|Implemented in this survey?|
Medifund use was extended to cover HIV treatment from 1 February 2010 onwards. To support this extension, the Ministry of Health has injected an additional S$8.5 million into Medifund.
Medifund is a means-tested safety net within Singapore's comprehensive "3Ms" healthcare system, set up by the Singaporean government in 1993, to assist Singaporeans who are unable to afford "needed medical care". However, its coverage did not include HIV treatment. This will change from February 2010 onwards. Needy Singaporeans who qualify for assistance can now tap into Medifund in order to receive help for their HIV treatment payments.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
Since Singapore's first HIV patient was diagnosed in 1985, the cumulative number of HIV-infected residents of Singapore has increased manifold, from 2 in 1985 to 4159 in 2009. Still, the HIV epidemic in Singapore is considered to be "low level", according to the World Health Organization's comparative country classification - meaning the prevalence of HIV does not exceed 5% in any defined subpopulation.
The majority of HIV cases are managed at the state-run Communicable Disease Centre (CDC) where patients have access to both inpatient and outpatient subsidised care. But this subsidised care does not cover expensive anti-retroviral drugs, as the latter are not included in the Ministry of Health's Standard Drug List. Patients can only withdraw up to S$550 a month from their own Medisave accounts to pay for anti-retroviral drugs. For many patients, this is inadequate, given that a typical drug combination for HIV treatment ranges from S$500-S$600 per month (for two medications) to S$1200-S$1300 per month (for three medications). This does not even include laboratory fees for monitoring treatment and detecting side effects, or doctors' consultation fees.
A major reason for the high costs of HIV treatment in Singapore is that most of the commonly prescribed HIV drugs are protected by patent rights. Singapore, under constraint by WTO's TRIPS (Agreement on Trade-Related Aspects of Intellectual Property) rules, does not allow generic equivalents of patented drugs to be sold in the open market. However, the government does not prohibit patients to bring medicine from other countries to Singapore for their own use. Hence, many patients have resorted to purchasing these drugs from neighbouring countries like Thailand and Malaysia. By doing so, they can save up to 90% of their drug costs.
|Implemented in this survey?|
For many years, the government's stance has been that expensive HIV treatment should not be funded by taxpayers. In the initial years, HIV still was poorly understood. Drugs were expensive and associated with many side effects, and their efficacy and cost-effectiveness were not clearly demonstrable. Therefore, such a position received the tacit approval, if not open support, of the majority of taxpayers at that time, given the social stigma associated with HIV infections. Minority voices of voluntary welfare organisations, patient support groups and doctors involved in the treatment of HIV patients mostly were unheeded - even when they later were able to point to advances in drug treatment and the mounting scientific evidence (both worldwide and in Singapore) which showed that treating HIV in early stages was cost-effective and warranted.
In announcing the policy change, the Ministry of Health acknowledged that its decision was partly in response to feedback that it had received from voluntary welfare organisations and doctors treating HIV patients. Thus, one can reasonably assume that a tipping point had been reached where the government felt it was no longer able to defend its previous position of not extending help to those Singaporeans who needed HIV treatment, but could not afford it. After all, when Medifund was first introduced in 1993, the government had publicly pledged that no Singaporean would be denied "needed healthcare" due to inability to pay. One can therefore safely conclude that HIV treatment is finally deemed to be "needed healthcare" in Singapore.
The approach of the idea is described as:
Most doctors and patients alike welcomed the move.
In a statement, Action for AIDS's president said the move was "a long time coming". However, while acknowledging that Medifund will benefit individuals in the lowest income group the unemployed, he continued to express concern that middle-class Singaporeans infected with HIV may not be eligible.
|Ministry of Health||very supportive||strongly opposed|
|Hospitals||very supportive||strongly opposed|
|Doctors||very supportive||strongly opposed|
|Patients||very supportive||strongly opposed|
|Ministry of Health||very strong||none|
The Ministry of Health (MOH) has in fact reaffirmed its existing policy of not including expensive anti-retroviral drugs in the Ministry of Health's Standard Drug List. Hence those who do not qualify for means-tested help from Medifund will not benefit from the policy. They will have to continue resorting to other means for paying their HIV treatment.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
More than 370.000 people received help from Medifund in the fiscal year of 2008. As Singapore's population is ageing, the importance of Medifund in Singapore's healthcare system is likely to grow.
Lim Meng Kin
National University of Singapore