From Astana to Singapore: Primary Health Care is key to the long-term success of Singapore’s health system

The Ministry of Health, Singapore (MOH) has launched a wide-ranging and ambitious initiative for a life-course approach to drive the population’s health.¹ This approach aims at ensuring the sustainability of the healthcare system. Crucially, it also embodies core principles of the health systems orientation that have long been advocated by the World Health Organization (WHO) and that is the cornerstone of the health strategy in the United Nations Sustainable Development Goals: Primary Health Care (PHC). PHC is a whole-of-society approach that aims to equitably maximise the health and well-being of all people. It focuses on people’s needs and preferences as early as possible along the continuum, from health promotion and disease prevention, to treatment, rehabilitation and palliative care. It brings care as close as feasible to people’s everyday environment.²

The 1978 Declaration of Alma-Ata was a seminal moment in the history of PHC.³ Adopted at the International Conference on PHC in the former Kazakh Soviet Socialist Republic that is now Kazakhstan, it birthed a global movement for PHC. Governments, WHO, United Nations Children’s Fund (UNICEF) and major global health actors pledged to protect and promote the health of all people in the world and recognised PHC as essential and fundamental to a country’s health system, inextricably linked to its socioeconomic development. The declaration provided a framework for the redesign of health systems and called for stakeholders to collaborate on urgent and effective action—both nationally and internationally—to develop, implement and maintain PHC throughout the world.

Fast forward 4 decades since this visionary and ambitious declaration, the uptake of PHC has helped to raise global standards of healthcare and improved health.⁴ However, many people in all parts of the world, particularly the poor and vulnerable, continue to have unaddressed health needs, including care for non-communicable and communicable diseases, maternal and child health, mental health, and sexual and reproductive health. Amid the growing needs and emerging health challenges of the 21st century, the vision of Alma-Ata has yet to be realised, largely because of maximising immediate impact through an emphasis on single-disease interventions rather than building comprehensive health systems. Emblematic are the ubiquitous health systems founded on targeted programmes, specialist-led care and intensive use of medical technology. These systems overestimate the benefits of efforts to cure, rather than to prevent disease or to promote health. Other contributory factors include insufficient intersectoral engagement, unregulated commercialisation and suboptimal use of evidence-based policies.

The deep and fundamental consensus remains, however, that the health and well-being of populations are most effectively, equitably and efficiently achieved through a PHC-oriented approach, further substantiated in a corpus of evidence.^2,3 The 2018 Declaration of Astana, signed on the 40th anniversary of the original declaration, reaffirmed solidarity around health as a fundamental human right and PHC as the cornerstone of every sustainable health system to achieve universal health coverage and health-related sustainable development goals.⁵ It called for fresh impetus to overcome challenges for PHC that have emerged over the years, including the growing burden of non-communicable diseases (NCDs) and multimorbidity, problems with fragmentation, coordination and continuity of care, shortage and uneven distribution of health workers, disproportionate out-of-pocket spending, rising costs and systemic inefficiencies.^6,7

Many of these challenges apply to Singapore.⁸ The most notable is its rapidly ageing population that faces a rising burden of NCDs, such as cardiovascular and mental health disorders, which contribute to more than 80% of the total disability-adjusted life years  of the country. Ageing has increased demands on the entire healthcare system, leading to shortfalls in acute hospital beds and intermediate- and long-term care services, plus concerns from the public about the affordability of healthcare. Complicating matters are certain characteristics of the existing PHC system that impede its ability to realise its potential. These include the majority of PHC being provided by single or small-group general practices, many of which have neither the scale nor the resources to manage patients with complex needs. Moreover, the inadequate integration of PHC with other health and social providers impedes the sharing of information that facilitates holistic care.

The 2018 Declaration also clearly articulated for the first time the 3 inter-related and synergistic components of the PHC orientation of health systems: (1) primary care (the first level of care with family medicine at the core of multidisciplinary teams) and public health functions as the central elements of integrated health services; (2) evidence-informed policies and actions across all sectors for comprehensively addressing the broader determinants of health; and (3) empowerment of individuals, families and communities as co-developers of health and social services, self-carers and caregivers. Perhaps more significantly, it clearly distinguished between the 3 fundamentally different concepts that can be conceived as nested within each other in relation to the first component: PHC, Primary Care and Family Medicine. PHC, as a property of health systems in the form of the specific whole-of-society approach based on the 4 components as previously identified; Primary Care, as a specific subsystem as defined by the first level of care, with its core functions of first access, comprehensiveness, continuity, coordination and patient centred care; and Family Medicine, as a medical specialty uniquely characterised by its life course and whole-person (rather than a disease- or health domain-specific) orientation, with particular consideration of patients in the context of their families and communities.

MOH has recognised PHC’s importance and taken definitive steps in recent years to transform primary care, enhance its capacity and capabilities, and strengthen public-private partnerships. These include constructing several new polyclinics, expanding coverage of the Community Health Assist Scheme subsidies and enhancing the Primary Care Network programme to provide better support to general practitioners in caring for patients with NCDs. Now it is taking the next step in embracing the wider PHC approach more comprehensively, to address the wider determinants of health along the life course across the whole country. At the core of the recently announced “Healthier SG” population health strategy, focused on promoting overall healthier living, is a nationwide primary care enrolment programme. From the second half of 2023, residents (starting with those 60 years and above) will be invited to enrol with a family physician as their first line of care, supporting their health needs across their life course. This will empower family physicians to build strong doctor-patient relationships and deliver patient-centred care that is focused on prevention and promoting healthy living.

The Declaration of Astana is about attaining health and well-being for all people without distinction, with health systems centred on a strong PHC foundation. The bold move to enlist PHC as the anchor of the national population health strategy is a major step forward in achieving this vision in Singapore. Having a strong and well-equipped Family Medicine that leads high-quality primary care is key.^9,10 While significant strides have been made in recent years to develop more trained Family Physicians, postgraduate training remains non-mandatory for physicians in Primary Care. Moving forward, steps must be taken to increase training uptake and capacity, while maintaining standards and quality. Additionally, the footprint of Family Medicine education in local medical schools must be enhanced in tandem with its increasing importance. This can spur interest and alter preconceived negative perceptions of the field. Furthermore, it will lay a strong foundational understanding of Family Medicine’s principles and practice among future healthcare practitioners regardless of eventual vocation, paving the way for a more coordinated and integrated PHC.

A PHC that cost-effectively provides holistic, longitudinal, whole-person care for local communities promises to be the elusive antidote for Singapore’s health challenges. Its success in delivering a healthier Singapore will require time and the joint efforts of all stakeholders, including the most important, our patients. We must push ahead together to make a nearly half-century-old vision come to fruition for the sake of our future generations.

REFERENCES

1. Ministry of Health, Singapore. Promoting overall healthier living while targeting specific sub-populations, 9 March 2022. https://www.moh.gov.sg/news-highlights/details/promoting-overall-healthier-living-while-targeting-specific-sub-populations. Accessed 16 May 2022.
2. World Health Organization and the United Nations Children’s Fund (UNICEF). A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals, 10 December 2018. https://www.who.int/publications-detail-redirect/WHO-HIS-SDS-2018.15. Accessed 16 May 2022.
3. World Health Organization and UNICEF (1978) Alma Ata Primary Health Care. Report of the International Conference on Primary Health Care Alma-Ata, USSR, 6–12 September 1978, 12 September 1978. https://www.who.int/publications/i/item/9241800011. Accessed 16 May 2022.
4. World Health Organization. The world health report 2008: primary health care now more than ever. https://apps.who.int/iris/handle/10665/43949. Accessed 16 May 2022.
5. World Health Organization and UNICEF. Declaration of Astana. Global Conference on Primary Health Care: From Alma-Ata Towards Universal Health Coverage and the Sustainable Development Goals. Astana, Kazakhstan, 25 and 26 October 2018. https://www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdf. Accessed 16 May 2022.
6. Kluge H, Kelley E, Birtanov Y, et al. Implementing the renewed vision for Primary Health Care in the Declaration of Astana: the time is now. Prim Health Care Res Dev 2019;20:e158.
7. Kluge H, Kelley E, Barkley S, et al. How primary health care can make universal health coverage a reality, ensure healthy lives, and promote wellbeing for all. Lancet 2018;392:1372-74.
8. Tan CC, Lam CSP, Matchar DB, et al. Singapore’s health-care system: key features, challenges, and shifts. Lancet 2021;398:1091-104.
9. Ricci-Cabello I, Stevens S, Dalton ARH, et al. Identifying Primary Care Pathways from Quality of Care to Outcomes and Satisfaction Using Structural Equation Modeling. Health Serv Res 2018;53:430-49.
10. Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. Identifying Factors Leading to Harm in English General Practices: A Mixed-Methods Study Based on Patient Experiences Integrating Structural Equation Modelling and Qualitative Content Analysis. J Patient Saf 2021;17:e20-7.