Dengue death: Statistical odds stacked against you?

This is a joint article written by Mr Leong Sze Hian and Roy from The Heart Truths. The article was first published on The Online Citizen. It was also carried by the United Nations – International Organisations Desk on 5 June 2013.

I refer to the article “Dengue death: Mother says son waited 5 hours but TTSH says 2” (TREmeritus, Jun 1).

Waited 5 or 2 hours at A & E?

It had stated that “According to media reports, the young person who died from dengue, Mr Ang Yong Han, 20, had waited for 5 hours at TanTockSengHospital’s emergency department. This was what the mother told the media.

Yong Han, the only child in the family, fell ill on Wed (22 May) with a high fever. He then went to TTSH’s emergency department the next day (23 May, Thu) and was diagnosed with viral fever. He was given Panadol and sent home. He was told to see a doctor in three days’ time, or to return if his condition worsened.

However his condition did not improve and went back again in the wee hours of Fri (24 May). The mother, Mdm Yap, told the media that after waiting for five hours, he left to go to a general practitioner near his home.

But TTSH said he arrived at 3am and was seen by a nurse within five minutes but didn’t get to see a doctor after waiting for more than two hours. The hospital said he approached a nurse at 5.18am to cancel his registration, and left.

Around Sat midnight (25 May) and in the early hours of Sun (26 May), Yong Han came back to TTSH with fever, body aches and vomiting and was finally admitted to TTSH. He was later transferred to the Communicable Diseases Centre (CDC).

He died three days later (29 May, Wed) of dengue shock syndrome.

When the family asked whether Yong Han could have been saved if he had been admitted to hospital earlier, Prof Lim said his condition deteriorated on Mon, and it would not have made any difference if he had been admitted to the hospital a day or two earlier.”

Delays at healthcare institutions?

When I read the 61 comments on this article (as of 8.25 pm, 1 Jun), I was struck by the fact that there were several comments from readers citing experiences of delays and long waiting periods at public healthcare institutions.

Let the numbers do the talking?

So, the first thought that came to my mind was – what do the statistics tell us about this issue?

Hence, I began my statistical journey to try to find out more – at the onset, I had an edgy feeling that maybe the odds were statistically stacked against the late Ang Yong Han.

Hospital beds decreased 4.5%?

In Chart 1, you can see that the total number of hospital beds in Singapore had decreased by 4.5% from 11,936 in 2001 to 11,394 in 2011.

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Chart 1:Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

You can see the proportionate change in Change 2, where the number of hospital beds never increased by more than 1%, but even dropped by more than 2% in 2006!

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Chart 2:Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Hospital admissions increased 22.2%?

But do you know that even though the number of hospital beds have been decreasing, the number of hospital admissions have actually been increasing!

In Chart 3, you can see that the number of hospital admissions have increased by 85,391 or 22.2%, from 384,054 in 2001 to 469,445 in 2011.

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Chart 3:Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Chart 4 shows you the proportionate change. On average, the hospital admissions increased by more than 2%. This is even when the number of hospital beds never increased by more than 1% in any year!

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Chart 4:Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

In Chart 5, this becomes a lot clearer. You can see the increase in the number of hospital admissions in the blue line. You can also see how the number of beds are simply increasing not as fast to meet the increasing load of patients (red line)!

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Chart 5:Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Population increased 25.3%?

Well there’s more. In Chart 6, you can see that the population grew by 1,045,700 or 25.3% from 4,138,000 in 2001 to 5,183,700 in 2011.

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Chart 6:Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Chart 7 shows you the proportionate change.

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Chart 7:Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

A & E increased 65.3%?

If you think that the total hospital beds’ statistics are bad enough above, the public sector attendances at Accident & Emergency (A & E) (where Yong Han’s parents feel may have saved his life) was even worse – it increased by 369,097 or 65.3% from 565,375 in 2001 to 934,472 in 2011, as can be seen in Chart 8.

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Chart 8:Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Chart 9 shows the proportionate change. In 2004 and 2007, there were even double digits growth!

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Chart 9:Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Most importantly, in Chart 10, you can see that the increase in the number of attendances to A & E (red line) is rising by so much faster than the population growth (blue line)!

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Chart 10: Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Yet, as can be seen in Chart 11, the hospital beds (red line) has been decreasing and simply cannot match up to the increase in the number of attendances to A & E (blue line)!

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Chart 11: Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Is it thus any wonder why waiting times at the hospitals can even go up to 5 hours on some days (Chart 12)? If you look at the website where the information can be found, the Ministry of Health had released the waiting times for only over a period of a few days? Why aren’t we given data on the waiting time across a broader time frame? So, was Yong Han’s mother stating the facts when she had told the media that they had to wait 5 hours?

Median Wait Time for Admission at ED

Chart 12: Ministry of Health Waiting Time for Admission to Ward

Most recently, in December last year, it had also been reported by The Straits Times that, “Patients at the A&E wards of six tertiary hospitals waited from an hour to five hours before being admitted to an inpatient ward, according to figures for the second week of this month published on the Ministry of Health (MOH) website. On Sunday and Monday, patients at Changi General Hospital (CGH) waited as long as seven hours. Bed occupancy rates averaged between 70 per cent and 95 per cent in the same period at these hospitals. The Health Ministry said the average daily median waiting time for admission to wards across public hospitals has remained largely stable between 2010 and last year.

It was also reported that the National Resuscitation Council chairman, Professor V. Anantharaman, had said that, “The bigger issue, he added, is the shortage of resources such as beds and doctors.”

Enough public dental clinics for Singaporeans?

There’s even more! If you look at Chart 13, the number of dental clinics in the public sector has remained stagnant over the past few years.

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Chart 13: Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Chart 14 shows you the proportionate change. There hasn’t been much growth in the last few years.

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Chart 14: Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Now, if you look at Chart 15, you can see that the number of dental clinics (red line) simply hasn’t been catching up with the population growth (blue line). Do we have enough public dental clinics for Singaporeans?

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Chart 15: Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

0% increase in polyclinics?

In Chart 16, you can see that during the period from 2005 to 2011, the number of polyclinics remained unchanged at 18, and had only increased by 2 from 2001.

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Chart 16: Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Chart 17 shows you the proportionate change. You can see that there has been zero growth since 2006.

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Chart 17: Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Polyclinics’ attendance increase by 19.4%

But even thought the number of polyclinics hasn’t increased, what is shocking is that the number of polyclinics outpatient attendances has actually been increasing, by nearly 1.5 million people or almost 50% from 3,023,794 in 2006 to 4,502,043 in 2011, as can be seen in Chart 18!

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Chart 18: Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Chart 19 shows the proportionate change. But take a look at the Chart 20.

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Chart 19: Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

In Chart 20, you can see that the number of polyclinic outpatient attendances (blue line) has definitely been increasing much faster than the number of polyclinics, which hasn’t change at all! Where do we expect the increasing number of people to go if there are not enough facilities for them?

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Chart 20: Yearbook of Statistics Singapore 2007, Yearbook of Statistics Singapore 2012

Medical tourism increased? 

Moreover, we were actively promoting medical tourism to foreigners (even public hospitals were promoting) to the tune of, as I understand it, about 850,000 medical tourists in a year.

“Fighting” for medical treatment?ighting” for medical treatment?

So, we do not just have foreigners and PRs literally fighting for stretched healthcare facilities and capacity in Singapore, but we may also be competing against foreign medical tourists who can pay higher non-subsidised fees (and arguably sometimes may be able to jump the queue – to the detriment of Singaporeans seeking subsidised medical treatment).

But what is really odd is this – if you look at Chart 21 and 22 for the respective angioplasty and spinal fusion surgery prices, do you know that Singapore’s surgery prices are actually comparatively quite cheap, even when compared to the developing countries! This means that Singapore is a very good medical tourist destination, doesn’t it?

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Chart 21: OECD Medical Tourism: Treatments, Markets and Health System Implications: A scoping review

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Chart 22: OECD Medical Tourism: Treatments, Markets and Health System Implications: A scoping review

But the question is – how much are Singaporeans really paying for our healthcare?

In Chart 23, you can see that Singapore actually has the second lowest per capita expenditure on health, as compared to the other developed countries.

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Chart 23: World Health Organisation World Health Expenditure Database

But the question is how much do Singaporeans actually pay? First, let’s look at how much the government is really paying. Chart 24 shows you the proportion of government expenditure, as a proportion of our healthcare expenditure. Our government actually spends the lowest proportion of our healthcare expenditure among all developed countries – now, take note that we are also the among the richest by per capita GDP.

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Chart 24: World Health Organisation World Health Expenditure Database

Worrying, you can see that the proportion of government expenditure has actually been dropping since the 1990s (Chart 25) – which means that it has been dropping lower and lower!

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Chart 25: World Health Organisation World Health Expenditure Database

So, what does this mean for Singaporeans – this mean that for our healthcare expenditures, we pay the highest proportion out of our pockets, as in Chart 26.

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Chart 26: World Health Organisation World Health Expenditure Database

Now, if you remember, Singapore has the second lowest per capita expenditure on health. But do you know that because the government spends the lowest proportion, this means that even though our per capita expenditure is the lowest, Singaporeans actually pay the highest amount out of our own pockets (Chart 27)!

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Chart 27: World Health Organisation World Health Expenditure Database

What’s more – what we have been spending out of our pockets has been increasing unabatedly and what we are paying has multiplied by 4 times since the mid-1990s (Chart 28)!

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Chart 28: World Health Organisation World Health Expenditure Database

But do you know how much the government is paying? In Chart 29, you can see what we are paying out of pocket in the blue line. Compare this to the red line and you can see that what the government is spending has been increasing by a much slower rate and had only increased by two times, but we have been made to increase our spending by 4 times!

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Chart 29: World Health Organisation World Health Expenditure Database

But are we being paid decent enough salaries to cover for the costs? In Chart 30, you can see how fast healthcare costs are rising in the blue line. Compare this to our wages in the red line – our wages are growing much, much slower!

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Chart 30: World Health Organisation World Health Expenditure Database, Ministry of Manpower Income

Do you remember when Khaw Boon Wan had told us that healthcare is very affordable?

Well, of course healthcare is cheap for him! Look at Chart 31 – do you know that on average, our median wages have only been increasing by 2.9% (blue line), but the ministers’ salaries are increasing by almost 2 times as fast, at 5.6%?

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Chart 31: Ministry of Manpower Income, White Paper for Salaries for a Capable and Committed Government

Of course it healthcare would be very affordable for ministers who are handsomely paid!

Statistical odds?

So, my dear readers – I’m no health expert – I’m just a layman – do you think the statistical odds may have been stacked against Yong Han?

Damn low healthcare spending?

Like people say – after all the arguments, at the end of the day – perhaps the best indicator is to follow the money – our public healthcare spending in the previous fiscal year as a percentage of GDP, at about only 1.6%, was probably the lowest (if not among the lowest) in the world.

And our share of private healthcare spending at about two-thirds against public healthcare spending share of about one-third, may also be one of the highest in the world’s developing and developed nations.

Leong Sze Hian and  Roy Ngemg of The Heart Truths

3 comments

  1. The Pariah

    Stats on hospital admission and A&E cases may be “massaged”. A friend recounted that she had two A&E consultations – both times, she was sent home with instructions to “monitor” and to return to A&E if symptons persist or condition deteriorate. It was only on the 3rd A&E visit that she was finally admitted when the pain became excruciating and she had terrible reaction to prescribed medication before her medical condition was properly diagnosed as “shingles”. Good thing that her husband postponed his business trip – otherwise, there wouldn’t be anyone to help her get to A&E again.

    Many ways to “manage” when there is shortage of hospital beds and when hospital corridors are also packed with trolley beds.

  2. Eric

    Looks like you put the blame on TTSh. Why? TTSh is not a private hospital. Even st private hospital”s A&E you still need to wait.

    Are your expectations set too high? You need immediate attention? Is that possible? Everyone who goes to any A&E will say their condition is dire, everyone will demand immediate attention, is that possible?

    Waiting time at A&E is reasonable, no govt hospital in the world will be able to provide you with immediate A&E service .

    Your argument on medical tourism is flawed. Is TtSh, SGH, AH, poly clinics chasing medical dollars from Indonesia or elsewhere? Glen eagles, Raffles hospital, mount E etc are chasing after it. Not govt healthcare. It’s unfair you paint a picture that distorts. You paint a picture that says we are not only fighting with foreigners for jobs but also fighting with them on healthcare! Is that responsible?

    How much you pay in tax? Do the govt make you pay compulsory medical insurance that cost few hundred a month? You chose to conclude the govt is ” stingy” . Have you step out in the world? Should you pay for your neighbors medical bill? Do you think Canada”s ” generous” medical benefits fall from the sky? Hello wake up! It’s paid by the citizens thru sky high taxes!

    • My Right to Love

      Hi Eric,

      Just to clarify on one point – I didn’t put the blame on TTSH. Clearly, the issue is broader than something that the hospitals can handle on their own. It requires additional funding from the government.

      On the question of taxes, the verdict is still out. According to the book, Empowering Public Wisdom, if people are given the time and information to debate and come to a conclusion on, most people would be willing to increase taxes, even if slightly, to cater for the poor and elderly in their country – and this has been shown to be consistent around the world.

      The question isn’t a matter of whether taxes should be raised or not. This is a foregone conclusion. The question is whether the government has the will. Once the question on taxes is raised, we will need to discuss wages – the answer would be the same. Singapore has the lowest wages in the developed world.

      Thanks.

      Roy

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