Healthier SG: a gateway for evolving public-private-population partnerships in population health

Summary

Singapore’s primary healthcare landscape is dominated by private sector general practitioners, who have more room to play in terms of safeguarding the health of the population. Through a transformative national policy, Healthier SG, Singapore is evolving its health system to lean on private-public partnerships. This is achieved through shared care protocols, interoperable IT requirements, new models of financing, shared responsibilities and human resources and, importantly, a bidirectional feedback channel. The Ministry of Health has attempted to address most of the pressing issues that prevent private sector general practitioners from enrolling into this newly implemented national primary care policy but continues to face unintended challenges. Disjointed and misplaced expectations between stakeholders, arduous administrative requirements that GPs need to perform to get their reimbursement, cherry-picking simpler patients to enrol as it makes more business sense and the prospect of continued care fragmentation are some of the loops that this national policy will need to jump through.

Healthier SG, launched nearly two years ago, is a national healthcare reform which focuses on preventive care, patient empowerment and relationship-based care anchored by private sector general practitioners (GPs). In Singapore, around 2400 private GP clinics manage about 75% of all primary healthcare attendances. Meanwhile, in the public sector, polyclinics provide heavily subsidised primary healthcare services. These multi-doctor medical centres, which also offer nursing and allied health services, are overwhelmed by demand. Redirecting care through the extensive GP network is a strategy to manage exponentially increasing healthcare costs amid demographic ageing and rising multimorbidity. Under Healthier SG, GPs are expected to deliver accessible, good-quality care for residents, with a strong focus on preventive and chronic disease care.

Singapore's three regional health systems—in the Eastern, Central, and Western regions of Singapore—serve as regional health managers to strengthen regional health ecosystems and streamline care across providers and care levels. Their goal is to address both biomedical and social determinants of health through collaborative public-private partnerships, including with GPs. Close to one million residents (about 40% of the eligible population), have enrolled into Healthier SG as of August 2024, which is an early indicator of acceptability and adoption.¹ In this Viewpoint, we review the progress and challenges of implementation at the two-year mark.

Building on public-private partnerships in primary healthcare

Singapore's healthcare financing model combines universal coverage with a system that encourages individual responsibility. While healthcare is largely financed by government subsidies, Singaporeans pay part of the costs and can tap on their Medisave account (a compulsory medical savings scheme where a portion of salary is set aside for healthcare expenses) and Medishield Life (a universal health insurance plan where co-payment is required).² Historically, patients seeking care at GP clinics did not have access to certain health financing schemes. This changed with the introduction of the Chronic Disease Management Programme in 2016, which allowed patients to tap on their Medisave accounts. Other schemes such as the Community Health Assist Scheme were subsequently introduced. Primary Care Networks (PCN) are public-private partnerships established in 2017 to harness private healthcare workers to meet the growing demand for primary healthcare and to refocus on integration between private GP providers and regional health systems.³

Within the PCN model, groups of GPs are supported by Ministry of Health-funded nurses and care coordinators to offer holistic and coordinated care for prevalent conditions with a high burden (e.g. hypertension, hyperlipidemia, diabetes and chronic obstructive pulmonary disease). They are also able to refer patients to subsidised ancillary services, such as nurse counselling and diabetic eye and foot screening. One example is the Delivering on Target (DOT) programme,⁴ where stable chronic patients are appropriately referred to partner GP clinics, while hospitals support nursing, ancillary services and administrative functions. These arrangements have expanded the range of services available at GP clinics.

Healthier SG builds upon this foundation by encouraging residents to enrol (soft empanel) with a regular primary care provider for preventive and curative services. Under this system, private GPs are integrated into the broader healthcare ecosystem and collaborate with public sector providers and community organisations within their respective regional health systems.

Balancing collaborative care for population health delivery

Primary care providers serve as the entry point into the healthcare system for many patients, playing a crucial role in delivering timely care for acute and chronic conditions. Under Healthier SG, residents can choose between a participating GP clinic or a polyclinic as their primary care provider. Enrolled residents receive free recommended national adult immunisations, subsidies for chronic disease medications, and subsidied health screenings.

Healthier SG promotes collaboration between private GPs and public care providers. Care protocols for chronic conditions are co-developed across institutions and stakeholders, including specialists and public and private primary care providers. This process has required deliberate engagement across stakeholders to reconcile differing levels of resources and expectations, with the goal of delivering integrated, evidence-based care.

In addition, collaborating with regional health systems offers channels for education and communication. Beyond e-learning modules on primary care education, dedicated chat groups, known as Virtual Curbside Consults, allow GPs to communicate with hospital specialists for case discussion, advice, triage, and access to rapid-review specialist outpatient clinics. These initiatives are intended to ensure patients get allocated to appropriate care settings, strengthen GPs’ capabilities, and promote shared care between GPs and specialists. However, cooperating with larger entities such as the regional health systems might highlight power imbalances between small private GP practices and large hospital-based systems. Communication and information-sharing strategies should be designed to support inclusive and bidirectional dialogue (where both GPs and hospital systems have equal say and power), instead of top-down dissemination.

Addressing fragmented care across multiple interfaces

To improve the coordination of care, GP clinics are equipped to collaborate with hospitals and community partners through established referral criteria and clinical pathways for care escalation, shared care, and health and social programmes. Efforts have been made to strengthen the role of GPs in population health management. This includes professional development programmes and the adoption of clinical management systems that connect with the National Electronic Health Records (NEHR). These systems provide GP clinics access to key patient information across both public and private providers. To support implementation, Healthier SG offers a one-time grant for clinics to upgrade their IT systems.

GPs are also financially incentivised to take a holistic approach to their patients' health and well-being. They are provided with an annual service fee for each enrolled resident based on their health risk profile and completion of required preventive care activities. Additionally, regional health systems deploy community care teams, such as Healthier SG Teams,⁵ consisting of community nurses and wellbeing coordinators, to strengthen care coordination among GPs, community partners, and hospitals. These teams collaborate with GPs to tailor community programmes to their patients’ needs.⁶

Despite these system-level improvements, several challenges persist. Data collection processes in primary care remain limited, and it is unclear whether current incentive structures adequately reflect the effort required to monitor patient outcomes. Furthermore, while information systems enable data sharing, effective integration still requires coordination among hospitals, community partners, and private GPs. Without consistent operational alignment, these partnerships risk becoming fragmented, particularly in a mixed public-private care landscape.

Unintended consequences and paving a new way forward

The Ministry of Health and regional health systems have implemented measures to address the challenges faced by GPs and encourage their participation. For these partnerships to remain effective and to reduce the risk of market failure, it is essential to address several factors.

Disjointed aspirations might impact GP's business model

Structural differences between the public and private healthcare sectors may influence the participation of private GPs in Healthier SG. Some GPs have expressed concerns that the financial incentives provided may not fully offset the increased workload and resource demands associated with programme participation.

The introduction of the Healthier SG chronic tier subsidy framework in February 2024 aimed to allow patients with high chronic medication needs to obtain subsidised medication at private clinics for whitelisted drugs (drugs approved for subsidies) at prices comparable to those at polyclinics.⁷ The margins on these whitelisted drugs are capped to prevent abuse of government subsidies.

This could prompt some GPs to prompt some GPs to take a relook at their revenue baseline and readjust their operations, though transparency regulations may restrict such changes. Additionally, competition from low-cost telemedicine services could further challenge the sustainability of traditional clinics.

The Ministry of Health's efforts to address the pricing gradient between private GPs and polyclinics were intended to reduce loss to follow-up when patients turn to polyclinics for cheaper medications after their portable (can be used in multiple care settings) government subsidies run out. While this will increase affordability for patients, several anecdotal issues have surfaced. Profit margins for private GPs could be reduced. In the past, GPs have relied on medication profits to keep consultation fees low and offset overhead costs such as clinic rental and staff recruitment^8,9 This could prompt some GPs to raise consultation fees, although price transparency policies which direct clinics to display consultation fees may limit this. Additionally, competition from low-cost telemedicine services, with consultation fees as low as SGD $8 could further challenge the sustainability of brick-and-mortar GP clinics.

Furthermore, GPs are no longer required to maintain stock of subsidised medications, which can instead be ordered from a central pharmacy managed by the national healthcare supply chain management agency, Agency for Logistics and Procurement Services. These measures aim to reduce inventory costs while preserving clinical decision-making. Nonetheless, balancing system costs with the financial sustainability of private practices will require ongoing dialogue and responsiveness to feedback from the ground.

Hitting their targets but missing the point of population health

Health promotion requires a biopsychosocial approach which addresses the determinants of health at all levels, from the individual to the system.

At the national level, the Health Promotion Board runs several health campaigns to encourage lifestyle changes. One example is Nutrigrade labelling, which highlights the levels of sugar, saturated fat, and salt in products. This helps improve individual health literacy and shifts social norms, putting pressure on companies to reformulate their products to be healthier.

At the individual level, Healthier SG offers structures such as a standardised, holistic health plan that includes social prescriptions. It also provides financial incentives for GPs to take responsibility for helping their patients engage in preventive health activities. However, effecting change in individual behaviour on the ground requires further examination.

Achieving meaningful behavioural change depends not only on structural changes but also on individual motivation and patient–provider interactions. Patients need to be actively engaged and motivated to adhere to lifestyle interventions. Motivational interviewing has been recommended as a method to enhance patients' intrinsic motivation and promote goal-oriented conversations between patients and healthcare providers. However, GPs have shared concerns about limited consultation time, which restricts their ability to build rapport with patients and tailor the interview and interventions to the patient's level of understanding and cultural attitudes.¹⁰ Working with regional health systems has improved access to nurse counsellors to conduct motivational interviewing, and community health partners (referred through the GP) to offer culturally tailored social services that better meet patients' needs at the community level. Despite these additional resources, GPs still face administrative burdens when referring patients, documenting progress, and tracking health parameters—particularly for those with complex chronic conditions. Additionally, there is a potential risk of loss to follow-up as these services are geographically and temporally disconnected from the GP consultation. Health behaviours are also influenced by patients' socio-economic factors such as occupation and economic status.¹¹ While it is important that GPs build rapport with the patient and develop a health goal together, and referrals for motivational interviewing might seem to fracture the continuity of care and relationship with the patient, staff who were specially delegated to perform motivational interviewing were more competent as compared to medical doctors, possibly due to multiple competing demands.¹² Moreover, approximately one-third of primary care consultations involve complex cases requiring longer appointments requiring GPs to find a new equilibrium that balances the demands of comprehensive clinical care with administrative responsibilities.¹³

Although current care guidelines are holistic in the medical aspect, they might not encompass other determinants of health that affect the outcomes of these chronic diseases. As GPs assume greater responsibility for managing complex cases, both clinical and operational parameters of Healthier SG may need to evolve. Increasingly, patient encounters in primary care require complex care and more consultation time, and it would be needed for GPs to find a new balance between patient care and administrative work. This may inadvertently or unknowingly lead GPs to favour patients who are easier to manage or, from a business perspective, those who offer the greatest financial return relative to resources invested, despite the support provided through national policies.¹⁴

Hence, iterative processes of engaging GPs and understanding their evolving business challenges to refine Healthier SG will drive primary care transformation while not risking hitting its targets but missing the overall goal of population health in this evolving private-public framework.

Including all stakeholders in shaping future implementation process

The Ministry of Health has made substantial efforts to engage the private GPs in co-developing the Healthier SG care protocols, working closely with PCN leaders and involving them in expert technical workgroups. Moving forward, continuous engagement and communication with GPs is essential for successful implementation. These processes and regular touchpoints help policymakers identify GPs' evolving needs and barriers, allowing the Ministry to adapt strategies to better support them. Additionally, keeping GPs informed about their progress in Healthier SG and the impact they are making in addressing population needs is essential for sustaining their motivation and commitment to the programme. Importantly, efforts to understand private providers’ perspectives will potentially foster trust and strengthen social capital and promote a more collaborative and sustainable long-term partnership.

Healthier SG also empowers community partners to participate meaningfully in a climate that has traditionally been more medical-centric. In this regard, regular discussions with the respective community care teams involving GP clinics, community nurses, care coordinators and community partners are needed to identify gaps in care provision for their residents and areas of improvement, which can reduce unnecessary service duplication and right-site patients.¹⁵ Such discussions will also help to improve workflows and the efficiency of care delivery, especially for patients with multiple chronic conditions.¹⁶ Despite having a care coordinator at every PCN to link suitable patients to community partners, the administrative processes and the prospective number of patients needing such services might require additional human resources. Shared human resources through integrated workflows between PCN and polyclinics and or automated referral systems integrated into existing clinical management systems need to be explored.

At the policy level, regular discussions between the GPs, regional health systems and policymakers are also needed to develop mutually beneficial care and business models in this dynamic public-private partnership for population health. These discussions could serve as a platform to contribute new ideas regarding the coordination of care, address any challenges in executing care protocols and keep the collaboration going. Moving forward, adopting an integrated documentation system could help analyse and predict trends in population health, to ensure that chronic care models are well-suited for the population and care providers and to measure the overall success of Healthier SG. Adjacent to this, policies surrounding primary care, such as promoting family medicine as an attractive specialisation for junior physicians via strategies such as improving mentorship opportunities and highlighting the role of family physicians in outreach campaigns, can prove strategic. Moreover, heightened emphasis on the adoption of technology to improve the efficiency of clinic consults should factor as a key pillar of Healthier SG.

Healthcare systems in the Western Pacific

In certain countries within the region, such as Vietnam, Thailand, and Indonesia, primary care is predominantly delivered through the public sector. Barriers to healthcare access in other countries include the physical accessibility, availability of healthcare services, financial gaps and equity issues,¹⁷ which are gradually being addressed through policies to make healthcare more affordable and accessible, especially for rural areas. Moreover, all countries face broader structural and environmental factors culminating in the commercial determinants of health, which encompass the influence of corporate practices, market dynamics, and profit-driven decisions. These need to be addressed by entities beyond primary care and the health system.

From a public health epidemiology perspective, countries in the region also share the challenges of an ageing population, a foreseeable rising burden of non-communicable diseases, and will require a strong primary care network. However, in most places, treatment is still primarily focused on being curative, and most countries have not made a significant shift to preventive care and private-public partnerships in primary care. Efforts to strengthen the role of primary care, where patients consult primary care physicians first are also limited by their distrust of the quality-of-care provision by primary care physicians, who might also not be prepared to deal with changes associated with an ageing population yet, and patients might continue seeking medical treatment from tertiary hospitals.^18,19 Fiscal resources are also needed to run these facilities. For that to happen, there needs to be better trust and credibility when funds flow from government to primary care providers and subsequently ensure that these resources reach the providers and their targeted populations in need. However, tracking of resource flows and efficient movement of needed funds necessitate systems, both financial and informational, to be present at all interfaces of the health system and across public and private sectors. This is no overnight task. Singapore has journeyed to this point across five decades.

Adopting public-private partnerships might be useful in this sense to increase patients’ access to care while keeping it affordable. However, simultaneous effort would also need to be invested in nurturing primary care physicians to manage chronic conditions associated with an ageing population. The availability and integrity of IT networks will also need to be developed to ensure streamlined transference of medical information from one provider to another. Hosting longitudinal data in an extractable format for analysis will also significantly enhance the ability to evaluate key success parameters of national policies. In terms of health system optimisation and health policy transformation, Singapore demonstrates its strength in learning from others and continuously drawing from the best primary care practices globally to enhance its health system and policies. By incorporating these insights into initiatives like Healthier SG and other policies, Singapore will move into a new era of a renewed private-public partnership model for population health.

Contributors

CDF and THW conceptualised the overall manuscript direction and prepared the first draft. All other authors were in charge of providing feedback in subsequent rounds of draft editing. All authors ensured that the content was credible and approve the final manuscript as submitted.

Declaration of interests

The authors declare no conflict of interest.