Transforming Singapore's healthcare delivery system: health care integration in Singapore

PURPOSE: The vision for transforming healthcare delivery in Singapore is to develop integrated Regional Health Services (RHS) to provide healthcare from prevention to palliation. Under the RHS concept, each region would be anchored by an acute-care hospital working in close partnership with other healthcare providers in the region, e.g. general physicians (GPs), polyclinics, community hospitals (CHs), nursing homes (NHs) and home care providers. Formalized partnerships, integrated clinical pathways and care coordinators working with a multi-disciplinary team over the patient's lifetime would help keep the care continuous, seamless and appropriate. Achieving this vision will require us to (i) significantly build up the ILTC and primary care sectors; and (ii) restructure our public healthcare system and strengthen the enablers and linkages between providers in each region to better integrate care and enable the entire system to work as it should. AGENCY FOR INTEGRATED CARE: A key part of achieving this vision is the development of a national care integrator: the Agency for Integrated Care (AIC). Formed in 2008, the AIC coordinates referrals to intermediate and long-term care services as well as facilitates discharge planning for patients discharged from acute-care hospitals through hospital-based ACTION Teams. To support the development of integrated RHS, its role will be expanded progressively to include a focus on developing the capabilities of local healthcare service providers as well as patient education. (Please see separate item presented by AIC that will focus on the work of the ACTION Teams—to show that ACTION teams through care coordination helps to reduce Average Length of Stay (ALOS) in acute settings, foster interagency collaboration and improve access to services for patients.) CONTEXT: In Singapore as in other countries, we face the twin challenges of an aging population and the growing burden burden of chronic disease. The current model of acute-care centered provision of healthcare has to transform and new services and linkages need to be developed to cater for the health needs of the elderly population and improve overall population health. DATA SOURCES: MOH/healthcare providers. CASE DESCRIPTION: Development of integrated Regional Health Services. DISCUSSION: Implementation of an integrated RHS model and challenges

Diarrheal disease, sanitation, and culture in India

The health burden of childhood diarrhea in India has been a major public health concern. This study examines the role of the individualism-collectivism dichotomy in the prevalence of diarrhea in children under the age of five in India. Using subnational data on rice suitability to measure collectivism, we provide evidence that collectivism is negatively associated with the prevalence of childhood diarrhea across 618 Indian districts. We find that the mechanism works through improvements in water and sanitation. Collectivism propagates values of interdependence, cooperation and collective action which increases safe water and sanitation practices, thereby reducing the prevalence of diarrhea in children

Syndemic thinking in large-scale studies : case studies of disability, hypertension, and diabetes across income groups in India and China

Syndemics consider where two or more conditions cluster, how they interact, and what macro-social processes have driven them together. Yet, syndemics emerge and interact differently across contexts and through time. This article considers how syndemics involving Type 2 diabetes (DM), disability, and income differ among men and women and between India and China. We use the WHO Study on global AGEing and adult health (SAGE) data. Using multivariable logistic regression, we assess the interaction of socio-economic factors and diseases on a multiplicative scale. We found that gender and income interact significantly in China to increase the odds of reporting hypertension and diabetes, but only for reporting diabetes in India. High income interacts with metabolic conditions to increase the odds of reporting comorbidity. Hypertension and diabetes were both independently and jointly associated with increase in the odds of being disabled in both countries, but the association varies by conditions. We argue that, first, our study reveals how these syndemics differ between countries and, second, that they differ significantly between income groups. Both findings refute the idea that a "global syndemic" exists. Instead, we emphasize the need for more ethnographic work that invests in local historical, social, and political interpretations of syndemics. Furthermore, ethnographic evidence suggests that the lowest-income communities face compounded social stress, untreated depression, and poor healthcare access alongside these clustered "metabolic" conditions. This point is most notable to demonstrate the need for chronic integrated care for not only the wealthy but also poorer people with metabolic conditions.Nanyang Technological UniversityThe corresponding author would like to thank Nanyang Technological University for Startup Grant (M4082411)

Replication Data for: Young Invincibles to young Insurables: Insurance take up by the healthy, wealthy and employed

One of the fundamental provisions in the Patient Protection and Affordable Care Act (ACA) is the allowance that people 26 or under may remain under their parents' health insurance policies. Based on data from the Survey of Income and Program Participation (SIPP) we use difference-in-differences estimate to examine whether the ACA enactment increased insurance uptake among the young. Furthermore, we evaluate the heterogeneous uptake patterns across health status, wealth quintiles and employment status. Our results show that the ACA led to an increase in insurance coverage among those between the ages of 19 and 25. More importantly, the results suggest that insurance uptake was higher in the wealthy and health population. Our findings highlight the success of ACA in increasing overall coverage and increasing the participation of well off individuals in the insurance risk pools. Notwithstanding, the reform did not increase the protection of the already less healthy and poor, and the magnitude of increased uptake are modest. This study emphasizes the role that governments have in addressing important insurance market failures; nevertheless future reforms should seek to increase coverage of those less well off

PROSPERO 2016 CRD42016052177. Systematic review of the burden of non-communicable diseases and injuries among the world's poorest billion people

Systematic review of the burden of non-communicable diseases and injuries among the world's poorest billion people. Review questions: What is the prevalence of non-communicable diseases, injuries, and their associated risk factors among members of the world's poorest billion in select low- and middle-income countries? What is the mortality due to non-communicable diseases and injuries among members of the world's poorest billion in select low- and middle-income countries? What interventions have been employed to address non communicable diseases and injuries in high-poverty populations

Considerations for modelling a broad food tax in the Philippines and other low-income and middle-income countries

Fiscal policies to improve diet are a promising strategy to address the increasing burden of non-communicable disease, the leading cause of death globally. Sugar-sweetened beverage taxes are the most implemented type of fiscal policy to improve diet. Yet taxes on food, if appropriately structured and applied across the food supply, may support a larger population-level shift towards a healthier diet. Designing these policies and guiding them through the legislative process requires evidence. Equity-oriented cost-effectiveness analyses that estimate the distribution of potential health and economic gains can provide this critical evidence. Taxes on less healthy foods are rarely modelled in low-income and middle-income countries.We describe considerations for modelling the effect of a food tax, which can provide guidance for food tax policy design. This includes describing issues related to the availability, reliability and level of detail of national data on dietary habits, the nutrient content of foods and food prices; the structure of the nutrient profile model; type of tax; tax rate; pass-through rate and price elasticity. Using the Philippines as an example, we discuss considerations for using existing data to model the potential effect of a tax, while also taking into account the political and food policy context. In this way, we provide a modelling framework that can help guide policy-makers and advocates in designing a food policy to improve the health and well-being of future generations in the Philippines and elsewhere

The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion

For the poorest of our world, non-communicable diseases and injuries (NCDIs) account for more than a third of their burden of disease; this burden includes almost 800000 deaths annually among those aged younger than 40 years, more than HIV, tuberculosis, and maternal deaths combined. • Despite already living in abject poverty, between 19 million and 50 million of the poorest billion spend a catastrophic amount of money each year in direct out-of-pocket costs on health care as a result of NCDIs. • Progressive implementation of affordable, cost-effective, and equitable NCDI interventions between 2020 and 2030 could save the lives of more than 4·6 million of the world’s poorest, including 1·3 million who would otherwise die before the age of 40 years. • To avoid needless death and suffering, and to reduce the risk of catastrophic health spending, essential NCDI services must be financed through pooled, public resources, either from increased domestic funding or external funds. • National governments should set and adjust priorities based on the best available local data on NCDIs and the specific needs of the worst off. • International development assistance for health should be augmented and targeted to ensure that the poorest families affected by NCDIs are included in progress towards universal health care