Healthier SG: Just What the Doctor Ordered?
Unpacking Singapore’s healthcare policy transformation.
Written by: Joel Tng
The Singapore parliament will continue to debate the government’s Healthier SG white paper at length today; the latest government healthcare strategy intended to drive a focus on keeping people healthy rather than treating ill health, and ultimately to reduce the rising costs of healthcare. The health of the Singapore population remains enviable – it has the fourth highest life expectancy worldwide, and the highest healthy life expectancy (i.e., expectancy of life lived without ill health due to disease or injury).
Although, rightly cause for celebration, this is leading to a rapidly ageing population, rise in chronic diseases and increased costs, like most high-income countries. Older people tend to have more co-morbidities that need to be managed and are heavier users of health services, and this tends to be concentrated into the final years of life. Over the years, Singapore has developed financial mechanisms to support people in Singapore to pay for their healthcare, with additional support for the most in need, including older populations. The government’s healthcare expenditure has tripled from $3.7 billion in 2010 to $11.3 billion in 2019 (2.2% of GDP) and could reach $27 billion (3.5% of GDP) by 2030. Although this is a steep increase, this would still remain lower than other developed countries.
Against this backdrop, Healthier SG represents a step change in government response to these challenges, building on the 3 Beyond strategy and making ambitious shifts to fundamental parts of the healthcare system. The ambitious 10+ year strategy, if successful, will shift from a health system that reactively cares for the sick, to proactively preventing individuals from falling ill, and drive efficiency into the system. The program is expected to cost the government S$1 billion (US$0.7 billion) in set up costs over the next 3 to 4 years, and S$400 million in running costs annually, representing approximately double the budget spent on preventive healthcare today.
Healthier SG will be rolled out in phases, with the first focused on Singapore residents aged 60 years and above who will enroll with a family doctor from mid-2023. This group will be able to access support and subsidized services like nationally recommended vaccinations and screenings, along with subsidies for medical bills for chronic illnesses and incentives to support active and healthy lifestyles.
However, central to the policy is the relationship between the resident and the family doctor, where the doctor can provide holistic care focused on prevention and better management of chronic conditions. Much of the management of health conditions happens at home, and this partnership can mean better outcomes. Family doctors can also become a care coordinator for a patient with complex conditions and understand their needs. Yet the focus on family doctors will need to be balanced by existing resources and preferences with public and specialist healthcare options, which should not be inadvertently downplayed or disincentivized. Nonetheless, a major shift in healthcare workforce will be needed and by 2030, the government intends that a quarter of the doctors and nurses will be in primary and community settings (up from only a fifth).
Ensuring enough family doctors and nurses are available to meet these changing priorities will be key to ensuring that waiting times and barriers to access to services are kept down, particularly in neighborhoods with high density of older people. It will also require a significant change in behavior as registration with one doctor discourages people from shopping around as they do at the moment. In a similar vein, cost transparency should be encouraged in GPs so that the parity of public healthcare is maintained despite the mobilization of private healthcare practices.
Joining up care and enabling the strengthening of the health systems will be underpinned by improving how data is shared and governed within the health system, while protecting patient data. GPs will be given a grant to offset the costs of IT adoption, but other initiatives will likely be needed to maintain systems and the headcount needed to support this over the long run. The expansion of another key technology enabler, the Healthy 365 application, will need to consider access to all demographics, whether financially able or sufficiently tech-savvy, in order to complete the loop on community care.
To ensure more consistent and well-coordinated care, particularly around common diseases, the Clinical Services Roadmap for Primary Care will be developed. These documents will be further strengthened over time but will be critical to how diabetes mellitus, hypertension, and lipid disorders are managed throughout the life cycle, as well as some preventative measures. This will be supported by a different payment model for GPs based on an annual service fee, which in turn is based on several factors including the health risk of each enrolled resident, scope of required care, and progress in care and management of chronic disease. These will sit alongside wider care protocols to guide screenings and vaccinations.
In the medium term, overall funding for the Singapore public health system will move to a capitation model where each health cluster will receive a budget based on the size of its population, rather than the amount of services being delivered. The budget per person will be tiered based on the health risk, so the elderly and children will likely sit in a higher tier and receive a larger budget. This is a major and ambitious shift, and brings the Singapore system into alignment with many other countries with developed public health systems that want to drive efficiency rather than activity.
Healthier SG is targeted to yield results over a long-term, with visible initial results likely within eight to ten years. Key indicators within the short-term will include enrolment, screening, and vaccination rates. In the longer-term, indicators include healthcare services utilization rates (admissions, costs, average bed days) and disease prevalence. It is a testament to the trust in the Singapore government that these changes have been broadly welcomed. The devil will be in the detail as to how these new models are rolled out.