KEEPING THE
NATION HEALTHY

Investments in affordable, quality healthcare and the dedication of our healthcare professionals have led to significant improvements in the lives of our people over the past five decades.

Singapore’s remarkable development over the past 50 years can be seen not only in terms of our rapid economic growth, but also the dramatic improvements to the lives of our people. At Independence, our life expectancy was only in the mid-60s; today, Singaporeans can expect to live into their 80s. 1 Infant mortality was as high as 1 in 38 births in 1965; by 2014, this had dropped to 1 in 509 births. 2 Decades of steady investment and improvements in environmental and public health, modern healthcare services, affordable and sustainable healthcare costs, and a skilled corps of healthcare professionals, have lifted us from urban squalor to become one of the world’s healthiest countries today, with one of the best healthcare systems to be found anywhere. In 2012, Bloomberg Rankings placed Singapore first amongst the world’s healthiest countries and as having the most efficient healthcare system. 3



EARLY YEARS OF IMPROVING PUBLIC HEALTH:
VACCINATION, SANITATION, POLLUTION CONTROL

Singapore’s early public health problems were of the sort typically seen in developing countries in the tropics. Communicable diseases, such as cholera, tuberculosis, and dysentery, as well as malnutrition, were the main causes for concern, and they were made worse by unsanitary living conditions and widespread poverty.

After Singapore became self-governing in 1959, the Government began a mass inoculation campaign against tuberculosis, small pox, diphtheria and poliomyelitis, and extended nutritional supplement schemes to malnourished children. 4 Given Singapore’s fast growing population at the time, maternal and child health were important priorities. New mothers had to be taught that breast or formula milk – rather than condensed milk – were better for newborns. Our healthcare workers had to explain to the largely uneducated public the link between good nutrition and good health, and why children ought to be immunised. These efforts signalled the beginning of decades of preventive medicine and health education to follow. 5 As the children grew and going to school became the norm, the School Health Services and School Dental Services became stalwart institutions in nurturing the health of our nation’s youth.

To improve public health in general, much effort had to be spent on creating a clean and liveable environment. The work of agencies outside the Ministry of Health (MOH) was also significant in this regard. Through the Public Utilities Board, the Government invested in providing clean, potable water and reduced the transmission of water-borne diseases. They also built an efficient public sanitation system, before which many Singapore households were still dependent on night-soil carriers to dispose of their daily waste. The Housing and Development Board’s mass public housing programmes also shifted the majority of the population from crowded, squalid slums into apartments with clean running water and proper toilets.

THE SCHOOL HEALTH SERVICES AND SCHOOL DENTAL SERVICES

School Health Services

Keeping our children healthy has been a priority in Singapore for a long time. The School Health Services (SHS) was first established in 1921, with just two doctors screening 5,000 children. 6 After World War II, many children were infested with head lice and scabies, and had conditions such as malnutrition. 7 There were many initiatives to address this, including putting children on a milk scheme or giving them extra food rations. Schools were also a good way to reach out to large numbers of children at the same time.

SHS veteran Ms Chor Swee Suet, now Deputy Director, Nursing and Clinical Standards, shares:
Where the students are gathered together in school, it is easier to reach out to them. We educate them on healthy habits, and hopefully, they will make such good habits part of their lifestyle when they become adults. 8 SHS has had to adapt its programmes to changing social conditions. For example, as myopia became more common among schoolchildren, 9 SHS launched programmes to promote good eyecare habits. The health teams who visit the schools have also evolved. While previously only doctors could assess and make referrals, SHS’s better-trained and empowered nurses are able to do so today.

While SHS has largely focused on primary school students, it has also turned its attention to some secondary schools, institutes of technical education and polytechnics. A registered nurse is stationed at each of these institutions, tasked with helping overweight students or those who smoke or consume alcohol. Since these are teenagers, it takes a special corps of SHS nurses to reach out effectively to this group.

Indeed, the many changes that SHS has witnessed over the course of its history are exemplified by the way a child’s health is documented over the years. For a period of time, the back of the birth certificate was used and stamped as an indication of a child having received his or her immunisation shots. To be more systematic, a Mother and Child Record Book was introduced, and this contained the child’s medical records from birth till the school-going age of 6. In 1984, the Health Booklet was introduced, which contained important health information from birth until the school-leaving age of 18. The Health Booklet itself has undergone changes since then. Prior to year 2000, the various private and public sector hospitals had their own variations of the Health Booklet, but this was standardised in 2001. This was to ensure that every child born in Singapore would have medical information recorded in the same way.

Today, not only are updates done in real-time and recorded electronically in a common system, the nurses are also able to retrieve the data of each student during the check-ups. Technology has enabled SHS to be more efficient in the documentation process of each child’s record. Ms Chor relates:


Last time, if I wanted to check on a child’s record, I had to call to ask a colleague to check for me in the system. Now, we are able to check the information ourselves and do not have to trouble someone else. Parents may not be able to recall certain information at times, so we have to refer to the system. Now that this information is available in real-time, it becomes much easier for the staff.













School Dental Services
Dental hygiene in post-war Singapore was atrocious. 10 The DMFT (Decayed, Missing and Filled Teeth) Index 11 for Singapore is a healthy 0.42 today, but in 1949 it was 15, which meant the average man on the street had barely half a set of good teeth in his mouth. 12

The best way to address this was to provide dental services and education to children so they could form good habits while young. The 1950s saw children being bussed to Singapore’s only dental clinic in Tan Tock Seng Hospital; 13 later, mobile vans would bring services to schools in outlying areas. There was no electrical supply in the rural schools at the time; each mobile dental clinic towed its own generator. 14

After Independence, “dental huts” were conceived as part of Singapore’s early school development programme in the 1970s. Principal Dental Therapist, Ms Lim Kah Choo, who has been with SDS for 44 years, recalls:

So it’s literally a hut. The school that I was in, there were two primary schools and [a] secondary school within the same compound. A site was selected to build two dental huts. One dental hut was manned by dental nurses while the other hut had a dental officer [a trained dentist] who also oversees the work of the dental nurses like me who had just graduated from training school. 15

Apart from actual dental treatment, SDS was tasked with inculcating good dental habits among students. This included conducting tooth brushing drills for all students during recess – a major programme from the 1980s to the 1990s. SDS even invented tablets and toothpaste that would stain dental plaque on teeth and gums that were not properly brushed.

Today, a dental clinic is part of every primary school that is upgraded or built in Singapore. 16 SDS services have also been extended to secondary schools. 17 The dental clinics themselves are no longer the cold rooms of the early days. Instead, they have been upgraded with soft toys and colourful posters, to make it less intimidating for young children to visit them. According to Ms Lim, nowadays “children come in to the clinic for dental treatment on their own accord”. 18

Staying Healthy, Starting Young
Today, both SHS and SDS come under the Youth Preventive Services Division in the Health Promotion Board (HPB). They play an important role in Singapore’s philosophy of encouraging preventive healthcare, anchoring annual screening programmes to detecting and managing health conditions among schoolchildren early, and helping our young people to cultivate healthy habits that will persist into adulthood. 19

Other initiatives in the 1970s, such as the Clean Air Act of 1971, and the Environment Protection Act, helped to maintain the cleanliness and the quality of our lived environment. Numerous campaigns were also carried out in the name of bettering public health: including campaigns against littering and for eradicating mosquitoes. A decade-long effort was also made to clean up the Singapore River.

In the interest of public health, Singapore became one of the first in the world to restrict tobacco use in public places, with a 1970 ban on smoking in omnibuses, theatres and cinemas. We also prohibited tobacco advertising from 1971 – the first Asian country to do so. 20

IMPROVING HEALTHCARE SERVICES: A NETWORK OF PRIMARY CARE PROVIDERS AND CORPORATISED HOSPITALS

As Singapore’s urban infrastructure was built up in the years following Independence, overall public health steadily improved. At the same time, efforts were also being devoted to make healthcare services better and more accessible to the public. In Singapore’s early years, the healthcare system was organised to deal with the acute medical problems common to a young population – either simpler conditions such as a mild influenza or emergency trauma care, which tend to require treatment over a brief period before the patient stabilises or recovers.

A number of public hospitals had already been established by the time Singapore achieved self-rule in 1959. These included the Singapore General Hospital (SGH), Alexandra Hospital (AH) and Kandang Kerbau Maternity Hospital (KKH). The Chinese migrant community had also set up a hospital, which came to be known as Tan Tock Seng Hospital (TTSH). Other than KKH, these hospitals were all geared towards acute care (such as general surgery and medicine, orthopaedic surgery and emergency medicine).

To alleviate the pressures from an overcrowded general hospital, primary health care was decentralised in 1959. By 1964, a network of satellite outpatient dispensaries as well as maternal and child health clinics had been set up across the island. These clinics were reminiscent of the outpatient services, infant clinics and travelling dispensaries that were common in the 1920s. These were to expand and become the broad network of private clinics and public sector polyclinics that we have today. 21

Over the years, Singapore’s hospitals have been rebuilt to expand and improve their facilities, capacity and services, beginning with SGH in the late 1970s and the other major hospitals, including TTSH and KKH, in the 1990s. In 1996, Toa Payoh Hospital and Changi Hospital merged to become the present-day Changi General Hospital, with new premises in Simei.

By the mid-1980s, priorities had shifted from basic healthcare provision to how we could make our public hospitals more responsive to patient needs and cost-effective. Beginning with a new hospital at Kent Ridge, which was to become the National University Hospital (NUH) in 1985, Singapore’s public hospitals were corporatised in succession. The objective was to instil operational efficiency and financial discipline in their day-to-day running, and allow for greater responsiveness to patient needs. Unlike privatisation (under which ownership is transferred to a privately owned entity), corporatised hospitals remained under state ownership, through the government-owned Health Corporation of Singapore (now renamed MOH Holdings). The restructured hospitals make their own decisions in areas such as human resources and in the provision of services. More sensitive matters such as fee increases require consultation with MOH. The 1993 White Paper on Affordable Health Care 22 would underline this use of market forces to improve efficiency and service standards as a principle of Singapore’s healthcare policy framework.

As of 2015, public sector hospitals remain the backbone of hospital care in Singapore, complemented by some private institutions such as Mount Elizabeth Hospital, Gleneagles Hospital and Raffles Hospital.

SINGAPORE’S POLYCLINICS: ONE-STOP HEALTHCARE CENTRES
Singapore’s government-run polyclinics are one-stop centres that offer a comprehensive range of healthcare services, ranging from the treatment of chronic and acute conditions, immunisation, dental care, family medicine and diagnostics to preventive screening and health promotion. They also support training of future generations of family physicians. Today, there are 18 polyclinics, spread out across Singapore. They continue to improve the quality of care and chronic disease management they provide to the general population, at affordable rates.

There is a limit to the amount of resources which can be devoted to health care, and to the financial burden households can bear. We must therefore establish guiding principles and policies to manage the health care system, and in particular to control health care costs…The question therefore is not whether the state or the individual should pay for health care in Singapore. It is rather how best to structure the health care system, and the means of financing it, in order to keep it efficient, and make it affordable to all citizens at rates they can afford. 23

– Ministry of Health,
1993 White Paper on Affordable Health Care

ENSURING HEALTHCARE IS AFFORDABLE AND SUSTAINABLE

Healthcare financing in Singapore adopts a hybrid approach. Most healthcare systems around the world are financed either by the state (through taxes) or by some form of social risk-pooling such as health insurance. Singapore balances both these approaches, along with some co-payment by individual consumers. This holds individuals responsible for their own medical expenses and encourages them to keep themselves healthy, while allowing government and society to help ensure that everyone has access to the healthcare services they need. This also helps to mitigate unnecessary demand for healthcare services, which can then be channelled to those who need them more.

To ensure that no Singaporeans will be denied access to care, healthcare is heavily subsidised by the state. Class B2 and C hospital wards are subsidised at up to 65% and 80% respectively; subsidies are also given for nursing homes and community hospital care. These subsidies depend on each patient’s means, with those of lower income receiving more help. Visits to the government-run polyclinics are also highly subsidised, so that all Singaporeans can afford good primary care. Certain types of treatment, such as cosmetic or experimental procedures, are not subsidised.Complementing government subsidies are Singapore’s 3Ms: Medisave, MediShield and Medifund. Medisave is a compulsory national medical savings scheme, introduced in 1984. Under the scheme, part of every working Singaporean’s earnings are put aside in their personal Medisave account to help meet future healthcare expenses. To account for large treatment bills that cannot be sufficiently covered by individual savings, MediShield was introduced in 1990 as a low-cost national health insurance scheme. To keep premiums affordable, MediShield has has deductibles and daily expense limits. Medifund was introduced in 1993 as an endowment fund to help needy Singaporeans – those who cannot pay for their bills, and who lack Medisave or MediShield coverage, or both. Together, government subsidies and the 3Ms form the basis of Singapore’s healthcare financing framework.

Towards Greater Collective Responsibility

While personal responsibility remains a central tenet of Singapore’s approach to healthcare, there have also been steps towards building a more inclusive and caring society, where resources are pooled together to help the sick among us and where those who are needy receive the help that they require. With the introduction of MediShield Life (to be effected by end 2015), lifetime coverage will be extended to all Singaporeans – even if they have preexisting conditions, or are too old to enjoy coverage under other insurance schemes. This has been made possible through premium subsidies, financial assistance and risk-pooling at the national level. At the same time, the Government is increasing its share of national healthcare expenditure. One example is the increase in subsidy at the subsidised specialist outpatient clinics and for standard drugs. These measures will reduce co-payment for lower-to-middle income households and help ensure healthcare remains affordable.

ADDRESSING FUTURE HEALTHCARE NEEDS
With improvements to health, longer life expectancies, lifestyle changes and an ageing population, Singapore’s healthcare needs are changing dramatically. Healthcare costs in Singapore are also expected to rise. This has meant that Singapore’s approach to healthcare is continually evolving and being refined to keep our nation healthy in the years ahead.

Healthcare 2020 Masterplan:
Transitioning to a Patient-centric System
 Launched by Minister Gan Kim Yong during the 2012 Budget, the Healthcare 2020 Masterplan focuses on improving the accessibility, quality and affordability of our healthcare system. 24 Since demand for healthcare is expected to rise, more hospitals and polyclinics will be built. The intermediate and long-term care sector will also be developed, including community hospitals, nursing homes and community-based services such as day centres and home care services in anticipation of future needs as Singaporeans live longer.

New primary care models are being introduced, such as the Family Medicine Centres (FMCs) and Community Health Centres (CHCs). The FMCs bring together small groups of private sector primary care physicians, supported by on-site nurses and allied health professionals. CHCs serve as resource centres for chronic conditions (such as diabetes, which require regular screening) at the community level. Working together with the existing network of polyclinics, general practitioners (GPs) and hospitals, FMCs and CHCs will be able to offer more comprehensive and personalised care to individuals throughout the course of their care. Beyond monitoring and treating patients, primary care providers play a critical role in the early prevention and treatment of chronic conditions. They can advise patients on how best to choose healthier living habits, reduce health risks and keep well at home and in the community.

[Within the RHS] patients can be assured that the different providers in each region are working together to better care for and support them, across different stages of their healthcare journey from diagnosis and treatment to post-discharge follow-up. It will also help patients navigate across providers more easily, enabling and empowering them to manage their own care needs more effectively. 25

– Mr Gan Kim Yong, Minister for Health, at the 2012 Committee of Supply Speech

To facilitate this, the implementation of the National Electronic Health Record system will allow patients’ medical records to be shared across the healthcare network, including all hospitals and primary care. This will make it easier to seamlessly coordinate care across the entire healthcare network, allowing different parties to follow up on patients’ treatment without having to rediscover their medical history or redo tests as patients move through the system. 26

Social and Aged Care

As Singapore ages, there are likely to be more seniors who need long-term or chronic care. At the same time, they may enjoy less social support, as family sizes shrink. To support our seniors, many of whom aspire to age-in-place in their own homes and in an environment they are familiar with, we will need to build up our home and community care services to care for our seniors at home and in the community: We need to develop a range of aged care services in every neighbourhood to meet seniors’ social and healthcare needs, to make care accessible to seniors needing care and to support their caregivers, and also to allow families to remain in close contact with the seniors even if they need to be cared for within institutions. 27 – Ministry of Health, 2012

The target is to grow from 2,100 day care places and 3,800 home care places in 2011 to 6,200 day care places and 6,500 home care places by 2020.

Recognising that healthcare and socials are intertwined, our hospitals are also playing their part in providing services to the community. The Ageing-In-Place (AIP) Programme at Khoo Teck Puat Hospital (KTPH), for example, has health and social care professionals making house visits to patients’ homes.






AGEING-IN-PLACE PROGRAMME
The Ageing-In-Place (AIP) Programme at Khoo Teck Puat Hospital aims to “develop and deliver a cost-efficient, patient-centric and community-based social-cum-health model of care beyond the hospital walls into the patients’ homes, reaching out specifically to the elderly and chronically sick.” 28 The programme has two main aspects: home visits to those who use hospital services frequently, and community nurse posts.

When the hospital first opened its doors, demand for subsidised beds rose sharply. It was found that a segment of patients was neglecting their health to the point that they had to be admitted repeatedly to the hospital to be treated. The problem that the AIP team was originally set up to tackle – reducing the rate of visits of these patients – turned out to be a much bigger one: how to provide these patients with the help they needed to improve their quality of life so that they would not have to keep resorting to hospital care.

The AIP programme shows how our hospitals are improving the quality and extent of their care by better understanding the changing needs of patients, and involving the community in supporting patients, without taking up more healthcare resources.




ENCOURAGING SINGAPOREANS TO KEEP HEALTHY

As Singapore’s public health improved over the years and the early spectre of communicable diseases such as tuberculosis and cholera receded, efforts soon turned towards addressing non-communicable diseases instead. Today, our most common healthcare concerns are so-called “rich country illnesses”, such as chronic diabetes or cardio-vascular diseases (stemming from a rich diet and sedentary lifestyle). Unlike the acute diseases of the past, these are more effectively addressed through lifestyle changes and preventive efforts.

Over the years, the Government has invested heavily in health education and disease prevention programmes. It has also encouraged Singaporeans to pursue a healthy lifestyle: getting people to eat more healthily, exercise regularly, cut down on alcohol and quit smoking. Prevention is better than cure: instead of treating illnesses after they occur, these efforts are aimed at helping Singaporeans to stay fitter, stronger, happier and more productive throughout their lives.

Established in 2001, the Health Promotion Board (HPB) 29 plays a central role in advancing this goal. Reaching out to Singaporeans from all walks of life, HPB’s many initiatives range from getting school canteens to serve healthier meals, to a Healthy Workplace Ecosystem framework to encourage a heathier lifestyle at work. The latter not only underscores the need for personal ownership of one’s health, but highlights the positive benefits that can come from staying healthy and well, apart from merely not falling ill. It represents the first tangible programme of HPB’s innovative Healthy Living Master Plan.

[T]he health of a nation depends on more than just curing sick people quickly and efficiently. It goes beyond pathology. It is about the people who form the unshakeable cornerstone of public health promotion and education. 30 – Health Promotion Board, 2011

As Singapore’s healthcare system evolves, fresh models of outpatient and inpatient care will be offered in response to the needs of citizens.

As Singapore’s healthcare system evolves, fresh models of outpatient and inpatient care will be offered in response to the needs of citizens.

HEALTHY WORKPLACE ECOSYSTEM AT MAPLETREE BUSINESS CITY
More than 60% of Singapore’s population is in the active workforce. The workplace is a natural catchment for getting Singaporeans to adopt healthy living habits, since so many of us spend so much of our day at work. As Ms Daphne Koek, Manager at HPB’s Workplace Health and Outreach Division explains, it makes sense to “incorporate healthy options into Singaporeans’ everyday living by bringing these options to their doorsteps – in this case, the workplace.” 31

The Healthy Workplace Ecosystem programme, piloted in Mapletree Business City (MBC) in 2013, focuses on building a healthier workforce through easier access to healthier options such as healthier meals and physical activity. One of its main innovations is to partner with the landlords of co-located workplaces, rather than with individual companies. Initiatives therefore have the potential reach and economies of scale to benefit a large number of workers at once. In the case of MBC, it was some 12,000 working adults across its tenant community. 32

The HPB worked closely with MBC’s developers, businesses and vendors to identify and provide for the needs and interests of the tenant community. Workers at MBC have access to healthier food options, such as wholegrain choices and 500-calorie meals, gym facilities, as well as exercise programmes and weekly-run sessions, morning workout programmes and health workshops. The results have been very promising. Ms Janelle Chia, Manager from the Workplace Health and Outreach Division, points out that “people who never used to exercise become regulars, and bring along their colleagues to these sessions. You know that this ecosystem is really something that is benefiting them.” 33

With some 290,000 companies (as of April 2015) in Singapore, ranging from small and medium-sized enterprises to multinational companies, reaching out to all companies individually can be a challenge. Adopting a Healthy Workplace Ecosystem model therefore provides an efficient way of promoting workplace health as programmes can reach a high concentration of working adults within a geographical area.

The approach demonstrates how public-private partnerships can effectively contribute to creating a positive, engaging and energising environment, making it conducive for Singapore residents to adopt healthy living every day by increasing the reach and penetration of health promoting initiatives.

The best part is, this model is not limited to white-collar locales like MBC. HPB is also looking to bring the ecosystem approach to industrial estates where there are more blue-collar workers, and different opportunities, preferences and needs, and will factor the different profiles and demographics of the workers at such work locations. Nevertheless, as Ms Koek points out, the approach is based on a set of broad principles that can be applied to a variety of settings:
Creating a supportive environment with a holistic suite of programmes through demand aggregation and maximising existing facilities and assets are the core set of principles in a Healthy Workplace Ecosystem. How each ecosystem develops will differ based on its occupants’ profiles and demographics. 34

Apart from MBC, other developers have joined the Healthy Workplace Ecosystem programme. In 2014, HPB collaborated with Ascendas to apply the approach to its seven clusters, which is expected to benefit up to 35,000 workers. The aim is to reach out to over 500,000 people by the year 2020.

AN ADAPTIVE HEALTHCARE SYSTEM
Healthcare in Singapore has come a long way in our 50 years of independence. It has helped to lift us out of squalor and suffering, making it possible for the nation to thrive in other ways, as only a robust, healthy people can. Today, our healthcare system is broad, sophisticated, sustainable and adaptive to evolving needs. Our healthcare system will continue to stay abreast of emerging trends, identifying future healthcare needs and responding to them in good time.

Singaporeans have come to expect world-class standards from our healthcare providers. With an ageing population and as manpower resources tighten, more innovative solutions will be needed to improve the quality of our healthcare provision and delivery, while keeping healthcare affordable and accessible for all. While healthcare professionals and policymakers strive to be nimble and responsive to future healthcare needs, Singaporeans too will contribute to the endeavour by staying active and through healthy living to enjoy the best possible quality of life.