In a parallel universe, the most powerful political leaders in the US would be debating solutions to the toughest and most pressing questions. Why is US life expectancy stagnating, and diverging from the average lifespan in peer countries? Why do we spend more than twice what those peer countries do on health care, as a proportion of gross domestic product, despite inferior outcomes? And what are we sacrificing with our myopic national focus on health insurance policy—instead of on gaps in delivering health services, acute workforce challenges, public health investment, and technological improvements in care?
Yet we need not jump through the multiverse to find a markedly different set of health policy debates playing out. Just across the Pacific, nations such as Singapore, Australia, and New Zealand are grappling with primary care reforms, digital health policy, and health equity considerations. Each of these countries has universal health coverage, although the path there was not always easy. Singapore spends about one-quarter of what the US does on health care, as a proportion of gross domestic product, whereas Australia and New Zealand spend about half. All rank in the upper echelon of international health system comparisons.
Within the last 2 years, each of these 3 nations advanced a set of health care reforms focusing on the specific challenges each is confronting. At the same time, there are commonalities across the reforms and lessons for the US. Primary care is seen as the linchpin of the health system in each reform, with varying strategies for changing the organization of and payment for general practice. Digital health is also viewed as a field where more investment is needed alongside appropriate regulatory and policy infrastructure. And health equity, still more of a buzzword in the US, is the centerpiece of some reforms, particularly in places where there are indigenous populations.
Singapore has oriented its health reforms, known as Healthier SG, around primary care. The government’s reasoning is 2-fold: first, Singapore’s population is aging, with a life expectancy of approximately 84 years of age and an estimated 1 in 4 citizens expected to be aged 65 years or older by 2030. Second, the increasing impact of chronic diseases like high blood pressure, diabetes, and high cholesterol is taking its toll, not just on health, but also financially for both governmental and family budgets. Taken together, these factors are viewed as a setup for unbridled cost growth in a system that largely remains fee-for-service and oriented around hospital care.
Jeremy Lim, MBBS, MPH, associate professor of public health at the National University of Singapore, said that these 2 phenomena have already put the health system under duress. “Singapore has seen costs spiral, waiting times lengthen, and worsening health workforce morale,” he said. “Healthier SG is a bold national attempt to stem this through paying providers for health rather than health care alone.”
The idea is to move from a reactive approach to disease to a proactive approach to preserving health. Each Singaporean is encouraged and incentivized to enroll in Healthier SG with the tagline, “One family doctor and one health plan for everyone.” Family physicians, 80% of whom are currently in private practice, will receive annual capitated payments to take on additional responsibilities related to preventive and chronic care. For example, they would steward individualized care plans for patients including lifestyle adjustments, regular health screening, and appropriate vaccinations.
The government of Singapore will fully subsidize nationally recommended screenings and vaccinations and provide a 1-time payment for family practices to support technology improvements. Healthier SG also emphasizes “social prescriptions” to support group activities like walking clubs for older adults.
Singapore is well-known for its emphasis on individual cost-sharing and health savings accounts as ways to curb unnecessary use of health services. However, Healthier SG is notable for the ways in which it relaxes cost sharing for preventive and chronic care and channels investment to primary care infrastructure. Primary care investment will augment capacity, for example, by increasing the number of community health centers, known as polyclinics, as well as community health workers, known as lay extenders.
The Singaporean emphasis on personal responsibility, then, is paired with a growing recognition of community-level drivers of health.1 “Healthier SG is moving Singapore in the right direction, but it is not just the policies of the Ministry of Health alone that will result in a healthier Singapore. It is a transformation of the way we live, learn, work, and play over the entire life course,” said John E. L. Wong, MBBS, former chief executive of the National University Health System and a member of the JAMA editorial board.
For older adults, the transformation is about adding life to years, and not just years to life, to paraphrase President John F. Kennedy. Because Singapore does not have abundant traditional natural resources, Wong has argued, the talents and wisdom of older adults should be seen as latent natural resources. Singaporeans’ lifespan is now approximately 20 years longer than in 1965. But communities will only benefit if those additional years of life are characterized by health rather than infirmity. And the steady, trusted, long-term relationships forged in primary care are the key to managing the chronic diseases that diminish quality of life.
Primary care is central to this gain in health span not just in Singapore but also in its English-speaking neighbors to the south.2 In Australia, the recent Strengthening Medicare reforms similarly emphasize primary care, patient registration with a preferred practice (and associated capitated payment), and team-based care beyond the physician and into communities. Nurses and pharmacists are of particular focus. New funding supports 6000 nursing students for clinical placements in primary care services around the country. Additional funding is set aside so that any Australian can walk into their community pharmacy to receive nationally endorsed vaccines free of charge, and obtain affordable treatment for opioid use disorder.
Just as in Singapore and Australia, the US is facing pressures on our health system: chronic diseases from diabetes to depression; an aging population; and direct links between eroding social conditions—such as inadequate and low-quality housing—and illness. The Centers for Medicare & Medicaid Services Innovation Center recently released a primary care strategy focused on financing, equity, and sustainability; this is a step in the right direction for addressing those health system pressures, but it needs to be backed up with major investments. And while primary care is the foundation of reforms in these peer nations, the debates and dialogues they are having extend beyond that. Part 2 of this article explores digital health and health equity in Australia and New Zealand, and it concludes with implications for the US.
Published: June 15, 2023. doi:10.1001/jamahealthforum.2023.2418
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Chokshi DA. JAMA Health Forum.
Conflict of Interest Disclosures: Dr Chokshi reported receiving travel support from the Commonwealth Fund, via AcademyHealth, for the international leadership exchange described below.
Additional Information: This article is the first of 2 that examines how 3 Pacific Rim nations approach health challenges that the US also faces. The author recently visited Singapore, Australia, and New Zealand, which regularly rank in the upper echelon of international comparisons, as part of an 11-day leadership exchange with the Commonwealth Fund and AcademyHealth. The second article, scheduled for publication on June 22, 2023, will cover digital health in Australia, health equity in New Zealand, and implications from all 3 nations for the US.
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