Journal of Contemporary

Asia

O Routledge

Vol. 38, No. 3, August 2008, pp. 395-416

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Singapore: The Limits of a Technocratic Approach to Health Care

MICHAEL D. BARR
School of Political and International Studies, Flinders University. Adelaide, Australia

ABSTRACT Being a tiny, easily managed polity run by Western-educated technocrats, Singapore is an ideal laboratory for those who believe that there is a "logical" answer to the problem of health-care funding in economically advanced societies. Certainly the ruling elite in this notvery-democratic country is convinced that Singapore is the epitome of a rational, technocratic state in which rule is based on supposedly impartial, objective criteria. The government's achievements in the delivery of health care are at the forefront of its showcase of technocratic achievements. This article uses the Singapore government's innovations in health-care funding as a case study to explore and test the limitations of trying to apply purist technocratic premises and methodologies to governance. The limitations it uncovers raise the question of whether a technocratic approach to governance can ever deliver the promised results and suggests that the attraction of "technocracy" is a chimera.
KEY WORDS:

Singapore, health-care policy, health-care financing, technocracy. Medical Savings Accounts, governance

In 1982 Singapore's then-Health Minister Goh Chok Tong declared that his country's British-style health system was among the "best in the world." This was a brave boast, but there was more to come. In the same speech he foreshadowed a complete overhaul of the system in a quixotic quest for efficiency: "We should not rest on our laurels, looking down from Mount Everest. In organisational efficiency, in the pursuit of quality and excellence, there can be no highest peak," he declared (Goh, 1982). The key words in this passage were "efficiency," "quality" and "excellence." The resultant reforms turned the Singapore health system into a multi-generational "work in progress" in which "organisational efficiency" and "quality and excellence" were identified as the primary benchmarks of success. The original vision enunciated by Goh Chok Tong in 1982 has provided the essential organisational culture for the Singapore health service, but, in February 2004 the current Health Minister, Khaw Boon Wan, raised the bar for hyperbole when he defined his ideal as a health-care system that has no patients (The Sunday Times, 29 February 2004). A month later he declared his satisfaction that

Correspondence Address: Michael D. Barr, School of Political and International Studies, Flinders University, GPO Box 2100, Adelaide SA 5001, Australia. Email: michael.barr@flinders.edu.au ISSN 0047-2336 Print/1752-7554 Online/08/030395-22 2008 Journal of Contemporary Asia DOI: 10.1080/00472330802078485

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Singapore's health-care financing system was "probably" the best in the world (Khaw, 2004). By its own bold claims, the Singapore government has consciously set itself up as a test case of the effectiveness of the relentless pursuit of organisational efficiency, excellence and quality as the drivers for solving the problem of the cost of delivering health care in a modern, capitalist society. In doing so it is also putting to the test a much broader element of its legitimating rationale: its claim that despite the fact that its style of governance can often appear to be hard-hearted and overbearing, it should be accepted because it is in fact the application of dispassionate and disinterested reason and is the key to and basis of Singapore's success and prosperity.' As one of the least democratic of any of the world's advanced capitalist societies, and being a tiny, easily managed polity run by Western-educated technocrats, Singapore is an ideal laboratory for those who believe that there is a "logical" answer to the problems of government, including those of providing universal, comprehensive and affordable health care in economically advanced societies. The ruling elite of this small country is convinced beyond all doubt that it has achieved these ambitions in all or most aspects of governance, and that it is the epitome of rational rule. As Prime Minister Lee Hsien Loong (2005) announced proudly in March 2005, the Singapore government has "shielded civil servants from political interference . . . [giving them] the space to work out rational, effective solutions for our problems" so they can "practise public administration in almost laboratory conditions." This vision that Lee was claiming to have achieved is, in fact, the ideal of the technocracy: a Utopian vision of governance that presumes that the system is able to rise above subjective considerations of politics, ideology and sectional interests by relying on impartial reason and the technical skills of modern, highly trained professionals. To borrow the words of sociologist Luigi Pellizzoni (which foreshadow those of Lee Hsien Loong to a remarkable degree), in a technocracy "the elite is suitably 'protected' against the rest of society and is able to perform its tasks efficiently" (Pellizzoni, 2001: 64). Rule in a technocracy is based on supposed impartial, objective criteria derived directly or indirectly from disciphnes such as economics, management, law, medicine and engineering.'^ In the Singapore example, systems engineers have been given a particular place of honour at the upper executive level of this schema. A team of systems engineers was even entrusted to reform the education system at the end of the 1970s to make it efficient and to cut "wastage" (Goh et al., 1979: 3-1; Hochstadt, 1993).^ The government's achievements in the efficient delivery of health care are at the very forefront of its showcase of technocratic achievements, which explains why government ministers are so pleased that their health system is providing a loose model for health care reforms in both China (Dong, 2006) and the USA (US Department of Treasury, 2006; US Office of Personnel Management, 2006). The system generating this pride was built upon the 1984 introduction of medical savings accounts (Medisave). These medical savings accounts were later supplemented by catastrophic illness insurance (Medi Shield) and various supplementary welfare measures (such as MediFund, ElderShield and the Comprehensive Chronic Care Programme [CCCP]) (Barr, 2005). The entire system is referred to routinely in a

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semi-official way as the "3Ms", referring to the central role of Medisave, MediShield and MediFund. This is not the place to engage in a comprehensive description of this system, but since the intention is to explore the implications of applying purist technocratic premises and methodologies to the provision of health care, a brief overview at least of the substance of the system is necessary. After this overview, the article will outline the established reasons to doubt some of the more extravagant claims about the achievements of the system before interrogating the implications and limitations of the technocratic ethos behind Singapore's health system. The Singapore System in Outline"* Since Goh Chok Tong's reforms of the mid-1980s, the Singapore government has been developing an increasingly complex system of health-care financing based on the principles of personal-cum-family responsibility for costs, enforced by cost-based rationing and high levels of micro-management in matters of health-care delivery (even using draconian measures to restrict the number of doctors being trained), but also subsidised by significant levels of government subsidy. In its original conception it was to have no insurance component at all. Insurance was identified as a driver in health-care consumption because it increased the "moral hazard." Avoiding this "moral hazard" has since been identified by Toh Mun Heng and Linda Low (1991: 9) as the main philosophical driver of the 3Ms system: A moral hazard problem is encountered when payment of medical expenses is borne by a third party, either an insurance company or the government, affecting the individual's own behaviour. It may lead the individual to overconsume medical services and his doctor to overtreat. It has nothing to do with morality but represents a misallocation of resources by a particular method of finance. Since the third party, be it the government or the insurance company pays the full cost, the individual bears no financial burden or faces a zero price for medical care. Consequently, consumption is greater following the law of demand. Today the government runs several interconnected health funding schemes. The core scheme is Medisave, which is effectively a special savings account to which those in the paid workforce, including the self-employed, must contribute up to 6-8% of wages or salaried income. Those on very high incomes can cap their contributions, and those whose Medisave accounts have reached an internal cap (at the time of writing, $S32,500) can divert their contributions to other approved purposes (Ministry of Health, 2006a). Members build savings to fund patient co-payments (at least 19% of cost) in the event of hospitalisation. To protect accounts from being run down - since Medisave operates without any insurance component - there is a strict fees schedule for medical services and Medisave will not pay above this. Under this regime many high-cost services that are routinely funded in other developed countries are excluded (see below). Originally access to government hospitals was intended to be facilitated by Medisave alone. The government discovered, however, that Medisave provided

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patients with grossly insufficient coverage, so in 1990 it decided to supplement it with an insurance scheme after all - but only catastrophic illness insurance, not general medical insurance. This scheme, called MediShield, draws premiums from a person's Medisave account arid is designed to cover most of the expenses of treating many major or prolonged illnesses and conditions up to pre-determined caps - but only after the member has paid a very high "deductible" or "co-payment" from their Medisave account, their personal savings, or a combination of both (depending on the rules governing payment for treatment of the particular illness). MediShield covers about 89% of the population, giving it a slightly better coverage than the American health insurance rate of 84% {The Straits Times, 4 February 2005). MediShield initially covered members to age 75, but this was increased to 80 in 2001 and then to 85 in 2005 {Channel NewsAsia, 25 September 2005). Next came MediFund, a central endowment fund that provides charity-style relief to those too poor to meet any costs. Interest from the fund is distributed to public hospitals and charities that allocate assistance on a case-by-case basis. These facilities are now supplemented by a growing number of targeted insurance and welfare schemes, such as ElderShield and the CCCP. None of these latter schemes, however, is designed to provide comprehensive cover. ElderShield, for instance, is an insurance plan that provides a modest fixed sum per month for up to 60 months to beneficiaries who suffer severe disability in their old age, while the CCCP piggybacks on government polyclinics to provide subsidised long-term health care to those suffering from three specific chronic conditions: diabetes, high blood pressure and high cholesterol. It should also be noted that charitable organisations are also an institutional part of the health financing structure. Voluntary Welfare Organisations, as they are called, receive government aid and MediFund-based financing to assist them as they care for many who require long-term institutionalised care. An anomaly of the system is that nearly one-third of the population is effectively outside the 3Ms because they are covered by generous employer schemes negotiated before the current systems were put in place (Hanvoravongchai, 2002). According to the Singapore Ministry of Health (2004), the financing philosophy of this complex health-care delivery system is based explicitly on: . . . individual responsibility, coupled with Government subsidies to keep basic health care affordable. Patients are expected to pay part of the cost of medical services which they use, and pay more when they demand a higher level of services. The principle of co-payment applies even to the most heavily subsidised wards to avoid the pitfalls of providing "free" medical services. The "Singapore system" is a continually evolving effort to reconcile the Singapore government's aversion to welfare with the reality that, for both economic and political reasons, it must ensure the provision of health services to the whole population, including low-income earners and the poor. In fact, the Singapore system developed as an explicit reaction to the perceived failures of "social and health welfare" in Europe and the USA - a perception premised more on ideological preconceptions than on empirical data. In November 1981, on the eve of the move to introduce medical savings accounts, then Prime Minister Lee Kuan Yew (1981: 8) told a meeting of government MPs:

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Subsidies on consumption are wrong and ruinous . . . for however wealthy a nation, it cannot carry health, unemployment and pension benefits without massive taxation and overloading the system, reducing the incentives to work and to save and care for one's family - when all can look to the state for welfare. . . . Social and health welfare are like opium or heroin. People get addicted, and withdrawal of welfare benefits is very painful. It is of some importance to realise that Medisave was not a "progressive" attempt to ameliorate the effects of a laissez-faire health system, but a bold attempt to introduce market forces into government-funded health care. Under the previous system hospital care was free and government clinics were subsidised directly. Furthermore, there was no immediate funding problem with the old system. Although per capita costs in simple dollar terms had been increasing by 11 % per annum (Hsiao, 1995), health costs as a proportion of GDP had been falling steadily since 1960 (Toh and Low, 1991: 26). Even the government's share of overall health costs had dropped slightly by the early 1980s, being 68% in 1980; down from 70.1% in 1970 (Blank and Burau, 2004: 26). This reading suggests that the government's introduction of Medisave and hospital fees, along with the use of the rhetoric of selfhelp and personal responsibility, was an attempt to both meet and restrict rising .middle-class expectations by replacing government regulation with the archetypal middle-class mechanisms of financial constraint and self-regulation. If it worked, then managed self-regulation would provide a sustainable basis for curtailing health costs into the long term. The rhetoric of self-help and personal responsibility that permeates public discussion of the 3Ms suggests that these systems are self-sustaining. In fact, none of them could function without government micro-management and subsidies. The government continues to subsidise hospital wards (up to 8 1 % of costs) even after it ensures that public hospital charges are kept down. Furthermore the entire system of polyclinics operates on direct government subsidies without drawing on the 3Ms at all. The most expensive section of any modern health-care system is hospitals, so it should not be surprising that the core of the 1984 reforms is found in this sector. The reforms were foreshadowed as early as the May 1981 announcement that the government intended to reduce "subsidies" to hospitals and polyclinics {The Straits Times, 11 May 1981). This initiative was followed by overt government efforts to encourage the establishment of private hospitals {The Straits Times, 10 April 1982, 24 December 1982), and across-the-board increases in hospital fees {The Straits Times, 17 December 1982). The expansion of expensive private hospitals at the expense of subsidised public hospital wards seems to have been an attempt to take advantage of the perception that Singaporeans had turned a socio-economic corner, and had become a bourgeois-cum-wealthy society; though the advent of parallel "privatisation" moves in the school sector in the pursuit of "excellence" in the late 1980s suggests that the "privatisation" of health was merely one aspect o f a much broader push that wilfully saw generic benefits in the private sphere. Regardless of motivation, these moves reached their logical conclusion when the government announced, in May 1984, that government hospitals would move towards privatisation, not in the sense that ownership would change, but they would

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be run as private enterprises: collecting fees for services, relying less on government "subsidies," competing for business, balancing their budgets and relying in part on profitable private patients (who pay their full treatment and accommodations costs) to provide income to subsidise public patients. The trailblazer in this new enterprise was to be the National University Hospital (NUH), which was restructured in 1987, followed by the National Skin Centre in 1988 and the Singapore General Hospital in 1989 (Toh and Low, 1991: 30-1). American consultants were duly engaged and the "privatisation"/"restructuring" programme continued into the 1990s, although it stopped a long way short of including all government hospitals. The NUH provided the model for the "restructured" hospitals. It was broken down into 50 cost centres that had to pay their own way. One interpretation of NUH's experience was provided by Toh Mun Heng and Linda Low in 1991, who began by observing that: The "privatisation" exercise at NUH is said to have provided new and more personalised services, promoted staff motivation, deployed nurses more effectively, and enabled greater financial accountability, among other advantages. ... Doctors are made more circumspect when requesting certain tests which indirectly keeps the cost to patients under control, too. Yet this rosy view was balanced by some strong criticisms that questioned the value of the entire enterprise: On the other hand, charges in the NUH have increased Government subsidies have not remained at the same level over the years. ... There is no concerted effort to contain costs with measures aimed at the supply side, such as physicians' earnings and mode of practice. These authors continued, observing that the "benefits of 'privatisation' of the NUH are difficult to prove or refute given the paucity of information and financial data [released by the government and NUH]" (Toh and Low, 1991: 32). One could add that, in terms of public accountability, nothing much has changed since this assessment and there is still no reliable basis for judging the strengths and weaknesses of the overall "privatisation" programme. In 1999, the government restructured public hospitals into two regional clusters, the National Healthcare Group and Singapore Health Services. Each comprises one of Singapore's two major tertiary hospitals, as well as general hospitals, a number of specialist centres and institutes (such as the National Cancer Centre), and government polyclinics. The government believes that by micro-managing both demand and supply, it can make the system efficient and cost-effective, minimising waste and maximising service delivery. Implicit in government control of inputs and the introduction of "business" principles to health management is the principle of rationing health services based on wealth. The 1993 White Paper on Health stated this without voicing the criteria of wealth: We cannot avoid rationing medical care, implicitly or explicitly. Funding for health care will always be finite. There will always be competing demands for

Singapore's Technocratic Approach to Health Care 401 resources, whether the resources come from the State or the individual citizens. Using the latest in medical technology is expensive. Trade-offs among different areas of medical treatments, equipment, training and research are unavoidable (Ministerial Committee on Health Policies, 1993: 17). The "Singapore system" is thus a continually evolving effort to reconcile the conflicting demands in the Singapore government's ideological, economic and political agendas. Regardless of any other criticisms that might tarnish its record, it should be acknowledged that as a result of this system, Singapore runs a modern, effective health system that absorbs only 3.63% of GDP (Ministry of Manpower, 2004) and 7.4% of government expenditure (Ministry of Finance, 2004). The government and many others attribute its success primarily to the 3Ms, with perhaps the strongest claim coming from the current Minister for Health who told Parliament in 2004 that "our 3M framework is far from perfect, but it is probably the best healthcare financing model in the world today" (Khaw, 2004).
Routine Scrutiny

With such an imprudent record of boasts from successive Health Ministers, it seems only proper that the system be brought under critical scrutiny. Yet this is not as straightforward as one might expect. Even the simple claim of having kept health expenditure low is difficult to verify because the Singapore government does not follow Organization for Economic Co-operation and Development (OECD) standards in measuring health expenditure. This makes international comparisons extremely difficult. Furthermore, the government is highly secretive about the detailed operation of its system, and has made neither the data source nor method of its calculations available to anyone outside those in the civil service and the government who need to know. So, although one can say safely that expenditure is low by Western standards, it may well be higher than the government's published figures suggest. The extensive list of exclusions from the 3Ms system also makes it difficult to establish a meaningful standard of international comparison. To make a very explicit comparison, the MediShield list of exclusions includes most of the services that have been identified as major drains on hospital budgets in the Australian health system at the end of the 1990s: cardiovascular disease, control of cancer, care involving dialysis, and care related to the treatment of HIV, mental health and diabetes. The basis of this comparison is spelt out in Barr (2005), but essentially a comparison is being made between the Singapore system and Australia's list of National Health Priority Areas (NHPA). The NHPA was an initiative of Australia's nine commonwealth, state and territory governments, and focuses on "diseases and other conditions that contribute most significantly to Australia's burden of illness and for which there is potential for the burden to be significantly reduced" (Australian Institute of Health and Welfare, 1999: 93). The NHPA list accounted for 40% of total hospital patient days in Australia in 1998-99. In Singapore, when it comes to outpatient renal dialysis, radiotherapy, chemotherapy, and AZT treatment, patients have not only been forbidden from using MediShield funds, they have also

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been forbidden from committing their future Medisave funds, as is allowed for the treatment of many other conditions. The burden on the Singapore health system has also been lightened drastically by the extraordinary youth of the society^ - an advantage that is now acknowledged by the government in the context of discussions about future challenges {The Straits Times, 15 November 2006). In 1991, 6.2% of Singapore's population was aged 65 or over, as opposed to proportions between 10.9% and 15.4% for the USA, Canada, UK, Australia, New Zealand and West Germany (Ministerial Committee on Health Policies, 1993: Appendix B). In 1988, the Ministry of Health estimated that by 2030, 52% of the population would be 60 years or older, though later figures suggest that this trend may have slowed (Low, 1998). This is a serious concern for the government when it is realised that in 1996, the aged of Singapore (65 and over) were admitted to hospital at 2.8 times the frequency of their younger counterparts, and stayed in hospital an average of 1.66 times as long. They were also higher consumers of the two most heavily subsided classes of ward (Prescott, 1998: 43). Thus, an increase in the proportion of the aged will inevitably increase demand for health services. A further factor contributing to the low expenditure on health is the anomaly of Traditional Chinese Medicine (TCM). It is commonplace among Singaporeans to rely on a mixture of Western and traditional medicines, or even to turn to Western medicine only as a last resort. The Ministry of Health estimates that about 12% of daily outpatient users also visit TCM practitioners (Ministry of Health, 1995), and even though TCM has been regulated by the Ministry of Health since November 2000 (Ministry of Health, 2006b), it is excluded from national health expenditure figures, thus artificially depressing expenditure figures. Despite the government's avowed intention to reduce health expenditure, and its routine claims to have contained costs, it seems that the introduction of Medisave in 1984 did not reduce or even contain health expenditure. In fact, immediately following the introduction of Medisave in 1984, the rate of increase in health expenditure per capita jumped from 11% to 13% per annum (Hsiao, 1995). The share of GDP absorbed by health expenditure also increased in the immediate postMedisave period, due largely to a sudden increase in expenditure on doctors' fees and the purchase of new technology as hospitals competed with each other for business and reputation in the new fee-paying environment (Toh and Low, 1991). It should also be realised that while the Singapore health system has delivered impressive statistics in terms of some major health indicators, notably longevity and infant mortality. Even so, in 2000, the World Health Organisation ranked Singapore only thirtieth in the world for the overall health of its population, using measures such as the average age of the onset of disability and the rate of incidence of illnesses that seriously affect not only life expectancy, but also quality of life (King, 2006: 353). On this ranking, health systems from countries such as Japan and Australia are far superior in maintaining a healthy population than is the Singapore system. A further dampener is placed on the more extravagant claims of the Singapore government when one compares the outcomes of the Singapore health system with those of societies that are, in various ways, more comparable than are Western countries, such as the UK, USA and Australia. Japan, South Korea, Taiwan and Hong Kong, for instance, have somewhat similar societies to that of Singapore, all

Singapore's Technocratic Approach to Health Care 403 being economically advanced East Asian societies, but they have very different health systems that nevertheless produce results comparable to - and, in some cases, significantly better than - those of Singapore in areas such as longevity and infant mortality (Gauld 2005; Gauld et al., 2006: 326-27). Furthermore, with the exception of Japan, their total health expenditure per capita (in US dollars at Purchasing Power Parity) is actually less than Singapore's (Gauld et al., 2006: 326). In the case of Taiwan, it is 22% less (on 2002 figures).
Effectiveness Through Efficiency

These well-established critiques make it clear that the more extravagant claims made by Singapore's leadership must be dismissed, but this does not mean that the system is not worthy of attention. The Singapore health system remains, on the face of it, an impressive system. And when one thinks of the endemic crises and shortcomings that beset many other health systems in advanced democratic societies - crises that seem to be routine in the various states of Australia, for example - one could be forgiven for thinking that perhaps the Singapore system is still an exemplar of technocratic methodology after all. This thinking becomes all the more reasonable when it is acknowledged that the technocratic methodology does not guarantee absolute perfection, but just a striving towards perfection based on the constant application of rationality and logic. Singapore's current Prime Minister, Lee Hsien Loong, encapsulated the spirit of this ethos in April 2004 when he told an audience of tertiary students that they must not be content to inherit and enjoy the Singapore built by their parents and grandparents. Instead he asked them to "change it, improve it and build on it" (The Straits Times, 6 April 2004). Several months later he delivered a similar message at the National Day Rally: We can never afford to be satisfied with the status quo, even if we are still okay, even if our policies are still working. People say, "If it ain't broke, don't fix it". I say, if it ain't broke, better maintain it, lubricate it, replace it, upgrade it, try something better and make it work better than before (Lee, 2004). Between them Lee's speeches encapsulate the spirit of Singapore's technocratic rule in a general way, but to identify the application of this spirit in the administration of the health system, in particular, calls for a return to Goh Chok Tong's 1982 speech, with which this article opened. The two sentences quoted above from Goh's 1982 speech fail to convey the full import of his message, so a fuller quotation is reproduced here: We have a hospital service that we can be proud of. It stands up to comparison with the best in the world. But having said that, I hasten to add that we shouldnot rest on our laurels, looking down from Mount Everest. In organisational efficiency, in the pursuit of quality and excellence, there can be no highest peak. It is not like Mount Everest which you can climb and plant a fiag and proclaim you have reached the peak. Of course, climbing Mount Everest is in itself a great achievement, as only a few can reach that height. But this organisational

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mountain of ours is even higher than Mount Everest. It is so high that even at 20,000 feet you cannot see the peak, even on a clear day (Goh, 1982). The imaginative analogy with mountain climbing is wont to distract attention from Goh's central message - which perhaps accounts for the academic neglect of this pivotal speech. It is clear that Goh was foreshadowing a major restructure of the Singapore health system - and indeed a radical new system of health care and hospital funding was introduced two years later. It is also indicated from the hyperbole that this reform was going to be an ongoing quixotic quest for perfection and indeed the system has, since 1982, been a continually evolving project in which the "summit" of perfection always seems to be just out of sight even though it is always said to be getting closer. Yet the core sentence contains a radical proposition that has not been given serious attention. It reads, "In organisational efficiency, in the pursuit of quality and excellence, there can be no highest peak." The goals identified by Goh were unambiguously "efficiency" and "quality and excellence," but the relationship between them is less clear. The sentence can perhaps be read as calling for "efficiency" and "quality and excellence" equally, but, if so, then it was an uncharacteristically sloppy piece of speechwriting. These two ideals potentially and routinely stand in opposition to each other in health care, as in most aspects of life and business. Alternatively, this sentence can be reasonably read as defining "quality and excellence" in terms of "organisational efficiency." On this reading, "organisational efficiency" is the master concept that provides the conceptual parameters by which the system is to be judged, and the prioritisation of "organisational efficiency" was, in fact, the deliberate message of Goh's speech, with his reforms following these principles to the letter. They turned the Singapore health system into a multi-generational "work in progress," in which the unending quest for "organisational efficiency" was identified as the primary goal, and "quality" and "excellence" were conceptually and actually subservient: they were, in fact, regarded primarily as outcomes of "efficiency" and defined in terms of "efficiency." This focus on organisational efficiency (which quickly came to subsume the objective of minimising government expenditure on health) has shaped the Singapore health system in both positive and negative ways. On the one hand, it has led to the production of an impressive infrastructure that delivers high quality health care to most of the population most of the time. On the other hand, the emphasis on systemic perfection breeds an element of blinding hubris that tends to make the system prone to rather spectacular failings. It is the proposition here that the quest for efficient systems has led the Singapore health system to crisis point, potentially putting lives and health at risk. With "efficiency" as a starting point, the government measures "effectiveness" by averages, metrics and the degree to which the wastage of resources is minimised (Khaw, 2004). Hence the government is inordinately proud to announce health achievements such as Singapore's ranking as the most cost-effective health care system in ASEAN {Channel NewsAsia, 22 October 2004) and that its rate of health expenditure is drastically lower than those in countries such as the UK and the USA (Khaw, 2007). These objectives are, of course, worthy in themselves, and the system should be credited with achieving good scores on these measures, but this mindset is prone to create a tunnel vision focused on throughput and average

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outcomes, which shifts focus from the health system's core business of patient care and public health. Impurities in "Technocratic" Approach There is concrete evidence that this type of problem is endemic at the level of health administration, and that it operates in ways that impact negatively on the quality of health service, but, before considering this evidence, it is important to make the point that there are good grounds for believing that the supposedly value-free, rational technocratic approach of the Singapore government to health policy is compromised severely by the operation of a priori assumptions and prejudices based on socioeconomic class and gender (to name just two areas), and by the surprisingly strong impact of public opinion in matters of health care. These distorting influences can be demonstrated as being at the core of the thinking of the designers of the system. A priori assumptions and prejudices. First, although the efficiency-driven approach being studied here is justified as the outcome of technocratic discipline, it would be truer to say that the idolisation of efficiency is one a priori assumption among many that have actively contributed to the character of the health system. The ideological rejection of "welfare-ism" that originated with Lee Kuan Yew has already been referred to. This was presented as a logical if unpleasant application of logic, but an alternate reading is that the Singapore government, dominated by middle-class politicians and technocrats, was transforming the health system into one that reflected their class' expectations by introducing the archetypal middle-class mechanisms of tight financial responsibility, self-regulation, rationing access to services on the basis of wealth, and turning public goods into commercial enterprises. This observation might be accepted as being merely a viable alternative to the government's explanation, except that it can be demonstrated that this reform of the health system was part of a broader pattern of the embourgeoisement of the public services, and reforms in housing and industrial relations that reveal explicitly middleclass societal views and prejudices. The other public good that was transformed in this way during the mid-1980s was the education system. Then-Education Minister Tony Tan took for granted that the best students would excel academically in Singapore schools, but according to Eugene Wijeysingha, a civil servant who took instructions directly from Tan,^ he wanted schools that would build their character and turn them into "gentlemen."' To this end he engaged in what was eff'ectively a programme of the gentriflcation of elite education to parallel the privileging of elite education per se. Tan's first step was taken in 1986 when he commissioned a group of 12 secondary school principals, including Wijeysingha, to tour a collection of elite schools in the UK and the USA, apparently to find the best way to implement privatisation initiatives that had been publicly urged by Prime Minister Goh Chok Tong the previous year. The result was a 76-page report titled Towards Excellence in Schools, which was substantially implemented over the next few years. The principals recommended that selected schools be eff'ectively privatised and given both considerable autonomy and extra resources to enable them to offer a better study environment and school experience. In the full spirit of this "privatisation," the Independent schools were given

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government grants of $S1 million each to launch their endowment funds {The Straits Times, 1 September 1987) and began charging fees that have progressively moved from being nominal in the 1980s to very substantial in the 2000s {Business Times, 3 November 1989; The Straits Times, 11 August 1990, 29 November 2005). Unsurprisingly, these newly created "independent" schools quickly came to be dominated by the children of middle-class and professional parents (Goh et al., 1987; Tan, 1993: 245-6). It stretches credulity to assert that the almost-simultaneous embourgeoisement of both the health and the education systems could have been a coincidence or the result of the independent application of objective "reason," but, in any case, the reader is not being asked to accept these two pieces of evidence in isolation. Even before these initiatives had manifested themselves in health and education, the government had already taken measures in the areas of housing and industrial relations that should remove all doubt about the operation of a middle-class bias in its approach to governance. In the area of housing, it took steps in 1980 to ensure that each housing block (in the government-run housing estates in which 67% of the population lived at that time {The Straits Times, 1 October 1980)) had a number of middle-class professionals as residents. There is no need to speculate on whether there were middle-class presumptions motivating this move because Lee Kuan Yew stated explicitly that the reason for this initiative was to ensure that ordinary people could benefit from the "quaUty community leadership" that would be provided by these "better education people" {The Sunday Times, 30 November 1980). A similar set of middle-class presumptions were operating in the field of industrial relations in the same period. From the mid-1970s onwards the trade unions were subjected to a parallel incursion of well-educated, middle-class "talent," whereby professionals (university-trained engineers, etc.) were parachuted into leadership roles in the union movement, coming to dominate the leadership of the National Trades Union Congress and most trade unions during the early 1980s (Barr, 2000a). In 1980, Lee Kuan Yew justified this programme on the grounds that "the unions must have their quota of talent" (Barr, 2000b: 116). Moreover the field of industrial relations also saw the introduction of a 12-hour shift for factory workers in the mid-1980s, an initiative that pleased employers unreservedly but showed contemptuous disregard for the health and family lives of factory workers (Koh, 2007). These examples are not the only pieces of evidence that indicate the presence of a middle-class agenda at the core of the government's reform programmes in the early to mid-1980s, but they are sufficient to leave no room to doubt that it was the case. The significance of this for our consideration of Singapore's system of health-care financing is that the government was supposed, according to its own logic, to be completely free of such biases, but this was clearly not so. Beyond these class-based factors, further evidence of the distortion of reason and logic in the operation of the Ministry of Health's basic premises is found in the restrictive cap on the number of female candidates allowed into the local medical school. This cap was imposed in 1979 and was Hfted only at the end of 2002 {Business Times, 6 December 2002). It was justified by the assumption that women would withdraw from their profession either partially or completely after marriage and starting a family (Kong et al., 2000: 515-16). Its effect on the operation of the health system is minor compared to the impact of the class-based distortions described

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above, but it is mentioned because its continued operation into the early years of the twenty-first century demonstrates how far the Ministry of Health is from being the rational, logical, sophisticated and modern creature that it claims to be. Public opinion and politics. The second set of grounds for doubting the purity of the Singapore government's technocratic approach to health care is a consideration of the potent operation of public opinion in this field. Although the government is the only proactive driver in health-care policy, the end result is a compromise between the "efficiency"-driven, technocratic assumptions of government, and strong reactions from the public. It is an understatement to say that public opinion is not generally a powerful factor in Singapore governance because the government is such a strong and overbearing player in politics, but - probably because health issues affect the lives of Singaporeans so intimately - it has nevertheless been a significant contributor to shaping health policy. According to the ideology of technocracy, such impacts are an irrational impediment to the quest for efficiency, but it is argued that they account for much of the positive outcomes for which the government takes credit. The key health issues raised routinely in newspaper articles and features, in the "forum" pages of newspapers, by opposition political parties and by government backbench MPs (reecting in turn the concerns raised in their "Meet-the People" sessions in their constituencies), revolve around the access of the poor and the lower middle classes to affordable health care. The vulnerability of the poor and the elderly was highlighted in 2005 when the government closed the evening service offered by the government polyclinics at the same time that it was inadvertently focusing public attention on the plight of the middle class by threatening to end their access to the cheap C Class wards in government hospitals. Such is the expense of being sick in Singapore that even the middle class are scared of the cost of the high "co-payments" and the large gaps between the amount covered by Medisave and MediShield and the actual bills received from the hospital. These problems moved to the front of the government's mind, not because of any efficiency-driven review conducted by its technocrats, but because public discontent threatened the government in the 2006 elections. The most spectacular eruption of the issue was the unprecedented spectacle of Health Minister Khaw being berated for a quarter of an hour by an aged constituent, but the more serious threat came from the opposition Workers' Party, which campaigned strongly on the issue (Channel News Asia, 4, 14 May 2006). The unambiguous result of this engagement was Khaw's mid-campaign announcement that he was deferring indefinitely the introduction of a means test for access to the highly subsidised C Class wards (Channel News Asia, 2, 3, 4 May 2006). Not since the late 1980s had the government engaged in such a spectacular volte face - and significantly on that occasion the issue was also about access to C Class wards, and it was brought about by the most vehement expressions of concern by government backbenchers passing on the concerns of their constituents.^ The government presents the history of incremental change in the health system since the original introduction of Medisave in 1984 as a triumph of reason and efficiency, directed towards the noble end of providing affordable health care for all, but without the input of ordinary politics it is doubtful that the regime and its mandarins would have seen any pressing need to engage in this masterpiece of micro-management. Granted that Medisave was

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originally intended as the final word in health-care financing, and taking into account the middle-class preconceptions from which the government was and is operating, the gradual watering down of the original drive against "moral hazard" is evidence that the operation of politics is the key dynamic in the evolution of the system, and insofar as the Singapore health system is a showcase, Singapore's vestiges of democracy deserve at least as much credit as does its technocratic ethos. Today, when the Health Minister focuses seriously and systematically on ways to reduce costs to the consumer and plugging the myriad gaps in 3Ms coverage that he admits often leave people with huge medical bills {Channel NewsAsia, 14 August 2006; The Straits Times, 19 October 2006), he is giving witness to the impact of even a modest degree of democratic forms, rather than the brilliance of his technocrats. Separate Problems? The remainder of this article focuses on some faults in the Singapore health system and argues that they are all the result of a common systemic failing. In essence, it is argued that the most basic publicly stated premise on which the Singapore health system has been built - the premise of striving for technocratic eificiency is responsible for its most spectacular and serious failings, rather than its achievements. Spectacular Failures When considering the Singapore health system's record of public failures, it should be noted that given the right setting and provocation, Singapore's leaders are willing to concede that their health system's record of achievement is less perfect than they claim in moments of bravado. A number of examples can be cited. First, there was the government's delayed response to the SARS epidemic in 2003. For the first five weeks of the SARS outbreak (13 March-20 April, 2003) there were no protocols or contingency plans to deal with an epidemic that had infected 65 people in its first fortnight {The Straits Times, 25 March 2003). The responses, such as they were, were ad hoc and reactive. The public marker of the ending of this rudderless period was the effective removal of the SARS response from the hands of then-Health Minister Lim Hng Kiang - who in March had asked the public to accept some deaths as inevitable (see The Straits Times, 25 March 2003) - and the creation of two ministerial committees to handle the crisis {The Sunday Times, 20 April 2003). It was five weeks (13 March-17 April) before the government began supplying free ambulances to take suspected SARS cases to hospital (Ministry of Health, 2004). Until then, suspected SARS cases generally made their own way to hospital by taxi or public transport, as was recommended by official bodies, such as the Office of Student Affairs at the National University of Singapore.^ As the current Head of the Civil Service, Peter Ho, has since acknowledged: "We were surprised by SARS. We were surprised by its epidemiology. We were unprepared for it. But we should have been prepared. It was not a fundamental surprise, because we knew that the risk of a highly infectious epidemic existed" (Ho, 2005: 3). The truly frightening aspect of this episode is that it was only because SARS threatened the family of the then Senior Minister Lee Kuan Yew at the five-week

Singapore's Technocratic Approach to Health Care 409 mark, when his wife was rushed to hospital with a suspected case of SARS, that Cabinet finally began to take SARS seriously (The Straits Times, 26 April 2003) and even then it took the direct intervention of SM Lee himself to galvanise Cabinet into action. This is not the sign of an efficient or far-sighted health system, but one that requires the most severe shocks to overcome a culture of complacency. Of more serious political consequence for the government was its failure to adequately oversee the National Kidney Foundation (NKF). The NKF is notionally an independent charity but is, in fact, an integral part of the health system as the main provider of kidney dialysis. Suffice to say that it is only thanks to the operation of the NKF that the government can afford to exclude dialysis and kidney-related treatments from the 3Ms (and even when it was operating properly, as in the mid1990s, the death rate from lack of access to dialysis was averaging not less than 30 per year [The Straits Times, 3 September 1997]). Yet, in 2005, the NKF was exposed as a corrupt institution that was grossly abusing public trust as well as public money. In its official report on the gross mismanagement of the NKF, auditing firm KPMG was scathing: Power was centred around one man, and was exercised in an ad hoc manner through [CEO] Mr [T.T.] Durai and his coterie of long-serving assistants. ... The NKF appeared to run and operate, and in fact did run and operate, on the ideas, whims and caprice of the chief executive (comments drawn from Today, 20 December 2005 and Reuters, 19 December 2005). Not that any government instrumentality or personnel can take credit for uncovering the NKF abuses. That honour goes to a humble plumber who was scandalised when contracted to install gold-plated taps and a luxurious toilet seat in the NKF executive office (Today, 26 December 2005). On this occasion the government was saved from facing serious consequences by the ineptness of its domestic political opponents - the Opposition Singapore Democratic Party (SDP) made the strategic error of questioning the integrity of the government rather than its competence. By questioning the government's integrity, the SDP invited a libel action that made it impossible for the NKF issue to be raised during the 2006 General Election campaign (The Straits Times, 26 April 2006; The Business Times, 11 May 2006). Yet, even so, as a direct result of this fiasco the Health Minister apologised to the public, conceding that he had been made to look "silly" (The New Paper, 23 December 2005), and the government conducted a major review of dialysis access, instituted audits of all Voluntary Welfare Organisations and overhauled its own procedures for overseeing these critical areas of health and welfare policy. It could be argued that the NKF and SARS are not a fair basis on which to judge the Singapore health system because they are both outside the 3Ms and so off the main stage of the health system. There are two answers to this objection. Regarding the consideration of the NKF, there can be no reasonable basis for not including dialysis treatment as part of mainstream health care. Regarding SARS, any health system must be judged as much by its capacity to cope with crises as it does with routine demands. That expectation is intrinsic to the nature of health care.

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Systemic Failures It is more difficult to interrogate the systemic core of the health system at the more mundane level of day-to-day practice because the government maintains close control over the relevant information, and it is generally successful in ensuring that only flattering information is released. Yet there are a few clear and public signs that the ethos of so-called efficiency-driven management of health care is driving down the standard of health care. These centre around a critical shortage of both hospital beds and doctors, both of which are putting lives at risk on a daily basis. First, the current shortage of hospital beds should be considered. Singapore's ratio of hospital beds to population stood at 1: 348 in 2004 (Ministry of Health, 2004). The most recent figures available show that after a year of intensive expansion this figure had improved to 1: 278 by 2005 (Ministry of Health, 2007). This is a commendable improvement, but, to put it in perspective, it needs to be realised that in 1960 (one year out from full colonial rule), the ratio of hospital beds to population was 1: 229 (Lim, 1989: 174), making the 2004 figure a deterioration of 52% in 44 years and the 2005 figure "only" a deterioration of 21% in 45 years. In fact, the 2005 figure is still worse than that of 1985 (in the first year after the reforms of 1984) when the hospital bed-to-population ratio stood at 1: 259 (Lim, 1989: 174). Oddly enough, the government regards this as an achievement. In his Budget Speech on 17 March 2004, Health Minister Khaw Boon Wan made it clear that the focus on efficiency and cost savings provides the core of the Singaporean health-care philosophy and he stated explicitly that he considers less consumption of public health services to be a positive outcome in its own right, and conclusive proof that the Singapore health philosophy of personal responsibility and self-help is among the world's best practice (Ministry of Health, 2004).'" Yet, in his less boastful moments, he admits that the shortage of beds is a problem that needs to be addressed because it is adversely affecting the delivery of health care: hence, his strenuous efforts to increase the number of beds over the last year and his lamentation that these initiatives are several years too late to address the crisis {Today, 11 July 2006). Minister Khaw now admits that the shortage of beds is "stressing" doctors and patients: "Stressful," he says, "in the sense that, every day, our doctors have to go down to beg the patients [to be discharged]" {Today, 25 May 2007). Yet, despite the obvious seriousness of the problem, his belated announcement of the opening of 200 beds by 2009 reveal the continuing presence of the mentality that led to the shortfall in the first place. He lamented that since public hospitals are heavily subsidised, "the more beds I add, I know tomorrow they will be filled up" {Today, 11 July 2006), by which he seemed to imply that it is the availability of subsidised beds, rather than illness, that drives people to hospital, ignoring the more likely explanation that there are currently people sick at home who should be in hospital. Yet, even the hospital-to-population ratio cited above ignores the recent phenomenon of international medical tourists who have also been placing increasing demands on the Singapore health system. According to Khaw, medical tourism attracted 200,000 international patients in 2002, 374,000 in 2005 and is increasing at a rate of 20% per annum, with a target of one million patients per year by 2012 (Ministry of Health, 2007; Australian Doctor, 23 March 2007), leaving one to wonder

Singapore's Technocratic Approach to Health Care 411 how many Singaporeans have benefited from the recent and planned improvement in the hospital bed-to-population ratio. With such statistics as a background, it should come as no surprise to learn that Singapore also has, according to Yong Ying I, Permanent Secretary in the Ministry of Health, the worst doctor-to-patient ratio in the developed world - 1: 652 in 2007, up from 1: 640 in 2005 (Agence France Presse, 21 February 2007; Ministry of Health, 2007). The low doctor-to-patient ratio is regarded in the Ministry as a serious problem and teams have been sent to Australia and London to recruit as many as they can from outside normal channels. In the longer term the Ministry intends to nearly treble its output of locally trained doctors from over 200 to about 600 per annum (Agence Prance Presse, 21 February 2007). Doctor shortages have multiple effects on patient care, the most obvious being that it increases waiting times and deters people from seeking routine medical services, but it also places stress on doctors and gives them incentives to push patients through as quickly and as routinely as possible, leading to mistakes and the premature discharge of patients. Yet, this phenomenon also contributes directly to the high throughput of patients of which the government boasts as evidence of the efficiency of its hospitals (The Straits Times, 8 March 2007). Yong Ying I understated the situation when she said that "We have very efficient doctors and they work very hard. But somewhere along the way we also don't have enough" (Agence Prance Presse, 21 February 2007). Both these shortages - of doctors and hospital beds - are the direct result of government policy described earlier that deliberately restricted the supply of doctors and hospital beds to avoid increased consumption of health care. By the government's own logic of the dangers of "moral hazard," the doctor and hospital bed shortages are at the heart of Singapore's ultra-efficient health-care system and are major contributing factors that have contributed to that reputed efficiency, yet now both are admitted to be serious problems, undermining the capacity of the health system to service its own population. This is part of the problem with running a system whose goals are all fashioned in terms of "organisational efficiency." The emphasis on "organisational efficiency" has had yet another deleterious effect. It is not "efficient" to build in a capacity to meet infrequent or unlikely scenarios, so the whole system - right down to the pattern of coverage and limitations by the 3Ms - is based upon an assumption that dealing with averages and common patterns is best practice because it is an "efficient" way to produce good measurable (average) outcomes. This ethos is becoming increasingly problematic for the government because the "unexpected" seems to be arising with increasing frequency, possibly because Singapore has positioned itself so successfully as a regional cross-road and so is open to every bug that is floating around the region. Yet, for whatever reason, 2006 proved to be yet another crisis year for the Singapore health system, with government polyclinics reporting that queues were so long and staff members so overworked that lives were being put at risk, with one death due to mistaken prescription already recorded (Ministry of Health, 2006c). In the same period the public hospitals struggled to cope with an increase in the number of patients, largely due to outbreaks of dengue fever and influenza (Ministry of Health, 2006c) and, as Health Minister Khaw has admitted implicitly, the failure of Ministry of Health planners to provide enough beds to cover peak demand (Today, 11 July 2006). Yet,

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such is the power of the drive to achieve efficiency and eliminate the "moral hazard" that hospital beds are provided only reluctantly, even to cater for an influenza epidemic. The explicit admissions of failures by the Health Minister and his Permanent Secretary reveal that it is at the very ordinary level of affordability and availability that the system is facing the most strain. This problem is of particular interest because it is thoroughly systemic: it affects the poor (especially the female elderly poor - see Chia and Tsui (2005)), the middle class and anyone with a serious chronic illness. This is a reach that makes everyone except the very wealthy and those lucky enough to be on generous employer-sponsored schemes - which the government is phasing out in any case (Hanvoravongchai, 2002) - feel a considerable level of vulnerability (Prescott, 1998: 2). The issue has driven the Health Minister to focus seriously and systematically on ways to reduce costs to the consumer and plug the myriad gaps in 3Ms coverage {Channel NewsAsia, 14 August 2006; The Straits Times, 19 October 2006), and to highlight the success of the 3Ms in offering adequate cover to most patients most of the time (see, for instance. The Straits Times, 23 August 2006). Talk of incremental modifications to the 3Ms have therefore come thick and fast, including a proposed extension of MediShield coverage to include some congenital disabilities in exchange for higher premiums {Channel NewsAsia, 27 October 2006), and extending Medisave to cover GPs' bills in relation to some chronic illnesses, including diabetes, high blood pressure and stroke {The Straits Times, 29 August 2006), with the possibility of including the treatment of asthma and mental illness {Channel News Asia, 3 November 2006). Creeping Ordinariness Of more significance for those who particularly admire the medical savings element of the Singapore schemes, Khaw has also been quietly but systematically moving the Singapore health funding model away from its intense focus on medical savings and giving medical insurance a more central role. He has foreshadowed higher premiums, broader coverage, lower dductibles and higher caps {The Straits Times Interactive, 12 August 2004; The Straits Times, 17 June, 19 October 2006). Specifically, Khaw has so far announced that the government plans to reduce the standard MediShield deductible of $S3000 by about $S500, and to halve the "gap" left by MediShield coverage of large hospital bills from 40% to 20% {Channel NewsAsia, 21, 22 January 2007). Such moves are radical in Singapore and are being rushed out to meet pressing political needs, but they are not exactly new or impromptu. They were broadly foreshadowed by Khaw's predecessor. Lim Hng Kiang, as far back as 2001 {Channel NewsAsia, 23 September 2001), showing that they are emerging systematically from the Ministry of Health's guided evolution of the health system. Yet, Khaw has gone further than anyone could have expected and has stated openly that he is looking at alternative health models, presumably from the West {Channel News Asia, 17 March 2004). From the point of view of this consideration of the Singapore health system as a case study of the application of technocratic approaches to governance, its significance lies in the fact that if it does prove to be the case that these

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developments mark the beginning of a new pattern of insurance-based health-care funding, then the Singapore system will increasingly resemble a particularly parsimonious version of Western health-care systems. It will most definitely not have the mystique of a cutting-edge pioneering venture developed by brilliant technocratic minds because brilliant technocratic governments do not normally take two decades of radical experimentation just to arrive at the point very near where they started. Efficient to the Core Yet, at this stage, the actual changes being implemented and planned (as opposed to merely mooted) are intended to introduce only incremental changes that will leave the system intact, with the mantra of "organisational efficiency" as the central objective and methodology. Consider the following report, taken directly from a Channel NewsAsia report from 3 November 2006: Health Minister Khaw Boon Wan says his key priority is to fine-tune and strengthen the 3M framework of Medisave, MediShield and MediFund - to make sure quality healthcare is available and affordable to all. One way to improve healthcare delivery is greater integration across primary, acute and step-down care between private, public and people sectors. . . . To keep them out of hospitals, family doctors will play a bigger role. They will help manage common illnesses like diabetes, high blood pressure and stroke, so patients will not have to go to hospitals for expensive specialist outpatient treatment. The quest for efficiency and cost-effectiveness is commendable, and there can be no doubt that some of the Singaporean initiatives are very imaginative, but it is of concern when the health system seems to be devoted to efficiency rather than patient care. This dichotomy also raises questions about the government's motivation in its current campaign to promote Advanced Medical Directives ("living wills") onto a population that is clearly unwilling to embrace them (Channel NewsAsia, 29 October, 6 November 2006). Conclusion Where does this leave the supposed miracle of the Singapore health system? Tt is touted by the Singapore government as world's best practice, and regarded by some as a model for advanced capitalist democracies, but one is left wondering if the key to the system is merely the government's monopoly of information and its authoritarian control of political discourses. It seems to be highly likely that if one could examine the Singapore health system from the inside, one would find a fairly ordinary health system with some strong points and many weaknesses - much like health systems all over the developed world. It is probable that there are aspects of the system worthy of emulation, but the image of a near-perfect system driven by a technocratic imperative for efficiency is likely to be revealed as little more than the result of government spin and tight control of information and, in so far as the

414 M. D. Barr quest for efficiency is a driving force, it seems likely to be as much a negative as a positive. The limitations of the Singapore health system raise the question of whether a technocratic approach to governance can ever deliver the promised results. The showcase product of Singapore's technocratic system of governance has been examined and a health system beset by contradictions and shortcomings uncovered, and one which is creeping closer and closer to becoming a "typical" health system. But should one be surprised? The image of the coldly rational and objective technocrat was a chimera in any case. The health-care experiment that started in 1984 was indeed bold and innovative, but from the start it was the product of prejudices and a priori judgements that find their origins in, among other biases, socio-economic class and gender, which then had to contend with the vital component of public opinion. The truly interesting conclusion that can be drawn from this study is not the positive role of technocracy (which is marginal at best), but the pivotal role of democracy in providing some level of protection from the ruthlessness of aloof political leaders and anonymous bureaucrats. Even the tokenistic version of democracy served up in Singapore has been sufficient to ameliorate the worst excesses of Singapore's drive for "organisational efficiency" and to insist that politicians become a little less aloof. Perhaps if Singapore had a little more democracy and a little less "efficiency," it might have an even better health system than it has now.
Acknowledgement
The author wants to thank the journal's two anonymous reviewers for their critical and invaluable input.

Notes
' There is no shortage of evidence to support the contention that the Singapore government projects itself as being "hard" but worthy of support because it follows correct prescriptions. For a small sample of contemporary evidence see Today, 2 and 5 May 2007, which report speeches delivered by two different government ministers over a period of three days. Headlines of these stories are respectively, "What's right, not what's popular; Buoyant economy, record job creation the result of hard work, sound policies: PM", and "Why S'pore went the hard way." ^ The pre-eminent profession in a particular technocracy and in theories of technocracy varies considerably (see, in particular. Winner (1977: 144-65)). ' This account of Singapore as a "technocracy" is drawn from Barr (2006). * This overview of the Singapore health funding system is based on Barr (2001, 2005). More detailed information can be found in these works. ' In 1996, industrialised countries' per capita health-care expenditure on the aged was up to five times that of the expenditure on under-65s (in Japan) and rarely less than twice the figure. The Netherlands, the USA, Australia, Switzerland, Finland, the UK and New Zealand all spent approximately four times more on the aged than they did on the younger section of the population (Prescott, 1998: 13). ' Eugene Wijeysingha was a former Deputy Director of Education who was posted as principal of Raffles Institution in 1986 to turn the school "Independent" {The Slraits Times, 9 October 1986). ' Interview with Eugene Wijeysingha, Singapore, 11 April 2003. * The government had been gradually reducing the number of C Class beds in hospitals since the introduction of Medisave in 1984, but pressure from government backbenchers forced the Ministry of Health to back down at the end of the 1980s (Toh and Low, 1991).

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The author has a copy of an official notice issued by the NUS Office of Student Affairs, dated I April 2003, which recommended that people with SARS-like symptoms "go immediately to the Accident and Emergency Dept of TTSH [Tan Tock Seng Hospital] by taxi or public transport." Khaw Boon Wan said: "Last week, my Ministry published a paper comparing the utilization of medical services in Singapore with several developed countries. Singapore has done well. We have lower hospital admissions per capita. Our patients generally do not overstay" (Ministry of Health, 2004).

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