Singaporeans are living longer but not necessarily healthier, and that has implications for the state and economy. There are ways, however, for policymakers to incentivise good health.
SINGAPORE (July 29): For those born in Singapore, good news — the average life expectancy in the Lion City has increased from 76.1 years in 1990 to 84.8 years in 2017. That works out to an additional 8.7 years alive. The not-so-good news: More than a decade of that extended lifespan is likely to be spent in poor health, no thanks to cardiovascular diseases, cancers, musculoskeletal disorders and mental conditions.
A lengthy period of poor health affects more than an individual’s quality of life; the state and broader society bears the consequences of the individual’s lessened contributions to the economy and society, and the cost of healthcare. It is in everyone’s interest to be as healthy as possible, but how can they do so?
Healthcare reforms in Singapore since 1990 are keeping people alive for longer, but policies have not managed to reduce the number of years spent with diseases and disabilities. In 1990, that figure was at nine years, but it increased to 10.6 years in 2017. This is because of an ageing population that is typically more susceptible to chronic diseases and disability than younger folk.
These statistics were released in a recent research paper titled “The Burden of Disease in Singapore” on the Ministry of Health’s website. The report was produced by MOH, along with the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, as part of the World Health Organization’s Global Burden of Disease studies.
Despite what may seem like dismal news for Singaporeans, the city state actually ranks at the top of a list of 38 countries for life expectancy, including the US, Hong Kong, Australia, South Korea, Switzerland and Japan. Compared with its peers in the Organisation for Economic Co-operation and Development, Singapore has the highest life expectancy and highest healthy life expectancy (74.22) at birth. Japan comes in second at 84.2 for life expectancy and 73.1 for healthy life expectancy; the Americans are eighth from the bottom with a life expectancy of 78.6 and only 66.6 of them as healthy years.
“Singapore is actually doing very well when it comes to health,” says Ali H Mokdad, professor of health metrics sciences at IHME.
So, the focus now should be on reducing the number of years spent in bad health, say healthcare experts, who call that the compression of morbidity. This gives the population a better quality of life, and also lightens the cost burden of ill health on the state, which is set to rise as Singapore ages.
In 2013, policy research think-tank the Institute of Policy Studies pegged the rise in cost of healthcare due to an ageing population at 2.5% a year. In 2016, a report by Marsh & McLennan Companies’ Asia-Pacific Risk Centre estimated that Singapore’s elderly healthcare costs — including public expenditure, private insurance and out-of-pocket spending — would increase tenfold from 2015 to 2030, reaching $66 billion a year.
Three in four Singapore residents aged 65 and above are affected by diabetes, high cholesterol or hypertension, or a combination of all three. The cost of diabetes alone, Singapore’s eighth leading cause of years of life lost and lived in disability, is projected to soar from $1 billion in 2010 to more than $2.5 billion in 2050. The estimate, done by researchers from the Saw Swee Hock School of Public Health, takes into account medical costs and indirect costs such as productivity loss, owing to absenteeism, premature mortality and non-participation in the workforce. In 2017, diabetes formed 11% of MOH’s expenditure.
There is no similar estimate for heart diseases and cancers here, but overall government healthcare expenditure has been increasing, from $4 billion in 2011, to a projection of more than $13 billion next year.
Says Christopher Gee, who leads the governance and economy department at the Institute of Policy Studies: “If the trends that we see play out and more people end up facing chronic diseases and multiple morbidities, and spend a prolonged time in a period of poor health before dying, that is expensive. It really cuts into the quality of the person’s life and also their caregivers’ lives, so that’s the big concern. And at the end of the day, it is expensive, it is a burden.”
Adds health economist Phua Kai Hong of the Lee Kuan Yew School of Public Policy, National University of Singapore: “The poor health before death must be shortened, even the period of disability, to as low as you can get so people live to a ripe old age and have a very quick period of disease and ‘conk off’. That’s the most ideal and cost-effective healthcare system.”
HALE and hearty
To extend the healthy years of Singaporeans, the Ministry of Health has a plan. A significant number of the years in which Singaporeans live with disabilities can be attributed to modifiable risks, it says. As such, reducing the exposure to these risk factors can prevent and delay the onset of diseases.
The Burden of Disease in Singapore report lists the top five risk factors as diet, smoking, high blood pressure, high blood sugar and obesity. The first four have ranked that way since 1990, with obesity jumping three places since to fifth position. Together, they contribute to heart diseases, cancers, and diabetes and kidney diseases.
In response to The Edge Singapore, a MOH spokesperson says: “Singapore’s public health policies and programmes are focused on tackling preventable risk factors such as unhealthy diets, insufficient physical activity and smoking… We will continue to do more through health promotion to prevent the onset of these diseases. Over time, we hope that the efforts in delaying diseases will lead to an improvement in Health Adjusted Life Expectancy (HALE).”
In 2016, MOH declared war on diabetes and launched a multi-year plan to promote good eating habits and exercise, and to encourage early screenings and better disease management. Singapore’s Health Promotion Board also runs a national steps challenge that dishes out rewards for those who walk at least 10,000 steps a day and runs campaigns telling Singaporeans to consume less sugar and salt, and fewer calories.
Incentivise, more than subsidise
“We need to invest in people when they are young so they maintain a healthy lifestyle,” says Phua, pointing to how the city state has been using nudge theory to encourage behaviours it desires, from not smoking to how many children to have. “Use pricing, use taxation and subtle messages to tell people who your role models are.”
On a more futuristic note, science can even be used to slow down ageing, says Jeremy Lim, partner at Oliver Wyman’s Asia-Pacific practice based in Singapore. He says the National University of Singapore has initiatives in that line of research. There are also ongoing trials of diabetic drug Metformin’s ability to reduce the impact of conditions commonly associated with ageing.
Another suggestion the experts have is to incentivise people to seek preventive care early. Gee says regular check-ups and health reviews may not be accessible or affordable for all. He suggests looking at what causes people to avoid dealing with these illnesses or not seek preventive care.
Indeed, there are even cases of people refusing treatment after a diagnosis, because of how much it would cost. Despite huge government subsidies, a portion of fees is still borne by the patient, ostensibly to discourage overconsumption.
As Gee’s recent report on end-of-life-care noted, owing to high costs, an estimated one in five patients might decline treatment when they first see an oncologist. Kidney patients have also been found to refuse dialysis treatment because of the costs of treatment, consultations, medication and even transport.
“Even with a substantial 90% of a $100,000 medical bill covered by MediShield Life, the remaining 10% co-payment may still be significant for an elderly person with no income,” wrote Gee and co-author Yvonne Arivalagan.
To nudge the population towards early detection and treatment, the government could look at the way healthcare financing is structured.
“Make sure that people get the right incentives to seek care in the community and also at home. Fund and subsidise more home care or primary care,” says Gee.
To be sure, the government has been stepping up subsidies for the needy. The Community Health Assist Scheme (CHAS) card, launched in 2012, subsidises visits to the general practitioner and dentists for low-income Singaporeans. This year, it was extended to cover all Singaporeans for chronic conditions, regardless of income.
While incentives are encouraged, however, Phua warns against finance structures that penalise those with ill health on the assumption that “it is due to your past sins”.
“If we’re going to price it differently and give incentives and rewards, then what is the criteria? We might end up penalising those who haven’t kept well and also those who try their very best to keep healthy but ended up with a stroke,” he says.
“Coming back to old-fashioned public health: It is a motherhood statement but you really should not leave people behind. You must include people who fall through the cracks. It’s about equity — nobody gets left behind. You must look after those with poor health. Universal health coverage really has to go for the most vulnerable.”
Lim cautions that the vulnerable must have the same access to healthcare. Pointing to how there is a disconnect between Singapore having the highest life expectancy, but also high rates of end-stage kidney disease, Lim says: “The conclusion is that there are many ‘Singapores’. There is the Singapore of the heartland, the Singapore of Shenton Way, the CBD and [Marina Bay Financial Centre], but also a Singapore of one-room rental flats that we don’t commonly see and these guys have some of the worst health outcomes.”
Closer eye on mental health needed
Mental disorders are the fourth-largest contributor to Singapore’s burden of early death and disability. From 1990 to 2017, mental disorders increased in the number of disability adjusted life years (DALYs) — a measure that summarises the burden of both early death and time spent with disability — by 70.9%.
Mental disorders were especially prevalent in young Singaporeans who were otherwise generally healthy. The disorders formed the single-largest contributor to disease burden for Singaporeans aged between 10 and 34, peaking for 15- to 19-year-olds, for whom mental disorders represented 25.8% of total DALYs.
Experts say this is an area that needs intervention.
Health economist Phua Kai Hong says: “Once a person is depressed and cannot function anymore, he will be surviving longer but is non-productive. We cannot have too many people watching the world go by, not contributing to the economy, are otherwise healthy but still a burden to their family. Psychologists and social workers keep reminding us, ‘Don’t just look at acute health, look at mental health.’”
A look at years lived with mental disorders shows that males experienced higher numbers of these because of autism spectrum disorders compared with females. But anxiety, depression and eating disorders made up a substantially higher percentage of years lived with disability among females than among males in all age groups.
Some of these conditions can also lead to suicide. Self-harm and interpersonal violence is the fourth leading cause of years of life lost (YLL) in 2017, forming the largest burden for YLL for Singaporeans aged 10 to 44.
This affects society by “cutting short lives with many potential years ahead of them — years of economic productivity, caring for families, and other societal contributions”, says the report.
Christopher Gee from the Institute of Policy Studies says: “Suicide at an early age does mean a drop in the number of productive years. The more we have of this and mental illness at whatever age, it’s going to create a very different disease burden and is clearly more expensive.”
The Ministry of Health says that, although self-harm and interpersonal injuries were the fourth-highest contributor to YLL in Singapore, “we ranked the fifth lowest among the comparison group locations”. “We will continue to take a multi-pronged approach to build mental health resilience among our youth, by providing access and referral to mental health services. To address youth mental health holistically, it is also important to strengthen knowledge and skills-building among youth, as well as parental engagement,” says the ministry.
