All over the world, ageing populations, falling birth rates and evermore ingenious scientific methods of keeping us alive for longer are playing havoc with national economies. For hard-pressed finance ministries, the search for ways to treat and prevent illness more cheaply without sacrificing quality has ac­quired the status of a mythical quest.

放眼世界，人口老龄化、人口出生率不断下降，甚至日趋先进的帮助人类延长寿命的科学方法，都在威胁各国经济。对重压之下的各国财长而言，如何能够在不牺牲质量的前提下以更低廉的成本治疗和预防疾病，已经成为一个无解之谜。

William Haseltine, a former professor at Harvard Medical School, biotech entrepreneur and Aids researcher, believes he has found, if not quite the philosopher’s stone, at least a piece of policy alchemy that deserves a wider audience.

曾在哈佛大学医学院(Harvard Medical School)担任教授的生物科技企业家以及艾滋病研究者威廉•哈兹尔廷(William Haseltine)认为，他找到了一套政策，它即使算不上是解开谜团的魔法石，那么至少也值得让更多人知晓。

Singapore provides universal coverage and world-class results in a range of areas, such as infant mortality and increased life expectancy. It achieves this while spending less than 4 per cent of gross domestic product – about one-fifth of the proportion spent in the US and approximately half of that in the UK. Both countries in some respects can only look enviously at the quality of care Singapore offers.

新加坡的医疗体系实现了全民覆盖，并在婴儿死亡率、预期寿命延长等许多领域交出了一流的成绩单。该国只花费不到其国内生产总值(GDP)4%的成本就做到了这些。这个数字约为美国的五分之一，英国的一半。在某些方面，后两个国家对新加坡的医疗保障质量只有羡慕的份儿。

In Affordable Excellence , Haseltine presents the nation’s medical scheme as an intriguing blend of paternalism and personal responsibility. The state does not hesitate to intervene in the healthcare market through measures such as the provision of subsidies to hospitals and polyclinics. It regulates and limits the type and number of doctors who can practice. This is “a kind of highly-calibrated capitalism”, in Haseltine’s phrase.

在他的《价廉质优》(Affordable Excellence)一书中，哈兹尔廷称，新加坡的医疗体系是家长制与个人责任的奇妙结合。这个国家毫不犹豫地对医疗市场进行干预，比如向医院和综合门诊诊所提供补贴。该国对执业医生的科别和数量进行监管和限制。用哈兹尔廷的话来说，这是“一种高度校准的资本主义”。

However, in a sign that this is no British-style munificent welfare state, every working Singaporean must pay into a mandatory medical savings account. The government believes this financial stake has deterred overuse or abuse of the health system and avoided reliance on state welfare or third party medical insurance.

然而，每个在职的新加坡人都必须向一个强制性医疗储蓄账户里存钱。从这里可以看出，新加坡绝不是英国那种大手大脚的福利国家。新加坡政府相信，让民众交钱抑制了他们对医疗体系的过度使用（或者说滥用），并避免了他们依赖国家福利或第三方的医疗保险。

Much in Haseltine’s analysis is persuasive. He tells a story of a nation which, more than three decades ago, realised health could not be left to the health ministry alone. In Singapore, all aspects of public policy – housing, waste disposal, road traffic, parks, tree planting – are harnessed to the goal of creating a fit and productive population. It has also invested heavily – and profitably – in becoming a regional hub for biomedical research.

哈兹尔廷书中的分析大部分很有说服力。他告诉我们，一个国家如何在三十多年前就意识到，医疗问题不能留给卫生部独自解决。在新加坡，所有公共政策——住房、垃圾处理、道路交通、公园、树木种植——都必须服从同一个目标：让民众健康地生活、高效地生产。新加坡在生物医疗研究方面也投入了巨资、且收益颇丰，希望在这方面成为地区中心。

But he is less convincing in his argument that this is a prescription ripe for wholesale export. Healthcare systems tend to be rooted in a nation’s culture and political traditions. The degree of central direction is specific to Singapore; so, too, is the stability of the political regime. One party has been in power for about half a century, ensuring extraordinary constancy of purpose. This may be a pity for all who do not live in the city-state since international evidence suggests stability, in itself, predisposes a health system to success.

然而，哈兹尔廷主张，新加坡模式是个值得批量推广的成熟模式，这不太有说服力。医疗体系通常根植于一个国家的文化和政治传统。政府指导的核心地位是新加坡所独有的，政治体制的稳定性亦然。新加坡目前的执政党已连续执政约半个世纪，确保了罕见的政府目标连贯性。所有不生活在这个城市国家的人，在这一点上或许都不太走运，因为许多国家的证据显示，稳定本身就预示了一个医疗体系的成功。

The idea that everyone must contribute financially towards their healthcare, crucial to controlling costs in Singapore, would prove disablingly contentious in countries with more generous systems. Although a number of recession-hit nations have quietly raised the level of contributions de­manded from citizens, they have done so without risking the public debate necessary to extend the approach that underpins Singapore’s success.

新加坡医疗体系控制成本的关键一点——每个人都必须为医疗交钱，在那些医疗体系更慷慨的国家可能引发巨大争议，导致其行不通。尽管有几个遭遇衰退打击的国家已悄悄提高了要求民众贡献的金额，但这些国家的这种做法，并未冒引发公众辩论的风险，而如果要实行铸就新加坡医疗体系成功的那种方法，一场公众辩论将不可避免。

He also concedes that it is hard to change healthcare delivery patterns once they are established, “as such decisions profoundly affect the lives of individuals and economies”.

哈兹尔廷也承认，医疗体系的服务模式一旦形成，就难以改变，“因为这种改变会对人们的生活和经济造成深远的影响”。

The one “export” attempt mentioned – an initiative to take some of the basic ideas behind medical savings accounts for use in China – proved unsuccessful. “Without Singapore’s wealth, its relatively younger population, its higher employment rate, its lack of rural areas, and its limited number of immigrants, Shanghai has not been able to emulate [their] effectiveness,” he writes.

哈兹尔廷提到了中国借鉴新加坡医疗体系模式——借鉴该模式中医疗储蓄账户背后的基本理念——的例子。事实证明，这是一次不成功的尝试。哈兹尔廷在书中写道：“新加坡拥有大量财富、人口更年轻、就业率更高，没有农村，移民数量有限。因为缺乏上述条件，借鉴新加坡模式的上海在医疗体系效率方面跟（新加坡）没法比。”

As an account of transformational political leadership, this book is nevertheless a substantial contribution to the canon of health reform. Singapore showed prescience in identifying as far back as 1983 the need to refocus the system on treating chronic conditions rather than infectious diseases – a switch other countries are struggling to make even now. It also identified the impact demographic change would have on the demand for services. It now operates a model approach to limiting costs while helping elderly people to live productive lives. A committee on ageing is the institutional embodiment of a cross-government approach guided by principles that include ensuring that all have access to good public transport and can remain in their homes, or at least communities, for as long as possible.

尽管如此，这本书介绍了新加坡的“变革式政治领导”，对我们找到医疗改革的正确道路贡献巨大。新加坡很有先见之明，早在1983年就意识到，必须将医疗体系的重点从治疗传染病转向慢性病。即便是如今，许多国家仍在努力实现这一转型。新加坡当时还意识到了人口结构的变化对医疗服务需求的影响。如今，新加坡建立了一种模式，这种模式一方面限制成本，一方面帮助老年人就业。新加坡人口老化问题跨部门委员会的指导宗旨包括，确保所有老年人都能享受便利的公共交通，并能尽可能久地继续住在自己家里，或至少能留在社区里。

It is here, in offering a humane and economically sensible approach to supporting people in the final section of their lives, that the lessons of this book have widest application – and offer a way forward for all countries as they confront the implications of demographic change.

这就是这本书介绍的经验中最值得推广的一条：如何为老年人提供既人性化、又经济的支持。同时，这本书也为所有面临人口结构变化影响的国家指明了前进的道路。