Commentary: Why is Singapore embarking on Healthier SG and population health?
Through Healthier SG, Singapore is redefining good health and building a system where Singaporeans can stay healthy for longer, says Dr Clive Tan of NUS Saw Swee Hock School of Public Health.
SINGAPORE: The Singapore Ministry of Health (MOH) announced on Mar 3 that all Singapore residents will receive S$20 worth of health points if they enrol in the voluntary Healthier SG programme and complete their first health consultation.
Healthier SG benefits such as free health screenings and vaccinations will commence in July, with enrolment starting for residents aged 60 and above.
Minister for Health Ong Ye Kung said on Mar 3 that Singapore will build a strong population health system through Healthier SG. The concept of population health - health for everyone in a defined population - is relatively new to Singapore and Southeast Asia. How does the concept translate to action and benefits for our citizens?
UNPACKING POPULATION HEALTH
At present, organisations practising population health have anything between a few hundred thousand to tens of millions of people under their care. United States healthcare provider Kaiser Permanente has more than 12 million members. Dealing with large numbers such as these can get mind boggling.
It may be simpler to think about a village, with 1,000 people, and the “organisation” as the village clinic, with a doctor and a support team.
When the population is young and their health needs are light, and if the village clinic only sits back and wait for patients to arrive - the clinic may not be very busy. But when the villagers get older, their health needs increase and compound, and the clinic may find itself overwhelmed.
If the clinic takes proactive steps to move beyond taking care of the ill villagers that appear at its doors, it can lead to better health for the village and reduce need for urgent care at the clinic.
It warrants emphasis that people who need healthcare services do not necessarily use them. A population health approach accounts for this and considers the people who need healthcare services even if they do not think they do so.
For example, most of us do not think that children need preventive health services, but population health needs to begin early and a S$100 top-up of ActiveSG credit will be provided to young children to encourage them to take up sports.
MOVING AWAY FROM EPISODIC CARE TO PREVENTIVE AND END-TO-END CARE
A key consideration for why the population health paradigm is a game-changer is related to the World Health Organization’s definition of health as not merely the absence of disease, but a state of physical, mental and social well-being.
This implies that health is bidirectional. That changes everything about the current healthcare model where we wait for the patient to fall sick, then attempt to treat and nurse the patient back to health. This is a -1 to 0 model, a repair shop.
If we see good health as a positive health state, then we move to a -1 to +1 model, a model that justifies and encourages investments and actions to bring health from a start state of zero to a positive value.
Episodic care works up to a certain degree. But as the population ages and their health needs become more complex, coupled with growing affluence and higher expectations, episodic care looks more like the poorer cousin of holistic, integrated and person-centred care.
Integrated care has been around in Singapore for more than a decade. But its status is that of a “good to have” ideal. Like how we aspire to see Singapore play in the World Cup - it creates a lot of excitement and energy, but the majority do not take it seriously. And when it does not happen, nobody is too disappointed.
But a population health system, if designed and architected right, makes care integration a cornerstone of the entire system. Preventive care and end-to-end care make sense when the organisation is responsible for the health of that defined population, and there is clear joint ownership of health in a system where interests and incentives align.
The organisation would then invest in value, strong relations and interventions that would yield the most health returns for the population. It will incentivise healthcare providers to design and deliver their services to meet population health needs and objectives. We would want to have a population that stays healthy for longer, and when ill health occurs to address it in a timely manner before it worsens.
SHIFTING TO POPULATION HEALTH MAKES A CHOICE FOR ALL
Shifting Singapore’s health system to a population health system is choosing for everyone and enables all to make healthier life choices. It is like tackling air pollution where regulatory decisions help everyone benefit from clean air. There is little reason why the public would say no to a well-designed population health system because we would be the beneficiaries.
But from a systems perspective there are genuine concerns. First, investments to get people into a positive state of health will cost more upfront, and the promise of future cost avoidance is uncertain. And the system is poor at measuring the intangible benefits of a healthier population, so the typical return on investment approach for this may be poorly understood.
Second, can we design a strong and sound population health system? Like a car - this system has many different parts that can go wrong. Learning from others on the theory and science is necessary, but the ability to learn while doing, and improvise while building and operating would be the key to success.
The truth is that no system has managed to tick all the checkboxes for success as it involves making value-based choices and accepting trade-offs. The United Kingdom National Health Service has a strong primary care system but waiting times for surgical procedures can be long - the average waiting time for cataract surgery is nine months.
Scandinavian countries provide high-quality health services with a strong focus on prevention and wellness, but these account for a significant portion of government spending. Denmark’s healthcare spending has been at 10 per cent of its gross domestic product for the last ten years.
Acknowledging that healthcare is a complex adaptive system, we cannot wait until we have all the answers before we start changing. Healthier SG is a good first step, but it is the start of a long journey. We need to stay nimble, humble and alert to make sure we build a sound system for ourselves and our loved ones.
Dr Clive Tan is Assistant Chief of the National Healthcare Group (NHG)’s Integrated Care division. He also lectures on healthcare management at the NUS Saw Swee Hock School of Public Health. This commentary was written in his personal capacity as a public health specialist.
