Singapore is radically changing its healthcare system with Healthier SG. Here’s how to make it work

Earlier this month, Health Minister Ong Ye Kung announced probably the most fundamental changes to the healthcare system in years.

First, the Ministry of Health (MOH) would establish a scheme where every Singaporean would be enrolled to a named general practitioner (GP) or family physician.

The thesis behind this is that a familiar health provider would have a trusted relationship with residents and hence be more effective in encouraging behaviour changes for good health and to detect any symptoms of sinister diseases earlier.

Secondly, the three public health care clusters, SingHealth, National Healthcare Group and the National University Health System, would be funded differently.

Instead of the current volume-based funding, the clusters would instead be moved to a capitation model.

In this model, each cluster would be assigned a defined population to provide health care services for, and to keep healthy.

The initiative, termed Healthier SG, is a radical departure from the current model which is more correctly described as “sick care” rather than “health care”.

In the current model, more care means more revenue for healthcare operators, and hence a perverse incentive to under-emphasise preventive health and over-service patients when they consult.

Healthier SG should motivate focus on preventive health and provide health care services only when needed and as efficiently as possible.

In a full capitation model, of which the American healthcare group Kaiser Permanente is the most well-known, funding is provided upfront to the health system to cater to all the healthcare needs of the covered population.

This funding model changes the entire dynamic — providing a service, say a bypass surgery, is no longer a revenue but a cost to a public healthcare operator.

Health systems then should be striving to prevent their covered population from even needing a bypass surgery.

What health systems would then need to do would be to move upstream to ensure diabetics have good blood sugar control, obese patients slim down to reduce their cardiac risks and everyone attends the appropriate health screenings so that diseases are detected and treated early and less expensively.

For population health to be achieved, primary care is the lynchpin and hence GPs and other community partners will be central to Healthier SG.

In capitated models, it is not uncommon for health systems to work with supermarkets on easy access to healthier foods as well as with fitness centres and health coaches to encourage exercise.

In his parliamentary speech announcing the changes, Mr Ong identified key enablers to realise Healthier SG.

He described three factors: Data flow across the ecosystem, appropriate financing and up-scaling of manpower in population health.

The public sector is very good at these and I have no doubt they will be thoughtfully and comprehensively detailed and implemented.

However, I would argue that these are insufficient for Healthier SG to succeed.

I would submit that the mental model also must change and this is fundamental.

Healthier SG is not just a healthcare re-organising issue; it is an incentive challenge with the end game being sustained individual and community behaviour change. Let me explain.

Compare Healthier SG to a two-sided marketplace such as ride-hailing application Grab or online e-commerce site Carousell.

Just as Grab, especially in the pioneering days, needed to make it easy to sign up to its platform, and provide incentives to both drivers and passengers to use its services, the health system likewise needs to onboard citizens and doctors with value propositions that make saying “yes” the easy and right thing to do.

Furthermore, just as Grab enables passengers and drivers to match seamlessly based on location and routes, help drivers find the most efficient routes and assist passengers to make payments effortlessly, the health system likewise has to enable seamless transactions so that doctors can help citizens realise and maintain good health easily.

This would require some degree of image or perception “makeover” as not enough Singaporeans partner their GPs for health, with interactions commonly limited to “sick care” — medicines, referrals and medical certification.

Finally, the external environment is not static.

Just as Grab needs to contend with user drop offs and in Singapore, “work from home” realities and ever-improving public transportation, Healthier SG will have to contest entertainment streaming services, social media and new bubble tea flavours, endless varieties of fried chicken for mind and tummy share respectively.

If we agree with the analogy of a two-sided consumer marketplace, then we should ask ourselves, what is needed?

Think of Healthier SG as a startup.

A startup will need upfront investment and funding to build up a USP or Unique Selling Proposition that will capture interest and attention from potential customers.

A startup then needs further investment and marketing to acquire customers and once customers are in its ecosystem, more and more offerings to retain interest and continued use.

Think Grab’s evolution from transport to its ambitions to be the Southeast Asian “super app”.

All these sounds straightforward enough but the road to success is bumpy and undulating, and startups often need to keep changing the route, even backtracking to get to the final destination.

For Healthier SG, this means structured mini-experiments and rapid cycle innovations, risk tolerance, and lots of ambiguity.

A major reform such as healthier SG which involves every part of the health ecosystem from regulators, payers, providers and patients, has never been attempted before — can the MOH and the public healthcare clusters pull this off?

After all, much of entrepreneurship and risk-taking are typically associated with the private sector and specifically startups.

I am optimistic. There is precedence in the public sector, namely GovTech, which gave us Parking.SG and TraceTogether, both of which have become ubiquitous.

The revamped SingPass is also impressive for its breadth and usability. GovTech says this on its website:  “Innovation is a way of life at GovTech. We think big, start small, and learn from failing fast”.

As MOH prepares to bring to Parliament a White Paper on Healthier SG later this year, I hope there will be a concurrent assembling of skills, expertise and mindset to bring Healthier SG to life.

Healthier SG needs not just civil servants at their best as meticulous “big picture” system planners. It also needs public servants to embrace their roles as health system entrepreneurs and venture builders, accepting and even celebrating failures.

We are in uncharted waters and there will likely be mistakes. There will also be U-turns or pivots in the lingo of startups.

But the prize of Healthier SG, a healthier Singapore, and sustainable healthcare spending, is one Singapore must win, and we can only win with both types of public servants.

ABOUT THE AUTHOR:

Associate Professor Jeremy Lim is director of global health at the National University of Singapore's Saw Swee Hock School of Public Health.