Singapore's health-care system: key features, challenges, and shifts

Tan, Chorh Chuan; Lam, Carolyn S.P.; Matchar, David B.; Zee, Yoong Kang; Wong, John Cm

doi:10.1016/s0140-6736(21)00252-x

Cited by 95 publications

(79 citation statements)

References 36 publications

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“…Public sector clinics in Singapore provide subsidized primary care services to a multiethnic patient population from diverse socioeconomic backgrounds [ 19 ]. These clinics are staffed by physicians and nurses, and have onsite pharmacies and laboratories.…”

Section: Methodsmentioning

confidence: 99%

Integration of a multicomponent intervention for hypertension into primary healthcare services in Singapore—A cluster randomized controlled trial

Jafar

Tan²,

Shirore³

et al. 2022

PLoS Med

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Background Despite availability of clinical practice guidelines for hypertension management, blood pressure (BP) control remains sub-optimal (<30%) even in high-income countries. This study aims to assess the effectiveness of a potentially scalable multicomponent intervention integrated into primary care system compared to usual care on BP control. Methods and findings A cluster-randomized controlled trial was conducted in 8 government clinics in Singapore. The trial enrolled 916 patients aged ≥40 years with uncontrolled hypertension (systolic BP (SBP) ≥140 mmHg or diastolic BP (DBP) ≥90 mmHg). Multicomponent intervention consisted of physician training in risk-based treatment of hypertension, subsidized losartan-HCTZ single-pill combination (SPC) medications, nurse training in motivational conversations (MCs), and telephone follow-ups. Usual care (controls) comprised of routine care in the clinics, no MC or telephone follow-ups, and no subsidy on SPCs. The primary outcome was mean SBP at 24 months’ post-baseline. Four clinics (447 patients) were randomized to intervention and 4 (469) to usual care. Patient enrolment commenced in January 2017, and follow-up was during December 2018 to September 2020. Analysis used intention-to-treat principles. The primary outcome was SBP at 24 months. BP at baseline, 12 and 24 months was modeled at the patient level in a likelihood-based, linear mixed model repeated measures analysis with treatment group, follow-up, treatment group × follow-up interaction as fixed effects, and random cluster (clinic) effects. A total of 766 (83.6%) patients completed 2-year follow-up. A total of 63 (14.1%) and 87 (18.6%) patients in intervention and in usual care, respectively, were lost to follow-up. At 24 months, the adjusted mean SBP was significantly lower in the intervention group compared to usual care (−3.3 mmHg; 95% CI: −6.34, −0.32; p = 0.03). The intervention led to higher BP control (odds ratio 1.51; 95% CI: 1.10, 2.09; p = 0.01), lower odds of high (>20%) 10-year cardiovascular risk score (OR 0.67; 95% CI: 0.47, 0.97; p = 0.03), and lower mean log albuminuria (−0.22; 95% CI: −0.41, −0.02; p = 0.03). Mean DBP, mortality rates, and serious adverse events including hospitalizations were not different between groups. The main limitation was no masking in the trial. Conclusions A multicomponent intervention consisting of physicians trained in risk-based treatment, subsidized SPC medications, nurse-delivered motivational conversation, and telephone follow-ups improved BP control and lowered cardiovascular risk. Wide-scale implementation of a multicomponent intervention such as the one in our trial is likely to reduce hypertension-related morbidity and mortality globally. Trial registration Trial Registration: Clinicaltrials.gov NCT02972619.

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Section: Methodsmentioning

confidence: 99%

Integration of a multicomponent intervention for hypertension into primary healthcare services in Singapore—A cluster randomized controlled trial

Jafar

Tan²,

Shirore³

et al. 2022

PLoS Med

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“…The representative strongly made the case that access to PM data may allow the development of more sophisticated models to stratify patients according to risk, which could result in lower premiums for low-risk groups; and that data accessed from PM programmes would not be used to assess or evaluate individuals applying for insurance coverage as they would not contain personal identifiers. Nonetheless, jurors remained concerned about the cost of health insurance 5 (Cindy, 2021;Tan et al, 2021) and the threat of genetic discrimination. While citizens and permanent residents are entitled to government health insurance (Ministry of Health, 2021a) the coverage is basic and many people buy additional private insurance.…”

Section: Recommendationsmentioning

confidence: 99%

“…Recent empirical research suggests that countries with heavily privatized health systems (such as the USA) may be associated with greater public reluctance to share health data for research and greater distrust, particularly of commercial end users of data compared to countries with a socialized single-payer system (such as the UK) (Ghafur et al 2020). Singapore has a substantial private healthcare sector, but the system is predominantly government-run and publicly funded via tiered insurance schemes, that is Medisave, Medishield Life and Medifund (Tan et al 2021). Indeed, survey research (Lysaght et al, 2021) correspondingly reported high levels of trust in Singapore hospitals and the health ministry with relatively less trust in private companies.…”

Section: Towards Trustworthy Governance For Sharing Of Pm Data With P...mentioning

confidence: 99%

Sharing precision medicine data with private industry: Outcomes of a citizens’ jury in Singapore

et al. 2022

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Precision medicine is an emerging approach to treatment and disease prevention that relies on linkages between very large datasets of health information that is shared amongst researchers and health professionals. While studies suggest broad support for sharing precision medicine data with researchers at publicly funded institutions, there is reluctance to share health information with private industry for research and development. As the private sector is likely to play an important role in generating public benefits from precision medicine initiatives, it is important to understand what the concerns are and how they might be mitigated. This study reports outcomes of a deliberative method of citizen engagement in Singapore that asked whether sharing precision medicine data with private industry would be permissible, and if so, under what circumstances. Findings from this citizens’ jury suggest sharing with industry would be permissible under certain conditions that are set out in nine recommendations. Implications of the recommendations and their underlying assumptions for policy decision makers are discussed. This study aligns with prior international studies which found conditional acceptance for data sharing with private industry, a public benefit requirement, specific reluctance to share with insurance companies and an emphasis on accountability and transparency to demonstrate trustworthiness. However, our results differ from prior studies in that opt-in consent did not dominate the deliberations as jurors were able to set it aside as an assumed prerequisite for participation in a precision medicine programme.

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“…Today, Singapore faces new MCH challenges as the nation's attention shifts from "survive to thrive", and from "healthcare to health" [10]. Achievements of the past, in terms of reduced maternal and infant mortality rates, have now been overshadowed by the sharp increase in metabolic disorders and non-communicable diseases (NCDs) [11], mainly arising from high rates of obesity [12].…”

Section: Introductionmentioning

confidence: 99%

A Golden Thread approach to transforming Maternal and Child Health in Singapore

Yap

Loy

et al. 2022

BMC Pregnancy Childbirth

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Maternal and child health (MCH) in Singapore is entering a new phase, with challenges different to those faced 50 years ago. The advancement of medical technologies and access to MCH resources have led to a dramatic fall in maternal and infant mortality rates. However, there has been a steep rise in the rates of obesity and related metabolic diseases. Alongside this is an emerging mental wellness challenge, with one in ten women experience depression across pre-, during and post-pregnancy. Maternal obesity and mental disorders before and during pregnancy not only increase a woman’s risk of pregnancy complications, but also result in increased risks in the offspring of childhood obesity, behavioral disorders and later life metabolic disease, catalyzing vicious cycles of disease. Thus, there is a pressing need to transform the current MCH system to address a burgeoning metabolic and mental health challenge for Singapore. Initiating interventions during preconception and continuing into the postpartum has the potential to confer long-term maternal-child benefits, promoting virtuous cycles of health. However, the current MCH system emphasizes antenatal care and lacks focus on the equally, if not more important, preconception, postpartum and inter-pregnancy stages. We describe a new model-of-care framework that integrates a life-course approach to health across preconception, pregnancy and postpartum phases, with the social-ecological model comprising individual, interpersonal, institutional, community and policy as the major targets for health promotion interventions. This “golden thread” approach is being established at the Singapore KK Women’s and Children’s Hospital (KKH), to address both metabolic and mental health challenges to achieve the goal of a thriving, healthy nation. This new model-of-care is set up in KKH as a pilot program known as Healthy Early Life Moments in Singapore (HELMS). HELMS will reach out to women planning to conceive through coordinated interventions across preconception, pregnancy and postpartum periods. A mobile health platform is being developed to facilitate interventions and engage participants in the program through a digital, personalized and interactive approach. This new model-of-care is designed to secure a population with healthy life cycles, by influencing each life-course, early-in-life, to provide the best start for generations to come.

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Singapore's health-care system: key features, challenges, and shifts

Cited by 95 publications

References 36 publications

Integration of a multicomponent intervention for hypertension into primary healthcare services in Singapore—A cluster randomized controlled trial

Integration of a multicomponent intervention for hypertension into primary healthcare services in Singapore—A cluster randomized controlled trial

Sharing precision medicine data with private industry: Outcomes of a citizens’ jury in Singapore

A Golden Thread approach to transforming Maternal and Child Health in Singapore

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