Population health research in Singapore: the experience of a research centre
Year: 2024
Type: article
Abstract: Despite having one of the longest life expectancies, Singapore’s healthy life years has not grown proportionally, and this leads to a higher duration in poor health.[1] In recent years, there is an upsurge in the incidence of non-communicable chronic diseases, due in part to a rapidly ageing population and evolving lifestyle patterns. Healthcare costs continue to outstrip gross domestic product growth and will become unsustainable if it continues along the current trajectory. In response, Singapore is attempting to shift the paradigm to focus on preventive health in addition to value-based health care. Research in population health plays an important role in innovating to meet these challenges. Population health is most commonly defined as ‘the health outcomes of a group of individuals, including the distribution of such outcomes within the group’,[2] with research in population health concerned with measuring these outcomes, and understanding their determinants across different domains (e.g., social, environmental) and the interactions of the determinants across the life course.[3-5] Finally, population health research is also concerned with health policies, interventions and their cost-effectiveness for producing health.[6] This article focuses on the state and direction of population health research in Singapore, from the lens of a public healthcare institution’s research centre. While topics such as medical technology and healthcare systems research (e.g. primary care integration or workflow optimisation) are relevant areas of population health, they are beyond our current focus and will not be discussed in this article. INVESTING IN THE FUTURE: FUNDING AND RESEARCH Population health research in Singapore has seen a growing interest, with the number of publications from government agencies, institutes of high education, public hospitals and other sources increasing over the past two decades and more than two-fold in the last 5 years (2018–2022) (n = 731) compared to 2013–2017 (n=317) [Figure 1]. Research ranged across various population segments (older adults, the elderly, children, caregivers), settings (hospital, workplace), diseases and conditions (chronic disease, coronavirus disease 2019, diabetes mellitus, mental health, frailty), and risk factors (stress, loneliness) and used a range of both qualitative and quantitative methods to address their respective research questions. There has also been an increase in papers seeking to understand health of the population in Singapore from a broader lens, such as through research priorities,[7] indicators and population segmentation frameworks.[8]Figure 1: Graph shows the number of publications related to population health research in Singapore as listed in PubMed from 2003 to 2022.This increase is attributable, in part, to the increasing targeted funding for population health research in the public sector, through centre grants (CGs) and competitive research grants. In 2017, Singapore Health Services (SingHealth) and National University Health System (NUHS) were the first two public healthcare clusters to be awarded CGs from the National Medical Research Council (NMRC) to support core research capabilities and manpower for population health research. Under SingHealth, the ‘Population-based, Unified, Learning System for Enhanced and Sustainable Health (PULSES)’ CG focused on four research themes — Population Segmentation, Diabetes, Complex Needs, and Pre-frailty and Frailty. The CG under NUHS, the Singapore Population HEalth impRovement Centre (SPHERiC),[9] focused on Nutrition, Physical Activity, Diabetes, Primary Care and Infectious Diseases. In National Healthcare Group (NHG), the Health Services and Outcomes Research Unit[10] also helps to drive population health research. Together, these centres covered a broad spectrum of population health research focus areas across life stages. The CGs also supported the first and second Singapore population health conversations and workshops, which were initiated and hosted by SingHealth and co-organised with NHG and NUHS in 2018 and 2019. In 2022, SingHealth successfully renewed the PULSES CG (‘PULSES II’), the only population health CG awarded in 2022, to build on the achievements in the initial PULSES CG (‘PULSES I’). With a redefined focus on important population segments across the life course, new themes such as ‘Maternal and Child Health & Vulnerable Adolescents’ and ‘Ageing in the Community’ were included, while the theme, ‘Diabetes’, was expanded to include a focus on hypertension [see Supplemental Digital Appendix at https://links.lww.com/SGMJ/A132]. Concurrently, the Centre for Population Health Research and Implementation (CPHRI) was established in SingHealth to act as a nexus for population health research, implementation and evaluation. The CPHRI’s distinctive positioning within SingHealth Regional Health System allows it to serve as a bridge between science and service, focusing on research around implementation and scaling. Enabled by the proximity to SingHealth decision-makers and programme implementers, along with certain researchers holding dual roles as field practitioners, research in CPHRI is intricately shaped by the needs and goals of the cluster as region health managers. This dynamic facilitates an accelerated translation of findings to improve and scale services. Recognising the need to develop novel and tailored strategies for individuals at different life stages, NMRC also launched the new Population Health Research Grant scheme in July 2022 to fund research proposals that seek to improve health outcomes through a population health approach. CREATING AN IMPACT ON POPULATION HEALTH OUTCOMES To meaningfully impact population health outcomes in Singapore, we must cultivate essential capabilities and foster collaborations not just within the health sector, but beyond. Increase capabilities from implementation to evaluation Employing implementation science and rigorous evaluation is important for translating research findings into successful interventions and programmes. The CPHRI organises annual programme planning and evaluation essential, and realist evaluation workshops, designed to provide research and evaluation staff, programme owners and managers, and administrative staff with specific skills and expertise in population health research. These programmes guide systematic data collection and help programme managers identify strengths and areas for improvement in their programmes. To facilitate capability-building and evaluation efforts, the Ministry of Health (MOH), Agency for Integrated Care and the three regional health systems have also developed a cross-sharing platform. This platform provides opportunities for collaboration, interactions and feedback, while creating a repository of programmes with the best programme evaluation practices. This also allows for the identification of promising programmes and interventions that have the potential for scaling up to other regions or at the national level. Enhance data sharing and analytics Information flow between ministries and institutions allows healthcare practitioners and policymakers to collaborate on data sharing and analytics. Platforms like Trusted Research and Real world-data Utilisation and Sharing Tech, a national data exchange platform, have been developed to enhance secure and anonymised access to cross-sector data. A notable example of collaborative data analysis is the harmonised population segmentation framework developed jointly by SingHealth and NUHS, and implemented by Health Promotion Board. It is used for the joint analysis of resident health needs and healthcare utilisation patterns for various population segments, offering policymakers insights into resident health needs and resource allocation requirements.[8] Increasing whole of government data sharing and analysis are vital to enable efforts to address wider determinants of health. Foster multi-sectorial collaboration Interdisciplinary collaboration is central to population health projects as it goes beyond the traditional healthcare domains to address the intricate and interconnected determinants of health.[6] Coordinated efforts across various industries in the public and private sectors including institutes of higher learning, industry professionals, statutory boards and social service agencies are needed to effectively identify and recommend senior-friendly policies and urban changes. Such partnerships leverage each party’s unique resources and expertise to provide a coordinated response and eventually support the project’s sustainability and translation. Examples of these interdisciplinary and multi-sectorial projects include the Elderly Life Activity-Space (EASE) and the Community Ageing in Place Ecosystem (CAPE) projects. Led by SingHealth, EASE explores an individual’s movement within their community and its environment (life space) to achieve life goals of self-care, employment, and social and recreational needs. CAPE (coordinated by SingHealth in collaboration with social service and government agencies) intervenes in the built environmental and social determinants to cocreate a vibrant, age-friendly community that is being test bedded at two precincts in the eastern part of Singapore. Evaluation frameworks are being developed to identify and track how key programmes, at both national and cluster levels, are contributing to intended health outcomes for Healthier SG.[11,12] To assess and refine implementation and aid in the evaluation of the initiative, CPHRI is conducting policy ethnography and longitudinal pulse-sensing studies with stakeholders such as residents, general practitioners, policymakers and the healthcare clusters. The studies were designed in collaboration with the College of Family Physicians Singapore and NUHS, and utilised implementation science frameworks to probe receptiveness and sentiments towards Healthier SG. The findings are actively shared with the management and implementation teams in SingHealth to inform and support successful implementation. CHALLENGES IN POPULATION HEALTH RESEARCH AND IMPLEMENTATION While the multidisciplinary nature of population health research may allow researchers to seek multiple funding sources (e.g. grants traditionally meant for built environments and technology), increased funding for non-randomised controlled trial studies employing realist evaluation or implementation research methods should be considered. To further develop population health research and implementation science capabilities in Singapore, sustainable funding is essential to support the long-term involvement of principal investigators and researchers. There is a gap between knowledge and implementation, where the translation of research outcomes is necessary to bring about real population health impact. Translation of population health findings requires the findings to be contextually relevant, feasible and timely. Purposeful and continuous engagement with policymakers and health system senior management through a project cycle are needed to shape relevant research questions, as well as facilitate effective and timely dissemination of findings and recommendations. Presently, there is no gold standard for measuring total population health. Various frameworks have been built to attempt to capture and assess population health, such as the Population Health Index[13] by NHG and the Healthy Precinct Index[14] by the MOH Office for Healthcare Transformation, through an amalgamation of health status indicators (e.g. chronic disease status), social determinants of health (e.g. education status, social isolation), attributes of the built environment (e.g. access to healthy food, green spaces) and indicators for the healthcare system context (e.g. access to services). However, the complexity of population health makes it difficult to capture all these in a single measurement. Ongoing efforts are needed to identify measures that are relevant and comprehensive enough to capture the intricate and consistently evolving healthcare needs and determinants such as the Healthier SG indicators contextualised for our local context. This article has its limitations. Its discussion is from the SingHealth perspective and may not fully cover the population health research efforts in the other two clusters and at the national level (e.g. MOH). Future research should also cover more on population health innovations and megatrends[15] such as digital health and artificial intelligence. CONCLUSION Population health research in Singapore is still nascent; while it is gaining recognition, it will require a concerted effort to harmonise and coordinate not only within the health sector, but also across other sectors such as the social and environmental sectors. Singapore population health research will need to prioritise interdisciplinary collaboration and focus on practical solutions that address the wider determinants of health to successfully transform findings to the population and its health. Government support is pivotal in enhancing synergy across healthcare clusters. By creating a conducive environment through supportive policies, resources (e.g. infrastructure, grants) and fostering collaborative attitudes, governments can empower clusters to collaborate effectively, addressing complex healthcare challenges for community benefit. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Singapore Medical Journal
Institutions: SingHealth, Duke-NUS Medical School, Singapore General Hospital
Language: English
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4402214478