SPEECH BY MR ONG YE KUNG, MINISTER FOR HEALTH AT THE DIALOGUE ORGANISED BY MCKINSEY HEALTH INSTITUTE ON “ADVANCING HEALTH IN CITIES: INSIGHTS AND TOOLS TO HELP CITIES AND COMMUNITIES THRIVE”, 28 MAY 2024

Friends

Partners

Ladies and Gentlemen

1.        Thank you for inviting me to deliver this speech. 

2.        In August last year, there was a Netflix documentary series called Live to 100: Secrets of the Blue Zones. Some of you might have watched it. It was done by Dan Buettner, who is an old friend of Singapore, an author and an explorer. He is not an academic, neither is this series a research piece. It is just an observation and documentary. 

3.        He featured a few places, such as Sardinia in Italy, Ikaria in Greece, Okinawa in Japan, Loma Linda in the United States of America, California. In all these places, there are centenarians living healthily. What is their secret? Turns out it is not that big of a secret after all. It is common sense. They live healthily. They have good habits. They eat well, with less red meat. They don't eat until they are 110% full. They move around with a good level of physical activity. They have good social support, friends and social activities. 

4.        What I thought is most interesting is the last episode because it featured Singapore. There is a difference between Singapore and the rest of the Blue Zones. Singapore has many centenarians, but we live a long life more because of government policies. The government has nudges, such as encouraging people to exercise, building infrastructure such as covered linkways and park connectors. We restrict cars and we are forced to walk. We have many policies that nudge people to take on a healthier lifestyle. 

5.        It was a very interesting episode, but when I watched it, my first reaction was that I think we do not deserve it. I do not think we are in the same category as the Blue Zones featured in the previous episodes. 

6.        Precisely because I find the way of life in Singapore is actually quite unhealthy. Our food is fabulous, but full of sodium, sugar and spices. We are largely a sedentary population, working in offices and probably do not exercise too much. But somehow, we have centenarians and Dan Buettner observed that it is likely because of the good healthcare system that keeps people well in life, and nudges that force people to stay healthy. In a way, that documentary series is a nudge to Singapore to say “You can do better. You are actually not healthy as a population, but you happen to have nudges”.

7.        I think what we need to do over time through sustained effort, is for those nudges and behaviours to become part and parcel of our way of life. Then we will truly become a Blue Zone. We are not Blue Zone 2.0 as Dan Buettner puts it, but maybe we can be a Blue Zone 3.0 where there is a way of life, not because of the historical geographical reason, but because of policies which allow us to adopt a new way of life which is healthy. We need to do this. It is a major imperative and a national priority of Singapore, because of our ageing population.

8.        We are maybe 10 to 20 years behind Japan and Europe, but we are ageing fast. Today about 20% of our population is 65 and above. Very soon, by 2026 we will cross 21%, which makes us a super aged society. By 2030, we will age further, one in four or 25% of Singaporeans will be 65 and above. All these means more fiscal burden, higher patient load, more stress on the healthcare system and more stress on families who have to take care of the elderly and sick. 

9.        Therefore, we must take this opportunity when there is a major demographic shift to transform our healthcare system and transform life in Singapore so that it is healthier. There is a great opportunity because as you get older, healthcare expenditure rises across the board in every setting and it is only when budgets and expenditure are rising, that you can use money to make people transform. 

10.       Imagine, when budgets are shrinking or stagnant, it is very hard to change things. When budgets are increasing, we have a chance to use the new money to reshape the way things are done.

11.       So today, let me present a few ideas that we have been implementing. They are all not new. What we have done is to launch a major national programme called Healthier SG. It is really not one policy but a combination of many policies. It is a movement to transform healthcare and transform the way of life in Singapore. 

12.       You will find that you might have seen each of these ideas from elsewhere but maybe we conceptualised them a bit differently. Maybe we used a different angle. Maybe we implemented them differently. So I thought I will share it with you. There are four key areas. 

13.       Number one is the way we fund hospitals. We made a decisive shift away from a fee for service funding. As you might know fee for service means you confirm budgets based on workload. The more surgeries you have, the more diagnostic tests you have, the more budget hospitals will get. Which means hospitals may not have a strong incentive to keep people healthy, or to keep surgeries and diagnostic tests low. 

14.       Therefore, some jurisdictions have moved towards episodic funding. For each episode, for example so long as it is a cardiac issue, they will fund the same amount and in that way you squeeze out certain inefficiency due to over-servicing. But episodic funding does not squeeze out another layer of important wastage, which is population level wastage, meaning this cardiac patient should not have been here in the first place, if he had been healthier, or lived more healthily. 

15.       Capitation funding is the only way to squeeze out both clinical as well as population level inefficiency. We have moved the entire healthcare hospital system to capitation funding. What we have done, through several years of effort, is to configure our healthcare system into three clusters, each looking after about 1.5 to 2 million people. Within each cluster, we will have primary, secondary as well as tertiary care and we capitate at the cluster level. 

16.       Capitation funding, the way we do it, might be slightly different from other countries which tend to capitate at the primary care level. We felt that this is not ideal. The whole idea of capitation funding is to impose discipline on an institution that has a range of interventions for the population, which is why at the cluster level we think it might be the most effective. This is still experimental. We just implemented it in April this year and will keenly watch the outcome. 

17.       The second area of intervention is primary care enrolment with General Practitioners (GPs) and private clinicians. Again, not a new idea at all. Many countries have done this before us. Ours is voluntary. We invite everyone aged 40 and above to choose a GP whom they are most comfortable with and then enrol with the GP. The GP will go through their lifestyle with them and develop a health plan on what they need to do. For example, I was told to cut all my snacks so I am trying to get rid of all my snacks.

18.       But what I think is different is the way we implement enrolment. In many countries, GP enrolment makes the GP a gatekeeper to the hospital. So if you need secondary or tertiary care, you have got to go to the GP first and he has to assess if your condition is serious enough to be referred to a hospital. In our case, we are using the GP more as a pathfinder to community support, not so much a gatekeeper. In Singapore, you can always access hospital care without going through the GP, but you go to the GP because the GP can then refer you to community support. In Singapore, there are many different groups in the community that organise exercises, brisk walks, Tai Chi classes, healthy cooking, for example. And all these resources are already available in our community. Through the GP, we think we can nudge people better to engage in these activities. 

19.       The third area is our funding policies. We are a big believer that how you fund healthcare will affect how much you pay for healthcare. How you pay for healthcare will affect how much you pay for healthcare. When we shift our policy gravity towards preventative care, we are also shifting the gravity of healthcare away from hospitals and clinics into the community. So it is important that we create a gradient of funding such that people know that it is more worthwhile to build health in the community than to seek treatment in the hospitals. 

20.       Many healthcare systems can easily make this mistake and we had as well, which is because your illness is more severe in the hospital, we fund you more generously such that I almost have no out of pocket when I go to a hospital. We go through surgeries and stay in the hospital ward. But when I get better, say you are ready for home care or community care, the funding level drops because it is less serious and suddenly, I find that I have to come up with out of pocket expenses. So therefore, my incentive is to stay in hospital. I think that happens in so many jurisdictions. So we have to design our healthcare system in a way that encourages right siting and movement into the community, emphasising on community care. 

21.       I think that is not enough. When it comes to preventative care, such as taking your vaccination, going through your recommended health screening, be prepared to fund fully 100%. Under the Healthier SG programme, the signal is sent very clearly to our population. The context of Singapore is that Singapore is the land of co-payment. In Singapore, not many things are free, other than public libraries, public parks and preventative care. It is a very clear signal that if they practise preventative care and they are fully funded 100% by government. And if you exercise, we give you incentives. So in Singapore, we have a wonderful programme, the more you exercise, government actually pays you to exercise. I don't know whether that is the right policy, but I think it creates the right financial gradient. 

22.       I just met a friend who is a fervent walker. He said he gets $20 of incentives from the government every month by exercising. The beauty of this is that we created this app and way of incentivising exercise, but a good proportion of people, having accumulated those incentives, do not claim them. It is for the satisfaction of just accumulating enough incentives.

23.       Finally, to actively shape lifestyles, and particularly diet. In our part of the world, diet shapes who you are and your health status in the long run. What we have found out is that it is better to educate and give people a choice to live more healthily than to tax them and unhealthy foods. What we have done is to put aside a sugar or salt tax, and instead use labelling to let consumers choose between healthier products and less healthy products and it has worked very well. This is an important lesson that we learned. When it comes to health, it is very personal. I think Singaporeans at least prefer to make their own choices. 

24.       The presenter said to add years to life and add life to years. I would nuance it a bit differently. I think it is worthwhile adding years to life, only if there is life to those years. If we just add years to life, it can be painful if you are not healthy. Singapore has one of the highest average lifespans in the world, at 84. But we also need to look at another indicator which is our health span. Our health span is a good 10 years younger at 74. So health span 74 and lifespan 84, which means the average Singaporean lives 10 years in ill health. Between raising 84 to 94, and adding two more years to health span to 76, I would rather choose increasing the health span. I think the holy grail of healthcare policy is not to just simply increase lifespan but to compress the difference between health span and lifespan. We are 10 years, which is typical amongst OECD countries and developed countries. But if we can compress it down to eight years to seven years to five years, then I think we will have a handle on the challenge of our demographic shift. 

25.       Ultimately, you cannot run away from the math, which is that more and more people will cross the line of 65 and be defined as aged. That proportion will just keep on increasing. The demography is predetermined and you can already calculate what will happen in the next 10 years.

26.       We cannot change that. But I think what we can change is the definition of ageing. What makes us think that 65 is the line that once you step across, you are aged? There is absolutely no reason. There was a time when people did not live beyond 65 but I think we can have a day when you cross 65 and say I am still young. Then we will have solved our aged problem. Thank you very much.