Case Study: Integrated Delivery in Singapore’s Healthcare System

Overview of Singapore’s Healthcare System

Singapore’s healthcare system is based on the fundamental principle of personal responsibility, wherein all stakeholders are regarded as crucial contributors to achieving sustainable universal health coverage (1). In recent decades, the Singaporean healthcare system has placed significant emphasis on prevention and public health initiatives as cornerstones of maintaining population health. Recognizing the importance of proactive measures in averting disease and promoting wellness, the system prioritizes preventive strategies aimed at addressing health risks at both individual and community levels (2). Notably, the introduction of the Healthier SG reform (3) in 2023 highlights the government's renewed focus on enhancing public health outcomes through targeted interventions and community engagement efforts. This initiative reflects a comprehensive approach to healthcare that extends beyond treatment to encompass proactive measures aimed at promoting holistic well-being and reducing the burden of disease on society. Furthermore, Healthier SG aims to use the capitation model for chronic diseases in order to incentivize providers to prioritize preventive medicine, thus aligning incentives of providers with the government.

The delivery system of healthcare is structured around a mixed public-private model, where public hospitals administer essential services at subsidized rates, while private hospitals furnish a broader spectrum of services at comparatively higher costs (1). Within this framework, the government assumes a pivotal role in orchestrating and overseeing healthcare services, ensuring adherence to established standards throughout the system.

Delivery Integration in Singapore

The Singaporean government takes proactive measures to ensure the seamless integration and continuity of care across the healthcare spectrum, aiming to prevent fragmentation and enhance overall patient outcomes. For integration, Singapore’s healthcare system relies heavy on central planning and strong regulation of the healthcare system to achieve its goals.

Centralized Regulation

Singapore’s healthcare integration is led by its Ministry of Health (MOH). Adjacent to the MOH, agencies are also set up for specific functions. These agencies or statutory boards provide uniform direction and improve coordination in Singapore’s Healthcare. Examples of health related statutory boards include:

  1. Synapxe (previously known as Integrated Health Information Services) (4) integrates, delivers and manages information technology systems across all public healthcare institutions. Being the central authority for information technology in Singapore, they have the ability to integrate data across clinical sites.

  2. Agency for Care Effectiveness (ACE) is Singapore’s national health technology assessment and clinical guidance agency. ACE provides guidance on cost-effectiveness of drugs and treatments for healthcare institutions in Singapore, providing a unified authority on this matter.

  3. Health Sciences Authority (HSA) centrally regulates the manufacture, import, supply, storage, presentation and advertisement of health products in Singapore. Their goal is to meet appropriate safety, quality and efficacy standards of all health related products in Singapore.

  4. Health Promotion Board (HPB) is responsible for promoting healthy living in Singapore. It formulates health policies, implements health promotion and disease prevention programs (like those for school health and workplace health) and works with industry partners for healthier food products.

Furthermore, Singapore adopts central regulation for all health services and information through the Healthcare Services Act (HCSA)  and Health Information Bill (HIB). These central pieces of health regulation play a crucial role in shaping the behavior of healthcare organizations and how they provide care. For example, the HIB has huge implications on Singapore’s National Electronic Health Record (NEHR) system, explained in a later section on health data.  

Agency of Integrated Care (AIC)

The Agency of Integrated Care (AIC) is a statutory board of the Singapore government, and is an example of how Singapore utilizes government entities to directly push for care integration. Initially founded in 1992 as ‘Care Liaison Services (CLS)’ under the MOH, they were tasked with coordination and facilitation of the placement of elderly sick to nursing homes and chronic sick units(5). AIC now plays a pivotal role in care integration(5) by coordinating the placement of individuals with community providers, facilitating service development and capacity building among these providers, and administering various subsidy schemes. These efforts by AIC ensures that patients are able to be discharged from acute hospitals into sub-acute care or back home into the community. Importantly, this enables the steady outflow of patients from acute hospitals into community services and prevents these patients from needlessly taking up bedspace.

On top of this, AIC is also the agency responsible for policy direction, regulation and funding for Primary Care Networks (PCNs) (6, 7). This is explained in a following section.

Vertical Integration of Care: Public Healthcare Cluster integration

Another significant example of the use of government power to integrate care is when MOH collated the various hospital systems around Singapore and instituted three integrated health clusters, strategically organized by geographic regions (8). These clusters encompass a spectrum of healthcare institutions, spanning from polyclinics to acute hospitals, all under the public healthcare umbrella. The primary objective of these vertically integrated health clusters is to foster collaborative partnerships with general practitioners (GPs) and other community stakeholders. Through the establishment of strong links between primary care providers, hospitals, and community-based services, they aim to streamline patient journeys, minimize disruptions in care, and enhance the accessibility and effectiveness of healthcare services.

Such organization of clusters enable a common electronic health record (EHR) and cohesive workflows within each cluster that enhances patient care. For example, a patient that requires specialist care might first be seen in a government polyclinic and then referred upwards within the healthcare cluster. Once in the hospital’s specialist clinic, the specialist is able to view all notes, patient history, laboratory results, and images collected in the community in order to aid in treatment. This avoids duplication and delays in medical treatments, allowing for smooth continuity of care. The reverse is also true, whereby a patient who was hospitalized in an acute hospital can be discharged back into the community with planned step-down care in the government polyclinics. All events and results from the hospital stay is visible to the primary care providers, who can follow up with care. On top of this, specialist services that are amenable to be delivered in the community can also be done by arranging for specialists to travel to polyclinics to deliver such services (e.g. common ophthalmology services provided in polyclinics by visiting ophthalmologists). This prevents the overcrowding of hospitals.

Moreover, integration of clusters extends beyond clinical care. Clusters also encompass social service agencies, mental health organizations and other relevant stakeholders. By having all these different assets within the same cluster under the same management and with integrated workflows and information systems, the integrated system can address broader determinants of health (i.e. social, economic and environmental factors).

Geographical Integration: Integrated Care Hubs (ICH)

Singapore’s government also uses central planning to deliberately build concentrated hubs of healthcare infrastructure. Due to the aging population and the need for co-located community and rehabilitation hospitals near acute hospitals, Singapore’s MOH has instituted plans to build Integrated Care Hubs (ICHs) within their integrated clusters. The central idea is to create an ecosystem where everything from acute care to rehabilitation to palliative care are provided in a single location. The seamless transition of patients between facilities according to what they might need enables the right-siting of care, freeing up the acute hospitals and ensuring that patients still receive the care they might need, ultimately promoting holistic healing and independence within the community.

Singapore’s first ICH was announced in a speech by the Minister of Health in August 2013 (9), and was officially opened in October 2023 (10). The ICH is a hub that was designed around one of Singapore’s main hospitals: Tan Tock Seng Hospital (TTSH). Upon full completion, the facility will house 608 beds not including TTSH, with a focus on rehabilitation and palliative care services. Other upcoming ICHs include Eastern Integrated Health Campus and the Woodlands Health Campus, planned to open in the next decade. 

Provider Payment Reform: HealthierSG

In 2023, Singapore introduced HealthierSG, a health reform campaign that aims to enhance disease prevention and health promotion at the PHC level, as well as further improving information technology and service integration. Underlying this, Singapore introduced a capitation payment system for PHC level care (11). Each of Singapore’s 3 healthcare clusters get a pre-determined fee for every resident living in the region that they are looking after, depending on ‘bands’ that are calculated using patient age and comorbidities (12). This is a deviation from the previous fee-for-service (FFS) payment model that was historically prevalent in Singapore’s primary care, and aims to reduce waste and improve quality of care. Furthermore, this capitation model aims to incentivize providers to engage in preventive medicine to keep patients healthy in the community and thus maximize their own profits. This is meant to be achieved via activities such as increased screening for chronic diseases or engagement of patients at an asymptomatic stage, resulting in early and more cost effective rather than delayed and more costly treatment. Overall, Singapore believes that this will lead to cost savings in the health system as well as better health outcomes for its aging population.

Electronic Health Data Integration

National Electronic Health Record (NEHR):

Singapore also used its strong government levers to enable the end-to-end integration of EHRs in Singapore. Each health cluster already has an integrated EHR with full visibility within each cluster. But the National Electronic Health Record (NEHR) aims to integrate the EHRs across all healthcare institutions in Singapore (13). Currently, all public providers and many private providers have already been onboarded with NEHR (14).  Singapore’s aforementioned Health Information Bill (15) which takes effect in 2025 will mandate all licensed healthcare service providers to contribute data to the NEHR. Meanwhile, the Early Contribution Incentive (ECI) program supports private healthcare licensees in data contribution. Recently extended in December 2022, the ECI scheme now includes GPs, private hospitals, radiological laboratories, and clinical laboratories, with over 900 applications received to date. Participants in the ECI program are obligated to contribute to NEHR and are granted NEHR view-access in return.

Singapore inaugurated the NEHR in 2011, and aims to create a seamless repository of patient health records accessible across both public and private healthcare institutions. The overarching vision of NEHR is to realize the concept of "One Patient, One Health Record," facilitating comprehensive and coordinated care delivery across the healthcare continuum. Ownership of the NEHR resides jointly with the Ministry of Health and Synapse.

Since its inception, NEHR has incurred a total expenditure of approximately $660 million SGD as of March 2023, funded by the MOH (16). By December 31, 2022, over 90% of licensed private hospitals and nursing homes have gained view-access to NEHR, with nearly half of them actively contributing data. Additionally, more than 30% of licensed private ambulatory care institutions, encompassing General Practitioners (GPs), specialists, dentists, and renal care providers, have NEHR view-access, with 12% contributing data.

Healthhub:

Healthhub was launched in 2015 (17), and built on the functionality of the NEHR. It serves as a user-friendly interface through which Singaporean citizens and permanent residents can access their health records. This digital platform, complemented by a smartphone application, offers individuals the convenience of managing various aspects of their healthcare journey. Users can track and coordinate medical appointments, request medication refills or renewals, and review billing information, all from their smartphones. Healthhub's integration with public hospitals, national centers, and polyclinics streamlines administrative processes, empowers patients to take proactive control of their health, and fosters greater engagement between individuals and their healthcare providers.

Primary Care Integration

In Singapore, government polyclinics take on 20% of the population’s primary care patient load by number, whilst private GPs (majority of them solo practices), handle the rest. However, polyclinics bear 52% of country’s chronic disease burden, whilst private GPs bear only 20% (18). The remainder of the load is borne by public hospitals. To shift some of the burden of chronic disease care (namely diabetes, hypertension, and hyperlipidaemia) to the private GPs, Singapore’s government created the Primary Care Network (PCN) scheme to integrate the fragmented private GP practices into cohesive units for integrated care most notably for chronic diseases increasingly affecting the ageing population.

Under this scheme, the MOH incentivizes private General Practitioner (GP) clinics to form networks aimed at enhancing the delivery of healthcare services through funding and persuasion (19). Under this scheme, private GP practices are given the autonomy to form and join PCNs of their choice. PCNs are also free to allocate financial and manpower resources provided by MOH and to dictate inner workings with the PCN leaders (18). The PCNs are funded by MOH to provide ancillary services (e.g. diabetic retinal photography and foot screening), nurse counselling and care coordination. These services are provided by a mobile team, which goes to every clinic in the PCN to conduct the services. All PCNs must also maintain a Chronic Disease Registry (CDR) which collects and processes clinical outcome indicators for monitoring of clinical quality. These assets (as shown in figure 1 below) are shared amongst several practices within the PCN. This collaborative approach facilitates more effective management of chronic conditions compared with only a solo-practice GP, and also facilitates the sharing of best practices for patient care amongst member clinics. The PCN scheme aligns with the Ministry of Health's (MOH) strategic objective to shift healthcare delivery beyond hospital settings and into the community, exemplified by Singapore’s HealthierSG strategy which began in mid-2023.

A budget of 45 million USD per annum by the MOH is allocated to fund PCNs. This funding is mainly distributed on a reimbursement basis, where PCN clinics submit claims for expenses used to run the duties of the PCN. Funding handled by AIC.

GP practices who join PCNs often do so because of the draw of treating patients in a “one-stop-shop”. Previously, if they want their patients to receive screening or counselling services, they would either have to invest heavily in the manpower and logistics to perform such services, or refer patients to government polyclinics or tertiary hospitals. Under the PCN, they are able to become a “one-stop-shop” where patients can see the GP, get screened, and collect medication all in one visit. This vastly increases patient satisfaction. Furthermore, the PCN funding includes the “Care Plus Fee”. This is essentially a pay-for-performance mechanism whereby MOH will pay GPs extra money if they conduct longer consults with patients with chronic conditions, with appropriate management and notification through the CDR (20). This allows the for-profit GP practices to address these more complex patients with appropriate time spent, without potential reduction in acute cases seen.


References

  1. Lee CE. Singapore. The Commonwealth Fund: The Commonwealth Fund; 2020.

  2. Tan CC, Lam CS, Matchar DB, Zee YK, Wong JE. Singapore's health-care system: key features, challenges, and shifts. The Lancet. 2021;398(10305):1091-104.

  3. Ministry of Health Singapore. Healthier SG: Ministry of Health Singapore,; 2024 [Available from: https://www.healthiersg.gov.sg.

  4. Synapxe. Our Role 2024 [Available from: https://www.synapxe.sg/about-synapxe/our-role.

  5. Agency of Integrated Care. About Us: Who is AIC 2024 [Available from: https://www.aic.sg/about-us/.

  6. De Foo C, Surendran S, Tam CH, Ho E, Matchar DB, Car J, et al. Perceived facilitators and barriers to chronic disease management in primary care networks of Singapore: a qualitative study. BMJ open. 2021;11(5):e046010.

  7. Agency of Integrated Care. Collaborating with Primary Care Networks: Agency of Integrated Care; 2022 [Available from: https://www.aic-yearbook.sg/supporting-healthier-sg/collaborating-primary-care-networks/.

  8. Ministry of Health Singapore. REORGANISATION OF HEALTHCARE SYSTEM INTO THREE INTEGRATED CLUSTERS TO BETTER MEET FUTURE HEALTHCARE NEEDS. News Highlights2017.

  9. SPEECH BY HEALTH MINISTER GAN KIM YONG AT THE OFFICIAL LAUNCH OF HEALTH CITY NOVENA, 30 AUG 2013 [press release]. News Highlights: Ministry of Health2013.

  10. SPEECH BY MR ONG YE KUNG, MINISTER FOR HEALTH, AT OPENING OF TAN TOCK SENG HOSPITAL INTEGRATED CARE HUB, 2 OCTOBER 2023 [press release]. Ministry of Health2023.

  11. World Health Organization (WHO). Singapore: a primary health care case study in the context of the COVID-19 pandemic: World Health Organization,; 2023 [Available from: https://www.who.int/publications/i/item/9789240079793#.

  12. Ministry of Health Singapore. CAPITATION 2023 [Available from: https://www.moh.gov.sg/news-highlights/details/capitation.

  13. Healthhub. What is National Electronic Health Record (NEHR)?  [Available from: https://support.healthhub.sg/hc/en-us/articles/15823581714073-What-is-National-Electronic-Health-Record-NEHR.

  14. Ministry of Health Singapore. Institutions participating in the National Electronic Health Records system (NEHR) 2016 [Available from: https://www.moh.gov.sg/institutions-participating-in-the-national-electronic-health-records-system-(nehr).

  15. Hai Pham GK, Pimploy Vivatanapaiboonlap, Rahul Rai. Singapore’s Health Information Bill US-ASEAN Business Council2024 [Available from: https://www.usasean.org/article/singapores-health-information-bill.

  16. EXPENDITURE ON AND UTILISATION OF NATIONAL ELECTRONIC HEALTH RECORD SYSTEM [press release]. Ministry of Health Singapore,2023.

  17. Chew HM. HealthHub launched: 7 things about the new online portal and app: The Straits Times; 2016 [Available from: https://www.straitstimes.com/singapore/health/healthhub-launched-7-things-about-the-new-online-portal-and-app.

  18. Foo CD, Surendran S, Jimenez G, Ansah JP, Matchar DB, Koh GCH. Primary care networks and Starfield’s 4Cs: a case for enhanced chronic disease management. International journal of environmental research and public health. 2021;18(6):2926.

  19. Ministry of Health Singapore. Primary Care Networks. In: (PCC) PaCC, editor. Healthcare Services and Facilities: Ministry of Health Singapore,; 2021.

  20. Chen ATH, Koh GC-H, Fong NP, Lim JFY, Hildon ZJ-L. Evaluating the Effects of Capacity Building Initiatives and Primary Care Networks in Singapore: Outcome Harvesting of System Changes to Chronic Disease Care Delivery. International Journal of Environmental Research and Public Health. 2023;20(3):2192.

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