Loopholes in Healthcare Information System may have failed Singapore COVID-19 model

In the initial days of the COVID-19 outbreak, Singapore was in the limelight for its effective healthcare system and pandemic response plan. However, Singapore has now joined the list of the worst-hit nations and the situation is even worse than Italy, Iran, and South Africa in terms of cases per million people. This fall of the Singapore model to fight COVID-19 can be linked to its healthcare information system which is plagued with several loopholes.

There are several awards and recognitions on the name of the healthcare system in Singapore such as  6^th in the world by the World Health Organization, the best in the World by Bloomberg in 2014, and first in Asia and 4^th in the world by the Bloomberg Health Index. Therefore, it was not surprising when the city-country, with a population of about 5.8 million, presented an impressive model for COVID-19 response before the world. It was due to these accomplishments attached to it that even the healthcare professionals and health policy experts in the USA and European countries started looking at Singapore as a role model. However, the country could not maintain this image for long.

Due to its proximity and connectivity with China, Singapore was among a few countries that were exposed to COVID-19 even before it was declared a Public Health Emergency of International Concern (PHEIC) on March 11. The island country reported the first confirmed case of novel coronavirus on January 23 but daily cases remained low till March. But it was on April 6 that daily COVID-19 cases crossed the 100-mark in Singapore and peaked with 1,426 cases on April 21. Since then, the cases have decreased gradually but remain above 200 cases per day on most of the days.

As per recent data on July 26, Singapore has 50,369 COVID-19 cases and 27 deaths. This figure may look small but a comparison of COVID-19 cases and deaths on the standard of per million people puts a big question mark on the pandemic response plan of Singapore. The city-country has reported 8,111 cases per million population which is higher than Italy (4,035), Iran (3,207), Russia (5,245), India (752), and close to the worst affected Brazil (9,627) and the US (11,020). This could be better understood by comparing Singapore with New Delhi with a population of 28 million (4.8 times) and 1,21,582 cases (2.55 times). The analysts often blame the high population of Singapore for the recent rise in cases but the population density of New Delhi which is 11,297 persons per square km as per the 2011 census is much higher than that of Singapore’s about 8,136 persons per sq. km in 2019. Besides, New Delhi has thousands of slums and highly congested unauthorized colonies.

However, another island country in the Western Pacific – New Zealand (4.8 million population) with almost the same population to Singapore, have performed better in both absolute terms and also cases and deaths per million population. The Kiwis have reduced daily COVID-19 cases to below 5 cases per day since April 22 with 0-1 cases on most of the days. Till July 17, New Zealand had reported a total of 1,206 cases and 22 deaths.

These data indicate major loopholes in the COVID-19 response and healthcare information system of Singapore. This necessitates a critical review of Singapore’s health information system for further improvements which can help the policymakers develop a pandemic resilient health information system.

Healthcare Information System in Singapore

The present healthcare system in Singapore is based on healthcare reforms in 2012 under which the entire healthcare system was reorganized into six regionally bounded care ecosystems called ‘regional health systems’ (RHS). Every RHS is led by a tertiary hospital and includes all the secondary and primary care providers including publically-run polyclinics, family medicine clinics (public-private partnership), private sector general practitioners, secondary and tertiary care hospitals, community hospitals, rehabilitation centers, social and community partners, home care centers and nursing homes, etc. which are interlinked through agreements.

Ministry of Health (MoH) Holdings, an umbrella company under MoH for public healthcare institutions, includes several specialized institutions for infrastructure management, training, and education of healthcare professionals, healthcare policy formulation, procurement, supply chains, price determination, management of information technology, health promotion, and provident fund, etc. Followings are the key features of Singapore Healthcare Information System: 

• National Electronic Health Record (NEHR): Launched in 2011, NEHR is the basic tool for health data collection from every individual and is referred to as the foundation of the healthcare information system in Singapore. It consolidates a patient’s medical information by extracting all clinically-relevant information from the patient’s every encounter with the healthcare system. As data sharing to NEHR is voluntary for all the private hospitals/healthcare providers, the project is still in the progress despite a push in 2018. Patients can access some of their health records via the internet but this facility is restricted for the citizens and permanent residents. They can also use NEHR for healthcare services such as fixing appointments and procurements.
• NEHR is aimed at helping the patients to navigate through the healthcare system and help them choose the most suitable healthcare facility in a convenient manner. There are three healthcare groups in the country namely – National Health Care Group, National University Health System, and SingHealth which lead the healthcare system.
• The NEHR data of patients are accessible to authorized healthcare professionals of RHS and also used in patient referral services.
• Integrated Care Pathways (ICP) has been set up for chronic diseases to ensure hassle-free care, particularly for the aging population.
• Ministry of Health (MoH) coordinates with the six RHS and also provides governance, funding, and strategic directions through them. Besides, the MOH and RHS jointly set up specific targets for their regions.
• Integrated Health Information Systems (IHiS): IHiS is the technology agency for the public healthcare sector in Singapore. It claims to support 50,000 healthcare users in Singapore's health ecosystem through application of clinical informatics, computer science, data science, mechatronics, standards-based IT that enables information exchange and cross-boundary workflows, analysis, statistical and machine learning techniques to discover insights. It has reportedly developed and is operating disease/problem specific mobile apps and online healthcare services such as telehealthcare, smart health video consultation, online financial transaction and appointment services, etc.
• SmartCMS Program: Singapore has a mixed system of healthcare financing which involves free government healthcare insurance, subsidies, compulsory savings, insurance schemes (public and private), cost-sharing, and out of the pocket financing. These services are largely based on the principles of affordability wherein low-income people are provided higher subsidies for using the same healthcare facilities in comparison to high-income patients. SmartCMS, through the voluntary contribution of information sharing, aims to integrate these services on the internet for efficient utilization. This program is also a work in progress.

Loopholes in Healthcare Information System of Singapore

The healthcare system in Singapore may be good on paper but it has received criticism of scholars for gaps between achievements and aspirations. As per the government data in 2019, about 1300 healthcare institutions participate in the NEHR but absolute adoption is still a dream even after nine years of launch. The loopholes in the Healthcare Information System of Singapore could be summarized as under:

• Launched in 2011, widespread application of NEHR is yet to be achieved. Lack of awareness, lack of accuracy, comprehensiveness of documentation, issues of privacy are considered major hurdles in the universal implementation of NEHR.
• The healthcare information system in Singapore primarily follows a disease centric clinical approach wherein high emphasis is provided on cure but less on prevention and healthy living. For a small city population of 5.8 million, Singapore has 18 acute (disease-specific specialized) care hospitals, nine public hospitals, eight for-profit hospitals, one not-for-profit Catholic hospital, and hundreds of secondary and community level healthcare institutions. It spends about 4.47 percent of GDP on healthcare but satisfactory healthcare to the aging population is still a dream.
• Super specializations of medicines have caused fragmentation of the healthcare system in Singapore as there is a shortage of multidisciplinary physicians to provide holistic care to patients.
• The government funding for healthcare comes through RHS to which an acute (specialized) hospital in the region acts as a lead hospital. Thus the acute hospital/s of the region get the lion’s share of government funding but community-level healthcare institutions face financial constraints due to which they are alleged to be of inferior quality and patients prefer to directly approach the specialized hospitals leading to congestion. This model may work for a small population in a small area like Singapore but will face huge challenges in countries of large areas and big population size.
• The healthcare information system in Singapore is said to have adopted a ‘top-down’ approach due to which healthcare users are not aligned and well versed with the system. This mismatch between conceptual expectations and ground realities is also a major hurdle in the implementation of NEHR.
• Every RHS is governed by different boards. They have little inter-RHS interaction which is against the vision of an integrated and holistic healthcare information system.
• Lack of Mental Healthcare Facilities: Singapore is yet to recognize the importance of mental healthcare facilities. According to media reports, the suicide rate is very high in Singapore. More people die to due suicides than road accidents in the country. But it still has only a standalone acute tertiary psychiatric hospital – Institute of Mental Health. The country lacks adequate professionals for counseling of students, youths, elders, and other vulnerable sections of the population.
• Affordability: Singapore's per capita income of $105,689 is the third highest in the world but the healthcare system is not affordable for a huge section of the population. In addition to several insurance schemes, the government is bound to provide healthcare subsidies to low-income patients.
• The various mobile apps are meant for different diseases particularly focus on medication and guiding the patients to the hospitals. There is hardly any mobile app to guide the people for a healthy lifestyle and healthy food habits etc.
• Unidirectional Health Information System: NEHR data are not used to create awareness among people for healthy living, preventive care, and awareness against chronic diseases.

COVID-19 Response of Singapore

A critical review of Singapore’s response to COVID-19 reveals that the initial success of the city-country was mainly due to strict decisions, administrative alertness, testing, contact tracing, and isolation. The government’s decision to provide paid leave for COVID-19 testing to employees, monetary assistance to workers for testing, punishment for hiding the disease, making non-wearing of face mask a punishable offense, mandatory temperature screening and sanitation at workplaces, travel restrictions and lockdown also helped in controlling the first wave of outbreak.

Healthcare communication plan involving direct video address by Prime Minister Lee Hsien Loong to citizens and Whatsapp service to counter infodemic has worked in favor of the country's fight against the disease. Besides, Singapore’s previous experience of handling SARS Coronavirus in 2003 also helped it in planning COVID-19 response and controlling the outbreak in the initial months. The analysts blame migrant workers living in cramped dormitories for the sudden rise and continued spread of COVID-19 in Singapore. However, these ‘cramped dormitories of migrant workers’ did not develop overnight and the authorities were supposed to be aware of the potential risk they pose in spreading COVID-19. Several countries in the world are fighting with the pandemic with migrant dormitories, slums, remote villages, tribal areas, etc.

It seems the relax-tight-relax approach which was considered as the uniqueness of Singapore and was initially manageable due to its small size and population, backfired in the long term and helped the virus to spread in asymptomatic form among the masses. The consistent increase in daily COVID-19 cases has compelled the analysts to look beyond the Singapore model of pandemic response. Had the government used this period in briding the loopholes of the health information system, the future of the Singapore model would have been better. As a robust health information system is crucial for successful response against a pandemic like COVID-19, the Singapore model is most likely to have stuck in these loopholes. The involvement of the Prime Minister in heath communication plan is praiseworthy but it also indicates the weakness of the healthcare information system in handling the crisis. This model was effective in managing the disease outbreak at the macro level when most of the cases were imported but a robust healthcare information system was required to manage it at the micro-level when community spread started.

Conclusion and Agenda for Discussion

Like many other countries, the potential of NEHR in Singapore is primarily being used to clear the bills of healthcare insurance. However, it has huge potential in predicting disease outbreaks, planning a response, healthcare forecasting, disease management, integrating supply chains with healthcare systems, training of healthcare professionals for known diseases, and also to develop a pandemic resilient healthcare system for unknown disease outbreaks and natural disasters in the future.

Singapore’s healthcare system of including private hospitals under a lead public hospital of RHS may not work in countries where private healthcare is highly organized, efficient, and caters or aspire to cater to the need of a large national and international population. The territorial and disciplinary restrictions to private hospitals are also difficult to implement in larger countries. Besides, hospitals in Singapore are also often blamed for profiteering, non-sympathetic, and non-empathetic behavior towards patients.

The above analysis reveals that Singapore might have a good infrastructure of health management information system but it lacks on several grounds in providing efficient healthcare to people. There is a great need to make the health information system bidirectional wherein the NEHR is not only a record of patients in the hand of healthcare professionals but also an instrument to reach out directly to the patients to help them in making informed decisions on their health and wellbeing. The infrastructural and procedural mechanisms should be developed to utilize the full potential of NEHR which is crucial for a robust, integrated, and holistic health management information system. 

VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.