HIP Report

The Health Innovation Project
A Report
Mohan J. Dutta, Desiree Soh, Munirah Bashir and Afreen Azim
ABSTRACT
This report presents an overview of the community-based healthcare
innovation programme: a culturally-centered community based approach
(Health Innovation Project) including its methodology and findings from
participant observations, in-depth interviews (community members, and
health care providers and social workers), three community advisory board
meetings, and a community-wide survey with 700 participants.
Health Innovation Project report
Center for Culture-Centred Approach to Research and Evaluation Page 1

Table of Contents
Summary ............................................................................................................................. 3
Introduction
The culture centered approach .......................................................................................... 4
Chapter 1
The Health Innovation Project ............................................................................................ 6
Chapter 2
Community Perceptions
Methodology & Participant observation ............................................................................ 9
In depth interviews............................................................................................................ 17
Findings ............................................................................................................................. 19
Chapter 3
Key informants and health care providers and social workers .........................................
Methodology...................................................................................................................... 28
In depth interviews............................................................................................................ 30
Findings: Key informants ................................................................................................. 31
Findings: Health care providers and social workers ...................................................... 32
Chapter 4
Advisory Boards ............................................................................................................... 40
Key issues identified ........................................................................................................ 42
Implementable solutions identified ................................................................................. 44
Appendix A: Health services maps of sampling areas ................................................... 47
Appendix B: Voices of the community members ........................................................... 53

Summary
The Health Innovation Project has as its main premise the fact that communities are
in the best position to identify the problems that face them and delineate the solutions
to these problems. The project takes a multi stakeholder approach to connect the
community to the key informants and health care providers to facilitate a dialogue
between them such that practicable and workable solutions can be identified and
implemented.
131 community and 20 stakeholders in depth interviews have revealed emerging

themes of social isolation among the community members, lack of links to the
community and community support, poor preventive care, fragmented care, gaps in
health information, the need for expanding the role of the GP while making GP practice
sustainable, encouraging community members to see one doctor in the community for
their needs, and challenges of shifting focus of care from hospital to community,
among others.
Three advisory board sessions which comprised of members selected from among the
interviewees highlighted issues of mobility, communication, coordination of care, long
waiting time and costs of care. Solutions proposed included setting clear expectations
for patients about costs, clear instructions at different stages of the treatment, access
to medical records, and follow up in between appointments, among others.
The project was wrapped up with a community-wide stratified random survey (n = 700)
in the proposed catchment area based on the key themes, issues, and quality
characteristics of an ideal hospitals that emerged in the culture-centered processes of
ethnography and advisory group meetings. The survey findings converge with the
findings in the participant observations and in-depth interviews. Community members
note costs, lack of coordination, waiting time between appointments, and lack of
communication as key challenges to healthcare. They identify an ideal hospital as one
that would clearly communicate costs, minimize waiting time between appointments,
and simplify the communication barriers to care seeking.

Introduction
The Culture Centered Approach (CCA)
The culture centered approach is founded on the principles of listening to the voices
of the marginalised that have hitherto been unheard in policy making spaces.1,2 These
erasures are communicative in nature and are further entrenched through top-down
programs that are often out of touch with the lived experiences of the marginalized.
Consequently, essential to addressing health disparities through the CCA framework,
is the foregrounding of community voices through the processes of dialogue and
listening at the sites of knowledge production and implementation.3
Co-construction and collaboration, referring to a process of power sharing between

academics and marginalized communities, lies at the heart of the CCA. 4 Local
meanings, located at the intersections of culture, structure, and agency as depicted in
the CARE logo below, form the bases for such participatory collaborations between
communities, advocates, and academics. Culture, which refers to the shared
meanings, values, and interpretations circulating in community life, offers the lens
through which health is understood and negotiated. Structure refers to the pattern of
organizing resources that shapes the access of individuals, families, and communities
to resources of health and wellbeing. Agency reflects the capacity of individuals,
families, and communities to actively negotiate and make sense of structures and
transform them.
1 Dutta, M. J. (2008). Communicating health: A culture-centered approach. London, England: Polity Press.
2 Dutta, M., & Thaker, J. J. (2016). Culture-Centered Method: The nuts and bolts of co-creating communication
infrastructures of listening in communities
3Dutta, M. J. (2012). Hunger as health: Culture-centered interrogations of alternative rationalities of

health. Communication Monographs, 79, 366–384.
doi: http://dx.doi.org.libproxy1.nus.edu.sg/10.1080/03637751.2012.697632
4Dutta-Bergman, M. J. (2004). Poverty, structural barriers, and health: A Santali narrative of Health
Communication. Qualitative Health Research, 14(8), 1107–1122

Agency
Culture Structure
Participant observations, in-depth interviews, and advisory boards form the basis of
the collaborative processes in the CCA. The participant observation shapes and
guides the in depth interviews while this ethnographic work done in a community in
turn corresponds with the formation of an advisory board comprising of community
members. The methodological framework of the CCA committed to listening is
expressed in the community advisory boards, community-wide meetings, and
community-based workshops. Through the selection of members who are in touch
with the community, its health needs and have an interest in developing partnerships
to address these needs, the advisory boards become collaborative space and a locus
of decision making.
The survey instrument introduced as a build-up to the etnography and advisory group
meetings validates and complements the narratives that emerge in the qualitative
research. The elements of structure, culture, and agency map out the community
resources, the structural challenges, and the design solutions based on community
participation.

Chapter 1
The Health Innovation Project
The management of the operations of Alexandra Hospital (AH) was passed into the
hands of NUHS and will complement existing NUHS services in western Singapore.5
NUHS is tasked with re-imaging health care for the future with AH or the nascent
Alexandra Campus serving as a test bed for innovative models of care.6 This research
applies the culture-centred approach (CCA) to understand the health care needs and
health seeking experiences of the community members in the vicinity of Alexandra
Hospital in order to make healthcare services at AH more accessible to community
members. Through its key ideas of listening, participation and partnership, the CCA
provides a space for the voices of the community members to emerge and
incorporate their opinions in creating a hospital that is responsive to their needs.
The purpose of this research is also to investigate how community members access
existing health services and how the health care system can be improved in order to
make it accessible for people of all ages and especially those from the lower income
group and the elderly who are residents in the nearby estates. Data was gathered
through participant observation, one-on-one in-depth interviews with community
members, and key informants and healthcare providers and social workers and,
advisory board meetings.
The first phase of the project involved participant observation and short informal
interviews with community members. The participant observation allowed the
researcher to embed herself in the community and closely understand it. This process
included understanding the location and the services available as well as
understanding community members themselves. Walk-abouts were undertaken in and
around Alexandra Hospital and locations where community members were likely to
congregate such as food courts, void decks and HDB blocks around Bukit Merah and
Queenstown. Field notes were compiled on the types of services available to the
community. Short interviews involving open ended questions were conducted and,
following an iterative process, aimed at informing the interview protocol for in-depth
community interviews which were conducted at a later stage.
5Lai, L. (2017, April 14). Alexandra Hospital to pass into NUHS hands. The Straits Times. Retrieved June 20,
2017, from http://www.straitstimes.com/singapore/alexandra-hospital-to-pass-into-nuhs-hands
6Yong, G. K. Speech by Minister for Health, Mr Gan Kim Yong, at the MOH Committee of Supply Debate 2017.
Speech presented in Singapore Parliament, Singapore. Retrieved June 27, 2017, from
https://www.moh.gov.sg/content/moh_web/home/pressRoom/speeches_d/2017/speech-by-minister-for-health--
mr-gan-kim-yong--at-the-moh-commi.html

Participant observation and short interviews were followed by 131 in-depth interviews
with community members of 60-90 minutes in length. Interviewees were paid an
honorarium of fifty dollars for their time. Interviewees were recruited through door
knocking and were screened for their experiences with chronic illnesses. These
experiences related to managing their health and to their own or a loved one’s illness
within an institutional setting or outside of it. The questions for these interviews were
developed in line with the overarching framework of theoretical sampling. The
concepts that were revealed through the analysis of the data gathered from the short
informal interviews and participant observation allowed the researcher to further
formulate specific questions for the in-depth interviews, based on these concepts. The
interview protocol thus developed, served as a guide for in-depth interviews. Following
a cyclical process, it was further amended as the in-depth interviews progressed, to
reflect the richness and diversity of the concepts revealed through the interviews.
In a similar vein, 20 interviews with Key informants and Health care providers and
social workers representing all levels of care and specialities were conducted to gather
detailed knowledge of how the system for prevention and treatment works in practice
especially in the neighbourhoods surrounding Alexandra. These interviews attempted
to bridge the gap between those on the ground- the community members- and those
in the medical profession. These interviews therefore complemented the in depth
interviews with community members. Representatives of the health care system were
invited to participate in this research and offer their ideas and professional opinions on
these institutions. Each interview last for about 60-90 minutes. Interviewees were
recruited through references from stakeholders, once again following the framework
of theoretical sampling.
Three advisory board sessions have been conducted. The advisory board members
were selected from among the community member interviewees. Selection to the
advisory board was grounded in the idea of erasure- asking the question, “What are
the voices that are missing from the discussion on health and health care?” The
composition of the advisory board was guided by an active engagement with this
question. Further, the inclusion criteria for the AB were 1) knowledge of community
health needs, 2) self-identify as or be perceived as opinion leaders in their
communities with influence with respect to issues of relevance to the community and
academic partners, and 3) keen interest in developing community partnerships with
the aim of eliminating health disparities. Each advisory board lasts up to two hours.

The advisory board meetings were primarily meant to gather the members’ views on
the challenges they face in accessing healthcare and then brainstorm over workable
solutions for these challenges. All interviewees and advisory board members are
reimbursed for their participation.
Finally, a survey was conducted with community members in the catchment area (n =
700) to identify the key challenges to health care, the characteristics of an ideal
hospital, and ranking of the key characteristics of an ideal hospital.

Chapter 2
Community Perceptions
Method
Participant Observation
The participant observation involved over two hundred hours expended in walk-abouts
to observe and map out the health services and amenities in the area. The
researchers looked for the presence and availability of community and health
resources such as community centers, senior activity centers, chronic disease
centres, nursing homes, polyclinics, dialysis centers etc. (which were mapped out in a
resource map appended to this report as Appendix A), GPs, fitness corners, their use
or under-utilisation by community members, their accessibility to them, the layout of
the hospital, and the physical layout of the neighbourhoods including presence of
barrier free access, void decks etc. Researchers went into the field with the goal of
observing community members in their natural setting, going about their day-to-day
activities. The researchers’ detailed field notes and photographs on the location were
used to inform the interview protocols. A visual health services map representing the
community health resources was drawn up based on the field tracing of the distribution
of health resources in the community.
Also, the participant observation involved 57 short Interviews conducted in Chinese,

Malay and English in the areas of Bukit Merah, Commonwealth, Queenstown and
Telok Blangah. The length of the interviews varied from 15 minutes to up to 20 to 30
minutes. Members of the public were approached and were asked open ended
questions about their attitudes to health, the barriers to health that they experienced,
perceptions of Alexandra Hospital and their expectations from an ideal hospital.
Broadly, their answers revealed the following-
Attitudes towards health:
 Community members, both young and old, were largely interested in knowing
about their health

 Taking care of their health meant taking their medication regularly and
abstaining from unhealthy food
 Majority of the interviewees did not use alternative medicine
 Visiting a ‘hospital’ meant going for appointments every 3 months or
hospitalization or for rehabilitation
 Most undertook walking and housework as exercise
 They felt that looking after health was a personal responsibility
 Some reported a sense of loneliness with old age and were living alone
 For others, poor mobility leading to a sense of ‘uselessness’ and dependency
on children for daily needs.
Some of the barriers to health articulated were:
Older population
 Unaffordability of costs of medication, health care services & hospitalization

despite the subsidies
 Unaware of how to get subsidies and where to get information on them
 Majority were unaware of the full range of health care services available,
especially chronic disease centres in their area
 Language barriers
 Disability, mental and physical.
Younger population
 Lack of motivation to exercise due to work commitments

 Language barrier was not an issue.
Awareness of AH
 Lack of awareness and information on services currently available at AH

 Unaware that AH has begun operations in phases
 Language barrier in health communication messages on one hand and
 Information overload on the other- multiple subsides, their qualifications &
benefits
AH as the ideal hospital
 Affordable yet high end facilities comparable to a private hospital

 Accessible to all including the low income and disabled

 Shorter waiting time
 Staff that is able to communicate in their mother tongue; i.e. dialects and Malay
 Continuity in therapy and exercise sessions after patients are discharged
 A positive environment where patients can engage in therapeutic activities
 Befrienders who can spend time with patients and, volunteers conducting
rounds to visit patients, particularly those with no family and visitors.
 Easy access to doctors
What it should not be:
 A hospice that is understaffed and where the environment is melancholic

 A small number of overworked doctors and nurses attending to many patients
Sampling frame
Demographic and health indicators data on Bukit Merah, Queenstown, and all of
Singapore was gathered to guide the sampling strategy. Where data for the specific
subzones was not available, it was extrapolated from the national level data. This was
incorporated in to a sampling frame comprising of gender, race, age, highest education
level, monthly household income groups for Bukit Merah and Queenstown. These
indicators along with mobility and living arrangements were also taken into account
and incorporated in to a participant information sheet that aimed at gathering the
interviewee’s information on these indicators. The following subzones in Bukit Merah
and Queenstown were selected for in-depth community interviews, based on the data
from data.gov.sg and their proximity to Alexandra Hospital by 3-7 bus stops.
Bukit Merah:
o Alexandra Hill
o Depot Road
o Telok Blangah Drive
o Bukit Merah
o Redhill and
o Parts of Henderson Hill and Tiong Bahru
Queenstown:
o Mei Chin
o Margaret Drive
o Tanglin Halt
o Commonwealth
o Holland Drive

I. Bukit Merah
a. By age
Age Number of People Percentage Sample (n=60)
20-24 3,459 7% 4
25-29 4,364 8% 5
30-34 5,689 11% 6
35-39 5,465 10% 6
40-44 4,950 9% 6
45-49 4,893 9% 6
50-54 4,890 9% 6
55-59 4,616 9% 5
60-64 4,554 9% 5
65+ 9,890 19% 11
Total 52,770 100% 60
b. By ethnicity
Ethnic Group Number of Percentage Sample

People (n=60)
Chinese 51,174 78% 47
Malays 5,918 9% 5
Indians 6,935 11% 6
Others 1,512 2% 1
Total 65,539 100% 60

c. By sex
Sex (Age 20 Number of Percentage Sample

& Above) People (n=60)
Male 25,653 49% 29
Female 27,117 51% 31
Total 52,770 100% 60
d. By education
Highest Qualifications Number of Percentage Sample

Attained People (n=60)
No Qualification 28,790 23% 14
Primary 10,278 8% 5
Lower Secondary 13,063 11% 6
Secondary 20,455 17% 10
Post-Secondary (Non- 10,390 8% 5

Tertiary)
Polytechnic 8,935 7% 4
University 26,196 21% 13
Professional Qualification 5,841 5% 3

and Other Diploma
Total 123,948 100% 60
e. By monthly household income
Monthly Household Income from Number of Percentage Sample

Work People (n=60)
No Working Person 10,311 19% 11
Below $1K 4,324 8% 5
$1K - $1,999 5,966 11% 6
$2K - $2,999 4,801 9% 5
$3K - $3,999 4,130 7% 4

$4K - $4,999 4,175 8% 5

$5K - $5,999 3,563 6% 4
$6K - $6,999 2,994 5% 3
$7K - $7,999 2,451 4% 3
$8K - $8,999 2,198 4% 2
$9K - $9,999 1,688 3% 2
$10K & Over 9,025 16% 10
Total 55,626 100% 60
II. Queenstown
a. By age
Age Group Number of Percentage Sample

People (n=60)
20-24 3,119 6% 4
25-29 4,470 8% 5
30-34 5,566 10% 6
35-39 5,697 11% 6
40-44 5,276 10% 6
45-49 5,105 10% 6
50-54 4,727 9% 5
55-59 4,217 8% 5
60-64 4,123 8% 5
65 and above 10,771 20% 12
Total 53,071 100% 60
b. By sex
Sex (Age 20 Number of Percentage Sample

& Above) People (n=60)
Total Males 24,689 47% 28
Total 28,383 53% 32

Females
Total 53,072 100% 60

c. By ethnicity
Ethnic Group Number of Percentage Sample

People (n=60)
Chinese 50,356 78% 47
Malay 6,201 10% 6
Indian 5,790 9% 5
Others 2,450 4% 2
Total 64,797 100% 60
d. By monthly household income
Monthly Household Number of Percentage Sampling

Income People Number (n=60)
No Working Person 6,642 19% 12
Below $1K 1,861 5% 3
$1K - $1,999 3,170 9% 6
$2K - $2,999 3,132 9% 5
$3K - $3,999 2,747 8% 5
$4K - $4,999 2,334 7% 4
$5K - $5,999 2,184 6% 4
$6K - $6,999 1,748 5% 3
$7K - $7,999 1,364 4% 2
$8K - $8,999 1,299 4% 2
$9K - $9,999 973 3% 2
$10K & Over 6,911 20% 12

Total 34,365 100% 60
e. By education

Highest Qualifications Number of Percentage Sample (n=60)

Attained People
No Qualification 13,711 18% 11
Primary 5,277 7% 4
Lower Secondary 6,944 9% 6
Secondary 12,517 17% 10
Post-Secondary (Non- 6,365 9% 5

Tertiary)
Polytechnic 5,436 7% 4
University 20,128 27% 16
Professional 4,067 5% 3
Qualification and Other
Diploma
Total 74,445 100% 60
In-depth interviews
An interview protocol was developed for 60-90 minute long in-depth interviews with
community members. Following the tenets of theoretical sampling, the protocol was
based on the concepts and themes identified from the data in the participant
observation which shaped more specific questions in the interview protocol for in-
depth interviews. The protocol was a dynamic document that was responsive to the
articulation by community members of the problems faced by them. The themes which
emerged from these interviews built on and added more depth to the themes identified
in the participant observation.
Drawing upon the central principles of culture, structure and agency of the CCA, these
community level interviews were intended to identify the culturally specific meanings
of health in the community, the barriers to health encountered and the use of agency
to surmount these barriers. These interviews contributed to an understanding and
identification of the needs of the local communities and their communication
requirements, among others, for the development of implementable community-driven
solutions.

The participants were required to sign an information sheet and the interviews were
audio recorded upon consent. All identifiable information is and will be kept confidential
and all data anonymized.
Questions in the interview protocol were open ended and covered the following
themes:
 Meanings of Health- Mental, Physical and Emotional

 Lifestyle and Control Over Health
 Questions relating to specific chronic diseases (Diabetes, heart health,
hypertension etc.) such as ability to self-manage cholesterol/ insulin/ blood
sugar etc.
 Preventive Care and Health Screening
 Experience with and Accessing Alexandra Hospital
 Accessing Various Healthcare Services
 Health Communication & Information
 Relationship with Doctors and Primary Care Providers
 General Practitioners- frequency of visits and for what kinds of health issues;
factors that can influence the family to see the GP for chronic illnesses etc.
 On Being Attended to by Nurses
 Experience in accessing Intermediate and Long Term Care Services and long
term care planning
 Continuity of Care
 Care Recipients and the Elderly
 Caregivers
 Living Arrangement and Connection to Wider Community or Family
 Intimate Relationships and Health
Recruitment process
Community members representative of the target sample were recruited through door
knocking. The HDB and other housing estates from low, middle and high income
groups relevant to the study’s sample were identified using the Urban Redevelopment
Authority data. These estates were mapped out for the researchers’ easy reference
using the easymapmaker service online. So far 131 community member interviews
have been conducted and about 95% have been transcribed.
Data Analysis
Analysis began with open coding with an attempt to open up and examine all the
possibilities within the data whereupon the data was labelled with interpretative

conceptual labels. These labels narrowed down the data which was followed by axial
coding showing the relationships within and among the analytical categories. In- depth
interviews were continued throughout and the field notes taken added to the richness
of the analysis. The emergent theoretical concepts were tied together using selective
coding to achieve theoretical integration.
Findings from in-depth community interviews:
I. Gaps in health care delivery
i. Fragmentation of care:
The issue of traveling to the hospital every few weeks and to multiple departments for
multiple ailments came up with interviewees. Caregivers and patients alike reported
the exhausting process of keeping up with appointments, attesting to the idea of
treating distinct organs instead of the individual as a whole.
Aside from the common issue of long waiting time at the polyclinics and public
hospitals as compared to the actual appointment time, some have experienced being
given higher dosage and a lot more medication when they see different doctors each
time.
ii. Community Support:
a. Social Isolation:
Participants reported social isolation and the need for discussing their health
experiences with others while some recounted difficulty in transitioning from being a
working adult to an inactive ‘elderly’. Some go to their church to exercise and mingle
with other community members and, from experience, have suggested that hospitals
tie up with community infrastructure such as religious establishments and reach out to
low income families.
Many elderly members who are in better health currently volunteer with the intention
of helping those who are less advantaged than they are. They pick communities and
organisations that they have experience in possibly due to being a caregiver to a
spouse who went through the same experience. Many of them are now health
ambassadors in their respective areas either alone or through an organisation. Others
express interest in volunteering once they retire and have more free time, as a way of
combating isolation and also to contribute to their communities.

Few of the elderly who are interested in volunteering are unaware of whom to
approach if they wanted to volunteer as most would disregard the community centres
and are most likely to ask around through word of mouth.
b. Community centre and Residents’ Committees:
Many interviewees pointed out that community members only go to the CCs or RCs
when they need to inquire about some kind of paperwork. They opined that this could
be because the CC and RCs are not fully integrated into the neighbourhood and the
staff seem cut off from the larger community.
c. Caregiving challenges:
Interviewees who are or used to be caregivers report ‘learning (how to be a caregiver)

‘on the job’ with no training received beforehand.
Caregiver stress was reported among some interviewees. Some attributed their poor
emotional and physical health to the complete modification of their routine and lack of
social life as a result of caregiving duties. Further, Interviewees report having elderly
parents or grandparents who are dependent on adult children to bring them to their
doctors’ appointments, often at different departments spread over various
clinics/institutions. This creates a strain on the adult children and also entails frequent
leave from work which is not always forthcoming. Creating provisions for applying for
such medical leaves was suggested.
In addition to stress from caregiving duties, caregiver interviewees also had their own
medical issues. In terms of long term care, for elderly parents as well as those growing
older and in their late 40s to 50s, there was a ‘We’ll think about it when we get there’
approach. This was also the case of self-care for middle aged working adults
accompanied by incomplete information or lack of awareness of what is needed for
self or preventive care at present. Many were willing to step up and financially support
their elderly parents if/when they would be in need of care.
Many were unfamiliar with the term ‘AIC’ and its website for ILTC services.
Interviewees also expressed the interest in joining support groups and training for
caregiving.
Caregivers and FDWs:
Where the caregiver was a foreign domestic worker and didn’t speak English, inability
to receive clear instructions from the doctor, when accompanying the patient, was

reported. Interviewees mentioned that their elderly parents may be averse to have an
FDW care for them as FDWs are perceived by them as ‘strangers.’
Some interviewees were open to receiving caregiver training for their loved ones (‘help
us to help our elderly at home’). Interviewees stated that they prefer to be the primary
caretaker for their elderly parent/s because of a sense of duty to their parents.
Domestic help in such cases would serve to provide additional support in the day-to-
day routines. Further, as elderly parents have rigid routines and need care at home in
a familiar environment and with a sense of autonomy, ‘outsiders’ in this case, whether
nurses or FDWs, should ideally assist the elderly with their activities at home with
minimum interference. In some cases where the cost of a nursing home was too high
for interviewees, they opted for an FDW to care for their family members.
d. General practitioners:
Among younger, upper income interviewees a reason for not sticking to one GP is
because when their company changes the insurer the identified panel clinics where
the subsidised rates are applicable also changes. It was easier for the elderly to stick
to one doctor whereas younger or middle aged adults moved or changed their place
of residence often.
Many preferred having a family doctor or seeing one doctor instead of seeing a
different one each time. Those who see the same specialist over a long period
attributed sticking to the same doctor to the fact that they are more familiar with their
health history and have developed a good relationship with them.
Despite wanting to stick to one doctor, interviewees cite higher cost as an inhibiting
factor. They pointed out that longer session with a GP would entail higher fees.
iii. Cost:
For some interviewees, costs are still astronomical despite partaking of the CHAS.
Many cite that the subsidies that they got from the Pioneer and CHAS card to be
significant for elderly interviewees who qualify for the schemes. Further subsidies
would lift their financial burden and help them. Shifting from one institution to another
has also been cited as being an expensive process. Hospitalisation fees for those in
the lower to middle income with financial difficulties, were cited to be the biggest
burden as they had to pay the fees in cash due to the limit they could deduct from
the Medisave account.

A number of elderly interviewees do not have much remaining in their CPF accounts
because their salaries were low in the past or they did odd jobs with no CPF
contributions. There is a fear that the money in their CPF/Medisave accounts may run
out and they will not be able to fork out the money in cash. For those who have
prolonged multiple health issues, their CPF accounts have been drained. This financial
burden is passed to their adult children. It is common among several interviewees to
contribute a share of their incomes to the care or upkeep of other family members,
mostly elderly parents, which impacts their own savings.
On the other end of elderly individuals with strong family support who may or may not
be living with their children, they do not bring up financial issues as a concern as they
currently are able to pay for their healthcare or have adult children who pay for all of
their healthcare needs.
Subsidies:
In some cases, interviewees who had consistently been interfacing with the same
officer at ComCare had suddenly found their officers changed. They then had to
repeat their case history, justification for the expenses and amounts demanded, which
was also a source of shame and stigma. Owing to this or after poor cooperation from
their new officer and decreased disbursement amounts some stopped applying for
subsidies altogether.
On numerous occasions, interviewees were unaware of the subsidies available to

them or where to apply for subsidies. For some in the lower income range, they had
expressed their financial difficulties to the doctor and had thus been referred to a social
worker. However for many, they did not know whom to approach and also thought that
getting help from a social worker would be an arduous and time consuming process
from past experience.
Some interviewees talked about being unable to qualify for subsidies because they
are said to have adult children to support them financially. Despite this, the money that
their children give to them every month is inadequate or is just enough to get by if they
reduce their spending by the dollar.
iv. Management of chronic illnesses:
Several interviewees had chronic illnesses-diabetes, high blood cholesterol, and

hypertension being the most common- or were at risk of exacerbating existing or
developing new chronic illnesses. This was largely because of heavy smoking, lack of
physical exercise, caregiver stress, and family history of chronic illnesses. In these

cases, interviewees did not engage in much preventive care and did not for
screenings. Many who did not report any chronic illnesses did not feel the need to go
for regular health check-ups as they perceive themselves to be healthy in that they do
not feel any sort of pain or discomfort.
Where screening had been done and interviewees showed awareness of the
conditions and illnesses they had, they reported an inability to adequately manage
their health. They explained that they did not have time to exercise and were not
motivated enough to follow up with hospital appointments. Their work or taking their
parents for hospital appointments also inhibits them from properly managing their
health.
Ineffective communication of chronic diseases was also an issue. Several

interviewees did not have an understanding of their health issues-what caused it, its
associated risks and, where the treatment was underway, the purpose of medication.
Mental Health:
One interviewee experienced anger issues and depression owing to newly diagnosed
Parkinson’s disease and expressed the need for some kind of counselling to help
adapt and adjust to life with Parkinson’s in conjunction with activities to keep physically
active.
Several interviewees also experienced stress owing to health problems, family conflict,
financial issues and caregiver stress. One interviewee who had vestigial mobility
issues from an accident and was dependent on her ex-husband for applying
for/renewing subsidies, now struggled to keep up with the paperwork and reported
seeing a counsellor at IMH.
Another interviewee, a student with a mental illness, reported poor coordination with
his case manager at IMH. He was expelled from his polytechnic as his case manager
at IMH was out of touch and could not submit medical leave on time. He is currently
awaiting transfer to NUH and is self-managing his symptoms in the absence of any
medication. Other interviewees who had overcome depression cited understanding
and non-judgemental counsellors as reasons for their better treatment outcomes. One
interviewee mentioned that the family service centres under the block and also regular
advice given by her family doctor who was concerned about her wellbeing, was more
helpful than going to the hospital for regular appointments with the psychologists.
Some elderly who were isolated, were afraid of falling while outside on their own either
because they have fallen before or were advised by their doctors to be careful about
falls while others had experienced dizziness spells. As a result, many of them resorted

to isolating themselves at home and experienced a poorer quality of life. They brought
up feelings of loneliness and a sense of uselessness with little to no social interaction
with others.
Cultural issues:
Perceiving mental health as ‘possession’ –superstitions were not addressed by

counsellor at IMH. One interviewee who has Parkinson’s and needs help with some
ADLs (Activities of Daily Living) also expressed reluctance about asking for assistance
with ADLs because of women in the household.
Many older interviewees have expressed reluctance seek help from their children as
they ‘do not want to be a burden’ and wish to age at home without the help of strangers
as well.
Caregivers and those likely to become future caregivers of their parents also
expressed notions of filial piety and a desire to take care of their elderly at home as
sending them to a center or ‘old folks home’ would be looked down upon in their
community.
v. Preventive care, early detection and health screenings:
Health Information
Television and newspapers were the main sources for information on chronic illnesses
like breast cancer and colon cancer.  Many pointed out how elderly individuals are not
able to read English or are illiterate. A lot of the elderly preferred information through
word of mouth rather than traditional media. Another major source of health
information was personal networks such as friends or neighbours in the community.
For example, they find out about subsidies from their friends through word of mouth
or seek out friends or family members who know or are health professionals for their
second opinion on caregiving and treatments.
Working adults interviewed mentioned that more information/persuasion was needed

along with activities different from those designed for the elderly. These adults and
some technologically savvy elderly look to the internet for information on certain
services and health information instead of consulting the doctor. There is an absence
of a one-stop portal for all their information needs and also a trustworthy resource to
tap into when necessary, rather than turning to the internet. Although a few may look
through some articles on for example, the C3A (Council for Third Age) app, they do
not refer to it for resources or participate in its activities. Where potentially valuable
apps or websites do exist, they are not utilised owing to lack of awareness.

Health screening
Some interviewees report not having gone for screenings in several years, some even
over ten, while others report that the screening provided by their companies is
inadequate or very basic and not thorough.
Among the lower income families, emphasis is placed on simply trying to not fall ill
(‘’just don’t fall sick”) and going to the doctor only when ‘things get out of control’.
Several of the interviewees were also divorced and single mothers and a few had
never married. Among this group screenings for health were lowest owing to time
constraints- they juggle care of the household, children or elderly parents or
both. Some also reported that constantly applying to ComCare for subsidies every
few months takes up a lot of time in addition to say, divorce proceedings, paying bills,
taking care of their children and elderly parent/s, such that health takes a back seat.
II. Suggestions to improve care delivery:
Several of these suggestions were further explored again, in-depth during the Advisory
Board meetings as set out hereinafter.
i. Ideal hospital within the community:
This was articulated as a place for recovery post-surgery, less expensive than a
general hospital and less crowded. Some interviewees suggested that it could be a
place where patients go for follow-up appointments or to collect medication instead of
going to the general hospital where it is more crowded. The waiting time would be
much reduced compared to the usual 4 to 5 hours that they have
experienced. Further, it could ideally have different exercise facilities for both, the
young and the old; some kind of play or care area that could serve as a drop off center
for children while their parents get check-ups and, medical facilities for children. It was
suggested that the ambience at AH should be similar to a community centre where
people feel welcomed to visit and join health maintaining and health building activities.
Several stated that they liked the garden which surrounds AH and suggested that
activities could be held in the garden for patients who are not bedridden. For those
bedridden or using wheelchairs, they suggested volunteers or befrienders assist them
around the garden or have the befrienders interact with these patients to prevent them
from being idle.
ii. Fragmentation of care:

Appointments with different specialists could be scheduled within a day instead of

scheduling multiple visits. Possible collaboration with GPs in the area to treat chronic
illnesses in order to save the trip to the hospital.
iii. Community center and residents’ committees:
Identifying and appointing ‘ambassadors’ who are community leaders, active and
embedded in the community to act as conduits of health information. These could also
connect the community to the CC programs and vice versa. Links between the
community and CCs/RCs could also be forged by AH for outreach purposes. Nurses
could be appointed at the CCs or RCs to conduct tests that would not require the
presence of a doctor so that healthcare is easily accessible.
iv. Caregiver support:
Respite services could not be utilised by some caregivers owing to the timings of these
centres. For others, their parents or grandparents were averse to day care centers
owing to its environment or being lumped together with patients there who were far
more ill than they were. A better environment for elderly patients at day care was
mentioned as a possible respite but where the elderly are not grouped together
irrespective of the extent of the mental deterioration as this makes the healthier
patients feel uncomfortable and degraded.
In order to keep working age adults updated with the medication and
recommendations that are given to their elderly parents at their doctors’ visits, it was
suggested that the medical records of their parents could be made accessible via
websites or apps to their immediate family members. This would also counteract the
fear that their elderly parents may forget to take their medication or misplace it.
v. Means testing:
Means testing could consider familial relations as there are instances where children
may not be consistently supporting their elderly parents financially on a consistent
basis.
vi. Accessible health screenings:
Some suggestions for making health screening more accessible included utilising the
neighbourhood CCs and some places of worship frequented by community members
to bring health screening to the people. Another alternative was to have medical
students conduct home visits and check-ups on the elderly in poorer households to
prevent exacerbation of medical issues, similar to the home visits befriending services
provided for elderlies at risk for social isolation.

Some interviewees from the upper income bracket who go for regular health
screenings expressed dissatisfaction at the post-screening consultation which they felt
did not adequately equip them with information to manage certain conditions (such as
high cholesterol) nor were the causes of their conditions explained clearly. They
suggested that employers and companies could provide and also encourage full and
compulsory health screenings such that screenings become a ‘norm’.
Encouraging working adults to exercise:
Working age adults could be reached through targeted ads on social media
(Facebook, YouTube videos, and search engines on health related queries). The
social aspect of exercising could work to motivate them to lead healthier
lifestyles. They can be encouraged to exercise through sporting events such as
marathons or triathlons and by making it more convenient for them to post a listing on
an app or website looking for company to join them for dual or team sports as and
when they are available. It was also suggested that GPs could play the role of ‘health
mentors’ to instil values of health and healthiness, reinforce them and appreciate
patient's’ efforts at maintaining health to incentivise health habits.

Chapter 3
Key informants and Health care providers and Social workers
Methodology:
A sample frame of the key stakeholders and health care providers was developed.
The goal of these interviews was to glean a range of opinions from across the health
care landscape in Singapore. To ensure that all the stakeholders crucial to the
healthcare delivery process were included, the NUHS team was consulted. These are
the stakeholders NUHS currently partners with or would, in the future, partner with,
making their opinions on gaps and suggestions to surmount these gaps valuable. The
data from these interviews was analysed and the key emergent themes were shared
with the NUHS team. Following the iterative process of the CCA framework, the team
gave the research team their inputs on what areas or concepts they would like the
research team to probe further.
The NUHS team included personnel from various departments at NUHS such as
interim and long term care, operations and administration lead, corporate
infrastructure office, communications, strategic planning office, regional health system
planning office, all of which are relevant to the study and who shared inputs with us.
In total, 8 Key Informants and 12 Health care providers and social workers were
interviewed.
Key Informants
Interview
Key Informants s done
NUHS Alexandra Team 5
NUHS Leadership 0
MOH Leadership (APO, PCC) 0
Alexandra Community Leadership
(grassroots associations- PA, CC,
MPs, Regional Health System etc.) 0
AIC 2
Architectural/Design Team 1
Total 8

Health care providers and social workers
Healthcare
Providers and
Social Workers Interviews done
Polyclinic (Case
managers, family
physicians,
psychologists,
social workers) 0
Private GP 3
Chronic
Care Centre
(Centre
managers). 1
AH Social Workers 0
Hospital Staff 5
Voluntary Welfare
Organizations
(CDCs,
SACs, Lions
Befrienders, ILTC,
Home Nursing
Foundation/HNF) 3
TCM 0
Total 12
In depth interviews
An interview protocol for stakeholder interviews was developed for 60-90 minute long
interviews. This was used, with necessary modifications, to seek the stakeholders’
opinions on how the system of care works in practise, their vision for the Alexandra
Campus, the challenges they see in accomplishing it with the broader themes of the
questions being as under:
 Ideal hospital
 Links with the community- how AH plans to be seen as part of community; how
they intend to engage the community members
 Relationship with other organisations-(RHS, community organisations and
grassroots, VWOs and chronic care centres)
 Accessibility of various health care services
 Doctor-patient relationship
 Hospital staff

 ILTC services/caregiving- barriers to these services and identifying caregiver

and care receiver needs etc.
 Health information and promotion
 Health screening- ideas on improvements, accessibility etc.
Recruitment process
While some of these professionals were contacted by NUHS and referred to the PI
through the Alexandra Campus Project Development team at NUHS others who are
familiar with the health care system were also approached in person through door
knocking and appointments. The healthcare professionals/policymakers were
approached by the PI and co-investigators for a request for interviews via email or in
person and are briefed about the interview process.
Data Analysis
Similar to the community interviews, analysis once again began with open coding and
was labelled with interpretative conceptual labels, narrowing down the data and
followed by axial coding. The relationships within and among the analytical categories
were thus established while in- depth interviews continued. These interviews and the
field notes taken added depth to the analysis. The emergent theoretical concepts were
tied together using selective coding to achieve theoretical integration.
Findings from in-depth stakeholder interviews:
Key Informants
I. Challenge of making care seamless
One of the challenges is posed by the tendency of health care organizations planning
in silos. An example of the gap between the hospital and primary care providers was
given. Further, providers tend to plan for illness rather than for health, being reactive
rather than preventive or proactive. It was hoped that this would change with
Singapore being organized into three clusters where each cluster has an entire set of
health facilities from acute hospitals to primary care and polyclinics.
Family medicine clinics or FMCs working with restructured hospitals was given as an
example where care can be better coordinated and integrated. A seamless two-way
direction of patients is established where the GPs can tap on the hospital specialists'
advice, and the specialists in turn can discharge patients to them. Another example
cited was that of the GPs signing on to a primary care network or PCN where the GPs
receive nurses’ assistance from the hospital. This would obviate the need for patients
to make multiple GP or hospital visits.
Sustainability was also an issue in terms of a lot of waste in healthcare with a lot of
patients with multiple illnesses seeing multiple specialists. Furthermore, the funding

mechanism, it was pointed out, also seems to favour ‘quantity rather than quality’ as it
is based on the number of patients seen in a hospital. In the context of the inpatient
setting, making the transition between acute care and community care more seamless
was a challenge. Administrative and funding roadblocks currently result in the patient
overstaying in an acute hospital by over several days than necessary, often waiting
for a bed at a community hospital. Conversely, wastage also manifests itself as ‘double
handling’ of patients and fragmentation between the community hospital and the acute
hospital where patients are discharged earlier and then re-admitted to the community
hospital.
Additionally, in terms of subsidies, the different subsidy systems for acute and
community hospitals, with the former based on personal income and the latter based
on household incomes, mean that patients see a drop in their subsidies.
II. Manpower challenges
Lack of manpower, providing care for the ageing and the chronically ill while keeping
costs low against the backdrop of a sub-par economy was mentioned as a challenge.
It was suggested that staff such as nurses can be freed up by levelling them up.
However as this would, paradoxically, create a manpower shortage at the bottom level.
It was suggested than an attempt should be made to draw upon volunteers-
housewives or retirees- to fill this gap.
An attempt is also underway to train ‘lay providers’ as part of a community cradle who
then go to people's houses to help them. This help comes in the form of delivering
food, feeding patients through the tube, etc. The other group of lay providers that can
be tapped on is the family members who can also be trained to look after their loved
ones.
III. Common platform to communicate and collaborate- better handshake

and information sharing between the social partners and the hospital
Some stakeholders felt that the health sector and the social
sector ‘have a very different lingo’ and tend to focus on different aspects of care.
There is a need for the hospitals and the social partners to have a common platform
to start a conversation and discuss the patient’s health
Gaps in patient information manifest themselves when discharge summaries that

are sent electronically contain low quality of information needed by the community
provider and which cannot be verified by the provider. A point of contact in this case
would be helpful for verifying the information. Patient ownership on the part of the
previous provider and taking responsibility to assist the next provider would be ideal.
Another suggestion was to blur the gap between the ‘health and the social (sectors)’.
It was mentioned that agencies such as the Senior Activity Centers or SACs tend to
see themselves as social agencies and direct patients to a Polyclinic or to a hospital
in the event of a medical issue. However, a nurse placed nearby or into the SAC can

potentially help look after many of the vulnerable people within an area or up to a
certain number of blocks.
Health care providers and social workers
I. Challenges in taking care from the hospital to the community
i. The primary care sector:
a. Expanding the role of the primary care sector:
Key challenges revolved around time, cost and a better mechanism for sharing patient
records. Interviewees believed that there is a need for the primary care sector to play
a bigger role especially in the area of chronic disease management and against the
backdrop of overcrowding in Polyclinics. However, it was also pointed out that the
current GP model of providing care is a ‘business model’ which entails seeing as many
patients as possible and precludes longer consultation time with the patient with each
patient getting approximately 15-20 minutes with the GP. The director of a chain of
family medicine clinics mentioned how the number of patients they saw was declining
which made it a challenge to bear the financial load of running the clinic. This is
because GPs need to defray costs of medicines and tests, overhead costs, and,
the cost of upkeep of their practice such as rent, staff salaries, book-keeping,
accounting and other paperwork.
It was mentioned that time is a barrier to building stronger relationships with the
patients even though GPs would like to engage in more holistic care. One of the GPs
interviewed characterised herself as an ‘Enhanced Care Practitioner’ said holistic care
and providing patients motivation for behavioural modification was among the main
reasons why her patients regularly followed up with her instead of going to the
hospital where her patients find the care to be ‘transactional and not relational.’ The
GP was also already managing patients from NUH and some from IMH. She was
asked to take on more patients from SGH but cited time constraints. In the context of
the NEHR and handling of medical records it was also mentioned that patients should
be empowered to be in control their own records through a ‘patient notebook’
containing information on, inter alia, the medication they take. On the question about
patients seeing multiple GPs it was mentioned that patients usually have a ‘touch &
go’ experience, i.e. they see multiple doctors as they are unaware about which doctors
specifically treat chronic diseases and there is a need for a register of such doctors for
patients’ awareness.
Other points mentioned revolved around the following themes:

o Dealing with patients with complex conditions which fall outside the category
of common chronic illnesses (e.g. rheumatoid arthritis);
o Right-siting of patients who are already stable and need to monitor certain
chronic illness indicators (LDL, HbA1c etc.). These patients need only some
supervision but return to the hospital instead of visiting the local GPs thereby
‘clogging up’ appointments
o Inadequacy of the NEHR and the need for a better records sharing mechanism
which can make immense difference
o GP training to treat chronic illnesses as some may be ‘rusty’; simplified and
adaptable protocols which can ‘empower’ GPs
o Example of Frontier FMC not taking a cut from sale of medicines, flags the
challenges of making GP practice sustainable with different avenues for
generating revenue; need for financial assistance from the State
o Up-skilling nurses so that they can effectively assist GPs
o Better mechanism for processing payments and a better IT system
o Engaging the community- the question of how to make community members
appreciate the benefits of visiting one GP for their needs instead of multiple
doctors was raised
o Need for targeting middle as well as low income groups.
b. Primary care sector and mental health
Community care for mental health patients was brought up. Since IMH began to bring
GPs on board nearly 10 years ago the number of doctors has doubled from 30 to
nearly 70, which, in the estimation of the GP interviewed is still quite low. It was
surmised that this is because GPs want their practice to be ‘clean’ and that there is
stigma attached to GPs treating mental health patients lest it turns other community
members away. Time is also a barrier as such patients go to a GP for personal touch
and take more time in contrast to IMH where the doctors may not spend as much time
on each patient owning to the large number of patients handled there.
c. Fragmentation of care- polyclinics; patient ‘fluidity’
Fragmentation in the form of availability of medicine was brought up as some

medicines that may be more effective are available at the GP’s clinic and not at the
Polyclinic. This can be an issue where a patient receiving subvented medication from
the Polyclinic makes a choice to buy unsubsidised medication from the GP which can
conflict with his treatment at the Polyclinic. A case was mentioned of one of the GPs’
patients who accessed SGLT2 from the GP but received hostile treatment at the
Polyclinic when he revealed this to them.

Patients who visited this GP also came from locations such as Tampines, Simei- partly
because of the GP’s reputation of charging less (she said she saw her work as ‘social
service’ and charged patients S$15) and because of word-of-mouth publicity by her
patients. Some of the patients also work nearby and it was acknowledged that this
‘fluidity’ and free mobility of patients could be a problem and that MOH could consider
NHS style 'zones' where GPs take care of a particular area and patients are not
allowed to have a certain number of GPs. Another GP highlighted varying patient
density as an issue with this type of care model.
d. Fragmentation of care- coordination between GPs and the VWOs:
FSCs and the case managers in the neighbourhood did not generally work with the
GP in respect of patient care and this was brought up as a possible area of intervention
especially in the area of patients’ records and eldercare. This could be in the form of,
for example, FSC personnel accompanying patients to see the GP where the patients
have nobody to accompany them or where the adult children cannot get leave from
work.
e. Coordination- better communication, handshake and information sharing between

the GP and the hospital
The need for a direct line of communication between the GP and the hospital for
sharing patient information was brought up both by the GPs as well as the healthcare
providers in the hospital. One of the GPs who was interviewed was wary of ‘tiring’
doctors with requests for information and suggested that it would be good for patients
and their families to be empowered in respect of patient information and carry their
own records (in the form of patient notebooks for example) as mentioned above. Better
handshake between Polyclinics and GPs was emphasised whereas the handshake
between hospitals and GPs did not seem to be an issue. Another GP spoke about the
ease of referring a patient to hospital specialists through a letter, but did not appear to
follow up afterwards about whether the patient approached the relevant specialist.
Although referrals to hospitals were present, the reverse was not - there had been no
cases where the specialist the GP referred the patient to referred the patient back to
his care after the patient’s condition stabilised. It was suggested that the handshake
could also possibly manifest itself in the form of cost reduction for patients where GP-
prescribed medication can be collected from the Polyclinic for those who find it
expensive.
ii. Coordination between VWOs and the hospital

A befriending service that runs island-wide and caters to those at risk of social isolation
pointed out that communication linkage between them and the hospital can be
improved. The example given was that of their clients who are hospitalised and then
are discharged, without the volunteers being kept in the information loop. This results
in an information gap where the befriending service, often in charge of clients who are
elderly and have poor family and wider social networks, do not know which institution
their clients have been admitted or transferred to and therefore cannot check on them.
Although it was acknowledged that confidentiality could be an issue, it was suggested
that a communication point or helpline for such information exchange between the
hospital and VWOs would be ideal. Coordination can also be improved between the
client’s medical social worker and the befriender service as the latter can help its
clients better understand and navigate the range of services recommended to the
client by the MSW.
iii. Challenge of seamless care- communication between community care providers

and hospitals
Another barrier to care for patients, particularly in the context of home nursing is the
communication between hospital and the community care providers. This was brought
up by a home nursing service where lack of information or clarity over the community
care plan for the patient was a challenge.
The service had tried to establish a single point of contact with the hospital so that in
the event of any queries pertaining to the patient’s care plans or patient’s condition,
they can directly contact the hospital. Another challenge in this context was the
withdrawal or rejection rates owing to the patient being re-admitted to the hospital.
Further, if the patient desired to go back to the hospital, they had to choose between
either going back to the A&E, where they get the subsidy or seeing the doctor at the
SOC. The home nursing organisation had not been able to establish a direct point of
contact with the hospital where the hospital could be informed about the patient’s
worsening condition and then re-admitted by the organisation directly. This is a
challenge when the patient is not known to the transitional care team at the hospital.
Communication, in terms of the seamless direct care between the doctors in the
community and the hospital could be improved. The referrals are usually done by
doctors, who are on rotation every 6 months and may not know the patient’s case.
They therefore may not be able to answer queries relating to, for example, the patient’s
medication.
Costs for community service providers, which are mainly non-profit organisations,
were an issue. The money received through government intervention was inadequate
and did not offset operating cost thereby compelling such organisations to fundraise.

They then face the situation of having to cover their operating costs while at the same
time, provide for the needy patients.
In terms of costs for the patients, the financial framework although becoming
increasingly more adequate still has some room for improvement. The withdrawal limit
for Eldershield set at 400 dollars are inadequate in terms of the community services
that are used to help care for the patients in the community as the patients cannot
utilize the CHAS or the PG card for community or home care services.
iv. Community Development Council- tailoring health interventions to community

needs
Curating and disseminating health information particularly for the most vulnerable was
cited as a challenge. Presently, the CDC interviewed relies on volunteers to distil
health information and make it accessible to the community. However partnering with
experts to co-curate information would be ideal along with a coherent plan for health
information to cover each demographic across all the constituencies. Such information
could be tailored to residents’ needs, be either preventive or reactive, based on
residents’ age and other demographic information. Similar to the challenge of
customising information was the challenge of adapting existing national level,
‘universal’ health policies to the residents in a specific, local area. Attention would have
to be paid to the language and phrasing of health communication messages as
different partners on the ground may not always use the same phrases and terms,
which could be a source of confusion for the layman. Question of who would guide
such an undertaking was raised with the CDC possibly being the chief coordinator to
synergize the efforts of all the partners working on the ground.
Education would also be required to be disseminated among organisers of health

screenings in terms of what kind of health screening includes its results in a national
database for baseline results and which one will not (fasting vs. finger prick test). More
clarity could also be given on the criteria to qualify for an MOH license to conduct
health screenings so that some of the CDC’s current partners can apply.
Health screenings could also be more customised and specialised- an example given
was of a particular area under the CDC’s ambit requiring more dental screenings as
the issue of dental health and its effect on the quality of living of the residents was
flagged by the CDC’s team on the ground. This also was a segue to flag an issue of
information mainly being available by ‘proxy’, that is, through volunteers and on the
ground staff. This is because multistakeholder information exchange is not always
possible, owing to the PDPA.

A wish list cited included more resources, training of volunteers to sustain progress,
engaging frequent admitters, a community network for seniors, and health
interventions in the style of the Wellness Kampungs in Nee Soon.
v. Community Pharmacy
The idea of upscaling nurses to take up some of the tasks that doctors are usually in
charge of and in turn, freeing doctors up to concentrate on other duties also applied in
the field of pharmacy. Moreover, there is a need to move services out into the
community, with community pharmacies following up on the social aspect of care.
vi. Rehabilitation in the community
In the context of integrated beds, similar to what was discussed by the NUHS
Alexandra Campus Project Development team, it was mentioned that there is a move
to integrate beds for the Alexandra Campus as well. This will obviate the need for
moving patients to a separate community hospital. Time and resources would be
saved with processing of discharge, appointments, prescriptions, and transport
minimised.
For the elderly who need or are undergoing physiotherapy, convincing patients to
follow up on exercise and practise at home and changing their perception were cited
as a challenge. These patients may be depressed and unmotivated to exercise. One
way to encourage them was through referrals to day care centers instead of following
up at hospitals. The day care centres have more intensive equipment and tend to be
more crowded but are generally preferred by patients as they involve more social
interaction. However, this would entail the need to close missing links in the care of
patients. For example, day care centres may not be aware of or have the full medical
history of a patient who then has to be sent back to the GP/ Polyclinic in case of a
medical complication. Whereas the day care centres may need to rely on their own
judgment in such cases, this is in contrast with the ease of communication and
coordination in a hospital where the physio department can send the patient back to
the relevant doctor.
II. Need of focusing on patients who neglect health or ‘fall through the cracks’:
Patients that are completely out of touch with the healthcare system and come to the
hospital or other care providers only when things get worse was the demographic
that was flagged as a cause for concern. A ‘carrot and stick’ approach was suggested
where healthy behaviour could be rewarded via vouchers where, for example patient

compliance is good. Access to affordable and nutritious food was brought up and it
was pointed out that low income individuals tend to have a diet high in carbohydrates.
It was suggested that healthier options such as brown rice be made more affordable.
This would prevent people from defaulting to the unhealthier and cheapest food
options such as white rice.
Reaching out to the patients who are left outside of the healthcare system was cited
as a challenge in the case of physiotherapy as well, as those who come to the hospital
already have a care coordinator tagged to them and their treatment in the community
can be followed up. The need for more preventive care by way of fall prevention
awareness for the elderly was also highlighted. This could be done by way of the
media in all languages including dialects and also through talks in the community.
Discussion about the lack of patient ownership of their health was also key due to
their dependence on the hospital. To make sure technology was more effective in the
context of patient ownership of health, consultation with patients to gather information
about their needs and their feedback was suggested. A community care provider at
the stroke support station mentioned that the introduction of technology was a good
thing but raised concerns about it replacing the 'human touch'.
III. Manpower challenges:
Some stakeholders mentioned the challenge of upskilling and levelling up nurses. This
is however accompanied by the paradoxical manpower challenge of filling out the
bottom layer of care providers. With regard to APNs, it was mentioned that people may
not be amenable to being treated for certain ailments or diagnosis/ prescription etc.as
there would still be a cultural barrier of not trusting nurses and perceiving surgeons
as the experts .
The nurses interviewed stated the need for surgeons and nurses to be able to better
communicate and for the latter to be more civil and respectful toward nurses. In this
context, the occasional meetings for nurses and surgeons presently being conducted
was welcomed but change was slow. High attrition rate among nurses was mentioned
as a problem. This was attributed to work pressure, long working hours/shifts and
incommensurable pay, better prospects elsewhere in terms of work load and welfare
in other countries. Although the large presence of foreign staff brought with
it language barriers and cultural differences, it was not a significant issue but seen as
the corollary to the attrition problem. Sense of isolation among the foreign staff nurses
owing to distance from family, staff shortage, stress and the absence of a buffer staff
were highlighted. Lack of respect for nurses, whether those in the lower or higher
ranks such as the APN was mentioned as an area to work upon.

In terms of intra departmental cohesiveness, it would help to have events for all
departments in the hospital as a whole to increase communication across all
departments as well.

Chapter 4
Advisory Boards
The advisory board members were selected from among the community member
interviewees. This follows from the fact community participation and partnership are
the key ideas underpinning the formation, agenda and direction of the advisory boards.
Selection was grounded in the idea of erasure- asking the question, “What are the
voices that are missing from the discussion on health and health care?” The
composition of the advisory board was guided by an active engagement with this
question. Further, the inclusion criteria for the AB were 1) knowledge of community
health needs, 2) influence with respect to issues of relevance to the community and
academic partners, and 3) keen interest in developing community partnerships with
the aim of eliminating health disparities. These advisory board sessions were
therefore one of the ways in which the local voices expressed ideas specific to their
culture and community. As a collaborative space, the community, in this case, was the
locus of decision making, identifying problems and the concomitant solutions. The
advisory group discussions typically last for approximately 120 minutes and contained
10 to 15 participants, representing the local community. All interviewees were
reimbursed for their participation. Location for the sessions was the Bukit Merah
Community Center owing to its convenience and accessibility for community
members.
Later versions of the advisory board might also include local leadership, health
promotion professionals, doctors, nurse practitioners, civil society representatives,
state actors, and policy makers in the communities. The advisory group may also
select from among them some members to serve the role of peer leaders in the
community who then act as co-researchers. This entails participating closely in the
research design and implementation processes, in recruiting community members for
in-depth interviews, focus groups, and workshops that follow. Peer leaders also play
key roles in the evaluation and implementation phases of the project. Owing to the
brevity of the project such peer leaders have not been selected at this early stage in
the project. Three advisory board meetings have been conducted so far.

Profiles of advisory board members
Names changed to maintain confidentiality
List of members for ABM 1 (23 March 2017)

Gende Ethnicit Education Housing Household Health issues and other
No. Name Area r Age y level type income challenges/experiences
Bukit Sporadic preventive care; pays for mother's
1 Sunny Merah Male 42 Chinese University 4-room $10K+ health expenses
O-levels; Schizophrenia
20- dropped out
2 Noor - Male 24 Malay of poly 4-room $1K - $1,999
No working No issues- former caregiver to husband
person; CPF who died from cancer. She is currently a
monthly health ambassador at Dover Park Hospice.
Bukit Lower Rental Flat payouts- $ 300
3 Ms Tan Merah Female 65+ Chinese Secondary - 1-room per month
Has a heart stent
Bukit 45- Rental Flat
4 Karim Merah Male 49 Indian Secondary - 2-room $1K - $1,999
looked after late mother in the past, wife is
Queenstow Rental Flat Indonesian
5 Siong May n Male 46 Chinese University - 2-room $1K - $1,999
has caregiver exp with parent in the past;
last health check up showed high bp, but
Bukit has delayed going for a follow-up because
6 Sim Merah Male 59 Chinese University 3-room $5K - $5,999 of work
high bp/cholesterol, caregiver to wife who
has stroke, is wheelchair bound and has
diabetes; Exp in caregiving, suggested van
as transport, unhappy with rehab services
after trying many of them that now he
resorts to taking care of us on his own as
Queenstow No Working he is retired, gets her to do simple
7 Keng n Male 73 Chinese Primary 4-room Person exercises every day
Secondary; occasional sleep disc pain, but otherwise
dropped out healthy. long working hours, lack of
of NITEC exercise. His wife is from India and his
Bukit Multimedia Rental Flat daughter was born premature, so he has
8 Harry Merah Male 31 Indian diploma - 2-room $1K - $1,999 issues with high healthcare costs
Was the main caregiver for her mother and
father-in-law who was hospitalised a lot
Bukit 40- No working
due to cancer. Leads a somewhat inactive
9 Linda Merah Female 44 Chinese Diploma 5-room person
lifestyle
Wong Fui Lih's husband who has been
looking for a job for a year. They both lead
Bukit 40- No working inactive lifestyles and do not exercise
10 Roland Merah Male 45 Chinese Diploma 5-room person regularly
She is a homemaker who used to care for
her brother who was hospitalised due to
neuro complications. She eventually did
her own research and transferred her
Queenstow 45- brother to a community hospital as he was
11 Lillian n Female 49 Chinese University 5-room $10k+ bedridden for a few months.
He is healthy and active for his age, does
Bukit not have any health complications but
12 Hong Merah Male 80 Chinese secondary 3-room Retired worries about health costs.
She works part time at a hawker centre,
Bukit has knee issues and has gone for several
13 Mr Hong's wife Merah Female 65 Chinese secondary 3-room Retired surgeries. Has occasional high BP
Has hypertension and is the main
caregiver of his wife who has depression.
Bukit 50- Has a somewhat inactive lifestyle as he
14 Queenie Merah Male 54 Chinese Primary 3-room $2-2,999 smokes and works as a van driver.
A kindergarten teacher who used to suffer
from depression but is now off meds as
Queenstow 35- she changed her diet and lifestyle to be
15 Jill n Female 39 Chinese Polytechnic 5-room $6-6,999 more active.
Advisory Board Meetings

The members were asked to sign consent forms before proceeding to introduce
themselves. One by one, they shared their experience with the health care system.
These members, as indicated by their profiles above, were either patients themselves
or caregivers to loved ones undergoing treatment for chronic and other illnesses. This
was followed by a briefing about the project and the purpose of the Advisory Board
which was meant to gather their view on the challenges they faced in accessing care
and workable solutions for these challenges. The themes revealed in these meetings
also overlap with the themes identified earlier in the community and stakeholder
interviews.
At the outset, with a goal of eliciting a range of points, as broad as possible, members
were first asked to articulate challenges to health care. These were all jotted down on
a white board. The members were then asked to form groups and jot down the barriers
they faced which substantially narrowed down the initial points identified. These issues
were later further streamlined based on the members’ discussion and consensus.
Issues identified after reaching a consensus in the advisory group:
1. Long waiting time
A&E
 Long waiting time and delay in help compounded by lack of assurance from the
staff on patient condition in the interim
 Patients’ lack of awareness on handling emergency cases; lack of training on
distinguishing between emergency and non-emergency cases
 Short consultation time with doctor before taking over of nurses makes it seem
that anyone could have done the consultation and cut short the waiting time
 Lack of patient & caregiver awareness on alternatives to A&E such as 24 hr
clinics
Ambulances
 Have to send patients to the nearest hospital even though it may be over-
crowded; this does not offer the alternative of sending the patient to a less
crowded hospital that is also nearby. This was perceived to be the result of poor
coordination between hospitals for transport. Consequently, treatment is
delayed when patient has to be transported to another hospital that is able to
take the patient in after arrival
 Unable to send patient to hospital of their choice that has their medical records
unless informed early until they are sent to the nearest hospital first; time is
delayed in the later transfer to hospital of their choice
 High cost for private ambulance to transport/ transfer patients to another
hospital & hospital that has patients’ medical records

Waiting time for appointments and in between appointments at the GP/polyclinic

 Patients who experience a re-lapse in their condition have to re-apply for
subsidies which results in delay & long waiting time for appointments. An
extreme example of this was brought up by a member whose close friend was
a mental health patient and ended her life after treatment and medication were
not forthcoming as a result of such a delay.
 Waiting time at GP/polyclinics was a recurring issue.
2. Mobility & Transport
 Support for elderly and those who lack caregiver/ family member to take them
for appointments
 Elderly who live alone and have to wait for the availability of children to take
them for appointments
 Seniors who are not technologically savvy
 Fragmented reach by VWOs - some people are outside the reach of social
services and VWOs
 Some elderly experience difficulties navigating the hospital and do not know
where to go
 Lack of information on existing transport services; need to better promote these
services
 Special arrangements for wheel chair users
 Low frequency of shuttle services which means that elderly have to wait too
long while there are few or no places to sit while waiting
 Pick up points are too small
 Lack of awareness on timings for special shuttle bus service for wheelchair
users (SGH)
3. Cost-Uaffordability of care and access to subsidies. Expenses for physiotherapists

are high as well.
4. Post discharge care, support groups and services
5. Communication and information gaps at different stages- challenges came all the
way from the diagnosis stage and there seemed to be miscommunication at
discharge, post discharge and then patients being at a loss in the community.
6. Patient empowerment- personal knowledge and symptoms of the signs
7. Coordination of care
 Mental healthcare is centralized and there seems to be an undersupply of

therapists. Some members report seeing their therapist after long intervals or

being appointed to different therapists, thus needing to repeat their case

histories. This was said to be tiring and a source of demotivation for continuing
treatment.
 Lack of communication with the different doctors and coordination between
hospitals and polyclinics. They treat each problem ‘separately’.
 Experience with care navigator: they did monitor patient medication and only
came over once. It was suggested that the frequency of monitoring was
increased to at least once a month.
Workable and implementable solutions identified so far:
i. Long waiting time:
 More manpower to attend to patients

 Technology-
 Developing a self-registration mechanism through a self-service kiosk
 A system for online registration that can reflect available slots in care
institutions and patients have the ability to choose other hospitals with
shorter waiting time
 An app or any other mechanism that can inform patients of estimated
waiting time
(Similar to the apps for buses) to be integrated with hospital and clinic
 Electronic system for patients to renew their subsidies and expiry date of
referral letter; automated reminder for patients about the expiration of
subsidy
 Automated process for collecting medicine (for regular patients) and
payment. This could be in the form of cashless payment (Pay Wave) or
online payment. Alternatively, the patient can be billed at their address.
 Combined counters for payment and medication collection
 Hospital medical records can be shared with care providers
(GP/Polyclinic/hospitals etc.)
 To alleviate the strain of long waiting time, patients can be directed to
consultation rooms first and attended to by nurses
 Public can be made more aware of alternatives to the A&E such as 24 hr clinics.
For example, grassroots could put up such information on HDB notice boards.
ii. Mobility and transport:
Shuttle bus
 Expand pick-up points with more sitting area + pick up for wheelchair users;
bigger shuttle buses for wheelchair users
 Increase the frequency of shuttle buses
 Disseminate more information on transport services

> Standees, advertisements on television screens, inform during patient

registration
 Ability to use MediSave for transportation to appointments
Hospital visits
 Streamline hospital visits/ appointments
Home visits/ mobile clinics for follow ups. These can be conducted at the
CC/RC.
 Usher at hospital taxi-stand/drop off point to guide elderly patients to respective
departments
A&E
 Empower patients about which cases is A&E suitable for and impart basic
training and information to patients for dealing with some emergency cases
which may not require A&E visits.
 Talks on emergency response (i.e. how to help yourself during a medical
emergency) could be conducted where residents gather
Hospitals and VWOs

 Hospital should ‘take ownership ‘ of patients within their cluster/region and work
with RCs and VWOs to coordinate services
 Hospitals can extend some services outside of the hospital
 RCs can assist patients with hospital visits and can draw upon other VWOs/
hospital volunteers
o Home visits and mobile clinics at RCs
o Voluntary caretakers/social enterprise looking after whole block
o Ride-sharing services among residents in a particular block who have
similar appointment times to bring them to the hospital and back together
 GP/polyclinics could take care of non-emergency tasks like the dressing of
wounds instead of the hospital. However, concerns were raised about the cost
of such GP visits.
iii. Costs and subsidies
 Medical equipment and medicine recycling –especially for those patients who
expend substantial amounts on buying medicines in bulk and have no use for
them after they have recovered.
 Streamlining the criteria for subsidies and a better framework for costs and
subsidies
 Setting expectations for costs by way of financial counseling, especially for
family members

iv. Social support
 Social support which is critical, especially a support system for monitoring

health, both within the hospital and externally
 House visits in between appointments particularly for those lacking caregivers
v. Communication and information gaps
 Clear instructions at discharge and also on the cause and effects of the
illnesses for patient and caregiver
 At discharge, clear instructions for the caregiver on follow-ups. Provision for an
online system for patient’s medical records with instructions easily accessible
to the patients and their caregivers
 Follow up between appointments especially when there are long intervals in
between appointments.

Chapter Six: Survey
Method
The survey complemented the emergent data that was gleaned from the participant
observations, community-wide in-depth interviews, in-depth interviews with providers,
in-depth interviews with key stakeholders, and advisory group meetings.
The survey sought to understand the health seeking behaviours, including health
information needs, unmet health needs, experience in accessing health care services,
and media usage habits of residents in the catchment area of the Alexandra hospital.
700 Singaporean or Permanent Resident members of the public who live in Bukit
Merah and Queenstown (collectively 80%), and Clementi and Bukit Panjang
(collectively 20%) were surveyed. Each survey took approximately 60 minutes to
complete. In the following section, the demographic composition of the sample is
offered, followed by a presentation of the key challenges to healthcare and the quality-
based indicators of an “ideal hospital.” Finally, the quality indicators are presented in
five categories and participants are asked to rank them from 1 to 5.
The survey items were developed through the in-depth interviews with community
members, health care providers, and key stakeholders. Using the three data points
contributed to the development of items that converged on key constructs regarding
the challenges to and quality of health care. The items were further validated through
the advisory group meetings, where initial constructs were discussed, items reflecting
these constructs were worked through, and constructs were re-worked through several
iterations. The final items included in the survey reflected the convergence between
the community members, health care providers, and key stakeholders.
The Tables presented below present the demographic characteristics of the sample.
The sample is predominantly female, predominantly older (with 17% of the sample in
the 56-65 age range, and 28% of the sample in the age range of 66 and above). While
37% of the sample is employed, 22% of the sample comprises of homemakers, and
21.7% is retired. 64% of the sample is married. Also, 61.6% of the sample has an
educational level that is secondary education or below, and 34.7% of the sample is at
an education level that is primary education or below.
Demographic characteristics of the sample
Table 1: Gender
Gender
Frequenc Valid Cumulative
y Percent Percent Percent
Valid Female 442 63.1 63.1 63.1
Male 258 36.9 36.9 100.0
Total 700 100.0 100.0

Table 2: Age
Age
Valid 18-25 44 6.3 6.3 6.3
26-35 93 13.3 13.3 19.6
36-45 111 15.9 15.9 35.4
46-55 137 19.6 19.6 55.0
56-65 119 17.0 17.0 72.0
66 and 196 28.0 28.0 100.0
above
Total 700 100.0 100.0
Table 3: Occupational status

Current occupational status
Valid Employed 259 37.0 37.0 37.0
Employed Part-Time 58 8.3 8.3 45.3
Unemployed, looking 17 2.4 2.4 47.7
for work
Unemployed, not 22 3.1 3.1 50.9
looking for work
Homemaker 154 22.0 22.0 72.9
Student 12 1.7 1.7 74.6
Retired 152 21.7 21.7 96.3
Unable to work due 8 1.1 1.1 97.4
to disability or long-
term illness
Freelance Work 7 1.0 1.0 98.4
Others 11 1.6 1.6 100.0
Total 700 100.0 100.0
Table 4: Marital Status

Marital status
Valid Married 449 64.1 64.1 64.1
Living as married 2 .3 .3 64.4
Divorced 42 6.0 6.0 70.4
Widowed 59 8.4 8.4 78.9
Separated 3 .4 .4 79.3
Single, never been 145 20.7 20.7 100.0
married
Total 700 100.0 100.0

Table 5: Education level

Highest education level attained
Valid No education/school 56 8.0 8.0 8.0
Pre-primary 19 2.7 2.7 10.7
Primary 168 24.0 24.0 34.7
Secondary 188 26.9 26.9 61.6
Post-secondary (non- 55 7.9 7.9 69.4
tertiary) (e.g. ITE, JC)
Polytechnic 55 7.9 7.9 77.3
Professional 19 2.7 2.7 80.0
Qualification and
other diploma
Bachelor’s degree 104 14.9 14.9 94.9
Master’s degree 32 4.6 4.6 99.4
PhD degree 4 .6 .6 100.0
Total 700 100.0 100.0
Table 6: Number of members in the household

Including yourself, how many people live in your
household?
Valid 1 70 10.0 10.0 10.0
2 148 21.1 21.1 31.1
3 166 23.7 23.7 54.9
4 154 22.0 22.0 76.9
5 92 13.1 13.1 90.0
6 39 5.6 5.6 95.6
7 23 3.3 3.3 98.9
8 6 .9 .9 99.7
9 1 .1 .1 99.9
10 1 .1 .1 100.0
Total 700 100.0 100.0
Table 7: Elderly in the household

How many elderly above the age of 65 live in your
household?
Valid 0 386 55.1 55.1 55.1
1 242 34.6 34.6 89.7
2 68 9.7 9.7 99.4
3 2 .3 .3 99.7
4 1 .1 .1 99.9
9 1 .1 .1 100.0
Total 700 100.0 100.0

Most respondents live in households with 2 or more members. Also, 34.6% of the
households have one elderly in the household, and 9.7% of the households have two
elderly in the household.
Beyond the demographic questions, respondents were asked about the challenges
they experienced in seeking healthcare in Singapore. They responded on a 1 to 7
scale, with 1 reflecting “strongly disagree” and 7 reflecting “strongly agree.”
Table 8 offers the list of challenges in a descending order, with the highest scored
items being listed first.
As evident in the table cost of healthcare is shared as the most significant challenge
to healthcare, followed by the waiting time at the clinic as well as to seek an
appointment. Participants also observed the necessity of needing to make multiple
appointments to see different specialists as a key problem. Communication
challenges such as difficulty in getting in touch with the provider between
appointments and lack of culturally appropriate health care were identified as
important challenges. Participants also noted the lack of coordination between
specialists as an important challenge.
Table 8: Challenges to healthcare in Singapore

Challenges to healthcare in Singapore
Minimu Maximu Std.
Challenges N m m Mean Deviation
Cost of screening. 700 1 7 4.85 1.389
Cost of medicines. 700 1 7 4.76 1.388
Cost of healthcare. 700 1 7 4.76 1.390
Long waiting time at 700 1 7 4.67 1.505
the clinic to see a
doctor.
Long waiting time to 700 1 7 4.52 1.487
get an appointment.
Cost of care (such as 700 1 7 4.52 1.375
domestic worker).
Lack of subsidies. 700 1 7 4.45 1.456
Long waiting time at 700 1 7 4.19 1.447
the point of
healthcare delivery.
Needing to make 700 1 7 4.16 1.412
multiple
appointments to see
different specialists
treating different
problems.
Difficulty in getting in 700 1 7 4.06 1.359
touch with the health
provider between
appointments.

Too many specialists 700 1 7 4.04 1.327

that do not treat the
whole body.
Lack of culturally 700 1 7 4.02 1.220
appropriate health
care.
Lack of affordable 700 1 7 4.02 1.235
options for healthy
eating.
Too many visits to 700 1 7 4.00 1.372
the hospital.
Too little time to 700 1 7 3.98 1.246
exercise.
Lack of coordination 700 1 7 3.97 1.329
between specialists.
Complexity of the 700 1 7 3.97 1.263
healthcare system.
Challenges of 700 1 7 3.96 1.153
intercultural
communication with
healthcare provider.
Lack of clear 700 1 7 3.93 1.251
guidelines on how to
navigate the
healthcare system.
Lack of patient voice 700 1 7 3.92 1.266
in healthcare.
Fragmentation of 700 1 7 3.83 1.270
care.
Lack of clear 700 1 7 3.82 1.335
communication with
between hospital and
general practitioner
(GP).
Difficulty in seeking 700 1 7 3.77 1.298
information from the
hospital after
discharge.
polyclinic.
Lack of a consistent 700 1 7 3.74 1.353
relationship with a
provider.

Lack of clear 700 1 7 3.73 1.332

communication at
discharge when
admitted to a
hospital.
Difficulty in clarifying 700 1 7 3.72 1.295
information about
follow-up after
discharge.
between the various
organizations offering
home-based care.
Lack of clear 700 1 7 3.71 1.290
communication at
discharge on follow-
up treatment.
Home-based ILTC
care (e.g. Home
Nursing Care, Home
Medical Care,
Palliative Home Care,
Meals
Residential
Intermediate and
Long Term Care
(ILTC) Services (e.g.
Community Hospital,
Nursin
No clear follow up 700 1 7 3.68 1.234
after discharge from
hospital with
community care.
Centre-Based ILTC
Services (e.g. Day
Rehabilitation Centre,
Senior Care Centre,
Dementia Day
Valid N (listwise) 700

Based on the challenges the participants shared in accessing healthcare, they were
offered the traits of an ideal hospital. Table 9 lists the traits of an ideal hospital,
presented in a descending order. According to the participants, both cost-related and
waiting time related items were highly rated. In their views, an ideal hospital would
minimize the waiting time between appointments as well as minimize the waiting
time at the point of healthcare delivery. Besides reducing the cost of healthcare, an
ideal hospital would educate patients about costs, and make sure patients have
access to subsidies. Communication also emerged as a key characteristic of an ideal
hospital such that an ideal hospital would make it easier for the patient or caregiver
to clarify information regarding follow-up after discharge, make it easy for the patient
to seek information from the hospital after discharge, and make sure communication
about follow-up treatment is clear at discharge.
Table 9: Traits of an ideal hospital in Singapore
An ideal hospital would:

Minimu Maximu Std.
N m m Mean Deviation
Have short waiting 700 1 7 5.74 1.325
time to make an
appointment.
Reduce the cost of 700 1 7 5.72 1.194
healthcare.
Make it easy to get in 700 1 7 5.64 1.302
touch with the health
provider between
appointments.
Educate patients 700 1 7 5.58 1.207
about costs.
Ensure patients have 700 1 7 5.56 1.194
access to subsidies.
Minimize waiting time 700 1 7 5.52 1.202
at the point of
healthcare delivery.
Make it easy for the 700 1 7 5.52 1.182
patient or caregiver to
clarify information
about follow-up after
discharge.
Make it easy for the 700 1 7 5.52 1.175
patient to seek
information from the
hospital after
discharge.
Ensure clear 700 1 7 5.50 1.176
communication at
discharge on follow-
up treatment.

Develop clear 700 1 7 5.49 1.186

channels of
communication with
Ensure clear 700 1 7 5.49 1.187
communication at
discharge when
admitted to a
hospital.
Ensure good 700 1 7 5.48 1.174
coordination between
hospital and
polyclinic.
Ensure good 700 1 7 5.47 1.168
hospital and general
practitioner (GP).
Have one hospital 700 1 7 5.46 1.194
appointment that
coordinates between
the different
specialists treating
different problems.
Have good 700 1 7 5.46 1.179
specialists.
Offer financial 700 1 7 5.42 1.232
counselling to set
expectations for
costs.
Make it easy to get 700 1 7 5.40 1.233
advice regarding
health problem
between
appointments.
Offer clear guidelines 700 1 7 5.37 1.194
on how to navigate
the healthcare
system.
Develop clear follow 700 1 7 5.35 1.194
up after discharge
from hospital with
community care
provider.
Make the healthcare 700 1 7 5.34 1.191
system easier to
navigate.

Have one doctor that 700 1 7 5.33 1.241

coordinates between
the different
specialists.
Develop good 700 1 7 5.33 1.175
the various
organizations offering
home-based care.
Offer culturally 700 1 7 5.31 1.213
appropriate health
care.
Ensure good 700 1 7 5.28 1.223
hospital and Centre-
Based ILTC Services
(e.g. Day
Rehabilitation Centre,
Senior Care Centre,
Deme
Offer transportation 700 1 7 5.27 1.282
services
Develop an online 700 1 7 5.27 1.216
system that indicates
the waiting times.
Increase the 700 1 7 5.24 1.336
frequency of shuttle
services.
Develop a wide reach 700 1 7 5.23 1.360
of pick-up areas for
shuttle services in the
community.
Ensure good 700 1 7 5.23 1.222
hospital and Home-
based ILTC care (e.g.
Home Nursing Care,
Home Medical Care,
Palliative Home Car
Ensure good 700 1 7 5.22 1.210
hospital and
Residential
Intermediate and
Long Term Care
(ILTC) Services (e.g.
Community Hospital

Educate patients 700 1 7 5.22 1.202

about the suitability of
cases for A&E.
system for renewal of
subsidy.
Offer Integrated Care 700 1 7 5.19 1.343
with alternative
medicine (e.g. TCM )
Educate community 700 1 7 5.19 1.195
members on
emergency
responses.
systems that reflect
waiting times at
different hospitals
show patients can
make appointments.
Disseminate 700 1 7 5.15 1.357
information on shuttle
services.
Conduct home visits 700 1 7 5.15 1.214
for follow ups.
Develop mechanisms 700 1 7 5.14 1.178
for taking patient
feedback.
Empower patients to 700 1 7 5.14 1.178
voice their
suggestions.
Have strong 700 1 7 5.14 1.216
connections with the
community.
Develop hospital 700 1 7 5.07 1.285
medical records that
can be shared by
patients and care
providers.
Offer community- 700 1 7 5.06 1.228
based prevention
programs.
Integrate with the 700 1 7 5.05 1.158
neighbourhood
community.
Offer services and 700 1 7 5.03 1.216
programs that invite
the community into
the hospital.

Offer prevention 700 1 7 5.03 1.171

programs for the
community.
Develop a volunteer 700 1 7 5.00 1.262
network of caregivers
in the community who
can look after
patients in a block.
Build an inviting 700 1 7 5.00 1.273
architecture.
Invite the community 700 1 7 4.98 1.197
to participate in
activities in hospital
spaces.
Develop a patient 700 1 7 4.94 1.331
navigator program.
Develop ride sharing 700 1 7 4.91 1.329
programs
Finally, given the wide range of traits offered by community members as

characteristics of an ideal hospital, participants were asked to rank order the various
traits. Among the various traits, short wait time, clear communication and good
coordination emerged as the most important traits of an ideal hospital.
Table 3: Ranking of the key traits of an ideal hospital
Ranked Traits of an ideal hospital (Rank 1 = highest rated; rank 5 =

lowest rated)
Minimu Maximu Std.
N m m Mean Deviation
Short Wait Time 700 1 5 1.63 .990
Clear Communication 700 1 5 2.36 1.035
Good Coordination 700 1 5 2.48 .942
Ease of Navigation 700 1 5 3.83 .839
Community 700 1 5 4.58 .845
Engagement

APPENDIX A
Health Services Maps
Map 1: Alexandra Hill, Redhill and Bukit Merah
Map 2: Commonwealth and Tanglin Halt
Map 3: Mei Chin and Margaret Drive
Map 4: Telok Blangah Drive, Depot Road, Telok Blangah Crescent
Map 5: Entire sampling area






APPENDIX B
Voices of the community members
Excerpts of quotes from community interviews
Connection to the community:
I don't know, there could be [an RC manager], but I don't know. But I don't see him,
you know. Cause the door is always like closed, I always see children inside,
kindergarten la.
I think [outreach for the RC downstairs] very poor, very poor. Because I like to sit at
the void deck, I can observe all this. After work and all that, sometimes morning ah...
Hardly any movement or anything.
Yeah. They built a white elephant there, I don't know for what. The lift is good, but that
shade they built... nobody uses it.
Yeah... Nobody uses it. Nobody, not for wedding, not for birthday. I haven't seen it
used for anything.
Even for Chinese New Year it was really quiet. Very quiet. We had a community those
days we had kampong spirit, ok. Everyone will go out and visit everybody. Now
nobody. It's dead, silence.
Yeah. Nobody goes. There was one event, wait ah... Organised by RC, National Day
event I think. Hardly anybody there. You know why? They don't announce it.
- Harjit, 57 years old Indian man living with his elderly mother in a 3-room flat
with monthly income of $1,000-1,999

Because I understand that the community centres or RCs, they're not really one to
one. Personal or one to one. Because if they are more personal or one-to-one, I think
the reach would be better. What I mean is like, for example we are saying a guy who
comes in a wheelchair, with his legs cut off, amputated. I also understand the same -
 a person in the same place would be much easier to relate to. Why did your leg get
amputated, what actually happened, all those things? From there this is when he can
say a CC can help you,  come to his house for visitation, offer him some this and that,
and introduce him to healthcare. It'll be a more one-to-one approach. 
I think RC they, RC or CC, they will organise a big event. But how sure are we that all
of them will come to the event? Cos there are many who are introvert, and many who
have closed doors. 
- Harry, 31 year old Indian man living with wife and child in rental flat with $1.3-
1.5k income
The other way would be ah... To have talks, not at community centres. HDB void
decks, RCs and all this right, that's very good. Then you can invite, put the posters
one two months in advance, that we gonna have this here, this here... Any concerns,
whatever it is, the officers will be here, please come.
Nurses, maybe you can have your medical social workers, you can have your
educational... Can be whatever, whatever, you know. Financially, you are down, you
know, you need financial help, you know, but don't have to be cash. Never give cash,
never give cash because I believe... You give cash those who drink and smoke and
all that will go and do that. So always give in the form of vouchers. NTUC vouchers,
food vouchers whatever. So yeah, let them apply, sit down, check with them, and then
ok, fine.
- Harjit, 57 years old Indian man living with his elderly mother in a 3-room with
monthly income of $1,000-1,999

Caregiving:
I also go for dementia class. Dementia lecture talk. At Queenstown CC. Because,
dementia you can look after the elderly you see. Then from there we learn whether
this old man or old lady ah, is it beginning stage or all this. From there we learn. Yeah,
because of my mum. My mum already started dementia. Eighty-two. Just starting to
have dementia. Yeah. So, from there, from there I know how to take care then I will
teach my maid how to take care of my mum.
- Gina, 53 year old Chinese woman living in 3-room flat with $2,000-2,999
household income
Personal responsibility:
No la like I said I have to take personal responsibility la. Because, I appreciate what
the, our government said. We must take ownership la ah. We must take ownership of
our health, and [pause] ya. So uh ya, what I mean is that I take it that you know, after
I got discharged ah from the army hospital and so on, I wasn't.. I become slack la you
know. Because I'm also over 50 then I don't really have so much drive and motivation
anymore really. I don't have. Because I've done, I've done quite a number of jobs, and
I mean I have enough for my livelihood la but I realize, that's it la. I can't and...and you
know our society has changed so much. Of course now we're much more open but
the expectation is higher la don't you agree?
Kim- single Chinese male, 50 yrs. Heavy smoker and was formerly a caregiver
to his mother who passed away from a heart ailment a few years ago.
Cost of care:
I would like to try it (referring to a treatment for asthma patients), if I got the extra
financial, or is extra cash. I would, ah, if we do have any extra financial help or extra
cash right? All of us would... not even me, all of us would want to take care of our
health, you know go to whichever doctor and surgeon and err, the person who can
help us cure our illness. Ya, but for me, currently I'm, I'm... not a rich person and I'm
surviving with my two children right now. Ya, so I cannot do anything at all.
Ana-40-44yrs, Malay female, mother of one, unemployed due to her chronic

asthma. Husband imprisoned for theft and thereafter diagnosed with
schizophrenia.

Fragmentation of care:
This doctor was running around. I went to SGH. I queue up like polyclinic, I tried to go
SGH since I'm staying at Kim Seng, but I went and queued and got the appointment
then they tell me say this doctor, the date you can queue until December. I said I'm in
a lot of pain you want me to queue until December?
..I will not be able to get back my doctor. It'll just be any doctor - if you are on subsidies,
you don't get your doctor you know.. Which I don't think I like to share too much things
with doctors here and there. I'm very tired to talk, repeating everything. So I see one
already, he has everything written there already, so I don't want to jump around mixing
up my doctors. I like to stay….Sometimes you feel that the problem I am going through
is not a pleasant one, not a happy one that I enjoy talking to people about. I don't like.
Because I feel ashamed about it.
Ally- 60yrs, Chinese female, divorced. Has had multiple operations for her spine;
diagnosed with depression and sees multiple doctors. Caregiver to her mother
who has dementia


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The Health Innovation Project

Center for Culture-Centred Approach to Research and Evaluation Page 1

The culture centered approach .......................................................................................... 4

The Health Innovation Project ............................................................................................ 6

Methodology & Participant observation ............................................................................ 9

Findings: Key informants ................................................................................................. 31

Findings: Health care providers and social workers ...................................................... 32

Advisory Boards ............................................................................................................... 40

Key issues identified ........................................................................................................ 42

Implementable solutions identified ................................................................................. 44

Appendix A: Health services maps of sampling areas ................................................... 47

Appendix B: Voices of the community members ........................................................... 53

Center for Culture-Centred Approach to Research and Evaluation Page 2

131 community and 20 stakeholders in depth interviews have revealed emerging

Center for Culture-Centred Approach to Research and Evaluation Page 3

The Culture Centered Approach (CCA)

Co-construction and collaboration, referring to a process of power sharing between

3Dutta, M. J. (2012). Hunger as health: Culture-centered interrogations of alternative rationalities of

Center for Culture-Centred Approach to Research and Evaluation Page 4

Center for Culture-Centred Approach to Research and Evaluation Page 5

The Health Innovation Project

Center for Culture-Centred Approach to Research and Evaluation Page 6

Center for Culture-Centred Approach to Research and Evaluation Page 7

Center for Culture-Centred Approach to Research and Evaluation Page 8

Also, the participant observation involved 57 short Interviews conducted in Chinese,

Broadly, their answers revealed the following-

Attitudes towards health:

Center for Culture-Centred Approach to Research and Evaluation Page 9

Some of the barriers to health articulated were:

 Unaffordability of costs of medication, health care services & hospitalization

 Lack of motivation to exercise due to work commitments

 Lack of awareness and information on services currently available at AH

AH as the ideal hospital

 Affordable yet high end facilities comparable to a private hospital

Center for Culture-Centred Approach to Research and Evaluation Page 10

 Accessible to all including the low income and disabled

What it should not be:

 A hospice that is understaffed and where the environment is melancholic

Center for Culture-Centred Approach to Research and Evaluation Page 11

Age Number of People Percentage Sample (n=60)

30-34 5,689 11% 6

35-39 5,465 10% 6

65+ 9,890 19% 11

Total 52,770 100% 60

Ethnic Group Number of Percentage Sample

Center for Culture-Centred Approach to Research and Evaluation Page 12

Sex (Age 20 Number of Percentage Sample

Total 52,770 100% 60

Highest Qualifications Number of Percentage Sample

Lower Secondary 13,063 11% 6

Secondary 20,455 17% 10

Post-Secondary (Non- 10,390 8% 5

University 26,196 21% 13

Professional Qualification 5,841 5% 3

Total 123,948 100% 60

e. By monthly household income

Monthly Household Income from Number of Percentage Sample

Center for Culture-Centred Approach to Research and Evaluation Page 13

$4K - $4,999 4,175 8% 5

Age Group Number of Percentage Sample

Sex (Age 20 Number of Percentage Sample

Total Males 24,689 47% 28

Total 28,383 53% 32

Center for Culture-Centred Approach to Research and Evaluation Page 14