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TRANSFORMING HEALTH SYSTEMS: EQUIPPING PRIMARY CARE TO MANAGE THE HEALTH OF
SINGAPOREANS

June 5, 2023 PLOS Global Public Health Global Health


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.


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