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A new approach to solving doctor shortage

Country: 
Singapore
Partner Institute: 
Department of Epidemiology and Public Health, National University of Singapore
Survey no: 
(15) 2010
Author(s): 
Lim Meng Kin
Health Policy Issues: 
HR Training/Capacities
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no no no no no no

Abstract

Despite stretching the production capacities of the two existing medical schools and actively recruiting foreign-trained doctors, the doctor shortage in Singapore continues unabated. An interesting and novel idea being explored by Singapore?s public sector hospitals is offering a ?pre-employment grant? to students studying medicine in overseas universities, helping them with their expenses overseas while obligating them to return to serve in Singapore hospitals after they graduate.

Purpose of health policy or idea

To alleviate the doctor shortage situation in Singapore.

Main points

Main objectives

The idea of offering a "pre-employment grant" to students studying medicine in overseas universities is to help them with their expenses overseas in return for an undertaking to serve in Singapore hospitals upon graduation. 

No details have been firmed up yet but it is understood that the MoH and the public sector  hospitals are currently in discussions, and that the ideas being tossed around include:

  1. Targeting Singaporeans already enrolled in top medical schools, and in their senior  years of study, e.g. the last two years of study.
  2. Basing selection on merit, i.e. good grades, especially in the clinical training years.
  3. Covering a significant part, say 60%, of the tuition fees for the remaining years of study, subject to a cap (the figure of S$50,000 per year has been suggested).

In return, the students will commit to serving the public sector hospitals for a minimum period. Currently, for the privilege of studying Medicine at the National University of Singapore, medical graduates serve a mandatory 5-year service bond with the government, in addition to the (also mandatory) 1-year housemanship required for licencing. For the pre-employment grant, a shorter bond period of say 4 years, which may include the 1-year housemanship, is being contemplated.

Groups affected

Medical students who could not get a place in the local medical schools, Parents of these medical students

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Characteristics of this policy

Degree of Innovation traditional innovative innovative
Degree of Controversy consensual neutral highly controversial
Structural or Systemic Impact marginal neutral fundamental
Public Visibility very low high very high
Transferability strongly system-dependent rather system-neutral system-neutral

Political and economic background

For more than a hundred years, Singapore has been making do with only one medical school. The Yong Loo Lin School of Medicine at the National of University of Singapore (NUS). is now running at maximum capacity, churning out close to 300 doctors a year.  In 2007, a second medical school - the Duke-NUS Graduate Medical School - opened its doors and will soon produce another 50 doctors a year. Now, plans are afoot for a third medical school to be established. More places are needed in order to meet the projected demands of Singapore's health care system. Competition for places in Medicine is intense, and the keenest among all fields of undergraduate study available locally.  About 150 rejected, but nevertheless very determined, Singaporeans head overseas each year to study medicine, at great personal or family expense.

In recent years, there has been a sharp rise in the number of foreign-trained doctors working in Singapore - thanks to the frequent overseas recruitment exercises that the Ministry of Health conducts regularly, including in places as far away as Britain, India and Taiwan. In 2009, the Ministry of Health (MOH) announced that it would be recruiting as many as 1,000 foreign-trained doctors into the public healthcare sector to ease Singapore's doctor shortage. Out of the 8323 doctors currently registered in Singapore, 24 percent are foreigners.

In order to alllow more doctors to be able to practise in Singapore, the MOH had earlier, in 2007, unlocked the floodgates by expanding its list of recognised foreign medical schools from 24 to 159, to include many top medical schools in Asia. This contrasts with the previous situation not too long ago, when the government actually considered oversupply to be the problem. Believing then that having too many doctors would resutt in supply-induced demand, the government in 1993 passed a law (the Medical Registration Act (cap 174) 1993) to drastically reduce the number of degrees recognised by the Singapore Medical Council from 176 to 24. So between 1993 and 2003, only graduates from this restricted list of recognised foreign medical schools could work in Singapore as doctors, unless they were already recognised specialists. But now, Singapore, like most developed countries, is facing an acute shortage of doctors, especially in the public sector.

The reasons for the acute doctor shortage are beyond the scope this short report, but the present predicament is largely a combination of the myopic manpower planning and policies of the past and the new realities of thee present such as an increased population (mainly through immigration), rising aspirations of an increasingly affluent population, expansion of health services to meet the health needs of a rapidly ageing population,   positioning of Singapore as the region's leading medical hub (Singapore now sees half a million foreign patients a year), and massive government-led investments in the biomedical sector, necessitating the generation of clinician-scientists in fairly large numbers and in double-quick time.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no no no no no no

Origins of health policy idea

The idea of a "pre-employment grant" to students studying medicine in overseas universities comes six months after Singapore's Prime Minister signalled in a speech that Singapore would continue to look at ways to expand the pool of local doctors, even after raising the annual intake at medical schools here to 350 new doctors a year. He said that this number (a doctor-patient ratio of one is to five; or 8 doctors to 10 beds) was still not enough to cope with the growing and ageing population.

In announcing the proposal in Parliament, the Minister of Health disclosed that although about 150 Singaporeans head overseas each year to study medicine, between 2005 and 2009, only 110 (or about 22 a year) returned after graduation while another 130 (or about 26 a year) returned after completing their housemanship or after working a few years. He vowed to "find a way to 'get our kids back'.

Initiators of idea/main actors

  • Government
  • Providers
  • Others

Approach of idea

The approach of the idea is described as:
new:

Stakeholder positions

The Singapore Medical Association has welcome the idea,noting that five years of medical school in the UK could cost at least S$500,000.  It will help plug the gap to meet demand for doctors in the years ahead.

Most students are supportive and welcome the idea.

Most parents are also supportive.

Actors and positions

Description of actors and their positions
Government
Governmentvery supportivevery supportive strongly opposed
Providers
Doctorsvery supportiveneutral strongly opposed
Others
Partentsvery supportivevery supportive strongly opposed
Studentsvery supportivevery supportive strongly opposed

Actors and influence

Description of actors and their influence

Government
Governmentvery strongvery strong none
Providers
Doctorsvery strongweak none
Others
Partentsvery strongweak none
Studentsvery strongweak none
Partents, StudentsGovernmentDoctors

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Expected outcome

Because of the high cost of training doctors, it could be argued that it makes economic sense for one country to have some other country train its doctors - thus benefitting from  someone else's heavy investments.

From the medical student's (and parent's) point of view, of course, overseas medical studies is a highly expensive undertaking. The obligatory 'bond' can be seenin positive light as it also means an assured job after graduation. Moreover, internship places overseas, especially in sought-after locations, may not be easy to come by expecially if there is a policy of giving priority to that country's citizens.

However, there are some disadvantages, like a possible compromise in the quality of care, which may be related to the different standards and methods of medical undergraduate training. There are, moreover, language problems, and indeed there is already anecdotal evidence suggesting that while doctors from historicallly and culturally closer countries like Malaysia typically encounter little or no difficulty in communicating with local patients, others from more distant places may have to rely on interpretation when seeing non-English speaking patients - a not uncommon situation among elderly patients in Singapore.

The Health Minister told Parliament recently that "with more and more foreign-trained doctors working in Singapore, there is a need to monitor their performance and ensure they are up to Singapore's standards and are adapting well locally."

In the meantime, the Ministry of Health has announced it is setting aside $120 million to enhance its specialist training programmes over the next five years, to enhance retention of doctors in the public sector.

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low high very high

References

Sources of Information

  • A Wong. "A grant to lure them home?" Weekend Today 10 March 2010
  •  Pre-Employment Grant in Lieu of Bond for Med Students
  • Channel NewsAsia. MOH mulling grants for S'porean medical students studying overseas. 9 Mar 2010. www.channelnewsasia.com/stories/singaporelocalnews/view/1042464/1/.html
  • Khaw BW. More Doctors, Greater Satisfaction. Apr 15, 2010. http://mohsingapore.blogspot.com/2010/04/more-doctors-greater-satisfaction.html

Author/s and/or contributors to this survey

Lim Meng Kin

National University of Singapore

Suggested citation for this online article

Lim Meng Kin. "A new approach to solving doctor shortage". Health Policy Monitor, April 2010. Available at http://www.hpm.org/survey/sg/a15/3