Holistic approach to elderly care

Singapore consolidated its various health and care systems to deliver integrated cost-efficientcare for its aging population

Introduction

In Singapore, 14.4% of its 3.9 million population was aged 65 years or older in 2019. By 2030, this number is expected to reach 25% due to rising life expectancy and lower fertility rates. Although the country currently has one of the lowest age-related disease burden rates in the world, demand for long-term care is expected to accelerate with increasing life expectancy and a growing number of single households in the next 2 decades.

With life expectancy among the highest in the world, Singapore is one of the countries leading the way in developing and implementing measures to meet the changing health and care needs of its population due to the demographic shift. Cognizant of population agings impact on the countrys future, the government has taken a multi-pronged, integrated, and holistic approach that takes into account the different requirements of individuals as they age under the Singapore Action Plan for Successful Aging. It has also developed policy and programs that include expansion of and integration of health and social care.

This article is adapted from Singapore's Long-Term Care System: Adapting to Population Aging published by the Asian Development Bank.

What challenges in care does an aging population face?

Better nutrition, living conditions, and public health, alongside Singapores rapid economic growth, have contributed to the peoples longevity. The average healthy life expectancy of women is at 82.3 years while that of men is at 79.6 years. At the same time, there are fewer births every year as more individuals opt to marry later and have fewer children. Longer lives, in tandem with declining birth rates every year, have hastened the aging of Singaporean society.

The number of households with at least one member aged 65 and above has increased steadily. Similarly, the number of older households and households of older couples without children has risen. These demographic changes have increased the burden on families, especially as older family members experience illnesses and injuries, such as cardiovascular diseases, cancer, and neurological diseases. The National Health Survey in 2010 showed that 37% of caregivers have provided care and assistance to family members and friends for more than 10 years and spent an average of 6.8 hours of care per day.[1]

Singapores healthcare budget rose to $11 billion in 2016 from $4.7 billion in 2012. The budget increase was partly attributed to aging, and the need to invest in infrastructure. Governments move to take on a greater proportion of healthcare costs also raised the budget.

What are essential to Singapores approach to long-term care?

Singapore recognizes the need to promote an age-friendly and enabling environment that integrates income, environment, health, and social issues in support of successful aging. For long-term care, its approach focuses on home and community-based care instead of only a reliance on residential care. Boosting the primary, intermediate, long-term, and home care sectors, as well as strengthening the partnership between hospitals and the care providers has streamlined processes, enabled shorter hospital stays, and supported faster recovery for patients.

The country has also undertaken a policy shift toward a population health approach. Population health is an interdisciplinary and multi-stakeholder approach that aims for better health outcomes across a population. Thus, a policy shift to a population health approach requires initiatives that improve physical and mental health outcomes, and overall well being, as well as reducing health inequalities and involving various stakeholders.

Aged care in Singapore begins with the individual and the family but engages communities, civil society, the private sector, and the government to ensure care for older persons. Such broad participation reduces unnecessary use of residential services and lowers the cost of delivery of services for older persons.

How can a holistic long-term care approach be implemented?

Under Singapores aging policy, health and care are integrated as part of a wider process of consolidating public health, primary care, acute care, rehabilitation, and long-term and palliative care. This minimizes cost, maximizes prevention, promotes individual and family responsibility, and reduces inefficiencies.

Singapore has placed aging, health, and long-term care initiatives under the Ministry of Health. It supervises the entire health and long-term care systems, including setting policy directions, financing health and long-term care, and developing regulatory frameworks. Under the governance of the ministry, the multipronged approach to aging, health, and care involves the following: Ageing Planning Office, Agency for Integrated Care, Integrated Clusters for Public Health system, and Ministry of Health Holdings.

The Ageing Planning Office oversees the planning and implementation of strategies to respond to the needs of Singapores aging population, coordinates age-related policies and programs across all ministries as the secretariat for a Ministerial Committee on Ageing, and implements national programs under the Action Plan for Successful Ageing. Launched in 2015, the S$3-billion [$2.2-billion] flagship project aims to make Singapore an age-friendly city so that all residents can have improved quality of life and older persons can continue to contribute to their families, communities and state. It includes more than 70 initiatives across 12 areas, including health and wellness, education and learning, employment, housing, and transport.

The Agency for Integrated Care consolidates and coordinates all health and care services, including home care, day care, community mental health services, and stay-in care. It also implements the national care assessment framework and improves the monitoring of long-term care through quality improvement initiatives.

The Integrated Clusters for Public Health system provides the platform for collaboration among service providers in a specific region and comes up with strategies and programs to address the needs of the regional population. The regional health system bridges the gap between public, private, community, and home-based health services to provide person-centered care.

The Ministry of Health Holdings serves as the common platform for human resources and information technology through the National Electronic Records.

What is Singapores strategy for financing the health and care of its aging population?

Singapores approach to financing the countrys health system focuses on the following:

1. Reduce overutilization of expensive health services.
2. Reduce overall need for costly health care by improving population health.
3. Harness volunteers.
4. Regulate health and care costs.
5. Increase insurance coverage and risk pooling.
6. Expand care services and support for aging in place.

The country has universal social health insurance coverage supplemented by private health insurance. Three main programs help guarantee citizens access to basic health care at a controlled costMediSave, MediShield Life, and MediFund. MediSave is a mandatory personal medical savings account where every working Singaporean contributes 8%10.5% of their salary while MediShield Life is a compulsory basic health insurance plan that provides universal lifelong coverage to offset large costs from unexpected illnesses that MediSave is inadequate to cover. MediFund is a government endowment fund accessible at selected institutions for those who cannot afford the subsidized bill charges despite MediSave and MediShield Life.

Three complementary insurance schemes also provide for disability coverage. A severe disability insurance scheme, ElderShield automatically covers from the age of 40 all citizens and permanent residents born before 1979 who have a MediSave account. Three private companies provide the insurance, with premiums paid for through MediSave accounts or through cash. ElderShield Plus offers higher monthly payouts or payouts for a longer period or a combination of both.

Meanwhile, a compulsory insurance policy introduced in 2020, CareShield Life provides payouts for people who are severely disabled. It automatically covers those born between 1980 and 1990 and those who reach 30 years old. Premiums can be fully paid by MediSave for those who cannot afford the payments.

Singapores financing package for health and long-term care also includes additional subsidies and schemes, some focusing on financial support to informal caregivers and home-based care.

However, since not all Singaporeans can afford insurance premiums and other costs related to health care, the government has expanded safety nets for those unable to pay and social assistance, including the purchase of assistive devices.

What lessons can be learned from Singapores long-term care approach?

Restructure systems to promote integration. As Singapore focused on enhancing the accessibility, quality, and affordability of the long-term health and care sector to meet the changing needs of the aging population, it also restructured the system to promote the integration of various health services.

Adopt the population health approach. As health and care requires a holistic approach, investment in health promotion, prevention, rehabilitation, enabling environment, and social care can improve outcomes and reduce cost.

Strategically use public financing. Public financing can ensure risk pooling, increase use of preventive and lower-cost health services, and reduce expensive use of hospital care. It can also provide the budget for non-health sector programs that facilitate aging in place.

However, while many countries can learn from Singapores current initiatives on long-term care and population health, the unique context of their health and care systems as well as their health care financing model need to be considered.

Resources

A. Y. Chang, et. al. 2017. Measuring Population Ageing: An Analysis of the Global Burden of Disease Study 2017. The Lancet Public Health. 4[3]. pp. 159167.

Asian Development Bank. 2020. Singapores Long-Term Care System: Adapting to Population Aging. Manila.

C.E. Lee. 2019. Improving the Health of the PopulationThe Singapore Model. SingHealth.

Department of Statistics Singapore. Elderly, Youth, and Gender Profile.

G. Yong. 2016. Better Health. Better Care, Better Life. Speech of the Singapore Minister of Health at the Ministry of Health Committee of Supply Debate. April 13.

International Longevity Center Singapore. A Profile of Older Men and Women in Singapore 2011.

J.A. Baker. 2020. Healthcare Spending on the Rise Because of Higher Utilization, Rising Manpower Costs-Gan Kim Yong. Channel News Asia.

K.C. Peh, W.C. Ng, and D. Low. 2015. Long-term Care of Older Persons in Singapore. SDD-SPPS Project Working Paper Series: Long-Term Care for Older Persons in Asia and the Pacific. Bangkok: United Nations Economic and Social Commission for Asia and the Pacific.

The Kings Fund. 2018. A Vision for Population Health: Towards a Healthier Future.

National Healthcare Group. RHS for the Central Region [accessed 15 May 2015].

T. Woon and K. Zainal. 2018. Successful Ageing: Progressive Governance and Collaborative Communities. Civil Service College Singapore.

World Health Organization. 2016. Global Health Observatory Data.

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