Contract of Service or Contract of Employment Research Paper

Agreement of Service or Contract of Employment - Research Paper Example In another ongoing case to be specific Express and Echo Publications Ltd v. Tanton (1999), the Court of Appeal held that if an individual isn't required to work by and by, he was not a representative. In one more instance of 2001, MacFarlane v Glasgow City Council (2001), the Employment Appeals Tribunal recognized the above Tanton case. The Glasgow City Council had connected with acrobat mentors at the different focuses of the board. In the event that a mentor couldn't take a class, she could substitute herself by another tumbler who was on the affirmed rundown of mentors kept up by the gathering. The substitutes were paid by the board and not the acrobat mentor. In Tanton case, the substitute could be from outside and he was paid by the individual and not the business. Therefore he was not expected to turn up for work and could send a substitute at a lesser cost and make a benefit out of it. He himself turned into the ace. In a previous instance of O’Kelly v Trusthouse Forte Plc (1983), ordinary casuals were held to be not representatives since there was no commonality of commitment and they were just kept as backup. Despite the fact that the court of Appeal attempted to give a finding that they were representatives, since they had no business of their own, that the business had successful power over the easygoing laborers, that there were control and complaint strategies, that they should take consent to take off from rostered obligations, the way that they were independently employed, uncovered that there was no commonality of commitment i.e the laborers didn't reserve the privilege to guarantee work if not offered nor they were under commitment to acknowledge work whenever offered with work.

Maltese Falcon :: essays research papers

The Maltese Falcon by Dashiell Hammett happens during the 1930s and has an assortment of strange charactersincluding: Sam Spade, Brigid O'Shaughhnessy, Joel Cairo, Mr. Gutman, and Wilmer. When O'Shaughnessy comes to Spade and requests that he shadow Thursby, the story takes off ona frenzy of occasions with apparently no importance until they are uncovered at long last. The contention that drives the story is the obscure area of the Maltese bird of prey, a brilliant hawk of huge worth. All the activities and even emotinos fo the characters are driven by the longing to get the hawk ormoney from acquiring the bird of prey. While a few characters are more moreal than others, every one of them have at any rate one issue which makes them deceitful: ravenousness, idiocy, or each of the three. The characters dispense with one another trhoguhout the story, either captured or slaughtered, until just Sapde is left sound. The book has three stages: distinct misconception, obscure misconception a nd appreciation. In the main period of the book, all the characters totally misjudge one another. As the book advances, the characters start to accept that they have a comprehension of one another, which muddles everybody's feelings. At long last, the characters grasp the past feelings of different characters and genuinely comprehend the occasions and the feelings of everybody. Afterward, Spade chooses to have a gathering ith O'Shbaughnessy and Cairo together. Befor ethe meeting, Spade sees a youngman shadowing him. HE incidentally overlooks it and goes to the gathering in his condo. At the gathering Cairo and O'Shaughnesy quickly talk about a bird of prey, however the doorbell interferes with them. Sam goes to the entryway welcomes two police analysts that are exploring the passings of Thursby and Archer. The officials request section when they hear a shout and a yell from inside,. At the point when they arrive at the room of the shout, they discover Cairo with a bleeding face, holding a firearm at O'Shaughnessy. While trying to mollify suspiciion, Spade says that it is an intentional joke. The police disregard Spade, yet they take Cairo to the station for addressing. In the end, the secretive youngster, Wilmer stands up to Spade and takes him to a condo. HE brings Spade into a room where Mr. Gutman is sitting. They botht ry to get data without giving data. Sam chooses to mastermind a gathering with Cairo, O'Shaughnessy, Gutman, and Wilmer. Prior to the gathering, the chief of the vessel, La Paloma, shows up at Spade's office, harmed however conveying what gives off an impression of being the Maltese bird of prey.

Change Management in Telecommunications Sector Omantel in Sultanate of Essay

Change Management in Telecommunications Sector Omantel in Sultanate of Oman - Essay Example This shows the nation is exceptionally proficient and privatizations of government possessed enterprises demonstrate an advancement of government financial and exchange arrangements. Be that as it may, not all associations stay aware of the social, financial and political changes in the nation, there are the individuals who stay customary and oppose change. Change is unavoidable if the association needs to seek after advancement and development. Change in the authoritative structure, the executives and utilization of innovation shows that the association is moving towards better proportions of adequacy and industry standing. â€Å"Change won't vanish nor disseminate. Innovation, human advancements and inventive considerations will keep up their ever-quickening jump onwards† (Paton and McCalman 2008, p. 5). Similarly as with any procedure and change, this is regularly met with cynicism and fear. Regardless of whether the change is for more prominent's benefit of the organizatio n, there will consistently be nervousness and pressure that is brought about by the procedure of progress. The investigation is discussions about the degree to which change the executives procedure are taken by the organization Omantel. It is the main Oman based Telecommunication Company and furthermore pioneer of complete answers for interchanges in the Sultanate of Oman. The Omantel is set up in 1987 and the objective client of the organization incorporates government, private and corporate. The organization gives total answer for all the correspondence related issues. Authoritative change is achieved by various variables; this could be from mergers and acquisitions, an administration dominate or the privatization of the association. The nervousness inciting perspective in any authoritative change isn't really the change of the association or the adjustment in the board yet the way that the representatives need to leave their old methods of getting things done; it is the learning of new assignments, new conventions and new working techniques that undermine workers to confront the hierarchical change. By definition, change implies disposing of the old and grasping the new, the new may not generally be acknowledged and increased in value by the representatives. â€Å"Two hidden convictions and their related suspicions about how change happens have formed a great part of the advancement of hierarchical change models. First is the conviction that hierarchical change can be arranged and overseen through a comprehension of its consecutive advances. The second conviction which has to a great extent advanced because of the reactions of arranged change has been the conviction that change is a natural procedure which can't be managed† (Turner et al. 2009, p. 27). Yet, some type of nervousness and anxiety are really normal response to any change, and it is invited by the operators of progress as a chance to cause the representatives to get mindful of what's goin g on in the association. It is when questions can be replied, when fears and questions can be mollified and when representatives are locked in as backers of the change procedure as they currently have the information and data that they can share to different workers who may have similar concerns. Change Management in association is about the activities essential for an association to perceive, arrange, execute and exploit impressive change. A definitive points of Change Management associations are: The effective arrangement, execution, estimation and protection of a change activity of the associations and improvement of their on-going capacity for overseeing change. Here the examination is discussions to assess change the board in Telecommunications division Omantel in Sultanate of Oman. â€Å"The Sultanate of Oman is among the Region’s most dynamic nations in the telecom segment as far as

Reaserch Paper on Othello the Moor of Venice, as a tragedy Research

Reaserch on Othello the Moor of Venice, as a disaster - Research Paper Example Aristotle’s idea of disaster depends on a whole of a couple of basic essentials that are a perplexing plot with a reasonable starting center and the end, natural solidarity, fitting length, the solidarities of time and spot, well-suited connection between the character and plot, goodness, consistency of portrayal, hamartia, peripity, anagnorisis or revelation, sentiments of pity and dread and catharsis.1 Based on the parameters as set up by Aristotle for a commendable catastrophe, William Shakespeare’s Othello, the Moor of Venice is a perfect Aristotelian disaster. Othello is a particular disaster of energy and to name it as an Aristotelian catastrophe is absolutely proper. Of all Shakespeare’s disasters, Othello is the most horrendously energizing and the most awful. As one experiences it, one encounters the boundaries of the sentiments of pity, dread, compassion, disturb, sickening expectation and loathsome desire. Framework I. Presentation A. Careless examinat ion of Othello B. Aristotle parameters for a disaster and a â€Å"tragic hero† II. Body A. Catastrophe and plot B. Traits of a â€Å"tragic hero† according to Aristotle B. Cleansing and disaster III. Decision A. Othello, the Moor of Venice fulfills all traits of a catastrophe articulated by Aristotle Essay Introduction Othello, the Moor of Venice, could and ought to basically be named a run of the mill Aristotelian disaster and Othello is the most commendable terrible saint of Shakespeare who fulfills practically all the qualifications of a sad legend as manifested by Aristotle. As one experiences the play Othello, one encounters the limits of the sentiments of pity, dread, compassion, appall, sickening expectation and a frightful expectation.2 Evil is uprooted before the peruser so that one basically watches its encouraging in an awed and intrigued way. A great deal of components add to the energizing and excruciating effect of this play as the contention in Othelloâ €™s mind, the resulting sexual desire, Desdemona’s mortification and murder, the going with interest thus much.3 Besides, the pretended by ‘accident’ in Othello produces not just a solid feeling of the working of destiny, yet makes the play progressively horrendous. In Othello, such a large number of things occur by opportunity to help Iago’s plot that one feels that his casualties are additionally the survivors of destiny. At that point there is the little entertainment in the pretense of Iago’s humor, which is the greater part of the occasions inauspicious instead of interesting. With regards to the catastrophe and a disastrous legend, Aristotle in his work Poetics clarified on some particular prerequisites concerning the nature and type of plot and the characteristics of a grievous saint. It will be truly intriguing to check Othello, the Moore of Venice, on the parameters set by Aristotle as to set up that it is a commendable catastrophe with a reasonable awful legend. Plot with regards to a catastrophe, Aristotle focuses on the supremacy of plot.4 He starts his positioning of the six pieces of the disaster with the declaration that â€Å"The generally significant of these parts is the game plan of episodes, for catastrophe isn't an impersonation of a man, as such, yet of human activity and life and bliss and misery.†5 Aristotle further strengthens the requirement for the correct plot by pronouncing the human life to be a procedure. Aristotle holds that the human life is continually changing and the progressions that a man encounters tend towards bliss or misery. In this manner a catastrophe is beyond the realm of imagination

Psychology and Life Quotes From Carl Rogers

Psychology and Life Quotes From Carl Rogers History and Biographies Print Psychology and Life Quotes From Carl Rogers Carl Rogers (1902 â€" 1987) By Kendra Cherry facebook twitter Kendra Cherry, MS, is an author, educational consultant, and speaker focused on helping students learn about psychology. Learn about our editorial policy Kendra Cherry Updated on May 06, 2019 Bettmann Archive / Getty Images More in Psychology History and Biographies Psychotherapy Basics Student Resources Theories Phobias Emotions Sleep and Dreaming Carl Rogers work and theories made him one of the preeminent psychologists of the 20th-century. He is best known for creating what is known as client-centered therapy, a nondirective approach that places the client in control of the therapeutic process. As one of the leaders of the humanist movement in psychology, Rogers believed that people were essentially good and healthy. This differed greatly from the psychoanalytic focus on abnormal behavior. Below are just a few Carl Rogers quotations. Selected Carl Rogers Quotes On Human Nature: When I look at the world Im pessimistic, but when I look at people I am optimistic. Rogers believed that people possessed an  inherent goodness and that all people are driven by the actualizing tendency. While Freuds psychoanalysis and Watsons behaviorism tended to take a much more negative view of human nature, often focusing on the abnormal or the problematic, Rogers approach was much more positive and centered on helping people becoming the best that they can be. On Learning, Growth, and Change: The only person who is educated is the one who has learned how to learn and change. If we value independence, if we are disturbed by the growing conformity of knowledge, of values, of attitudes, which our present system induces, then we may wish to set up conditions of learning which make for uniqueness, for self-direction, and for self-initiated learning. The very essence of the creative is its novelty, and hence we have no standard by which to judge it. â€"  From On Becoming a Person, 1961 Experience is, for me, the highest authority. The touchstone of validity is my own experience. No other persons ideas, and none of my own ideas, are as authoritative as my experience. It is to experience that I must return again and again, to discover a closer approximation to truth as it is in the process of becoming in me. Neither the Bible nor the prophets  â€" neither Freud nor research â€"  neither the revelations of God nor man  â€" can take precedence over my own direct experience. My experience is not authoritative because it is infallible. It is the basis of authority because it can always be checked in new primary ways. In this way its frequent error or fallibility is always open to correction. â€"From On Becoming a Person, 1961 Rogers believed that people were always in the process of changing and growing. The striving for self-actualization leads people to pursue happiness and fulfillment. The ability to adapt, learn, and change plays a vital role in his theory, as individuals work toward becoming what he referred to as fully-functioning people. On Psychotherapy: It is the client who knows what hurts, what directions to go, what problems are crucial, what experiences have been deeply buried. â€"From On Becoming a Person, 1961 Rogers is remembered for the development of his non-directive approach to therapy known as client-centered therapy. This technique gives the client control over the process and in which the therapist is non-judgmental, genuine, and empathetic. Unconditional positive regard for the client is essential for effective treatment. On the Good Life: A second characteristic of the process which for me is the good life, is that it involves an increasingly tendency to live fully in each moment. I believe it would be evident that for the person who was fully open to his new experience, completely without defensiveness, each moment would be new.  â€"From On Becoming a Person, 1961 In my early professionals years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth? I have gradually come to one negative conclusion about the good life. It seems to me that the good life is not any fixed state. It is not, in my estimation, a state of virtue, or contentment, or nirvana, or happiness. It is not a condition in which the individual is adjusted or fulfilled or actualized. To use psychological terms, it is not a state of drive-reduction, or tension-reduction, or homeostasis.The good life is a process, not a state of being.It is a direction not a destination.  â€"  From On Becoming a Person, 1961 This quote captures the essence of so much of Rogers humanistic theory. His approach turned from simply diagnosing and treating pathology into using therapy as a tool to help people grow. His approach also stressed how each person continually strives for actualization and self-fulfillment, but as Rogers so eloquently notes, this is not a state you can simply reach and then be done. Part of self-actualization is the actual process of reaching, striving, and growing. The good life, as Rogers calls it, is the journey not just the destination.

Public Private Partnership in Healthcare - Free Essay Example

Transforming Singapore Health Care—MK Lim 461 Commentary Transforming Singapore Health Care: Public-Private Partnership†  MK Lim,1FAMS, FRCP (Edin), MPH (Harvard) Abstract Prudent health care policies that encourage public-private participation in health care financing and provisioning have conferred on Singapore the advantage of flexible response as it faces the potentially conflicting challenges of becoming a regional medical hub attracting foreign patients and ensuring domestic access to affordable health care. Both the external and internal health care markets are two sides of the same coin, the competition to be decided on price and quality. For effective regulation, a tripartite model, involving not just the government and providers but empowered consumers, is needed. Government should distance itself from the provider role while providers should compete – and cooperate – to create higher-value health care systems than what others can offer. Health care policies should be better informed by health policy research. Ann Acad Med Singapore 2005;34:461-7 Key words: Health care costs, Health care regulation, Health economics, Health reform Introduction Should health care services be publicly or privately funded? And should these services be publicly or privately provided? The answers to these questions largely depend on whether one considers health care a public or a private good. Most people would consider the provision of street lighting and national security to be a public sector responsibility, and luxury items like cars and annual holidays abroad to be private consumption goods best left to the individual to purchase and the private sector to provide. When it comes to health care, however, the issues become highly contentious and the answers are not as clear-cut. While consulting a doctor is a very personal matter, the thought of denying a fellow human being access to the same level of health care because of his or her inability to pay, stirs deep emotions. Historically, the pendulum in the health care debate has swung back and forth between the state and the private sector. Definitions In this paper, the term â€Å"public sector† refers to that part f the economy concerned with providing basic government services while the â€Å"private sector† is that part of the economy not controlled by the government. The latter could be â€Å"for-profit†, or â€Å"not-for-profit† in nature. The term â€Å"public-private partnership† in health care finance refers to the situation where the government mobilises private sector sources of funds to finance health care services. Correspondingly, public-private partnership in health services provision entails government encouragement of private sector participation in the delivery of public services. The possible combinations of publicprivate mix in the health sector are shown in Figure 1. International Experience The ke y questions surrounding health care systems around the world are: (a) how to raise revenues to pay for health care; (b) how to pool risks and resources; and (c) how to organise and deliver health care in the most efficient and cost-effective manner. Whether the strategies adopted rely on public sources like taxes and social insurance, or private sources like private insurance and out-of-pocket payment, Department of Community, Occupational and Family Medicine National University of Singapore, Singapore Address for Reprints: A/Prof Lim Meng Kin, Department of Community, Occupational and Family Medicine, National University of Singapore, MD3, 16 Medical Drive, Singapore 117597. Email: [emailprotected] edu. sg †  Based on an invited lecture delivered at the 30th Medico-Legal Society Annual Seminar: Transforming Health Care at the Grand Hyatt, Singapore, 6-7 November 2004. 1 August 2005, Vol. 34 No. 7 462 Transforming Singapore Health Care—MK Lim Provision Public Publi c Finance Private Publicly financed Publicly provided Privately financed Publicly provided Private Publicly financed Privately provided Privately financed Privately provided for this include insufficient government resources and poor performance on the part of the public sector. State-run institutions are notoriously bureaucratic. There is a growing realisation that involving the private sector in health services provision could lead to improved systems efficiency. Even in Europe, the sustainability of health care systems founded on egalitarian welfarism is increasingly being challenged as growth in demand outstrips supply. 3 The debate is no longer about â€Å"who should pay? † or â€Å"who should provide? † but â€Å"who can do the job more efficiently? †. Singapore’s Experience Health Care Finance Singapore’s experience exemplifies an evolving publicprivate partnership in health care financing and provision. In the 1980s, the Singapore gov ernment reexamined from first principles the role of the state in health care financing and provision, and concluded that a British-style National Health Service was neither a viable nor a sustainable option. It decided that while the government would continue to subsidise health care (along with other important social areas like housing and education) to bring prices down to an affordable level, the people would have to share in the costs of the services they consume. The â€Å"3M† system — Medisave (1984), Medishield (1990) and Medifund (1993) — which forms the centrepiece of Singapore’s health care financing system, was therefore premised on the philosophy of shared responsibility, and the economic principle that health care services should not be supplied freely on demand without reference to price. In persuading the people to accept this hard-nosed policy, the government reasoned that the question â€Å"who pays? was not the right question to ask, f or â€Å"whether it is the government, Medisave, employers, or insurance, it is ultimately Singaporeans themselves who must bear the burden† — since insurance premiums are ultimately paid by the people, employee medical benefits form part of wage costs, and taxes are paid by taxpayers. Over the years, the demand for health care has increased in tandem with the key drivers of health care costs, such as the rapid ageing of the population, advancing medical technology resulting in the increased range and number of possible interventions, and rising public expectations. Singapore’s innovative 3M system of health care financing has proven to be very effective in mobilising private financial resources. Medisave, the state-run medical savings accounts, which is compulsory for the working population, today stands at a staggering S$30 billion, an amount that can underwrite Singapore’s total health care expenditure for the next 5 years. A most remarkable achieve ment has been the gradual Fig. 1. Public-private mix in health care provision and financing. will have a profound impact on heath care costs, quality, and access. In making the choice, technical efficiency is an important, but not the only consideration. Most health care systems in western industrialised countries assume a high degree of responsibility for personal health care because they are driven by values which lean heavily towards notions of equity, fairness and solidarity. With the notable exception of the United States, all the Organisation for Economic Cooperation and Development (OECD) countries (including Japan and South Korea) have opted for publicly financed health care systems that provide universal coverage. The United States relies heavily on the private sector to finance health care, with the result that in 2002, 15. 8% of its population (or 42. 3 million people) were not covered by health insurance of any form. 1 The Europeans and Canadians (and indeed many A mericans themselves) consider this to be highly inequitable. At the same time, they are saddled with runaway health care costs from which they are struggling to break free. The facts on the ground are often different from the official rhetoric. Thus, although the British in theory enjoy free health care under the National Health Service, 10% of the population have purchased private health insurance, with one-fifth of all elective surgery being performed in the private sector. Likewise, although New Zealanders may enjoy free health care, one-third of the population have private health insurance, with one-fourth of all surgery being performed in private hospitals. 2 In Canada, where the single-tier health care system is mandated by law, increasing numbers who are frustrated with the growing waiting lists for surgery simply cross the border to the United States to buy more esponsive, private health care. In fact, all the welfare states have, without exception, found it necessary to impose arbitrary limits on health care spending and to ration access to expensive medical technology — to the extent of compromising on health care quality. In recent years, the trend in both the developed and developing worlds has been towards greater private sector involvement in health care provision and financing. Reasons Annals Academy of Medicine Transforming Singapore Health Care—MK Lim 63 100% 80% 60% 40% 20% 0% 1965 1970 1975 1980 1985 1990 1995 2000 Year Government expenditure Private expenditure Fig. 2. Public versus private health financing, Singapore (1965-2000). shift of the financial burden from the government to the private sector (Fig. 2). 5 Since access to needed care is explicitly guaranteed for the poor,6 and the state-run Medishield insurance scheme protects against financial ruin from catastrophic illness, the system is on the whole no less humane than a state-funded one. Health Care Provision Health care provision comprises a mix of 8 public h ospitals and 5 specialty centres which together account for 80% of inpatient beds, with 13 private hospitals accounting for the remaining 20%. Primary health care is easily accessible through an extensive and convenient network of private general practitioners (80%) and public outpatient polyclinics (20%). In addition, an estimated 12% of daily outpatient attendances are by traditional Chinese practitioners in the private sector. The successful corporatisation of Singapore’s health care institutions between 1985 and 2002 has resulted in better efficiency and improved service levels. Market mechanisms and structures have replaced old bureaucratic ones. Presumably, better and more informed decisions are being made at the local level, compared to central planning by the Ministry of Health (MOH). Patient responsiveness today is a far cry from the overcrowded wards and specialist outpatient clinics of yesteryear. Patient satisfaction is reportedly high (85%); average waiting time for elective surgery is apparently a mere 2 weeks; and the average length of stay in a public hospital is 5 days. With first-world standards of health attainment (an average life expectancy of 78. 4 years and an infant mortality rate of 2. 2 per 10007) at an affordable 3% to 4% of GDP for the last 3 decades, Singaporeans appear to be getting good value for their money. Singapore Health Care at the Crossroads Looking ahead, a number of challenges place Singapore’s health care system squarely at the crossroads. These include (a) the need for cost containment on the domestic front; (b) Singapore’s push to become a regional hub of medical excellence; and (c) the ongoing quest for quality and patient safety. After years of continuous growth averaging 8. 0% between 1965 and 2000, the Singapore economy began to flounder during the 1997 regional financial crisis and the subsequent economic slowdown in 2003 associated with the SARS outbreak. Although it has since bounc ed back (8% to 9% projected growth for 2004), Singapore’s maturing economy faces tough times ahead, including the effects of lobalisation and increased competition from China as the emerging economic powerhouse. The government is committed to restructuring the Singapore economy and some recommendations of the Economic Review Committee (2002) have implications for the health sector such as (a) the reduction of the Central Provident Fund (CPF) contribution rate (thus affecting the Medisave contribution rate) and (b) the identification of the health sector as an important sector to target economic growth – in other words, to further commercialise medicine and turn it into a money spinner for the Singapore economy. Challenge of Cost Containment In theory, rising health care costs should not pose a problem if the rate of increase is matched by rising national income, just as the legendary Milo of Crotona grew stronger each day by lifting his calf every day — as th e calf grew, so did his muscles! Unfortunately, in Singapore’s case the calf is growing faster than our ability to carry it. Health care expenditure cannot remain at 3% of GDP for long. For one thing, as the economy matures and GDP growth inevitably slows, the masking effect of an expanding GDP denominator will disappear. Another factor is the rapidly ageing population, now constituting a mere 7. 7%, but projected to increase to 14% in 2010 and 25% in 2030. The 3M formula was not designed to take into account the long-term care needs of the elderly. Advancing medical technology in the era of genomic medicine will add to the mounting cost pressures. New schemes like Eldercare and Elderfund have been added. The government has acknowledged that the key parameters for Medishield (since 1990) such as premiums, deductibles and benefits have not been sufficiently updated to reflect the increased cost of hospitalisation. Hence, a major revamp is underway to fine-tune Medishield and to broaden its risk pool. However, a more fundamental weakness of Singapore’s cost containment strategy that has not been adequately August 2005, Vol. 34 No. 7 Percentage 464 Transforming Singapore Health Care—MK Lim addressed is its almost exclusive focus on the demand side. The 3M system was explicitly designed to curb overconsumption and to counter the â€Å"moral hazard† associated with fee-for-service, third-party reimbursement. The result has been the successful moderation of the government’s share of total expenditure, but not private spending. It can be observed that total health care spending has in fact risen exponentially, despite the 3M system being in place (Fig. 3). The focus has been on how to pay for health care, not how to purchase health care wisely. It is pertinent to point out that every dollar spent on health care is a dollar earned by health care providers. Hence, there is inherently no incentive for health care providers to want to contain costs. Indeed, providers could be expected to exhibit entrepreneurial behaviour. Casemix was introduced in 1999 as a cost containment measure to check supply-side moral hazard. But alas, since E = P x Q (where E = expenditure, P = price and Q = quantity) controlling price (P) alone (which is what reimbursement based on DRG attempts to do) is not going to curb the quantity (Q) of services supplied. There is also no evidence that the splitting of Singapore’s heath care institutions into 2 competing clusters has resulted in competition of the healthy kind that would justify the increased overheads of having 2 clusters, or that Singapore’s doctors are rendering health care at the economically optimal point, where the marginal benefits to patients would justify the marginal costs of treatment. Challenge of Becoming a Regional Medical Hub The fact that Singapore’s major private sector health care players are listed on the Singapore Exchange refle cts the government’s favourable disposition towards the commercialisation of health care services. The government has in recent years also allocated billions of dollars to attract foreign pharmaceutical and biotechnology companies to Singapore, including multinationals like ScheringPlough, GlaxoSmithKline, Merck, Sharp Dohme, Aventis and Pfizer. Realising that Singapore doctors enjoy a good reputation, as attested by the 200,000 foreign patients who came from the surrounding region in 2003,8 it wants to turn Singapore into the premier medical hub in the region. The Economic Review Committee, charged with making recommendations to improve Singapore’s competitiveness, has set an ambitious target of one million foreign patients a year by 2010, which would bring in an estimated $3 billion annually and create 13,000 jobs. In 2004, the Economic Development Board, Singapore Tourism Board (STB) and International Enterprise Singapore (IE) announced the launch of Singapore M edicine, a multiagency government initiative aimed at developing Singapore into one of Asia’s leading destinations for health care services. Who should drive the regional push: the public or private sector? As with health care financing, focusing on â€Å"who? † is to ask the wrong question. To use Deng Xiaoping’s metaphor, what matters is not the colour or breed of the cat, but its ability to achieve results. The challenge is not only to achieve the set targets, but to do so in a manner that enhances Singapore’s standing in the international arena and its relations with its neighbours. The last thing we want is to become a high-priced medical â€Å"tourist trap† founded on activity-based, rather than evidence-based medicine. This means a focus on the basics — ethical, cost-effective medical practice, with emphasis on quality and patient safety. This leads us to the third challenge, which has implications for both the domestic and regiona l/international fronts. Challenge of Quality and Patient Safety There is growing concern worldwide that the health care industry is plagued with unnecessary and inappropriate care, even replete with medical errors. The Institute of Medicine’s 1999 report, â€Å"To Err is Human†, has put the issue of patient safety and quality firmly on the public agenda. The 2001 sequel, â€Å"Crossing the Quality Chasm†, has described the wide gulf that exists between what is and what should be in terms of quality health care. 10,11 How does medical care in Singapore measure up in terms of safety, effectiveness, patient-centeredness, timely care, efficiency and equity? To safeguard patient safety and ensure quality care, it is essential that these unknowns about our health care processes and outcomes are measured — for what we do not measure we cannot manage. Singapore’s journey in quality and patient safety has been discussed elsewhere and will not be repea ted here. 12 5 4. 5 4 3. 5 $ billion 3 2. 5 2 1. 5 1 0. 5 0 1965 1970 1975 1980 1985 1990 1995 2000 Year Government expenditure Private expenditure Total expenditure Fig. 3. Trends in national health expenditure, Singapore (1965 to 2000). 4 Annals Academy of Medicine Transforming Singapore Health Care—MK Lim 65 One thing is clear, however: while professional selfregulation is important, it is insufficient. Regulatory structures external to the doctor-patient relationship are needed to protect the public interest and to align provider behaviour with desired goals. However, government regulation is also of limited effectiveness, for the government, too, faces the same problem of information asymmetry as the patient — given the large grey zone of clinical judgment and the delicate nature of the doctorpatient relationship, which precludes over-intrusive monitoring. What is needed is a new paradigm of health care regulation involving the participation of empowered consum ers, more of which will be described later (Fig. 4). Regulator Empowerment Price and Quality transparency Patient Trust Performance indicators Provider Fig. 4. Tripartite regulatory framework. The Way Forward The three challenges highlighted above — cost containment, developing a medical hub and ensuring quality and patient safety — are interrelated. A focus on costs without a corresponding focus on quality and patient safety is meaningless. Care that is cheap but of poor quality is surely not what Singaporeans want or deserve. Neither will a reputation for expensive or inappropriate treatment propel us towards our goal as a medical hub. Both cost containment and quality of care are critical factors to Singapore’s success as a regional medical hub. The international market competition, as with the domestic market competition, will ultimately be decided on the basis of both price and quality. A first step towards achieving all of these goals is to create the r ight conditions for (a) competition, (b) consumer choice, and (c) provider cooperation. Competition The literature on the effects of hospital competition in the US reveals that competition has been beneficial, lowering cost and increasing quality. Market competition is conducive to innovation and continuous improvement. It provides a more appropriate equilibrium of prices, technology, and capacity than would be possible by central planning. Furthermore, studies have shown that private delivery of health care services has efficiency advantages over public delivery. Still, whether private hospitals are more efficient than public hospitals is beside the point; what is important for market competition to work is that there is a level playing field for both public and private providers. Such a competitive model provides strong incentives for both technical and allocative efficiency. Those providers (public or private) unable to compete in terms of price and quality of their service s should bow out and let others step in. The government’s role would be to monitor and enforce contractual arrangements. It should provide oversight, not micro-manage, and should intervene only when there is market failure. It is telling that the imperative for cost control and increased efficiency has driven even the welfare states of Europe to introduce competition in their health care systems. In tax-based systems (e. g. , the UK), this has meant the establishment of â€Å"internal market† mechanisms, enforcing a split between purchasers and providers. The evidence from Scandinavian countries shows that competition and a split between providers and purchasers improve productivity, access and quality. 13 Singapore’s health care environment is presently competitive in form but not in substance. Despite restructuring, the Singapore government still multi-hats as regulator, policymaker, asset owner, and major purchaser and provider of services, remaining ef fectively in control of the 2 health care clusters. This makes arms-length regulation difficult. The inter-cluster competition is somewhat artificial and may even be counterproductive. The government should further distance itself from the public provider role and confine itself to being a policy setter and unbiased regulator, applying a consistent approach to all service providers. Public sector providers should be given greater exposure to market forces, including having to compete with the private sector for a share of statesubsidised patients. Consumer Choice Singapore’s regulatory framework should not merely consist of 2 parties, namely the regulator (MOH) and the regulated (public and private providers). It should ideally be tripartite, in which empowered and well-informed consumers play their rightful role in selecting health care providers on the basis of price and quality of care provided (Fig. 4). Information asymmetry would not be an insurmountable barrier on ce the full power of information technology plus the role of the media is brought to bear. The government’s role should be to ensure transparency of key performance measures across the system so that consumers will be well informed and able to make sound August 2005, Vol. 34 No. 7 466 Transforming Singapore Health Care—MK Lim decisions. The publication of selected prices of certain procedures on the Ministry of Health website in 2004 has already led to some dramatic price reductions. Once government websites start publishing reliable and valid provider data on quality, safety and health outcomes in addition to pricing, there will be a major shift in the balance of power, resulting in a more stable equilibrium of provider accountability. Providers would be motivated to improve responsiveness to consumer preferences, and consumers would be empowered to choose freely between providers, both public and private, on the basis of cost, quality and other desirable attribute s. Cooperation The twin notions of competition and cooperation among providers need not be contradictory. Providers already know there is advantage to be gained by cooperation (which was what â€Å"clustering† of public sector hospitals was supposed to do, except that it would have worked better if the cooperation had been spontaneous rather than forced). â€Å"Coopetition†, or cooperation amidst competition, should be the watchword as Singapore strives to become a regional medical hub. Ultimately, Singapore’s health care institutions must compete successfully with the â€Å"competition out there† on the basis of clinical quality and price, in addition to other desirable service characteristics such as â€Å"one-stop, seamless care†. For this to happen, Singapore providers must first get their internal act together. Only by cooperating can they leverage on the respective strengths of the public and private sectors, and can they hope to innova te and create higher-value health systems than what others offer. The Electronic Medical Records Exchange (EMRX) is a fine example of inter-cluster cooperation. In addition, Singapore’s first Cyclotron (at a shared cost of $5. million) to support the operation of positron emission tomography scanners is a good example of cooperation between the public (SingHealth) and private (AsiaMedic and MediRad Associates, a subsidiary of Parkway Holdings) sectors, contributing to the common goal of enhancing Singapore’s standing as a hub of medical excellence. Continuous dialogue is needed to build trust and to evolve a common strategic vision. Just as cooperating with competitors in the local market brings mutual advantages, avenues for strategic alliances with external partners or competitors to achieve win-win situations should also be explored. Conclusions Strength: Public-Private Partnership Foundations Already in Place Prudent policies involving public-private partnership s in both health care provision and health care finance have conferred on Singapore a distinct advantage over other nations facing similar challenges of diminishing resources in the face of increasing demands: It is far easier to set priorities when patients are conditioned to cost-sharing rather than free health care, and when the range of policy options available is broadened by a healthy mix of public and private providers. Weakness: Insufficient Evidence Base for Policy Making A key weakness of Singapore’s health care system is its lack of a culture of rigorous and transparent evaluation. For example, no major effort has been undertaken to gather relevant data in a systematic manner over time to assess the full impact of hospital corporatisation. Neither has the 3M system been subject to critical analysis with all the relevant data at disposal. Likewise, to be the market leader in health care provision in the region requires in-depth knowledge nd an understanding of th e nature and behaviour of crossborder trade in health care services, the cost and quality performance of self versus the competition, and the healthseeking behaviour of local and regional consumers. Formulating health policies without the benefit of health policy research is like flying an expensive passenger aircraft without instruments. Given that Singapore spends $5 billion on health care annually, and is set to invest millions more to build the base to attract the regional health care clientele, it would seem penny wise, pound foolish not to invest a tiny fraction of that to find out what works and what doesn’t. Going Forward If Singapore’s health care system is to be transformed into a modern and responsive 21st-century health care system, it needs to be decidedly consumer-focused. In particular, it needs to be competitive in terms of price and quality because that is what consumers everywhere expressly look for. A tripartite model of health care regulation, in volving the active participation of empowered consumers, is Singapore’s best hope for containing costs and ensuring quality of care. Getting the internal (i. e. , domestic health care) and external (i. . , regional medical hub) acts together are two sides of the same coin, involving the same principles of competition, consumer focus and cooperation. â€Å"Who (public or private) does what† is not as important as â€Å"what gets the job done†. Recommendations The devil is (as always) in the details, but it is proposed that the following broad principles should form the basis of strategic planning and structural reform aimed at getting our internal and external acts together: Annals Academy of Medicine Transforming Singapore Health Care—MK Lim 467 1. To contain health care costs, both sides of the equation must be simultaneously addressed: supply side control mechanisms in addition to demand side constraints. 2. To achieve greater efficiency, public sect or provisioning should be exposed more to market forces. 3. To grow as a regional medical hub, a coordinated effort involving greater public-private, private-private, and public-public partnerships is necessary. 4. To ensure a level playing field for market competition to take place, the government should further distance itself from the public provider role and confine itself to being a policy setter and unbiased regulator. . To empower consumers to choose providers on the basis of price and quality, the government should actively pursue a policy of transparency of information on the price and quality of care of providers. 6. To balance the need to grow commercial medicine on the one hand, and keep domestic health care costs affordable on the other, health policy makers need to pay attention to the alignment of incentives with goals, and anticipate unintended side effects. 7. To improve health policy-making, the evidence base should be strengthened considerably. Health policy needs to be informed by health policy research. REFERENCES 1. US Census Bureau. 2003 Current Population Survey (CPS) Annual Social and Economic Supplement, 2003. Available at www. census. gov/ apsd/techdoc/cps/cps-main. html. Accessed on 9 November 2004. 2. Goodman JC, Musgrave GL. Twenty Myths about National Health Insurance. NCPA Policy Report No. 166, 1991. 3. Duffy K. Final report of the HDSE Project. Opportunity and risk: trends of social exclusion in Europe. United Kingdom: Council of Europe Publishing, 1998. 4. Lim MK. Health care systems in transition II. Singapore, Part I. An overview of health care systems in Singapore. J Public Health Med March 1998;20:16-22. 5. Lim MK. Shifting the burden of health care finance: a case study of public-private partnership in Singapore. Health Policy 2004;69:83-92. 6. Goh CT, 1996. Speech by the Prime Minister at the National Day Rally on 18 August 1996. 7. Ministry of Health, Singapore. State of Health the report of the Director of Medi cal Services. Singapore: Ministry of Health, 2001. 8. Singapore Tourist Board Press Release. Singapore set to be health care services hub of Asia. Available at: https://www. app. singapore medicine. com/asp/new/new0201c. asp? id=881. Accessed October 20, 2003. 9. Anonymous. Singapore faces new competitors in services. The Straits Times. 2003 January 24:1. 10. Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington, D. C. : National Academy Press, 2000. 11. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001. 12. Lim MK. Quest for quality care and patient safety: the case of Singapore. Qual Saf Health Care 2004;13:71-5. 13. Hjertqvist J. Competing hospitals and providers work miracles confirmed by Swedish experience. Policy Frontiers, September 13, 2004:12. August 2005, Vol. 34 No. 7

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