War on Diabetes Summary Report • 2016 – 2019

Objectives

Singapore’s War on Diabetes is a whole-of-nation strategy to create an environment in which people can live free from diabetes and those with diabetes can manage the condition well.[1][2]It combines prevention, early detection and intervention, and better disease management, enabled by public education, personal empowerment, data, analytics, research and whole-of-society participation.[3][1]

• Promote healthy living across the life course by improving access to healthier food and drinks, encouraging informed food choices, and increasing physical activity in schools, workplaces, homes and communities.[1][4][5]
• Prevent diabetes and its complications by supporting healthier diets, exercise, weight management and early intervention for people with pre-diabetes.[5][6]
• Detect diabetes and pre-diabetes early through regular age-appropriate screening, risk assessment for younger adults with risk factors, and gestational diabetes screening and follow-up.[7][6]
• Improve long-term disease management by anchoring care in primary care, empowering patients to co-own care plans, and reducing kidney disease, lower-extremity amputations and diabetic retinopathy.[8][9]
• Strengthen public awareness and individual responsibility through multilingual education, public campaigns, targeted outreach and messages on preventing or reversing pre-diabetes.[10]
• Generate evidence for scalable policy and clinical interventions through research on diabetic kidney disease, microvascular complications and progression from pre-diabetes to diabetes.[11][2]

The strategic direction also seeks to shift mindsets towards sustained healthier behaviours, innovative solutions and active community support for people at risk of, or living with, diabetes.[12][11]The supplied material does not specify a single consolidated set of national outcome targets or an overall formal performance framework.[3][6][9][2]

Implementation

Implementation uses a coordinated whole-of-government and whole-of-society delivery model, led through the Diabetes Prevention and Care Taskforce established in June 2016 and involving government, healthcare providers, community organisations, industry, academia, employers and residents.[3][1]Delivery combines population health promotion, targeted screening and referral, primary and specialist care, community support, digital tools, integrated data and research.[8][13][11]

• Improve food environments through the Healthier Choice Symbol, lower-glycaemic-index product categories, healthier supermarket house-brand products, the Healthier Dining Programme, and the Healthier Ingredient Development Scheme.[4]
• Deliver healthier meals in early childhood settings through the Healthy Meals in Pre-Schools Programme, involving the Health Promotion Board, Ministry of Education and Early Childhood Development Agency.[1]
• Expand physical activity through free community sessions, workplace programmes, the National Steps Challenge, ActiveSG, cycling paths and park connector networks, working with Sport Singapore, the People’s Association, National Parks Board, Land Transport Authority and private partners.[5][7]
• Provide subsidised cardiovascular risk screening through Screen For Life and Community Health Assist Scheme general practitioner clinics, using non-fasting glycated haemoglobin testing and the Diabetes Risk Assessment tool to improve convenience and identify younger adults requiring screening.[7][6]
• Strengthen referral and follow-up by linking public healthcare institutions, general practitioners, polyclinics, grassroots organisations, residents’ groups and workplace partners with community lifestyle programmes and health coaching.[6][8]
• Build primary care capability through Primary Care Networks, multidisciplinary teams, subsidised Family Medicine training, Appropriate Care Guides and access to diabetic foot, eye-screening and nurse-counselling services.[8][9]
• Implement complication-prevention programmes through the Holistic Approach in Lowering and Tracking Chronic Kidney Disease programme, the National Diabetic Foot Workgroup and the Singapore Integrated Diabetic Retinopathy Programme.[9]
• Empower patients, caregivers and communities through care teams, educational materials, the Care Team Education Framework, Health Peers, roadshows, health talks, screening and the Diabetes Support Package.[9][13]
• Co-create solutions through public engagement sessions, Listening Points, a World Diabetes Day Designathon and a Citizens’ Jury, with the Ministry of Health, subject-matter experts and partner agencies participating in recommendation development and implementation.[12]
• Use the National Diabetes Database, Healthy 365 application and research studies including DYNAMO and Pre-DICTED to support policy planning, targeted outreach, clinical management and evaluation of community-based interventions.[11][2]

Operational monitoring includes measures of healthier-product market share, healthier-meal availability and uptake, physical-activity participation, screening uptake, referral activity, programme reach and selected clinical screening outcomes.[4][5][7][9]Reported results include growth in Healthier Choice Symbol product market share from 18% in 2016 to 25.4% in 2018, more than 65,000 people benefiting from subsidised cardiovascular and cancer screening in the 18 months after the 2017 enhancement, and 10 Primary Care Networks comprising over 450 general practitioner clinics by December 2018.[4][7][8]

Affordability measures include enhanced screening subsidies, subsidised community and workplace screening, expanded Chronic Disease Management Programme and Community Health Assist Scheme coverage, and MediSave support for eligible diabetes-management supplies.[7][6][8]The source material does not specify an overall programme budget, expenditure total, financing gap or resource mobilisation plan.[4][9][11]

Monitoring & Evaluation

Monitoring combines programme reach, service uptake, behavioural measures, clinical screening outcomes, public engagement and research evidence, but no consolidated national evaluation framework, reporting timetable or overarching accountability system is specified.[3][1][6][9][10][13][2]

• Track healthier food availability and consumer uptake through the Healthier Choice Symbol market share, which rose from 18% in 2016 to 25.4% in 2018 across 100 categories; healthier meals eaten out increased from 25 million to 180 million over the same period.[4]
• Monitor delivery of healthier food schemes, including 1,230 participating pre-schools by March 2019, 91 food outlets in Institutes of Higher Learning under the Healthier Dining Programme, and 67 Healthier Ingredient Development Scheme grant applications across 42 partners.[1][4][5]
• Measure physical-activity participation and behavioural outcomes through weekly community sessions, workplace activities, ActiveSG registrations, the National Steps Challenge, daily steps and moderate-to-vigorous physical activity.[5][7]
• Monitor screening uptake, risk assessment, follow-up and referral pathways; following subsidy enhancements, more than 65,000 Singaporeans received cardiovascular and cancer screening in 18 months, nearly 30 times the preceding 18-month total.[7][6]
• Evaluate joint physical-activity pilots involving the Health Promotion Board, Sport Singapore and the Singapore Armed Forces before considering wider implementation.[7]
• Track primary-care capacity and disease-management services, including 10 Primary Care Networks comprising more than 450 general practitioner clinics by December 2018, kidney-risk-factor management, diabetic-foot service uptake and retinopathy screening.[8][9]
• Record retinopathy programme reach and outcomes, with attendances rising from about 14,000 in 2012 to 92,000 in 2018 and approximately 25% of screened patients having abnormal findings requiring specialist referral.[9]
• Use patient follow-up, campaign engagement and online risk-assessment completion as operational measures for education and community support, although formal outcome indicators are not specified.[10][13]
• Assess public views and co-created solutions through engagement sessions, the Designathon and the Citizens’ Jury; 17 engagement sessions generated about 2,000 responses, while 12 Citizens’ Jury recommendations had been implemented by April 2019.[12]
• Use National Diabetes Database dashboards to inform policy planning, targeted outreach, interventions and clinical management through analysis of diabetes profiles, trends and patterns.[11]
• Generate evidence through the Diabetes Study of Nephropathy and other Microvascular Complications and the Pre-Diabetes Interventions & Continued Tracking to Ease out Diabetes study, including evaluation of community interventions intended to reduce conversion from pre-diabetes to diabetes.[2]

Costing & Financing

Financing information is limited to subsidised screening, patient charges and healthcare subsidy arrangements; the material does not provide a consolidated budget, total implementation cost, funding gap, resource-mobilisation plan or economic assumptions.[3][1][4][5][7][6][8][9][10][13][12][11][2]

• Set the eligible patient charge for Screen For Life screening and follow-up at Community Health Assist Scheme general practitioner clinics at 5 Singapore dollars from 1 September 2017; CHAS Blue, CHAS Orange and Merdeka Generation cardholders pay 2 Singapore dollars, while Pioneer Generation cardholders pay nothing.[7]
• Provide community and workplace screening at a subsidised charge of 5 Singapore dollars or less, alongside follow-up support such as general practitioner consultations, lifestyle programmes and health coaching.[6][8]
• Expand the Chronic Disease Management Programme and the Community Health Assist Scheme to cover pre-diabetes, and permit eligible insulin users who regularly monitor blood glucose to use MediSave for test strips and lancets.[8]
• Increase the MediSave withdrawal limit under the Chronic Disease Management Programme from 400 to 500 Singapore dollars.[8]
• Provide, from November 2019, Community Health Assist Scheme chronic-disease subsidies of up to 540 Singapore dollars annually for diabetes and other covered chronic diseases treated at participating general practitioner clinics, regardless of income.[8]
• Support workforce development through subsidised Family Medicine training, without specifying the funding amount or allocation.[8][9]
• Identify grant schemes for diabetes research, but provide no monetary values or detailed financing arrangements.[11]