Rural nursing in Singapore?
Article Type: Editorial
Subject: Nursing services (Analysis)
Rural health services (Comparative analysis)
Author: Hegney, Desley
Pub Date: 09/22/2010
Publication: Name: Online Journal of Rural Nursing & Health Care Publisher: Rural Nurse Organization Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2010 Rural Nurse Organization ISSN: 1539-3399
Issue: Date: Fall, 2010 Source Volume: 10 Source Issue: 2
Geographic: Geographic Scope: Australia; Singapore Geographic Code: 8AUST Australia; 9SING Singapore
Accession Number: 245393197
Full Text: I have now been living in Singapore for approximately 19 months. Singapore, for those who do not know about this Republic city-state, has a population of about 5 million people. About 75% of these people are Singapore Citizens or Permanent Residents--the rest are foreigners (like myself). Singapore is a multi-cultural and multi-religious country. The main ethnic groups are Chinese (about 75%) followed by Malayas and Indians. Chinese, English, Malay and Tamil are the four official languages of the nation. English is the 'official' language and schools, universities and government and all teaching etc is conducted in English. We have many holidays due to the multi-religious aspect of the country so it is most enlightening for a Westerner such as myself to learn about "Hungry Ghost" festivals and other such interesting beliefs.

Singapore is 85 miles north of the Equator, and although they talk about 'fall', 'spring' and 'winter' the temperature is constant, hot and humid. It rains most days--lovely noisy storms which cool down the temperature for a short while. Most newcomers (and even older residents) have a slight sheen to them (hot and sweaty)! Singapore is one of the most prosperous economies in the world. It is a capitalist mixed economy with minimal government intervention. I call it the 'city of cranes' as the amount of construction is amazing and the speed is also unbelievable. Sitting in my office here at the university looking out my window I can see 43 cranes! And this is only a very small part of the island.

Singapore consists of one large island and about 59 small islands, with most of the population on the main island. The main island is about 247 square miles, so it does not take long to drive from one end to the other (except in peak hour or if there is a "jam"). It is separated from Malaysia in the north and Indonesia in the south. There are two 'crossing' land bridges to Malaysia. One has to get to Indonesia by ferry. So everytime one gets on a plane it is an international flight! And many Singaporean people drive or get buses into Malaysia to do their shopping as the Singapore dollar is worth about 2.5 times that of the Malaysian dollar. However, the crossings can take quite some time, and so one has to learn to be patient!

Nothing is free in Singapore. There is no welfare and so people are expected to work (the unemployment rate is 2.2%) and save for their future. There is a compulsory savings scheme for health care and other needs which Singaporeans contribute to while working. Thus for any health care access there is a co-payment of some sort which can vary depending upon the health insurance cover one has.

There is both a public and private medical and hospital system in Singapore. However, one still pays in the public system (unlike Australia which is free). About 20% of Singaporeans visit the government primary care clinics (polyclinics) and about 80% go to one of the many (and very large) public hospitals. There is no community or district nursing as such. There is a beginning APN service, mostly in the government hospitals and polyclinics. There are community hospitals (or step-down) and long-term care facilities, although the latter are a place of last resort as the culture is one of filial piety where the eldest son or other member of the family are expected to care for (physically and financially) the parents.

When I think of rural nursing and its primary health care focus and the more autonomous role of the nurse, there is some transferability within this highly urbanized environment. There are also gaps. Singapore has a very poorly organized community or domicillary nursing service. It used to have a visiting community nursing service in the past (I have seen pictures of nurses wearing white uniforms and veils getting into sampans to go across a river or to an island). However, home visiting was stopped and people are now required to attend either the clinic or the hospital. This, as one can image, can be difficult even on a small island. While there is excellent public transport in Singapore (and it is cheap), if one is disabled or sick, it is difficult to use this for frequent access. Additionally, the taxi service can be quite expensive if one is taking it every day. At this stage there are no programmes such as 'hospital in the home' for patients who are discharged early. There are some for profit and not-for-profit organizations that provide home care, but these are means tested and are limited in their availability.

In the polyclinics, however, there is an excellent self-management model of chronic disease management which is nurse-led. Most of the government polyclinics have been using this model for some time, where an experienced registered nurse works as a case manager for a person with chronic disease/s. Once the patient is diagnosed and stablised, they are referred to the nurse who works as a case manager to provide the education and lifestyle management needed. There is a co-payment for this service. Very different from Australia, is the fact that prescribed medications are given out at the polyclinic. Pharmacies (or drug stores) do not dispense any drugs other than 'over-the-counter' or Schedule 3 drugs. All prescription drugs are provided at the same time as the visit to the doctor. This has good aspects (you don't have to find a pharmacy to dispense the drug somewhere else) and bad points (you can only get a couple of months at a time, which means you have to go back more frequently, and then you have to store them in a fridge). It is cheaper than Australia where we would pay through our subsidized pharmacy system about $35 per medication and an out of pocket payment of about $30 for the GP (much more for a specialist or for radiography). Here in Singapore the doctor visit and medication cost me $5. It does not prevent a person "doctor shopping" though as there is no standard electronic health record in Singapore.

Very different to rural areas, there are many very large hospitals here in Singapore. Not only are they large, but they are expanding their bed numbers! For example, Singapore General Hospital (a tertiary teaching hospital and the first and only Magnet Hospital in Asia) has more than 30 specialty services and the 7,000 strong workforce annually sees over 1 million patients. This is but one of the public hospitals in Singapore. In addition to this large public hospital there are many large private hospitals such as Raffles and Glen Eagles. Nurses in these hospitals work similarly to nurses in acute care facilities other highly developed countries.

So what is the future for Singapore? There is growing interest in ways to deliver home care and home monitoring in a cost-effective way. For example, there is interest in TeleHealth. One only has to be caught in a "jam" for two hours to see how this technology would be effective even in a highly urbanized environment. In fact anything high tech would be seen to be great, as Singaporeans are among the first to embrace any new technology. There is also recognition of the need to grow community outreach services, and , in a society which is rapidly ageing and in one where traditional cultural norms are being eroded, there is a need for a new approach to aged and end of life care.

In many ways one sees that living in such an urban environment is an advantage (no long distances to travel to obtain tertiary level care). On the downside, however, from an Australian perspective, the cost of services can be crippling and I would rather pay higher taxes as I do in Australia and know that I can access health care without having to sell my assets, than be in the situation in Singapore (which is probably not unfamiliar to people living in the USA).

The status of nursing in Singapore is also very low. Nurses are not paid well. Very different to Australia, most nurses in Singapore work full-time (there is very little opportunity for part-time work). Most are educated in one of the two Polytechnical Colleges and graduate with a diploma. Or the enrolled nurses attend the Institute of Technical Education. At NUS we only take about 90 students per annum into our Bachelor of Nursing programme. Many of our nurses travel to Indonesia and Malaysia to provide volunteer work and so see a very different type of life--especially in the rural villages.

As you can imagine, many of the nurses are multi-lingual and speak one or more Chinese dialects and Malay (or some Malay if they are Chinese). This is needed to cope with the patients, especially those who are older who do not speak English. The workforce is supplemented by nurses from mainland China, the Phillipines, Malaysia, India and Indonesia. These nurses make up some of the over 1 million foreign workers in Singapore.

My research that I am undertaking here is a primary prevention programme where we are screening a well population. I have two registered nurses who are working with me and undertaking the screening. We are supported by four cardiologists. So I have not moved away from the primary health care focus that I developed in rural Australia!!!

Desley Hegney, PhD, RN

Editorial Board Member
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