Key Content: Responses in a diverse society
Management and impact of socio-cultural diversity
Assimilation model (Case study: France)
Integration (Case study: Singapore)
Management and impact of socio-economic diversity (3 Approaches to healthcare)
market-based approach
shared responsibility approach
government-financed approach
French policies assume that there can be no unity in diversity, no liberty in their fraternity.
To bind together this diverse population, France continues to demand a degree of assimilation that expressly seeks to homogenize all immigrants into a shared mold of “Frenchness.”
Key meaning of French fraternité — a brotherhood that erases all differences to create the “French people.”
This policy has noble intentions - It is intended to ensure that France is not divided and no particular group is favored, instead, all are equal before the law.
(1) EDUCATION
Secular (not connected with religious or spiritual matters) Education System - strengthens French National identity. No discussion about religions except in History and Philosophy classes.
Adaptation classes conducted for children to improve their French – join regular French schools in the future.
Immigrants interact and make friends who will be able to teach them more about life as a French citizen. Pick up norms in French society.
Could mean that the children will lose some of the religious/cultural influences that were previously part of their identity
(2) EMPLOYMENT
Through employment, immigrants are committed to stay in the country and quicken the acquisition of Social Capital (social network of people where one connects with others.)
They need to learn French for work communication. But, unemployment rate was 3x national average for immigrants mainly because of discrimination in hiring practices.
Assimilation ineffective Govt introduced Diversity Charter to encourage support for discrimination free work-place.
Allows immigrants to interact with other French people, gain acceptance and form social capital that enables them to be accepted into French society.
Effectiveness depends on the job that the immigrant is taking and the peers he/she is interacting with.
(3) NATURALISATION PROCESSES
Naturalisation Programmes help assimilate immigrants to develop basic knowledge about life in France and what being French means.
Necessary for all immigrants to take French language courses, attend civic education about life in France, demonstrate knowledge of history and culture of France and language proficiency, and pass French cultural tests.
Immigrants must know what it means to be a French national, how to speak French and gain knowledge about the history & culture of France. This is in hopes that they will be able to better converse with French people hence making assimilation more effective.
Tensions: Giving up ties to their homeland and own cultural practices = lose identity ?!?!
Perceptions of weakening sense of national identity due to influx of immigrants
Displays of religious beliefs and ethnic customs are expected to be kept in private – the prohibition of display of several religious items in public heightened tensions along ethnic lines
Tension between religious identity and French national identity
Immigrants retain their unique identities while forging common ground with the groups already living in the host country.
Idea of harmony is achieved through firm anchor on shared values of upholding law and order, respecting racial and religious groups and a commitment made to working together for a better future
(1) BILINGUAL POLICY (Ensures differences are recognized and respected)
Singaporeans learn both English and their mother tongue languages in schools
English provides a common language necessary for communication especially in professional settings and establishes a sense of belonging for better integration
Learning one’s mother tongue preserves one’s cultural identity
(2) PRESIDENTIAL COUNCIL OF MINORITY RIGHTS
A council to ensure all laws passed by the Parliament is not discriminatory towards any racial/religious community.
(3) GROUP REPRESENTATION CONSTITUENCY (GRC SYSTEM)
A Group Representation Constituency (GRC) is a type of electoral division or constituency in Singapore where teams of candidates, rather than individual candidates compete to be elected into parliament as MPs.
It was primarily implemented to enshrine minority representation in parliament whereby at least one of the MPs in the GRC must be a member from a minority community
It officially came into effect as of 1988, prior to which, all constituencies were Single Member Constituencies (SMCs), following amendments to the Constitution of the Republic of Singapore and the Parliamentary Elections Act.
Strengths:
The GRC system entrenches the presence of minority MPs in Parliament, ensuring the interests of minorities are represented.
It also allows for a maximum of 6 MPs which provides flexibility to ensure the expanding population is properly managed since it is increasingly difficult for an MP to single handedly represent all the constituent’s views.
Criticisms:
It is questionable if the GRC system is effective in fulfilling the promise of minority representation since they remain numerically underrepresented in parliament.
It is also considered as a recruiting tool for the PAP
(4) ETHNIC INTEGRATION POLICY (Ensures differences are recognized and respected)
The Ethnic Integration Policy (EIP) was introduced in 1989 to ensure a balanced mix of ethnic groups living communally in HDB estates instead of forming racial enclaves, so as to promote racial harmony and strengthen social cohesion.
This is on the basis that residents of different ethnicities live together and interact on a regular basis in public housing, where 80% of the population lives.
Prevents the build-up of ethnic enclaves and to ensure interaction between neighbors from different backgrounds.
Under the EIP, there are limits on the total percentage of a block or neighbourhood that may be occupied by a certain ethnicity.
When these limits are reached, no further sale of flats to the affected group is allowed, unless the seller and buyer belong to the same ethnic group.
It applies to the sale and purchase of all new and resale HDB flats, and is implemented for all ethnic groups.
Granted, The EIP leads to BTO units perpetually left vacant in land-scarce Singapore
The effect of this is visible in HDB’s build-to-order (BTO) flat selection processes, where there are unfilled Chinese quota leftover flats in cheaper, non-mature estates such as Woodlands and unfilled Malay quota leftover flats in more expensive, mature estates such as Bedok.
The Ethnic Integration Policy works on the heavy assumption that by living in close quarters, residents of different ethnicities will be forced to mingle and interact with each other, thereby strengthening the racial harmony and unity in Singapore.
However, this opens the question: Does living together equal, or necessarily lead to, integration and understanding?
(5) NATURALIZATION INITIATIVES
Citizenship E-journey (see below), Singapore experiential tour, Community Sharing Sessions
New Singaporean citizens have to go for a mandatory programme
2 months to complete to receive Singapore identity card and citizenship certificates
Case Study: Singapore Citizenship Journey
The Singapore Citizenship Journey (SCJ) is a mandatory programme for new citizens who have been granted in-principle approval for Singapore citizenship.
The SCJ helps enrich new citizens’ understanding of the key milestones in Singapore’s history and development and deepens their appreciation of Singaporean norms and values, as well as provides opportunities for meaningful interaction with their local community.
It is a collaborative effort between the Ministry of Culture, Community and Youth (MCCY), the Immigration and Checkpoints Authority (ICA) and the People’s Association (PA).
(6) COMMON EXPERIENCES
Singapore Permanent Residency quota, EIP quota, Serving of NS
Help adopt and build common ties
e.g. national service allows people from diverse racial, religious, language and educational backgrounds to train together
This fosters greater cohesiveness among people and creates a strong national identity.
Fulfilling the NS obligation shows that new immigrants embrace this rite of passage which is distinctive for Singaporean men.
(7) COMMUNITY SUPPORT
Grassroots-organized events and activities, apps, plays/skits
National Integration Council launched the community integration fund to support organizations interested in implementing ground up integration initiatives e.g. SG Sauce
Initiatives organized by People’s Association (PA) include block parties, festive celebrations at community clubs, home visits and orientation tours
This helps immigrants adapt and alleviate the anxiety faced when adjusting to their home.
Case Study: People’s Association - Community Integration
PA through its Grassroots Organisations (GROs) and Integration and Naturalisation Champions (INCs), help new citizens and Permanent Residents (PRs) settle in the community, providing platforms for them to interact with and bond with the local residents.
Through their participation in various integration-centric programmes and GRO programmes/activities, new immigrants can make friends and develop mutual understanding with their neighbours and other residents in the community.
PA has adopted the following three key strategic approaches:
Intensifying local integration efforts through the Residents' Committees and Neighbourhood Committees;
Multiplying outreach through partnership with Immigrant Associations and external organisations; and
Promoting greater awareness on integration through publicity and social media.
Integration Programmes from the PA also include:
House Visits and Welcome/Floor Parties
INC Activities
Integration of New Immigrants through Interest Groups
Community Learning Journey
Citizenship Ceremony
Tensions: increased competition + Singaporeans unhappy with foreigners
MARKET-BASED APPROACH
Government gives citizens freedom to decide how much they wish to pay for healthcare and allows the market to determine the provision of services to meet healthcare needs.
Background:
No single national policy guiding the healthcare system in the USA.
Have both private and public hospitals and differentiation in the types of healthcare provided at each hospital.
The US Government does not intervene in the setting of prices by healthcare service providers nor interferes with the healthcare service options by citizens.
Americans have to cope with the cost of healthcare by themselves, buying insurance to ensure they can receive and pay for necessary medical treatment, yet not everyone can afford it
Strengths: Citizens free to choose their preferred healthcare services, pay for what they get/need
Challenges: Cost and coverage of medical insurance is substantial especially for those from lower SES
The need to purchase medical insurance, yet unaffordable for many.
Those of a lower economic status are unlikely to visit a doctor when sick or seek proper treatment due to high costs.
Insurance companies charge higher in order to earn more profit-making insurance more expensive
Impact:
Affordable care act – low to middle income families able to apply for medical assistance.
Majority of Americans from middle and higher SES groups obtain medical insurance as part of their employment package.
Market based approach makes it harder for lower SES groups to pay for much needed healthcare, resulting in exclusion for healthcare services.
Policies to help lower SES groups
Medicare – health insurance for Americans > 65 y.o. or those with disabilities
Medicaid – health insurance to people and family who have limited income/disabilities
Legalization of emergency medical treatment – emergency departments are required by law to provide treatment to anyone requiring it.
SHARED RESPONSIBILITY APPROACH
Government provides basic healthcare services and shares the costs of some aspects of healthcare.
Balance between personal responsibility and the role that the government plays in providing for healthcare
Background:
Guided by a combination of personal and collective responsibility and government provision.
Comprises both public and private healthcare service providers for different SES offering different levels of subsidy
Primary care - provided by government in polyclinics, and general practitioners (private)
85% of inpatient beds are in public hospitals, the remaining in private specialist hospitals
In public hospital system - different ward types
Unsubsidized A class wards
Heavily subsidized b2 and c class wards
Intermediate and long term care services to provide further community care to patients who are stable enough to be discharged from hospitals. - community hospitals, nursing homes and hospices
Provide further community care and treatment
Services provided by voluntary welfare organizations with the government providing subsidies to ensure care provided is affordable for needy
Individual and family responsibility still important
Concept of Risk pooling
Portion of every individual’s CPF savings is set aside in Medisave to help them pay for healthcare.
Encourages patients to take personal responsibility for their healthcare choices, such as the type of services and where they go to seek these services
This is achieved through tiered subsidies for different ward classes and income levels
Note: Prices of medical services are gradually adjusted to reflect true costs of healthcare provision, though there continues to be challenges in doing so
Ensures and provides universal access to healthcare for Singaporeans
Financing system anchored on individual and collective responsibility
Keep national healthcare expenditure of about 4% of GDP - considered LOW for developed countries
BUT healthcare expenditure is still expected to grow due to an ageing population
Multiple tiers of protection
First tier of protection - heavy government subsidies of up to 80% of total bill in acute public hospital wards
Second tier - proved by Medisave, a compulsory medical savings account
Third tier - Medifund - for patients who are unable to pay despite the support from the first to third tiers
Organization of service delivery of medical services (Mixed delivery model)
Public sector dominates the acute care sector (80%)
Primary care sector - general medical practice is dominated by private sector providers
ILTC sector- mostly provided by voluntary welfare organizations funded by the government
Multiple tiers of protection to help ensure healthcare cost is affordable
Balancing between inculcating personal responsibility and providing for lower income groups with subsidies and safety nets
Subsidies are tiered to ensure lower income groups receive more support - ensures nobody is denied to healthcare that they need
Subsidies by the government
Subsidized treatments in polyclinics, public hospitals, community hospitals and nursing homes
Lower to middle income groups receive additional means-tested subsidies under CHAS
3Ms - Medisave Medishield and Medifund to pay for hospital bills
Policies to require co-payment to discourage over-consumption and over-treatment, which has become a problem in many advanced countries.
Medisave
Compulsory individual medical savings scheme which helps CPF members put aside part of their income into their MediSave Accounts to meet their future personal or approved dependant’s hospitalization, day surgery and certain outpatient expenses.
Under MediSave in Singapore, every employee contributes eight to 10.5 percent (depending on age group) of his monthly salary to a personal MediSave account.
Help lower income Singaporeans pay for their share of medical treatment without financial difficulty
Working Singaporeans and their employers contribute part of monthly wage into the account to save for their future medical needs
Medishield Life
MediShield Life is a basic health insurance plan, administered by the Central Provident Fund (CPF) Board, which helps to pay for large hospital bills and selected costly outpatient treatments, such as dialysis and chemotherapy for cancer.
Allows Singaporeans to effectively share the responsibility of paying for large bills by risk pooling the financial risks of major illnesses
It is structured so that patients pay less MediSave/cash for large hospital bills.
All Singapore Citizens and Permanent Residents, including the very old and those who have pre-existing conditions are eligible
MediShield Life is sized for subsidized treatment in public hospitals and pegged at B2/C-type wards.
If you choose to stay in an A/B1-type ward or in a private hospital, you are still covered by MediShield Life. However, you will find that your MediShield Life payout will cover only a small proportion of your bill.
A deductible is applicable to help focus insurance coverage on large bills
Deductible - medical expenses to be paid by the insured before the insurer covers the rest of the cost (paid by Medisave or cash)
Individual responsibility for one’s healthcare needs is maintained by requiring co-payment
Since medical fees are borne by partially by individuals, citizens become more health-conscious to avoid incurring unnecessary medical costs.
MediFund
MediFund is an endowment fund set up by the Government.
It provides a safety net for patients who face financial difficulties with their remaining bills after receiving Government subsidies and drawing on other means of payment including MediShield Life, MediSave and cash.
MediFund Silver and MediFund Junior are carved out from MediFund to provide more targeted assistance for the needy elderly and the young respectively.
As an endowment fund, interest income generated from the capital sum is allocated to approved healthcare institutions , for them to assist with the medical bill payments of needy patients.
For the future - Keeping pace with Singaporean’s needs
New schemes to mitigate rising healthcare costs for the elderly and lower income groups
2014 - higher outpatient subsidies for specialist care and drugs introduced at public hospitals and polyclinics to lower the costs for lower/middle income Singaporeans
Pioneer and Merdeka generation - enjoy special subsidies and Medisave top ups to alleviate healthcare costs
2015 - Medishield was replaced by Medishield life to cover every Singaporean from cradle to grave
These policies help to address rising socio-economic diversity and ensure that quality and affordable healthcare is available for all Singaporeans, regardless of income levels.
Balancing healthcare affordability with rising healthcare costs in the context of a rapidly ageing population
Managing the growing demand for healthcare
Singapore’s Population grew by 25% over the past 10 years and will continue to grow over the next decade
Healthcare services will need to grow in tandem with a rapidly aging population
By 2030, one in 4 singaporeans are aged 65 and above
This is a threefold increase from 2012 figures.
The ageing population will be a strong driver for healthcare demand, as the elderly require more intensive medical care
Elderly - 5 times more likely to be hospitalized compared to younger singaporeans, and more likely to stay longer in hospital when hospitalized
This has implications on the infrastructure required to support the healthcare needs with an aged population
With increasing life expectancy and more sedentary lifestyles, there is a greater need to treat chronic diseases
Chronic diseases on the rise - better coordination and continuity of care is important to ensure the best health outcomes
Shift the focus of care away from hospitals and specialists towards primary care through family doctors in the community to enable a more sustainable healthcare system
Primary care as the first point of contact - regular family doctor that understands their health needs to provide the first level of care and advice
Rising healthcare costs
Many governments are struggling to contain rising healthcare costs with Global healthcare inflation
Improve financing policies including more subsidies to low/middle income groups and the elderly to reduce out of pocket expenses
Effectiveness and sustainability of these measures are influenced by our age-dependency ratio because it is funded by government revenue
Using a shared responsibility approach, it places the healthcare decision in both the hands of patients and doctors
Both to embrace care that is cost effective and appropriate to one’s needs e.g. the use of generic drugs which are cheaper than brand name drugs
To manage cost becomes everyone’s responsibility
Maintaining healthy lifestyle and diet to reduce nationwide healthcare costs
Challenge is to continually review the system to ensure healthcare needs are sufficiently met in the context of rising costs and expectations.
Case Study: CHAS - Additional healthcare support and financing
The Community Health Assist Scheme (CHAS) enables all Singapore Citizens, including Pioneer Generation (PG) and Merdeka Generation (MG) cardholders, to receive subsidies for medical and/or dental care* at participating General Practitioner (GP) and dental clinics.
The colour of the CHAS card indicates the subsidy tier that cardholders are entitled to. Singapore Citizens who are on PG will receive full subsidies for the treatment of conditions covered under CHAS.
Strengths of Singapore's Healthcare system
healthcare kept affordable with govt subsidies, citizens take responsibility for healthcare choices, healthcare available for all regardless of income levels
Healthcare financing with multiple tiers of protection to ensure healthcare is affordable.
Tiered so that lower income groups receive more support
Ensures no Singaporean is denied of access to healthcare
Healthcare subsidies – subsidized treatments available in all public healthcare institutions and selected private clinics
Challenges in Singapore's Healthcare system:
ageing population = increased demand, more infrastructure needed, rising healthcare costs
Difficulty in balancing healthcare affordability with rising healthcare costs
Growing ageing population with increased life expectancy and more sedentary lifestyles results in greater need for treatment of chronic diseases
Effectiveness and sustainability of policies are dependent on age dependency ratio i.e. the number of working citizens that contribute to government revenue
GOVERNMENT-FINANCED APPROACH
Government provides substantial subsidies & services for most of the healthcare needs for its citizens. This approach could mean that healthcare is kept free or close to completely free.
In Sweden, there is a fundamental belief that citizens should have access to healthcare services regardless of background of socioeconomic status.
In Sweden, there is a fundamental belief that citizens should have access to healthcare services regardless of background of socioeconomic status.
Healthcare and dental coverage is high quality and universal, and patients get to choose their doctors. This is afforded by one of the highest tax rates in the world.
Idea that everyone pays, everyone gets back
By saving expenditure on national defense, much of the GDP is allocated to social welfare.
The benefits of free public goods and services extend beyond healthcare. There is free day care for children offered from age 1, with free primary and secondary education that extends to university and postgraduate years. A public pension system pays out income for retirement
Four Key Policies to keep healthcare affordable in Sweden
National ceiling for out of pocket payments - to ensure lower income families do not incur long term healthcare debt especially due to chronic illnesses
Cost of prescriptions - Those who require long term medication are not subject to ever increasing costs of treatment
Child protection - ensures large families and lower income households are not in debt due to children's healthcare expenses
Freedom to choose private insurance - flexibility to choose medical plans according to needs
Evaluating Sweden's Government-financed approach
Strengths: universal access to healthcare, largely owned and financed by government, choice of having private insurance
Challenges: high taxation for low healthcare costs that is subject to increasing demand due to the ageing population. This means that the government needs to fund a larger group of people which increases competition for existing healthcare resources. The tax burden also increasingly falls on a smaller group of working citizens.
Furthermore, there is an increasing number of people requiring healthcare with society becoming more diverse. Besides immigrants, citizens of EU member nations may also benefit from Sweden's healthcare without paying taxes.
As a result, this approach does not yield much political support
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