Mr Deputy Speaker sir, my adjournment motion today focuses on transforming our preventive health efforts. In the view of some Singaporeans and healthcare workers I have spoken to, these efforts are not yet fighting fit to take on some of the big health challenges of the near future, and are already not delivering the health outcomes that we could be achieving for a wealthy, developed nation.
By preventive health efforts here, I mean our policies and programs for reducing the incidence of chronic disease conditions like diabetes, hypertension and so on; as well as our policies to move Singaporeans towards better health outcomes in general.
In this speech, I will detail proposals fitting into three overall thrusts:
One, we should adopt an outcome-focused approach that is long-term but given tough regular reviews;
Two, we should reward the good health choices of individuals, especially at-risk groups; and
Three, we should use highly-targeted strategies that nudge healthcare providers and leverage data towards better health outcomes.
But first, let’s take stock of our preventive health efforts and the huge health problems we face.
The facts – an A for effort but a C for outcomes?
Sir, HPB was founded in 2001. Our spending on preventive healthcare efforts last year was about 5% of total non-Covid MOH spending, with about $330M allocated to HPB[1].
There are many worthy programs that have been undertaken. For example, in public discussions of what the government does to nudge Singapore towards living healthier lifestyles, the National Steps Challenge is often mentioned.
However, what is the picture that emerges when we look at indicators of chronic conditions? We find that the incidence of certain dangerous chronic conditions has increased steadily in recent decades. Are we in danger or racking up a A grade for effort but a C grade for outcomes?
Our mortality rates for cancer, stroke and heart disease have improved, perhaps owing to technological and economic factors
But, as the Singapore Public Sector Outcomes Review does, soberingly, acknowledge, about one in three residents aged 40 to 69 years has hypertension; and two in five have high cholesterol.[2] Based on the last like-for-like comparison I could find, our 2015 diabetes prevalence among those age 20-79 at about 11%[3] is much higher than the OECD average of 7%[4]. In 2015, Singapore was #2 in the world in diabetes prevalence.[5]
In fact, 1 in 4 Singaporeans aged 40 years and above have at least 1 chronic disease.[6] The proportion of older adults with three or more chronic diseases nearly doubled from 2009 to 2017.[7]
A 2017 MOH study showed that Singaporeans may have a longer life expectancy today, but do not necessarily enjoy a better quality of health. Singaporeans born in 2017 are expected to spend on average 1.5 more years in poor health, compared to those born in 1990 – and this refers to the years spent on average in poor health.[8]
Sir, these trends are likely to worsen if transformative intervention is not done.
In 2017, a HPB expert noted that if obesity is not effectively curbed, Singapore could hit obesity rates of 15% in just seven years. That was the point at which obesity increased rapidly in the United States, where it is now considered an epidemic.[9]
According to a report by the Economist, cardiovascular diseases (CVDs) contribute to approximately one in three deaths in Singapore, and levy about US$11 billion in costs on individuals, their households and the public finances. Modifiable risk factors (for CVDs) such as smoking and high cholesterol levels account for 60% of these costs.[10]
In short, we have a very big problem that needs to be tackled now with new thinking. I would like to make some policy recommendations to reverse these worrying chronic condition trends and get tough on preventive health.
A tough, outcomes-driven approach
My first recommendation is that the government should focus more clearly on outputs and outcomes. We should set clear goals for outputs like the proportion of persons exercising regularly, for example. We should also state clear short and medium-term targets for lowering chronic disease incidence. We cannot succeed if we do not define what success looks like.
Meeting such targets is dependent on a range of factors and not only government policies. This is clear and I do not disagree with this. We cannot ultimately micro-manage personal behaviour.
But we should know what are the short and medium-term targets for outputs and outcomes that we are aiming at, so that we know when we are away from goodness.
It is useful to refer to participation rates for programs and events, the number of app downloads, and so on. But these are effort indicators. We must not over-emphasise effort indicators in our public communications. Doing well on effort indicators can lull us into a false sense of security. We should prioritise outputs and outcomes. These determine whether we have won or lost the battle.
For instance, although it has been 5 years since Singapore declared “War on Diabetes”, MOH said at COS 2021 that the “prevalence of diabetes has not decreased” from 2017 to 2020.[11] Furthermore, during this time, the prevalence of obesity, high blood pressure and high blood cholesterol have risen.[12]
Some types of efforts may not yield good outcomes. One example: HPB’s One Million KG Challenge in 2014 set a clear target of a collective weight loss of one million kilograms from at least 300,000 participants over three years.[13] The HPB CEO has publicly acknowledged that they only managed to lose “a few tens of thousands of kilos”.[14] It is important to draw lessons from such experiences.
As an international example for comparison, I will cite the Nordic Plan of Action, which sets specific ambitious targets for reducing obesity rates and improving physical activity levels and healthy diets with a regular monitoring system every 2 years.[15] While recent results have not been very good, at least there is a robust, transparent system with targets and monitoring to drive towards the right outcomes.
Sir, let me go on to make some very specific policy recommendations.
Rewarding good health choices of individuals, especially at-risk groups
Firstly, I will speak on rewarding good health choices. It is time to provide serious financial nudges to citizens to encourage healthy behaviours.
Providing cash incentives or subsidies for MediShield Life Premiums for those with healthier behaviours
First, we should provide some cash incentive or subsidies for MediShield Life premiums to those who demonstrate a commitment to healthier behaviours, such as regular screenings or regular exercise, as verified by way of attendance records; or wearable technology.
We have tried such schemes before, such as LumiHealth, the Apple Watch tie-up[16]. But we must put our money where our mouth is to ensure these schemes reach more people, in particular, those who are not yet exercising, eating well, or going for their screenings. We can use various touchpoints like family doctors – in whom many trust deeply – to spread the word.
There are examples of health insurers in other countries that provide premium discounts based on the adoption of behaviours that tend to make pay-outs for medical treatment less likely. The US insurance provider Vitality provides premium discounts for members, alongside freebies[17].
I realise that this is a significant departure from the current approach. Further study should be done before adopting this as a general policy. The approach of testing a major policy through controlled randomised trials was also something I argued for when calling for smaller form class sizes in schools in an AM in 2017.
Making more vaccines free
Next sir, let me turn to vaccines. In its GE2020 manifesto, the Workers’ Party called for making Covid-19 vaccines free, long before they had been successfully launched. This is something that most governments in the world have done and rightly so.
But the principle of making vaccines free can be extended. Other things being equal, higher vaccination rates have the potential to minimise disease incidence and hence reduce public and private expense in healthcare treatment for those diseases.
Sir, in the past, I have argued for making HPV vaccines free and added to the compulsory immunisation schedule for children. I also called for a bigger role for free vaccines in the public health system, rather than simply allowing Medisave to be used for vaccines. Medisave is, after all. “our own money”. Many Singaporeans are reluctant to touch it for something less tangible like a vaccine, fearing that they will need all the Medisave they can get later in life for actual medical treatment. Vaccines have huge public benefits, as we are seeing during Covid, so the government should pay for them.
In 2020, the government announced some improvements to subsidy levels for vaccines. I remember having an exchange in this House with then SPS Mr Amrin Amin,[18] asking him if the subsidy for vaccines can be pegged to the amount of money the state would save from higher vaccination rates. He replied saying that they were crafting this package and would announce the details in time. I would like to repeat this call.
There is much more that can be done to improve vaccine take-up rates. Our take-up for flu vaccines, for example, is much lower than it should be, compared to some other developed countries. In a reply to my earlier parliamentary question, the government acknowledged that our take-up rate for flu vaccinations, of 24% in Singaporeans aged 65 years and above, is significantly lower than the equivalent rate of about 70% in Australia, the United Kingdom and the United States.[19]
According to one widely cited figure, about 4,000 people die in this country from pneumonia and influenza every year.[20] There is a great deal of suffering and cost involved in treating flu patients who become ill.
Let’s start with making flu vaccines free and thus easy to get for key groups like pregnant women, those with chronic health conditions, and older folks over 65. Again, GPs can play a big role in promoting adult vaccination. The same can be said for the pneumococcal vaccine.
Even setting aside the toll in human suffering, if we calculate the costs, it could benefit the state to make such vaccines completely free, as this would save downstream fiscal expenditures like hospital subsidies. A healthier population is always worth investing in.
Increasing take-up for health screening
Next, I would like to talk about health screening.
Screen for Life is a well-intentioned policy, but low take-up rates leave much to improve on. According to MOH’s response to a PQ I filed, 100,000 out of 1.8 million (5.6%) eligible Singaporeans have benefited from SFL subsidies.[21] By comparison, take-up rates of national health screening programmes are 22% in Japan and 30% in Taiwan.[22]
Take-up is notably skewed towards the Chinese compared to other ethnic groups.[23] Sir, I do acknowledge the government’s efforts to reach out to community groups, to raise health screening take-up, including among minority communities. These are worthy efforts. But clearly the results leave much to be improved upon.
HPB should, I think, conduct studies into the reasons for low take-up rates despite heavy subsidies for health screening under SFL. Anecdotally, lower-income constituents I have met have occasionally shared that they do not wish to go for health screening as they are daunted by the high costs of treatment if disease is detected. If those who are most at risk of chronic diseases are not getting screened, this would not only incur greater downstream costs to the individual and society, but also raises deeper questions about access to basic healthcare for the most vulnerable among us. But for now, I would like to offer some policy suggestions here on raising these rates.
Firstly, as mentioned earlier, the government could provide subsidies for Medishield Life premiums for those who regularly undertake health screening. Some insurers, like NTUC Income, reward policyholders with good health screening results with shopping vouchers.[24]
Sir, many studies prove it is far cheaper to screen and to catch a disease early and slow its progression. In Singapore, one in three diabetics, one in four people with hypertension and almost half of those with high cholesterol levels do not know that they have these conditions. Those who do not know they have these diseases would push up costs for everyone.
I have called in a past PQ for inclusion of waist circumference measurement in national health screening.[25] This metric is important in defining obesity risk, rather than over-relying on the BMI. I am glad that MOH is moving to implement this, and I look forward to seeing more evidence-based inclusions in health screening.
Health inequality
Sir, in nudging individuals towards healthier choices, I think it is important to pay special attention towards especially vulnerable groups like the lower-income. Many lower-income Singaporeans lack the means to purchase and cook healthier foods. When I say this, of course I don’t mean that all healthy foods are costly, but many healthy food decisions are more expensive, complicated or more time-consuming.
In providing aid to lower-income families, can some of our aid be provided in the form of highly-frictionless digital currency earmarked for the purchase of healthier food products with, for example, less saturated fat and sugar? It could also focus on unprocessed foods like raw meat. A digital currency would be easily programmable and could be updated monthly to reflect inflation[26]. With RFID technology in supermarkets and grocery chains, this should not be too difficult to do. In the past, we have tried vouchers and other similar programmes, but if we can have a regular provision of frictionless aid, this would a much stronger nudge to eat healthily at home.
Sir, I also want to make a more philosophical point about helping the poor on health. Our preventive health programmes tend to place personal responsibility on individuals to take charge of their health and lead healthy lifestyles.[27] However we have a collective responsibility to ensure the less privileged among us also have access to healthy lifestyle habits and are supported in that direction. Health is a critical dimension in improving lives and livelihoods for poorer Singaporeans.
In a reply to my earlier PQ in 2020, MOH revealed that the life expectancy gap between those with post-secondary and above education compared to those with below secondary education was 5.8 years.[28] This is a shocking figure, though it should be said that similar statistics can be found in other developed countries.
At the 2021 COS, then Health Minister Mr Gan Kim Yong remarked that MOH “pay[s] special attention to lower-income households” including their preventive health needs.[29] This is a welcome assurance.
How effective are the existing preventive health care programmes targeted at low-income groups (e.g. Healthy Living Passport[30] programme, KidStart, ProPEL[31])? Can we release more data on chronic disease prevalence and other health outcomes by gender and socio-economic status?[32] With more data, we can devise better programs to nudge those on lower incomes towards better health outcomes.
A highly-targeted, data-driven approach towards better health outcomes
Incentives for health, not only treatment
Next, I would like to talk about incentives for healthcare providers. Can we think of alternative models where there is a degree of incentivization based on the success of the healthcare provider in nudging patients towards better health outcomes? In other words, instead of paying providers for treating the sick, can we pay them, in part at least, for encouraging their patients to not get sick in the first place?
This notion is not as Utopian as it seems. A few healthcare systems in the world are inching towards that. For example, Kaiser Permanente – California is well-regarded as a provider of high-quality, efficient and affordable integrated care. It has three separate entities: a health plan that bears insurance risk, medical groups of physicians, and a hospital system. The financial incentive is to provide a high-quality continuum of care and maximise population health rather than profiting from a high volume of compensable services.[33]
Can we this remodel our system of healthcare providers to incorporate incentives for effective preventive health work with patients, rather than compensation to the healthcare provider being linked only to the performance of treatment and tests.
One other specific example would be to empower healthcare providers with interoperable IT systems that can flag out if a patient has not got a mammogram or blood screening recently and direct the patient to get that done, while they are visiting for something else entirely. This would be the medical equivalent of a “no wrong door” approach.
Moving towards such an alternative system of compensation for healthcare providers is indeed a very big, some would say radical, idea. As always, piloting, randomized controlled trials are all advisable. But the time to act is now.
Data, data, data
Lastly, I would argue that we should make health data available more quickly and in more granular detail regarding chronic conditions. Much of the data on disease incidence is not published so frequently and after a significant time lag from data collection.
Covid has shown that we can publish data on healthcare metrics practically in real time, if the political will is there. It would help us to have public data on diabetes say quarterly, to ensure not only better public debate on healthcare policy but also better alignment of outcomes and incentives to providers.
And on this note, I would like to ask if MPs can be given data on chronic disease patterns and also other relevant indicators at the precinct level. It would help MPs to know where there are concentrations of particular health issues, for the purpose of raising relevant talking points when we meet constituents and perhaps organizing relevant ground events such as talks.
Can we conclusively move to a system where comprehensive data on a patient is easily and always available to healthcare providers, assuming permissions are given, of course. In fact, can we nudge patients to provide permission for data sharing across healthcare providers. This would enable medical professionals to reduce duplication of tests and get a more holistic picture of every patient’s health situation, at any time. Right now, data is available from the NEHR but feedback is that the process of accessing it is not easy and streamlined.
I would also suggest that the government invest more in workforce automation of sorts for doctors – such that the IT system prompts them about possible conditions the patient may have or alternative theories, based on data analytics and AI. The US NPO Kaiser Permanente is widely recognised as having pioneered some world-class IT systems that help doctors do just that – suggesting to doctors that patients may have a certain condition in some cases in the same way that Amazon prompts buyers by saying those who bought this book also liked this other book.
Conclusion
In conclusion sir, we are not faring well on many chronic disease indicators and this could portend worse to come. That would mean more human suffering, and more pressure on our fiscal resources. When the costs of failing are socialised as it is in this preventive health war, stronger action is justified.
The challenges we face in preventive healthcare are large, complex and defy any one magic bullet. But there are good ideas for change on the table, ideas that have been researched and put to the test academically and in the experience of other countries.
The rewards for early, bold, decisive action can be tremendous. Our children and grand-children will thank us for taking those actions today. So let’s do this today.
[1] https://www.moh.gov.sg/news-highlights/details/preventive-care-spending-and-impact
[2] https://www.mof.gov.sg/singapore-public-sector-outcomes-review/citizens/opportunities-for-all-at-every-stage-of-life/health-and-wellness
[3] https://mtalvernia.sg/education/living-with-diabetes-for-elderly-patients/#:~:text=In%202015%2C%20the%20International%20Diabetes,69%20years%20old%20having%20it.
[4] https://www.oecd.org/health/rising-diabetes-and-obesity-threaten-progress-in-tackling-cardiovascular-diseases.htm
[5]https://www.straitstimes.com/singapore/health/singapore-has-2nd-highest-proportion-of-diabetics
[6] These refer to diabetes, high blood pressure, high blood cholesterol & stroke. https://www.hpb.gov.sg/article/tips-to-prevent-and-manage-chronic-diseases-in-the-workplace.
[7]https://www.straitstimes.com/singapore/health/proportion-of-older-adults-with-multiple-chronic-diseases-surges
[8]https://www.moh.gov.sg/docs/librariesprovider5/default-document-library/gbd_2017_singapore_reportce6bb0b3ad1a49c19ee6ebadc1273b18.pdf. Gains in Life Expectancy have not been matched by gains in Healthy Life Expectancy (HALE, or average number of years a person can expect to live in full health from any given age). In 2017, HALE at birth in Singapore was 74.2 years, up from 67.1 in 1990. That means the average Singaporean born in 2017 could expect to live for 84.8 years, but that 10.6 of those years would be spent in poor health. In 1990, the difference between LE and HALE was 9.0 years. The difference between LE and HALE at birth, then, has grown by 1.5 years.
[9]https://www.straitstimes.com/singapore/singapore-risks-hitting-obesity-rates-of-15-in-seven-years
[10] https://eiuperspectives.economist.com/sites/default/files/ECO048%20Amgen%20CVD%20Paper%2014.pdf p.21
[11] https://www.moh.gov.sg/news-highlights/details/peech-by-ms-rahayu-mahzam-parliamentary-secretary-for-health-at-the-ministry-of-health-committee-of-supply-debate-2021-on-friday-5-march-2021
[12] https://www.moh.gov.sg/news-highlights/details/peech-by-ms-rahayu-mahzam-parliamentary-secretary-for-health-at-the-ministry-of-health-committee-of-supply-debate-2021-on-friday-5-march-2021
[13] https://sprs.parl.gov.sg/search/sprs3topic?reportid=motion-222
[14] https://www.psd.gov.sg/challenge/people/cuppa/the-truth-comes-out-when-people-feel-safe-to-fail
[15] http://norden.diva-portal.org/smash/get/diva2:701045/FULLTEXT01.pdf; https://norden.diva-portal.org/smash/get/diva2:1066553/FULLTEXT01.pdf (Interim update in 2014: Results have not been particularly encouraging)
[16] https://www.todayonline.com/8days/seeanddo/thingstodo/how-earn-380-vouchers-staying-healthy-new-app-apple-health-promotion-board
[17] https://hbr.org/2017/06/can-insurance-companies-incentivize-their-customers-to-be-healthier
[18] https://sprs.parl.gov.sg/search/sprs3topic?reportid=oral-answer-2134
[19] https://sprs.parl.gov.sg/search/sprs3topic?reportid=oral-answer-2134
[20] https://www.straitstimes.com/singapore/politics/spore-could-see-2000-covid-19-deaths-yearly-govt-using-vaccines-boosters-to-stem
[21] https://www.straitstimes.com/forum/letters-in-print/making-up-lost-ground-in-war-on-diabetes?fbclid=IwAR0IMrHdNlPh2tBOjX-RY8C_ZsFaVgvKZ8_I2WnIEcx_-2MUdgEiwzyxJMc
[22] https://www.straitstimes.com/forum/letters-in-print/making-up-lost-ground-in-war-on-diabetes?fbclid=IwAR0IMrHdNlPh2tBOjX-RY8C_ZsFaVgvKZ8_I2WnIEcx_-2MUdgEiwzyxJMc
[23] https://www.straitstimes.com/forum/letters-in-print/making-up-lost-ground-in-war-on-diabetes?fbclid=IwAR0IMrHdNlPh2tBOjX-RY8C_ZsFaVgvKZ8_I2WnIEcx_-2MUdgEiwzyxJMc
[24] https://www.straitstimes.com/opinion/forum/suggestions-to-boost-screen-for-lifes-take-up-rate
[25] https://www.moh.gov.sg/news-highlights/details/screen-for-life-waist-circumference-test
[26] https://www3.weforum.org/docs/WEF_Digital_Currency_Governance_Consortium_White_Paper_Series_2021.pdf
[27] https://fass.nus.edu.sg/srn/2013/09/17/being-personally-responsible-is-key-in-preventive-care/; https://www.todayonline.com/singapore/talking-about-personal-responsibility-thinking-about-nation; https://www.hpb.gov.sg/about/about-us
[28] https://www.moh.gov.sg/news-highlights/details/average-life-expectancy-and-prevalence-of-chronic-illnesses-amongst-different-groups-of-singaporeans/
[29] https://www.moh.gov.sg/news-highlights/details/speech-by-mr-gan-kim-yong-minister-for-health-at-the-ministry-of-health-committee-of-supply-debate-2021-on-friday-5-march-2021
[30]https://www.straitstimes.com/singapore/politics/parliament-education-income-correlate-with-singaporeans-life-expectancy-and
[31] KidSTART: gives children from low-income families a good start in life through upstream support. KidSTART parents are equipped with skills and knowledge to support their child’s development and physical and socio-emotional well-being. National University Hospital started an intervention programme called Promoting Parental Emotional Health to Enhance Child Learning (ProPEL). It supports mothers and mothers-to-be from low-income families through pregnancy into motherhood to enhance the child’s development and learning. (https://sprs.parl.gov.sg/search/sprs3topic?reportid=budget-1630
[32] https://www.moh.gov.sg/news-highlights/details/speech-by-mr-gan-kim-yong-minister-for-health-at-the-ministry-of-health-committee-of-supply-debate-2021-on-friday-5-march-2021 COS 21: GKY said that more data will be released later this year
[33] https://www.brookings.edu/wp-content/uploads/2016/07/KaiserFormatted_150504RH-with-image.pdf