SPEECH BY ASSOCIATE PROFESSOR KENNETH MAK, DIRECTOR OF MEDICAL SERVICES AT A REGIONAL OUTLOOK ON THE GLOBAL CRISIS IN DIAGNOSTICS - THE LANCET COMMISSION ON DIAGNOSTICS, 16 FEBRUARY 2022

Professor Fong Kok Yong, Deputy Group CEO (Medical & Clinical Services), SingHealth

Associate Professor Chow Wan Cheng, Vice Dean, Office of Academic & Clinical Development, Duke-NUS Medical School

Prof Teo Eng Kiong, Master, Academy of Medicine Singapore

Prof Kenneth Fleming, Chair, The Lancet Commission on Diagnostics, University of Oxford, UK

Dr Soumya Swaminathan, Chief Scientist, The World Health Organisation

Colleagues

Ladies and Gentlemen

        It is my pleasure to join you in this dialogue today on “A Regional Outlook on the Global Crisis in Diagnostics”, which will discuss the global findings from the Lancet Commission on Diagnostics and how they can be implemented to improve diagnostics and healthcare delivery in the region.

DIAGNOSTICS A KEY PART OF HEALTHCARE SYSTEMS

2.     Diagnostics is often the first critical step for any patient seeking answers to a health issue, without which effective and timely clinical intervention and disease management would not be possible. Having a system of robust diagnostics – be it radiology, pathology or laboratory services – is central and fundamental to all healthcare institutions. Singapore recognises this and has, over the years, been constantly reviewing our policies to improve safety and quality, access, as well as affordability of diagnostics for our people.

Safety and Quality

3.     On safety and quality, we evolved the regulations at the start of the year for diagnostics through the implementation of the Healthcare Services Act (HCSA) to replace the Private Hospitals and Medical Clinics Act (PHMCA), where enhanced and new requirements were introduced to provide additional safeguards for patient safety and welfare, as well as to support quality in diagnostics. Suitably qualified persons with the right skills and competencies are required to be appointed to provide adequate oversight of the day-to-day operations, as well as the clinical and technical aspects of the diagnostic services. Continuous training and competency assessments are also to be put in place to ensure that all personnel are skilled and well-informed of quality control protocols and safety aspects, crucial for accurate diagnosis and safety for patients and our healthcare workers.

Access

4.     Ensuring diagnostics remain accessible is as important. Primary care being the foundation of Singapore’s healthcare system, we have since built an island-wide network of outpatient polyclinics where most routine laboratory tests or imaging services and point-of-care services are easily available. Provision of complex and specialised diagnostics are nested in the acute hospitals, where on-site 24-hour laboratory and radiology services are mandated to support emergency and critical care. Referrals of patients or outsourcing of tests can be facilitated between primary care and acute hospitals in the same geographic regions via the Regional Health Systems (RHS) framework introduced in 2012, to better optimise resources and capabilities.

5.     Strengthening access includes not just physical infrastructure, but also fostering the use of innovation and technology to improve diagnostics capabilities, enhancing productivity and efficiency while ensuring diagnostic accuracy, quality and safety. Usage of information and communications technology-based management and reporting systems such as the Laboratory Information System (LIS) and Radiology Information System and Picture Archive and Communication System (RIS/PACS) have long been well-established in Singapore’s healthcare system, to enable central storage of data associated with diagnostic test orders and results, and seamless integration with other healthcare information systems for treatment planning purposes.

6.     Besides existing capabilities and technologies, significant investment has also been made into our biomedical sciences domain under Singapore’s $25 billion Research, Innovation and Enterprise 2025 (RIE2025) plan, so as to ensure that we develop new medical technology and diagnostics such as integrated medical devices and digital health, and bringing more of such new innovations to market to benefit the healthcare workforce and our community. RIE2025 is expected to strengthen the medical devices industry in Singapore and the region, and I believe many of you in the audience will play an important part in this ecosystem.

7.     Advances in medical technology and diagnostics will also continue to be central to Singapore’s Smart Nation Initiative. From the healthcare perspective, we are talking about an end-to-end approach to provide ‘smart healthcare’ to our population through the application and adoption of novel technologies at all levels of care. Many of our healthcare institutions have explored the usage of artificial intelligence in clinical practice such as performing pattern recognition of radiological images to enhance diagnosis and increase productivity in terms of reporting. Still, there remains huge potential in how we can leverage technology to set new benchmarks of excellence in diagnostics for accuracy and efficiency, and ultimately to improve care outcomes.

Affordability

8.     As we innovate, we have to ensure that adoption is affordable and sustainable. To identify such technologies and the populations who would benefit from them, the Agency for Care Effectiveness was set up in 2015 as the National Health Technology Assessment agency in Singapore to evaluate the clinical and cost effectiveness of health technologies, and to support better-informed decisions on usage and subsidies. Examples include guidance for FDG-PET-CT for oncological scans and clinical contexts for which chest X-rays are unlikely to confer clinical benefits.

RESILIENT SYSTEMS FOR HEALTHCARE IN THE REGION

9.     The findings of Lancet Commission on Diagnostics show that while diagnostics undergirds quality health care, its importance is often overlooked and leads to resource constraints globally. Beyond building capacity at the national level, we need to look into supporting improved access to diagnostics at the regional level. Like many other clinical specialties, there is currently more global studies into diagnostics for the Western population, from which the other parts of the world take reference. With Asians having different genetic make-up and demographics, specific studies and discussions on the application of diagnostics for our region are needful. Moreover, Singapore’s heterogeneous and racially diverse population makes us a great testbed for diagnostic research and capability testing.

10.     In this regard, we are well-positioned to excel. Our clinicians and scientists are engaged in international partnerships that aim to strengthen the health system capacity across the Asian region, and support the advancement of access to diagnostics and development of diagnostics technology. In 2018, Singapore hosted the 18th ASEAN Ministerial Meeting on Science, Technology and Innovation, and the 77th ASEAN Committee on Science, Technology and Innovation. The ASEAN Diagnostics Initiative was launched to facilitate the co-development of healthcare diagnostics solutions, with the goal of strengthening the medical diagnostics ecosystem across Southeast Asia.¹

11.     In addition, Singapore is supporting the ASEAN Medical Device Directive system for uniform classification in registering and assessing medical devices. This allows manufacturers to have faster market access to the ASEAN countries with reduced technical barriers and regulatory hurdles, which will be helpful to countries where local medical device industries are not yet matured, and are heavily dependent on medical device imports.

12.     In tandem with national efforts on this front, the SingHealth Duke-NUS Academic Medical Centre’s Global Health Institute has been driving regional partnerships and knowledge exchange initiatives to address global health challenges, including those that can be overcome with the support of diagnostics. Today’s gathering of diagnostics specialists from around the region and strategic partnership with the Lancet Commission, is one of the ways that we can dive deep into important issues and find ways to advance the field together – with a common goal of raising the standards of diagnostics and healthcare to benefit our region and communities.

DIAGNOSTICS AS PIVOTAL IN THE MANAGEMENT OF COVID-19

13.     Turning now to the COVID-19 pandemic, which has laid bare the interdependence between countries and the need to strengthen regional partnerships. It has also highlighted the importance of diagnostics and the difference that access to diagnostics can make in managing local, regional and global health emergencies.

14.     In fact, COVID-19 was a burning platform that accelerated new diagnostic innovations and technologies at an unprecedented speed – the world saw novel COVID-19 test kits including self-administered tests developed and integrated into our daily lives in less than a year. In Singapore, the Health Sciences Authority (HSA) created a Provisional Authorisation process to expedite the availability of COVID-19 test kits, both professionally and self-administered, so that we are able to detect the virus swiftly across many fronts, such as when entering or leaving the borders, prior to attending an event or when one is not feeling well or a close contact of a case. Today, individuals are able to monitor themselves for COVID-19 effectively through self-administered Antigen Rapid Tests (ART), allowing us to better manage the situation and transit to living with the virus safely.

15.     Singapore and many of our regional partners were part of this global effort in developing COVID-19 diagnostics. For example, we worked with collaborators around the world to set up and maintain the genomic database for COVID-19 under the Global Initiative on Sharing all Influenza Data (GISAID), which has helped inform the global response towards the crisis, including facilitating the successful and rapid development of COVID-19 tests.² In addition, under the leadership of the 79th ASEAN Committee of Science, Technology and Innovation (COSTI), Singapore is co-leading two COVID-19 research collaboration projects among ASEAN Member States to boost the region’s knowledge and capacity in combating the current and future pandemics.³

16.     Locally, we have developed our own test kits. The Agency for Science, Technology and Research (A*STAR) has worked with partners such as local hospitals and Duke-NUS Medical School, to develop ground-breaking COVID-19 Polymerase Chain Reaction (PCR) and serological tests for hospitals and laboratories in Singapore and many other countries, even when little was known about the novel coronavirus. Examples include Fortitude 2.0, a real-time PCR assay developed in under a month, and cPass SARS-CoV-2 Neutralization Antibody Detection Kit, which even received United States’ FDA emergency use authorisation. There are also up-and-coming testing technologies, such as the COVID-19 Saliva Amplified Antigen Rapid Test that was co-developed by the SingHealth Duke-NUS Academic Medical Centre and National University of Singapore at the end of last year. The self-administered test allows individuals to test for the virus using their saliva, which is more convenient and comfortable than nasal swabs, and has licensed the technology to a commercial partner so that it can be brought to market for use.

17.     Beyond test kits, our healthcare professionals also implemented many innovative solutions in the clinical setting. For example, the Singapore General Hospital’s Department of Radiological Sciences and Department of Anaesthesiology developed the SG.SAFE.R booth, which isolates COVID-19 patients when they undergo chest X-rays. Since COVID-19 patients do not come into contact with the imaging equipment or staff, the risk of viral transmission is mitigated, and disinfection and turnaround time is reduced – leading to safer and more efficient operations.

18.     As swift public health interventions are crucial in our fight against COVID-19, we have also made use of technology to set up a COVID-19 Test Repository (CTR) as the central source for laboratory results, to allow laboratory results to be submitted to various organisations via the Laboratory Information System (LIS). This reduces the administrative burden for laboratories to perform manual submission and supports reconciliation of the results across the whole end-to-end process from laboratory reporting to case notification and contact tracing of close contacts.

19.     Support was also provided through financing levers to facilitate ring-fencing of clusters. Government-funded ART and confirmatory PCR tests are available for individuals experiencing acute respiratory symptoms and subsidies are available for individuals and companies in higher risk work settings of COVID-19 exposure and spread, where currently an ART-based Rostered Routine Testing (RRT) is mandated as a precautionary measure.

20.     Timely detection of COVID-19 cases could not have been achieved without trained medical laboratory technologists working around the clock since the start of the COVID-19 outbreak to test patient specimens from suspected and confirmed cases of COVID-19 over and above supporting the usual operations of the hospitals.

21.     On this note, I would like to take the opportunity to thank all healthcare institutions and their staff for their dedication, hard work and commitment in providing timely and accurate results crucial for the caring for patients, especially when managing the containment of the spread of COVID-19 in Singapore. While we continue the fight against COVID-19 and transit into endemicity, we would like to seek your continued support and commitment to work on new diagnostics and test their accuracy so that we can be better prepared to deal with any new COVID-19 variants of concern or a new Disease X.

CONCLUSION

22.     As we reflect on the lessons from COVID-19 and look ahead to the future for the field of diagnostics, we will realise that we are only as strong and as prepared as our collective efforts enable us to be. I hope that the strong collaborative spirit we’ve seen surface time and again during this pandemic will set the tone for your discussions today, and inspire future innovation and problem-solving in the face of global health issues. I hope this event will be the start of many more meaningful conversations and collaborations to come.

23.     I wish all of you a fruitful and stimulating meeting today.

¹ https://www.a-star.edu.sg/News/a-star-news/news/press-releases/singapore-to-catalyse-asean-medical-diagnostics-initiative-and-deepen-regional-connectivity & https://aseandx.com/about-us/
² https://www.pmo.gov.sg/Newsroom/DPM-Heng-Swee-Keat-at-the-SingHealth-Duke-NUS-Scientific-Congress 
³ https://www.a-star.edu.sg/News/a-star-news/news/press-releases/singapore-to-advance-covid-19-research-collaboration-with-asean