War on Diabetes Summary Report • 2016 – 2019

Objectives

Singapore’s War on Diabetes is a whole-of-society strategy to create conditions in which people can live free from diabetes and people with diabetes can manage the condition well. It combines prevention, early detection and intervention, and improved disease management, supported by public education, patient empowerment, data, analytics and research.[1][2]The strategy uses a life-course and ecosystem approach that promotes healthier eating, physical activity, routine health checks and shared responsibility among individuals, communities, institutions and industry.[1][2]

• Prevent diabetes and other non-communicable diseases by shifting attitudes and supporting sustained healthier behaviours, particularly healthier food choices and active living.[3][4]
• Improve access to healthier food and drink options across homes, schools, pre-schools, workplaces, communities, retail outlets and food-service settings.[2][5]
• Promote physical activity among all age groups through accessible programmes, workplace initiatives and active-living infrastructure.[6][7]
• Detect diabetes and pre-diabetes earlier through regular, affordable screening, risk assessment and targeted outreach to higher-risk groups, including younger adults and women with previous gestational diabetes.[7][8]
• Prevent or delay complications by strengthening chronic disease management, primary care, self-management and services for kidney, foot and eye complications.[9][10]
• Empower people with pre-diabetes or diabetes, alongside their families and communities, to co-own care journeys and sustain lifestyle changes.[9][11][12]
• Generate evidence and use technology, data and research to improve policy, outreach, clinical management and scalable interventions.[4][13]

Implementation

Implementation is led as a national collaborative effort rather than a single health-service programme. The Diabetes Prevention and Care Taskforce, established in June 2016, leads the whole-of-nation initiative, bringing together government agencies, healthcare providers, community-based organisations, industry partners, academics and Singaporeans.[1][2]Delivery combines population-wide environmental measures with targeted screening, referral, primary-care management, community support, digital tools and research-informed improvement.[3][4][13]

• Expand healthier food environments through collaboration between the Health Promotion Board, Ministry of Education, Early Childhood Development Agency, schools, food-and-beverage operators, supermarkets and manufacturers.[2][5]Use the Healthier Choice Symbol, Healthier Dining Programme and Healthier Ingredient Development Scheme to increase the availability, visibility, affordability and innovation of healthier products.[5]By March 2019, 1,230 pre-schools participated in the Healthy Meals in Pre-Schools Programme, all mainstream Ministry of Education school canteens offered healthier food and drink options, and 91 Institute of Higher Learning food outlets were covered by the Healthier Dining Programme.[2]
• Deliver physical-activity opportunities through partnerships involving the Health Promotion Board, Sport Singapore, the People’s Association, National Parks Board, office landlords and other partners.[6]Provide free sessions, workplace programmes, the National Steps Challenge and initiatives such as Sunrise in the City, alongside cycling paths and park-connector links under the National Cycling Plan.[6][7]
• Provide cardiovascular-risk screening and follow-up through Screen for Life for Singapore Citizens and Permanent Residents aged 40 years and above, generally at three-year intervals.[7]Use the Diabetes Risk Assessment tool to help adults aged 18 to 39 identify whether diabetes screening may be appropriate, and provide gestational diabetes screening in public maternity hospitals.[8]Enhanced Screen for Life subsidies introduced in September 2017 were followed by more than 65,000 Singaporeans receiving cardiovascular and cancer screening over 18 months, nearly 30 times the preceding 18-month total.[7]
• Strengthen referral and prevention pathways by linking risk assessment and screening results to nutrition, physical activity, weight-management and pre-diabetes programmes.[8]Implement and evaluate pilots including Pre-diabetes Interventions and Continued Tracking to EaseOut Diabetes, Diabetes Lifestyle Intervention using Technology Empowerment and Pre-diabetes Management.[8]Extend outreach through public healthcare institutions, grassroots organisations, general practitioners, polyclinics and workplaces, including sectors with less structured work arrangements.[8][9]
• Anchor long-term diabetes care in primary care through Primary Care Networks, which enable partner general practitioner clinics to share resources and offer multidisciplinary services involving doctors, nurses and primary care coordinators.[9]Ten networks covering more than 450 general practitioner clinics had been established by December 2018.[9]Build professional capability through Family Medicine training and diabetes-related Appropriate Care Guides, and provide diabetic foot and eye screening, nurse counselling and complication-prevention services.[9][10]
• Implement complication-management programmes through all 20 polyclinics for chronic kidney disease, and use the National Diabetic Foot Workgroup to develop a national strategy and risk-stratified foot screening and management.[10]Monitor diabetic retinopathy services through screening findings and attendance, which rose from about 14,000 in 2012 to 92,000 in 2018.[10]
• Engage and support communities through mass-media and digital campaigns, targeted outreach, the Diabetes Community Intervention Programme, Health Peers, care teams, grassroots organisations, voluntary welfare organisations and places of worship.[11][12]Use HealthHub reference materials and a Care Team Education Framework to support self-care and strengthen the capacity of professionals and lay volunteers.[10][11]
• Involve the public in co-design through Listening Points, the War on Diabetes Designathon and the Citizens’ Jury.[3]By April 2019, 12 Citizens’ Jury recommendations had been implemented, eight were being implemented and seven remained under exploration.[3]
• Use the National Diabetes Database and associated dashboards, developed by the Ministry of Health and Integrated Health Information Systems, to consolidate diabetes information for policy development, targeted intervention and clinical management.[4]Support research grants and evaluations to improve outcomes, identify complication risks earlier and assess conversion from pre-diabetes to diabetes.[4]

Monitoring & Evaluation

Monitoring combines programme-reach measures, service uptake, behavioural outcomes, clinical follow-up and data infrastructure, but the source does not set out a single consolidated evaluation framework, routine reporting timetable or formal accountability structure.[1][2][5][6][7][8][9][10][11][12][3][4]

• Track healthy-food implementation through participation and coverage indicators. By March 2019, 1,230 pre-schools participated in the Healthy Meals in Pre-Schools Programme, all Ministry of Education mainstream school canteens offered healthier food and drink options, and 91 food outlets in Institutes of Higher Learning were covered by the Healthier Dining Programme.[2]
• Measure market uptake of healthier products through the Healthier Choice Symbol market share, which increased from 18% in 2016 to 25.4% in 2018.[5]
• Assess early behavioural effects through a preliminary survey indicating greater uptake of healthier food among participating pre-school children both at school and at home.[2]
• Monitor physical-activity delivery and participation, including more than 1,000 free weekly sessions reaching 189,000 participants, over 9,000 monthly participants in 450 Sunrise in the City sessions as of March 2019, and more than 800,000 Season 4 National Steps Challenge sign-ups as of April 2019.[6]
• Assess activity-related outcomes through reported improvements in body mass index and physical activity among Healthy Workplace Ecosystems workers, a rise in average daily steps from 9,000 in Season 3 to 9,100 in Season 4, and an increase in median moderate-to-vigorous activity from 112 to 131 minutes weekly.[6]
• Monitor screening uptake following enhanced Screen for Life subsidies. More than 65,000 Singaporeans received cardiovascular and cancer screening in the 18 months after the September 2017 enhancement, nearly 30 times the number screened during the preceding 18 months.[7]
• Use diabetes-risk assessments, medical records, screening results, referrals and lifestyle-intervention follow-up to identify and support people at risk, including younger adults and women with previous gestational diabetes.[8]
• Evaluate physical-activity pilots involving the Health Promotion Board, Sport Singapore and the Singapore Armed Forces before considering broader implementation.[7]
• Track primary-care implementation through the growth of Primary Care Networks. Ten networks involving more than 450 general practitioner clinics had been established by December 2018.[9]
• Monitor complication-prevention services through kidney-care implementation, risk-stratified diabetic foot screening and management, and diabetic retinopathy screening. About 25% of patients screened under the Singapore Integrated Diabetic Retinopathy Programme had abnormal findings needing specialist follow-up, while annual attendance rose from about 14,000 in 2012 to 92,000 in 2018.[10]
• Use operational engagement measures, including completion of the Diabetes Risk Assessment tool, campaign prompts, patient follow-up and adherence to care plans; however, no quantitative indicator set or surveillance schedule is specified for public education and community-support activities.[11][12]
• Consolidate diabetes information through the National Diabetes Database, developed by the Ministry of Health and Integrated Health Information Systems, and use dashboards on diabetes profiles, trends and patterns to inform policy, outreach, interventions and clinical management.[4]
• Evaluate community interventions through the Pre-Diabetes Interventions & Continued Tracking to Ease out Diabetes study, including effects on progression from pre-diabetes to diabetes.[4]
• Track follow-through on participatory recommendations. By April 2019, 12 Citizens' Jury recommendations had been implemented, eight were under implementation and seven were being further explored.[3]

Costing & Financing

Financing is principally described through patient subsidies, MediSave withdrawal arrangements and research or innovation support. The source does not provide a consolidated budget, total expenditure, resource-mobilisation plan, funding gap analysis, unit-cost schedule or economic assumptions for the wider programme.[1][2][5][6][7][8][9][10][11][12][3][4]

• Provide enhanced Screen for Life subsidies at Community Health Assist Scheme general practitioner clinics from 1 September 2017. Eligible Singaporeans pay 5 Singapore dollars for screening and follow-up consultations, Community Health Assist Scheme Blue and Orange members and Merdeka Generation cardholders pay 2 Singapore dollars, and Pioneer Generation members make no payment.[7]
• Support community and polyclinic screening outreach, follow-up consultations and lifestyle programmes at 5 Singapore dollars or less where specified.[8]
• Maintain subsidised health screening for people aged 40 years and above at 5 Singapore dollars or less, alongside follow-up support for people at risk or with abnormal results.[9]
• Expand diabetes-management financial support through Chronic Disease Management Programme and Community Health Assist Scheme coverage for prediabetes, and through MediSave use for glucose-monitoring supplies for eligible people with diabetes.[9]
• Increase the Chronic Disease Management Programme MediSave withdrawal limit from 400 Singapore dollars to 500 Singapore dollars in 2018.[9]
• Provide, from November 2019, Community Health Assist Scheme chronic-disease subsidies of up to 540 Singapore dollars annually for all Singaporeans receiving Chronic Disease Management Programme treatment at participating general practitioner clinics, irrespective of income.[9]
• Support food-sector product reformulation through the Healthier Ingredient Development Scheme, which had supported 67 grant applications across 42 partners by March 2019; no grant value is reported.[5]
• Identify grant schemes for diabetes research and for improving health outcomes and healthcare-delivery efficiency, without reporting grant amounts or allocations.[4]