By Beryne Odeny (Washington University in St. Louis, Department of Surgery) and Julia Robinson (PLOS Global Public Health) The first in-person CUGH…
By guest contributors Chuan De Foo and Hui Xiang Chia
Singapore has achieved one of the highest life expectancies in the world with a low government health expenditure of just 3.2% of GDP, demonstrating its ability to deliver good health outcomes cost-effectively. However, as the country is rapidly ageing, healthcare needs are rising in tandem, driving healthcare expenditure to triple from 2010 to 2019. To address this challenge, the Ministry of Health unveiled the national vision for the healthcare system in 2017, termed the 3 Beyonds – beyond healthcare to health, beyond hospital to community, and beyond quality to value. In 2022, this paved the way for Healthier SG, a major reform to manage the health of the population through preventive and holistic care approaches.
Healthier SG presents a window to leverage on synergies between primary care and population health management. Population health principles should be actively incorporated in the strategy, policies, and implementation of health systems. Below we discuss how population health has been and will be incorporated into Singapore’s primary care transformation.
1. Instilling a population health lens to primary care practice
Healthier SG is a monumental shift to instil a population health lens to primary care, empowering general practitioners (GPs) to transcend their traditional roles as “cough and cold doctors” and step up to provide services across the life course. The population will be soft-tagged to a private GP of their choice, primarily encouraged by residential proximity. Each resident will have a tailored health plan encompassing promotive and preventive health aspects, such as health screening, vaccinations, and healthier lifestyle behaviours. Social prescribing will be used to connect patients and their families to a range of community services, spanning exercise or cooking classes to encourage healthier lifestyles to social services for those with psychosocial needs.
Unfortunately, the National Electronic Health Record (NEHR) system is not compulsory for private primary care providers, meaning that information on the bulk of private primary care attendances in the country is not collected in the Ministry of Health’s information systems. This poses a barrier for policymakers in understanding and addressing the population’s primary care needs, particularly the management of chronic conditions by private GPs. While NEHR use is not compulsory under Healthier SG reforms, participating GPs will be required to contribute data of their patients to the Ministry of Health, including progress and clinical outcome indicators monitoring chronic disease management. This can be achieved through a registry which enables policymakers to assess the effectiveness of Healthier SG reforms on improving the health of the population and formulate more targeted interventions to address the chronic disease burden. Data sharing will also be safeguarded by an upcoming Health Information Bill.
2. Pinpointing and tackling the highest-burden conditions in the community through different vehicles of care
To improve population health and reduce burden to the healthcare system, reforms have targeted the highest-burden conditions, namely diabetes mellitus, hypertension and hyperlipidemia. Since 2013, Family Medicine Clinics (FMCs) which reference patient-centred medical homes, offer a suite of healthcare services for patients with stable chronic conditions down-triaged from tertiary hospitals. Community Health Centres (CHCs) were also established to augment private GP practices. As most GPs are solo practitioners with no access to ancillary services such as nurse counselling and physiotherapy, CHCs provided a way for GPs to refer patients to these subsidised services. In 2018, Primary Care Networks (PCN) were implemented to encourage private GPs to organically form teams to share resources and learn from each other. Funding is provided for each network to offer ancillary services for common chronic conditions. Some of these networks were co-led by public healthcare clusters. PCNs provide platforms for communication between the public and private health sectors and facilitate the sharing of best practices.
3. Advocating for healthier lifestyles: Leveraging digital health innovations to keep populations healthy and healthier
Singapore has leaned into digital health innovation to power its health reforms. The HealthHub app enables residents to access their health records easily, including their medical appointments, lab test results, screening and vaccination records, hospital admissions and discharges, and medication prescriptions. Healthy lifestyle innovations such as the Healthy365 app nudge citizens into healthier lifestyle choices by rewarding them if they complete physical activities or healthy eating behaviours. This app will be linked to future Healthier SG initiatives which are interlocked with preventive and promotive health services offered by GPs. Enabled by a robust digital infrastructure, these innovations enhance population access to health information and empowers individuals to take an active role in improving their health.
4. Cross-training of primary care physicians in population health
While primary care physicians have been called upon to be ambassadors of population health, they might not be fully able to do so unless population health practice and research take a more central role in family medicine training. Primary care doctors would be more willing and better equipped to go beyond their traditional remit to deliver promotive and preventive care if they have a deeper understanding of how to look after the patient population soft-empanelled to them. As such, we advocate for more cross-training in population health for primary care providers starting from medical school curriculums to residency programmes. This would also provide platforms for population health and primary care practitioners to find areas of synergy and collaboration.
5. Primary care safeguards the health of the population during crises
Primary care clinics served as vanguards for public health emergencies. Since the advent of transboundary haze and the H1N1 pandemic, Public Health Preparedness Clinics (PHPCs) have been established to provide frontline responses to public health emergencies. PHPCs are private GP clinics trained and equipped to be operationally ready for emergency mobilisation. From community surveillance to digital health consultations to vaccinations, PHPCs discharged their duties dutifully. The national COVID-19 response also showed the viability of public-private partnerships, as GPs stepped up to be the first point of contact for COVID-19 patients, managing stable patients in the community while up-triaging serious cases to tertiary hospitals. The contributions of the primary care sector in the pandemic demonstrated to policymakers the critical need to engage and resource this essential node in Singapore’s health system.
Integrating population health management and primary care strengthens health systems
From ageing populations to zoonotic outbreaks, health systems have learnt that primary care must not just be another stopgap measure during a health crisis nor bolted on as an afterthought when hospitals are inundated with chronic loads. The COVID-19 pandemic has brought us a narrow window of opportunity to build more resilient health systems. We look forward to seeing how Singapore leverages on primary care to safeguard the health of Singaporeans in both crises and peace time.
Chuan De is the regional leader for the Western Pacific at the International Working Group for Health Systems Strengthening. He is also a public health professional based at the Leadership Institute for Global Health Transformation (LIGHT) in Singapore, an associate editor at the Journal of Migration and Health and a correspondent for the International Health Policy Platform based in Antwerp. His areas of expertise lie in primary healthcare, health financing for universal health, integrative health delivery models, health equity and pandemic preparedness. Twitter handle: @chuande99.
Hui Xiang Chia is a researcher at the Leadership Institute for Global Health Transformation, Saw Swee Hock School of Public Health, National University of Singapore. Her research focuses on systems and policies which support the health and care needs of ageing populations.
Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.