27% by the year 2030. The Singapore healthcare industry represents SGD1.3 billion in Gross Domestic Product (GDP). The infant mortality rate has improved from 82.2 in 1950 to 3.6 per 1000 live births in 1997 (Singapore, MOH, 1997). Average life expectancy rate has increased from 62 years in 1957 to 77.1 years in 1997 (Singapore, MOH, 1997). The leading causes of morbidity and mortality are currently the major non-communicable diseases such as cancer, coronary heart diseases, strokes, diabetes, hypertension and injuries. Cancer and cardiovascular diseases together accounted for approximately 64% of the total causes of death (Singapore, MOH, 1997). The National Health Expenditure (NHE) as a percentage of GDP rose from 2.4% of GDP in 1983 to 2.8% of GDP in 1997 (Singapore, MOH, 1997). The NHE had increased from SGD881 million in 1983 to SGD4.0 billion in 1997 (Singapore, MOH, 1997) while Government subsidies on health services rose correspondingly from SGD405 million to SGD1,240 million or 0.9% of GDP (Singapore, MOH, 1997). Per capital healthcare spending had increased from SGD366 in 1983 to SGD1,080 (Singapore, MOH, 1997).

A National Health Plan introduced in 1982 aimed at building a healthy, vigorous, active and physically fit population also provided for the introduction of Medisave and the upgrading of hospitals and polyclinics. Under the Medisave scheme, 6-8% of an employee’s income is set aside each month to be used to defray approved hospital expenses at government and private hospitals. The White Paper (Singapore, MOH, 1993) based on the Ministerial Committee's recommendations outlines the Government's healthcare philosophy which includes nurturing a healthy nation; keeping medical services affordable and intervention to structure and regulate the healthcare system to prevent over-supply of medical services and dampen demand.

Healthcare Delivery and Financing System

Singapore's healthcare delivery system has evolved over the last two decades. The evolution includes 4 phases: expansion (1945 - 1970), specialisation (1970s - 1980s), restructuring and consolidation (1980s - 1990s) and restriction (1995 and thereafter). There is a dual system of healthcare delivery, a mixture of public and private sectors, a structure dominated by modern Western medicine, co-existing with Chinese medicine. The Government runs the public system while the private hospitals and general medical practitioners provide the private system. The healthcare delivery system comprises primary healthcare provision at private medical practitioners' clinics and the government outpatient polyclinics and secondary and tertiary specialist care in the private and public hospitals. The private medical practitioners provide 80% of the primary healthcare services while the government polyclinics provide the remaining 20%. The aim is to keep fees for consultation and treatment at an affordable level. For the more costly hospital care, it is the reverse situation with 80% of the hospital care being provided by the public sector and the remaining 20% by the private sector. Patients are free to choose the providers within the dual healthcare delivery system and can walk in for a consultation at any private clinic or any government polyclinic. The Ministry of Health (MOH) is responsible for formulating national health policies, co-ordinating the development of planning of the private and public health sectors, as well as regulating health standards.

Singapore healthcare financing philosophy is based on individual responsibility coupled with Government subsidies to keep basic healthcare affordable. Patients are expected to pay part of the cost of the medical services that they use, and pay more when they demand higher levels of service in terms of comfort and ward amenities. To help Singaporeans take responsibility for their own healthcare needs, the government introduced the Medisave Scheme in 1984 to help Singaporeans save and pay for their hospitalisation expenses. To supplement Medisave, low-cost catastrophic illness insurance schemes called MediShield and MediShield Plus were introduced in the 1990s. MediShield is designed to help members meet the medical expenses of major or prolonged illness that the Medisave balance would not be sufficient to cover. Additionally, the Government in 1993 has set up an endowment fund called Medifund to help needy Singaporeans pays their medical bills. Together with Government subsidies, Medisave, MediShield and Medifund ensure that every Singaporean has access to basic medical care irrespective of their socio-economic status.

Although Singapore has come a long way in improving the health status and standard of medical services, major problems exist in Singapore's current healthcare delivery system. These are:

i. inadequate financial discipline to rationalise the healthcare delivery system and control the rising cost of healthcare.
ii. lack of integration between financing and delivery of healthcare.
iii. increasing shortage of manpower, nurses and ancillary staff such as health therapists.
iv. insufficient quality management monitoring system.
v. insufficient attempts made to understand customers' expectations and offer services beyond satisfaction level.
vi. insufficient resources allocated for research and teaching, industrial and academic collaborations.
vii. insufficient buyer information - customers lack relevant information for comparative pricing of healthcare services.
viii reliability and validity of accreditation criteria and standards need to be questioned and revised.

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