Health Policy 125 (2021) 351–362

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Health Policy
journal homepage: www.elsevier.com/locate/healthpol

Integration of health services for the elderly in Asia: A scoping review

of Hong Kong, Singapore, Malaysia, Indonesia
Alex Jingwei He ∗ , Vivien F.Y. Tang
Department of Asian and Policy Studies, The Education University of Hong Kong, 10 Lo Ping Road, Tai Po, New Territories, Hong Kong Special Administrative
Region

a r t i c l e i n f o a b s t r a c t

Article history: Against the backdrop of rapid ageing populations, there is an increasing recognition of the need to inte-
Received 23 August 2020 grate various health services for the elderly, not only to provide more coordinated care, but also to contain
Received in revised form the rapid cost inflation driven primarily by the curative sector. Funded by the Asia-Pacific Observatory
23 December 2020
on Health Systems and Policies, this scoping review seeks to synthesize the received knowledge on care
Accepted 29 December 2020
integration for the elderly in four Asian societies representing varying socioeconomic and health-system
characteristics: Singapore, Hong Kong, Malaysia, and Indonesia. The search for English-language litera-
Keywords:
ture published between 2009 and 2019 yielded 67 publications in the final sample. The review finds that
Care integration
Elderly
both research and practice regarding health service integration are at a preliminary stage of development.
Ageing It notes a marked trend in seeking to integrate long-term elderly care with curative and preventive care,
Scoping review especially in community settings. Many distinctive models proliferated. Integration is demonstrated not
Health system only horizontally but also vertically, transcending public-private boundaries. The central role of primary
Asia care is highly prominent in almost all the integration models. However, these models are associated with
a variety of drawbacks in relation to capacity, perception, and operation that necessitate further scholarly
and policy scrutiny, indicating the robustness and persistence of siloed healthcare practices.
© 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
The rapid ageing of the population in most parts of the
world has led to increasing pressure on health service delivery
arrangements. The epidemiological transition from infectious to
non-communicable degenerative diseases and mental illness, has
aggravated the burden on the curative systems of most high- and
middle-income economies. In the meantime, many of these chronic
conditions require long-term medical and social care, because
elderly patients commonly suffer from multiple morbidities, fur-
ther complicating the joint delivery of care [1,2]. Despite the widely
promoted value of preventive and promotive care, however, most
health systems remain largely dominated by a preference for cura-
tive medicine [3]. Even within a curative system, there remains
remarkable fragmentation in service delivery, impeding patient-
centered care for the elderly [4]. There is an increasing recognition
of the need to integrate various health services for the elderly, not
only to provide more coordinated care, but also to contain the rapid
cost inflation driven primarily by the curative sector [1,5]. Without
∗ Corresponding author.
E-mail address: jwhe@eduhk.hk (A.J. He).
a paradigm shift in service delivery, health systems will remain and
perhaps become even more fragmented, cost-inefficient, and finan-
cially unsustainable, in light of the rate of demographic change.
Defining integrated health services as “the organization and
management of health services so that people get the care they
need, when they need it, in ways that are user-friendly, achieve
the desired results and provide value for money,” the World Health
Organization [5] has been championing care integration initiatives.
The call for integrated care has been translated into a host of exper-
imental programs and health policy innovations in England [6],
continental Europe [7,8], Canada [9], and the United States [10].
However, much less is known about the situation in Asia. The vary-
ing degree of demographic shifts and the vast diversity in health
system arrangements make Asia a highly dynamic place to exam-
ine the demands, practices, and challenges associated with care
integration for the elderly. Funded by the Asia-Pacific Observatory
on Health Systems and Policies, this study is part of a larger project
that synthesizes received knowledge on various aspects of inte-
grating health services for the elderly in the region. This report
presents a scoping review of related studies based in Singapore,
Hong Kong, Malaysia, and Indonesia, representing societies with
diverse socioeconomic profiles and health-system configurations.
This review seeks to 1) map out the structural and operational

https://doi.org/10.1016/j.healthpol.2020.12.020
0168-8510/© 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
4.0/).
A.J. He, V.F.Y. Tang
demands for care integration in the four societies, 2) summarize
the emerging integration frameworks as well as the initiatives
and collate the available evidence on their outcomes, and 3) iden-
tify implications for further academic research and health policy
reforms in the region.
The four societies selected in this review cover a remarkable
range of socioeconomic and demographic diversity. Singapore and
Hong Kong are high-income societies. Malaysia is a middle-income
country, while Indonesia belongs to the low-income category.
Table 1 summarizes the general socioeconomic and demographic
profiles of them, illustrating this significant diversity. All soci-
eties spend relatively little on health. However, this should not be
interpreted as signifying poor health outcomes or low-performing
health systems. In fact, the world’s highest life expectancy at birth
and lowest infant mortality rate are found in Hong Kong and
Singapore, respectively [11]. In spending significantly lesser on
healthcare compared to economies with a similar level of afflu-
ence, while still achieving world-class population health status,
these two health systems were ranked by Bloomberg as the two
most efficient in the world [12].
All four societies are at different stages of demographic tran-
sition. Low fertility rate, coupled with very high life expectancy
in Hong Kong and Singapore has made them two of the most
rapidly ageing societies in the world. In comparison, Malaysia and
Indonesia have a younger population and indeed technically do not
fall within the definition of ageing societies. The relative under-
development of the health system, especially in elderly care, in
Malaysia and Indonesia has prompted government authorities in
both countries to place the issue high on their respective policy
agendas, in preparation for the acceleration of ageing [13,14].
2. Materials and methods
This study consisted of a scoping review undertaken to achieve
the research objectives stated above. Aiming to map the key con-
cepts and themes of emerging research areas, a scoping review
is an ideal method to identify the scope and coverage of a body
of literature, especially when it is complex or has not yet been
comprehensively reviewed [15]. Instead of answering scientifically
structured questions of causality, scoping reviews mainly report on
the types of initial evidence that can address and inform practice
in a field and the way in which the research has been conducted
[16]. We followed the five-step methodological framework for
scoping reviews proposed by Arksey and O’Malley [17]: 1) iden-
tifying the research question, 2) identifying relevant studies, 3)
study selection, 4) charting the data, and 5) collating, summariz-
ing and reporting the results [17]. The research objectives were
as stated in Section 1. The remainder of this section describes the
methodological protocols used.
2.1. Search strategy
A search protocol was designed and mutually agreed, after sev-
eral rounds of discussion, by the three research teams undertaking
this project. We defined the time span of the review as between
2009 and 2019 in order to collect the most recent publications.
Four databases were used to search for relevant literature: PubMed,
Google Scholar, JSTOR, and World Wide Science. Given the highly
multidisciplinary nature of this topic, the search strategy was
designed to be as inclusive as possible. The following academic sub-
jects were covered by our search: health services research, health
policy, gerontology, social work, and public health. A search strat-
egy combining both Medical Subject Headings (MeSH), individual
keywords, and a combination of keywords was constructed as fol-
lows:
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Health Policy 125 (2021) 351–362
• “elderly” or “older person” or “older adult” or “seniors” or “aged”
or “geriatrics” AND “integration of care” or “community-based
care” or “long-term care” or “continuum of care” AND “Hong
Kong” or “Singapore” or “Indonesia” or “Malaysia;”
• “elderly” or “older person” or “older adult” or “seniors” or “aged”
or “geriatrics” AND “healthcare” or “models of healthcare” or
“healthcare services” or “health services” or “health service
systems” AND “Hong Kong” or “Singapore” or “Indonesia” or
“Malaysia;”
• “elderly” or “older person” or “older adult” or “seniors” or “aged”
or “geriatrics” AND “programmes” or “program” or “policies” AND
“Hong Kong” or “Singapore” or “Indonesia” or “Malaysia.”
Supplementary searches were also conducted within individual
care sectors in order not to miss relevant studies:
• “elderly” or “older person” or seniors” AND “rehabilitative care”
or “promotive care” or “preventive care” or “palliative care” AND
“Hong Kong” or “Singapore” or “Indonesia” or “Malaysia.”
2.2. Inclusion and exclusion criteria
Both formal scholarly publications and the grey literature (con-
sultancy reports, policy documents, commentaries, and official
speeches) were included. Because many of the initiatives are
emerging and innovative, policy-makers often express the vision
and reform design in official speeches and parliamentary debates;
this part of the grey literature is also relevant in the current review.
Non-English publications were excluded. The search yielded 133
publications. Both authors read the abstract independently and
reached a consensus in terms of inclusion or exclusion. Three types
of publications were sifted out: 1) clinical studies, 2) letters and
correspondence, and 3) projection studies. Although some publica-
tions did not use “elderly,” “older adults,” or other relevant terms
in their titles or abstracts, we included them because a scan of the
text suggested relevance to our topic. The final collection of studies
for the review comprised 63 publications. Fig. 1 below depicts the
search flowchart.
2.3. Quantitative description
Fig. 1 below presents a quantitative description of the studies
in our collection. Of the 67 studies, those focusing on Singapore,
Hong Kong, Malaysia, and Indonesia accounted for 41.8 %, 34.3
%, 11.9 %, and 11.9 % of the total, respectively. A wide range of
disciplinary approaches was observed, including health services
research, public health, health policy, and social work, suggesting
that the integration of health services has attracted scholarly atten-
tion across disciplines. The majority of the publications (32; 47.8 %)
were primary research, while 22 (32.8 %) were review articles. Of
the empirical studies, 18 (56.3 %), 10 (31.3 %), and 4 (12.5 %) adopted
quantitative, qualitative, and mixed methods, respectively (Fig. 2).
3. Results
3.1. The imperatives of integrating health services for the elderly
A very common theme in the literature articulates the imper-
ative of integrating health services for the elderly. Despite the
disparities between the four societies in socioeconomic status, it
is apparent that they are all facing daunting challenges to their
respective health systems as a result of ageing. Most studies in
this category are review articles that broadly discuss the need for
integration in relation to the changing demographic structure and
growing needs of the community. They also identify the structural,
A.J. He, V.F.Y. Tang Health Policy 125 (2021) 351–362

Table 1
Socioeconomic and demographic profiles of the study sites.

Singapore Hong Kong Malaysia Indonesia

GDP per capita US$ 64,582 US$ 48,696 US$ 11,373 US$ 3894
Total expenditure on health as % of GDP 4.4 5.8 3.8 3.0
Fertility rate 1.14 1.07 2.00 2.31
Life expectancy at birth (M) 81.5 81.8 74.1 69.4
Life expectancy at birth (F) 85.6 87.6 78.2 73.7
% of 65+ 12.4 17.5 6.9 6.1
Old-age dependency ratio 17.6 26.3 11.4 10.2

Source: GDP per capita (2018) from World Bank, https://data.worldbank.org/indicator/ny.gdp.pcap.cd?most recent value desc=true.
Fertility rate (2018) from World Bank, https://data.worldbank.org/indicator/SP.DYN.TFRT.IN?locations=SG-HK-MY-ID.
Life expectancy (2018) from United Nations Development Program, http://hdr.undp.org/sites/default/files/hdr2019.pdf.
% of 65+ and old-age dependency ratio (2019) from United Nations, https://www.un.org/en/development/desa/population/publications/pdf/ageing/
WorldPopulationAgeing2019-Highlights.pdf.

Fig. 1. Flow chart of the literature search.

material, operational, and cognitive barriers to such integration.
We also found some empirical studies that employed qualitative
or quantitative methods to solicit opinions from both the demand
side [18,19] and the supply side [20–24] with regard to the need
for, and barriers to, integration.
3.1.1. Systemic fragmentation in health services
In analyzing the health system arrangements of their respective
societies, some studies have illustrated various forms of sys-
temic fragmentation in Singapore [25–27], Hong Kong [23,28,29],
Malaysia [14,30–32] and Indonesia [13]. Normative discussions
have established that fragmented health services present great
challenge to providing comprehensive, coordinated, and continu-
ous care. This is especially true for the growing elderly population
given the likelihood that they usually suffer from multiple chronic
conditions and have complex medical as well as nonmedical needs
[31,33]. Some studies also advocate the inclusion of end-of-life and
palliative care into existing care integration frameworks [34–36].
A synergy should be fostered across the full spectrum of health
services for the elderly: preventive, curative, promotive, and reha-
bilitative care [14,23,37]. Family medicine, geriatric medicine, and
chronic care management should be promoted [22,30]. Within the

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A.J. He, V.F.Y. Tang
Fig. 2. Quantitative description of the literature collection.
curative system, the traditional barriers presented by the roles and
specifications of primary and secondary care need to be removed
so that all providers can work collaboratively to provide seamless
services for the elderly [28,30].
Some studies reported society-specific barriers towards care
integration. For example, the large disparity in government funding
between acute and long-term care (LTC) in Singapore has essen-
tially encouraged the elderly to prefer hospital treatment rather
than LTC services, because of the large subsidies offered to inpa-
tients [25–27]. Such perverse incentive has not only heightened the
burden on the hospital system, but also hindered essential plan-
ning of LTC services. As a result, the relative value of community
care was under-appreciated [27,38] until the recent years when
the Singapore Healthcare Masterplan 2012–2020 accelerated the
development of nursing homes, home care centers, day care cen-
ters, and rehabilitation facilities [39–41]. The underdevelopment
of post-discharge community services and LTC in Singapore may,
in turn, further shift care demand to acute facilities [26,36]. This
vicious circle has resulted in frequent discharges and avoidable
readmissions to acute care hospitals [38,42] and is likely to hamper
care integration.
The problem of avoidable admissions resulting from inadequate
integration is also reported in Hong Kong [43]. Although public
hospitals do provide discharge plans for elderly patients, no coor-
dinated referral mechanisms are in place to ensure that patients
are provided with necessary community care after discharge. This
problem reveals the lack of effective coordination among “cure”
and “care” service providers for the elderly [24,37], even though a
strategic framework for the elderly exists [44]. The cases of Hong
Kong and Singapore illustrate that policy changes are needed to
bring fundamental principles of social care into the health system
mindset and practice and break down the silos.
Fragmentation is also noted within the primary care system,
hampering synergy between providers from working towards col-
laborative care management [21]. The weak provision of preventive
and holistic care in the primary system has exacerbated the siloed
service provision. The scarcity of primary care services in Hong
Kong also thwarts specialists from referring patients back to pri-
mary facilities for follow-up [45]. Primary care professionals also
find it increasingly challenging to manage the complex multiple
morbidity issues of older adults [21]. Primary care is not only
expected to serve the curative needs of the elderly but should also
play an active role in preventive and promotive care. Chau et al. [46]
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Health Policy 125 (2021) 351–362
find that despite the comparatively low total mortality rate in Hong
Kong, there is still a substantial percentage of avoidable mortality
in the elderly population that can be attributed to a weak primary
care system.
One of the barriers to care integration peculiar to Hong Kong is
the lack of collaboration between Western and traditional Chinese
medicine. The latter has long been held by local elderly Chinese as
an important alternative treatment approach [47]. However, the
dominance of Western medicine in the formal health system and
the absence of inter-professional collaboration have hindered inte-
gration between the two, with referral rates being very low [29].
In Hong Kong’s Western medical system, there are high levels of
overutilization of acute care, undermining the timeliness of many
hospital discharges [48] and leading to avoidable readmissions [43].
The government has been attempting to develop sub-acute care
so as to relieve the pressure on acute care and improve patients’
health outcomes through a multidisciplinary approach. However,
Wong et al. [23] identified a multitude of barriers in terms of sys-
tem design, clinical behaviors, and patient preferences, suggesting
that the siloed curative system remains robust.
In contrast to the relatively small societies of Hong Kong and
Singapore, Malaysia and Indonesia face distinctive challenges in
care integration. Because both are large countries with vast regional
disparities, geographic hurdles appear to be highly significant. For
example, the majority of geriatric services in Malaysia are based
in major cities, making them much less accessible to large num-
bers of residents in other cities, let alone the rural elderly [31].
The community health and welfare infrastructure in rural Malaysia
is clearly inadequate [14,49]. This problem is even more serious
in Indonesia due to its peculiar geography with numerous islands
[50]. Mulyanto et al. [51] highlight significant regional as well as
urban-rural inequalities in the accessibility of secondary and pre-
ventive care in Indonesia. In this context, integrating health services
entails not only inter-disciplinary and inter-departmental coordi-
nation, but also geographic integration. Without this, poor physical
accessibility will continue to inhibit the elderly, especially rural
low-income elderly, from receiving the services they need.
A prominent theme emerging from this review is the need to
integrate public and private health services. Some forms of public-
private imbalance have been noted in the health systems of Hong
Kong and Malaysia. In these dual-track health economies, public
facilities are the primary – sometimes the only – choice for the
elderly, particularly those from low-income households [47,49].
A.J. He, V.F.Y. Tang
Heavy subsidies and low fees in public hospitals have resulted in
a significant price differential between the public and private sec-
tors [32,37]. The large, and still growing, elderly population and
the frequency with which older adults use health services have cre-
ated enormous pressure on the public system. Both physical as well
as staffing capacity are under pressure, as is the long-term finan-
cial sustainability of these services [31,37]. Against this backdrop,
recalibrating the public-private mix in the health systems has been
widely advocated, especially in Hong Kong [52]. Experiments with
public-private partnership programs have been conducted with
a view to improving integration between the public and the pri-
vate health systems in terms of delivering curative, preventive, and
long-term care [53]. It is worth noting that one of the strategic pur-
poses of these partnership initiatives is to relieve the heavy burden
on the tax-funded public system by making more effective use of
private health services [37]. These initiatives also help reduce wait-
ing times for the elderly so that their medical needs can be met in
a timely manner.
3.1.2. Staffing and training
A salient theme reported in many studies is the shortage of
staff in the health systems of all four societies: Hong Kong [28,37],
Singapore [25,26], Indonesia [13,50], and Malaysia [31,32]. The pro-
vision of integrated care for the elderly requires a large number of
competent professionals equipped with necessary knowledge of
geriatric medicine. Unfortunately, outside hospital settings, many
frontline services seem to be delivered by inadequately trained staff
[25,28,32,37,54]. Low remuneration relative to physicians, and high
levels of occupational stress, appear to be the principal obstacles to
recruiting and retaining skilled allied health workers in community
and LTC facilities [25,28,31,49]. In Singapore, foreign workers are
hired to fill the staffing gap, but this may lead to communication
barriers between caregivers and the elderly [55]. For Singaporeans,
a long-term career in community care is perceived to be inferior
and of low occupational prestige, leading to a high turnover rate
among practitioners [27]. In Hong Kong, the lack of competence on
the part of community care workers is found to hinder effective
post-discharge coordination of care [24]. In Malaysia, difficulties in
recruiting competent medical and allied health professionals in the
public sector have prevented the necessary expansion of secondary
care support services in the community [30,31].
In order to improve care integration for their rapidly growing
elderly populations, governments need to develop sufficient exper-
tise in geriatric medicine and provide all the related subdivisions of
the health and social care workforce with necessary training in inte-
grated care services. It is proposed that geriatric medicine be firmly
embedded into all curriculums for health service providers, along-
side the development of evidence-based elderly care management
programs [28,30].
3.1.3. Primary care
Another prominent stream of the literature concentrates on the
central value of a well-functioning primary care system. Even in
Singapore and Hong Kong, where the colonial NHS legacies have
shaped a three-tiered health service delivery framework, primary
care systems are still found to be inadequate [19,21,22,45]. In
Singapore, one of the major challenges is care coordination within
the primary care system, since Singaporeans are free to select
any doctor they wish [22,42]. Similar “doctor shopping” behav-
iors are also prevalent in Hong Kong, undermining the necessary
relational continuity between doctors and patients [19]. Indonesia
appears to offer good experience from which other societies may
draw. Its government-financed national health insurance program
is used to leverage care resources by designating primary care as the
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Health Policy 125 (2021) 351–362
gatekeeper and requiring all beneficiaries, irrespective of socioeco-
nomic background, to seek services from primary facilities [51].
3.1.4. Demand-side issues
Although some basic forms of integrated care for the elderly
have been put in place, their uptake tend to be low owing to a
range of demand-side issues. For instance, Nurjono et al. [27] report
a mismatch of expectations and perceptions of integrated care
between service providers and elderly users in Singapore. Users
typically showed little appreciation of the need for team-based
care and the link between their social and medical needs. Dif-
ferences in subsidies between hospital-based care and integrated
care have incentivized the elderly users to adhere to hospitals
[27]. These demand-side problems have resulted in low accep-
tance of, and adherence to, integrated care programs among the
elderly users [27]. Similar findings are reported in Indonesia where
elderly participants showed very limited interest in many of the
services provided by the poslanisa program [56]. Cultural factors
and low health literacy also appear to be major obstacles. Kadar
et al. [13] report that although nursing homes are widely available
in Indonesia, the take-up rate is low as most elderly demonstrate
a strong preference to live with their families. Ethnic diversity in
Malaysia is also found to introduce challenges to care integration
because the cultural and religious differences between Malays, Chi-
nese, and Indians have led to different care preferences, making
integration even more complicated [32,49]. A lack of the knowledge
necessary to navigate the referral system also deters those with less
education, especially older adults, from accessing secondary care
[51].
Insufficient health literacy is closely associated with the low
uptake of integrated services or low utilization of preventive and
long-term care services in Hong Kong [20,57,58], Singapore [55],
and Indonesia [51]. The over-emphasis on curative care is also
reflected in health-seeking behaviors, as most individuals in Hong
Kong seek primary care for curative rather than maintenance pur-
poses [45]. The elderly tend to be passive in seeking out medical
check-ups and encounter cognitive barriers to making rational
decisions about the use of preventive care [51,58]. Therefore, a
more instructive doctor-patient relationship is crucial because doc-
tors’ ability to empower patients and offer clear guidance will
facilitate the appropriate use of preventive and promotive services
among the elderly [19].
3.2. Ongoing integration initiatives
Our search yielded 11 publications that clearly stood out from
the rest of the collection as they focus exclusively on existing inte-
gration initiatives. Unsurprisingly, most of these publications are
neither qualitative nor quantitative, but belong to the grey liter-
ature: policy reports, commentaries, and the like. Nevertheless,
we found them highly informative, because they describe ongo-
ing reforms in a strategic and clear fashion. Somewhat to our
surprise, however, most publications in this category were from
Singapore, reflecting the possibility that this city-state may be at
the forefront of innovation in care integration. Equally, it must be
emphasized that the Singapore studies reported here are predom-
inantly descriptive. Because most integration initiatives have been
only recently introduced, there is a lack of quantitative evidence to
underpin a thorough evaluation of their outcomes [59].
Singapore has adopted three health policy strategies in response
to the ageing population; 1) moving beyond healthcare to care, 2)
from hospital to community, and 3) quality of value [39–41,59]. The
Agency for Integrated Care (AIC) was established in 2009 to over-
see, coordinate, and facilitate all efforts towards care integration
[60–62]. At the systemic level, Singapore’s health system is being
transformed from a hospital-centric towards an integrated care
A.J. He, V.F.Y. Tang
model to meet the challenges brought about by ageing. A regional
health services (RHS) framework has been set up to enhance the
provision of integrated care. Consisting of restructured hospitals
and other health service providers, the RHS aims to integrate
services vertically, enhance synergy and economy of scale, and
ultimately to improve the quality of care delivered to the elderly
[27,36,63,64].
As the first point of contact for older Singaporeans, primary care
represents the foundation of the country’s integrated care frame-
work. The government launched the Community Health Assist
Scheme (CHAS) initiative to subsidize costs for patients visiting pri-
vate general practitioners. Family medicine clinics have also been
established to provide an environment for the delivery of com-
prehensive care to patients with chronic conditions [59,64]. New
integrated care models such as geriatric service hubs, community
preventive health initiatives, and senior care centers have also been
experimented as a means to tackle multiple morbidity and chronic
case management [39,59,61,69]. The government has also provided
support to facilitate the development of day care centers, which
provide a spectrum of programs including social support, physical
exercise, active rehabilitation, community nursing, and dementia
care. However, Liu et al. [55] identified a multitude of drawbacks
in the day care center system, such as capability constraints and
duplication of work, which warrant further attention from policy-
makers.
One of Singapore’s “best practices” is its integrated health infor-
mation system that strives to break down the boundaries between
public and private providers. Since 2011, the government has been
progressively deploying the National Electronic Medical Record
system, guided by the vision of “one patient, one health record.”
This integrated virtual system enables all authorized providers
across care settings and sectors to access patients’ records. Such
a system is intended not only to reduce duplication in treatment
and diagnostic tests, but also to enable all providers to monitor their
patients’ health conditions effectively and coordinate the provision
of care [35,39,60,63,64]. Although the full adoption of this ambi-
tious nationwide system remains a work in progress and certain
barriers are being encountered [27], a fairly extensive integrated
electronic health record system is now in operation in Singapore’s
RHS systems, and private practitioners have been granted access
[42,64].
In comparison, Hong Kong is lagging behind Singapore in reduc-
ing communication barriers between service providers, owing to
privacy and liability concerns. The lack of information sharing
impedes cross-sectoral collaboration and leads to the inefficient
use of resources [24]. Chau and Leung [66] conducted a timely
study on the use of health informatics among health practitioners,
demonstrating a considerable lack of familiarity with even basic
technologies. The lack of integration and the outdated data infras-
tructure in Hong Kong’s health system present a barrier to the
introduction of integrated care and must be addressed.
While this section focuses primarily on Singapore’s approach
towards care integration, we also observe a variety of integration
models in Hong Kong and Indonesia. Table 2 sets out a comprehen-
sive summary based on the publications reviewed. According to the
WHO [5], the integration of health services can take place at both
organizational level and operational level. Organizational integra-
tion takes place when there are mergers, contracts, or strategic
alliances between different health facilities, whereas operational
integration happens when different health professionals or spe-
cialists work together to provide joined-up services. We also
distinguish horizontal and vertical integration. Horizontal integra-
tion refers to the provision of various allied health services, in
addition to the medical services provided by physicians, to address
patients’ manifold health needs [67]. Vertical integration involves
linkages across various levels of care from primary care clinics to
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Health Policy 125 (2021) 351–362
tertiary general hospitals. [62]. As shown in Table 2, the majority
of these models represent operational integration, although some
comprehensive organizational integration models of varying scales
can be observed too. Many models seek to foster integrated care by
transcending public-private boundaries and providing platforms
for different providers to collaborate and leverage each other’s
strengths. Remarkably, the centrality of primary care is very salient
throughout these models.
3.3. Assessment of integration models
Eleven publications in our collection set out to conduct some
form of assessment of existing integration models. Both quantita-
tive and qualitative methods were observed. Given the short history
(and in some cases the experimental nature) of care integration
initiatives, these evaluation exercises by no means call on the use
of national-level systematic data. In fact, most are based on small
samples or case studies. Although the results may not necessar-
ily be generalizable, they still offer highly valuable evidence about
the achievements and gaps of current care integration practices.
The insights derived from these studies can also be used to inform
more rigorous and systematic investigations in the future.
Lau et al. [24] offer a comprehensive account of various barri-
ers observed in Hong Kong’s integrated care system. While a basic
framework integrating health services for the ageing population
has been put in place in the territory, in-depth interviews with
key informants reveal operational, communication, and percep-
tion barriers in practice. Despite a common framework, a lack of
shared values and common goals is often observed among health
professionals, leading to confusion about roles and insufficient
communication between providers [53,68]. As such, major gaps
still exist in Hong Kong’s current model of integration. In Singapore,
despite the vision of care integration discussed above, similar gaps
as reported for Hong Kong are also observed. Lai et al. [69] point out
an over-emphasis on specialization among practitioners instead of
focusing on a holistic approach to care and interdisciplinary collab-
oration. Hence, the traditional siloed approach has not been broken
down in Singapore.
Moreover, the lack of staffing, skills, competency, and resources
is, once again, found in this thematic category [24,68,69]. Such a
capacity deficit appears to be even more pronounced in Indonesia.
While the Indonesian government has embarked on a series of
care integration initiatives such as the posyandu lansia (Integrated
Service Post for the Elderly) and the poslansia (a community-
based program for older adults), substandard staff training and
resource shortages have been shown to create a bottleneck in
implementation [56,70]. Limited financial and in-kind support
from communities also appear to pose major challenges to the long-
term sustainability of these programs [56,70]. That said, however,
preliminary evidence gleaned from small-N studies reveals moder-
ate levels of satisfaction among elderly service users in Indonesia
[70,71].
In Singapore, a significant policy shift towards care integration
has been the establishment of RHS that is expected to integrate
various service providers into a larger geographic network. How-
ever, Saxena et al. [42] find a high degree of cross-utilization across
Singapore’s three RHS and a notable number of frequently admit-
ted hospital patients, the latter accounting for nearly 20 % of all
inpatient episodes in Singapore. The large number of patients seek-
ing care from sources other than their designated care providers
undermines the purpose of integrated care and erodes service con-
tinuity. As well as exploiting the power of electronic health records
and information sharing among providers, stronger gatekeeping
mechanisms are necessary.
Nurses and lay extenders are found to play an increasingly piv-
otal role in various care integration models, ranging from case
 A.J. He, V.F.Y. Tang
Table 2
Summary of integration models in the selected societies.

Program Society Public/Private Level of Vertical level of Horizontal care sector Key features Drawbacks
integration care

Regional Health Singapore Public & Organizational Primary, Preventive, Curative, • Health system divided into three geographically • Limited input from users
System (RHS) Private & Operational Secondary, & Rehabilitative & defined integrated clusters
Tertiary Promotive
• Each RHS consists of an acute general hospital • Inadaptability of
working closely with community hospitals, nursing financing to support
homes, hospices, clinics, etc. team-based care
• Linking public and private providers
• Depending on care needs, calibrated modular care
services to be planned and delivered
Delivering on Target Singapore Public & Operational Primary & Preventive & • Supporting the transit of clinically stable diabetic • Limited incentives for
(DOT) Private Secondary Rehabilitative patients from public hospital to private practitioners public hospitals
closer to home to reduce waiting times
• An opt-in program for patients
• Updates sent to the referring specialist with regard to
shared care follow-up
• Providing continuous subsidized drug delivery
services and diagnostic tests
CARITAS Integrated Singapore Public Operational Primary Preventive, Promotive • To provide accessible, responsive, individualized and • The need for island-wide
Dementia Care & Social Care transdisciplinary care for patients with dementia expansion of service
network
• Care includes home-based counselling, elder sitters • Inadaptability of
for companionship, regular case management, and a financing to support
357

senior care service team-based care

• Equipping and empowering caregivers to better care
for people with dementia
SGH Transitional home Singapore Public Operational Primary Rehabilitative & • To reduce acute hospital utilization and improve • Financial hurdle created
care program Promotive coordination and continuity of care between by self-financing
healthcare settings
• A multi-disciplinary team conducts a comprehensive
assessment within 1 week of hospital discharge
• Aims to educate patients and caregivers on managing
chronic disease
• Providing coordination of care for specialist and
community care
Elderly Healthcare Hong Kong Private Operational Primary Preventive & Curative • To encourage elders to use private services, • Inpatient care not
Voucher Scheme especially preventive care included
• To reduce waiting time and increase access to care • Elders’ persistent use in
for elderly curative care
• Elderly citizens may use vouchers to purchase private
services
Public Private Hong Kong Public & Operational Primary & Preventive & Curative • To promote collaboration between public and private • Limited reception in

Health Policy 125 (2021) 351–362

Partnership Scheme Private Secondary sectors and channel patients away from the some schemes
overburdened public system
• Government purchases private services for public • Coordination gaps in
hospital patients who may pay nominal fees. some schemes
Integrated Service Post Indonesia Public & Organizational Primary Preventive, Promotive • To improve the quality of life and wellbeing of the • Poor service quality
for Elderly (Posyandu Private & Social Care elderly
Lansia)
 A.J. He, V.F.Y. Tang
Table 2 (Continued)

Program Society Public/Private Level of Vertical level of Horizontal care sector Key features Drawbacks
integration care

• Providing an integrated health service focusing on • Low attendance

health promotion and disease prevention
• Minor treatment and referral services also offered
Frailty-ready Initiative Singapore Public Operational Primary Preventive, Curative, • Integrating care for the frail elderly across various • Difficulties in engaging
Rehabilitative & settings and reducing hospital readmission rate frail elderly who are at
Promotive times adverse to care and
treatment
• Enhancing the continuum of care through
prevention, planning and active engagement with
community partners
• Team-based geriatric-focused service to ensure that
geriatric symptoms are detected and treated early
• Individualizing a comprehensive discharge plan to
home care
Singapore Program for Singapore Public & Operational Primary Preventive, • Providing interdisciplinary services in both center • Varying service quality
Integrated Care for Private Rehabilitative & Social and home
the Elderly (SPICE) Care
• Comprehensive assessment, regular reevaluation and
detailed individualized plan implemented to avoid
institutional care
Agency for Integrated Singapore Public & Organizational Primary Preventive, Curative, • To coordinate and support integrated care • Long waiting time for
Care Private & Operational Rehabilitative, coordination
Promotive & Social
Care
• A one-stop agency to coordinate the delivery of
services, enhance service development, and build
capacity across organizations
358

Family Medicine Singapore Private Organizational Primary Preventive & Curative • To increase accessibility and flexibility for individuals • Higher cost if subsidies
Clinics and & Operational to manage their chronic conditions in community are removed
Community Health
Centers
• Direct visit to FMCs for follow-up health checks • Varied quality among
FMCs and CHCs
• Providing specialized medical procedures to reduce
acute hospital visit
JIntegrated Home Care Hong Kong Public & Organizational Primary Preventive, • To enable ageing-in-place and continuum of care • Lack of staff
Services Private Rehabilitative & within community setting
Promotive
• Providing enhanced support, care, and rehabilitative
services
Enhanced Home and Hong Kong Public & Operational Primary Preventive, • A platform to provide integrated services for the frail • Lack of staff
Community Care Private Rehabilitative, elderly, allowing them to age at home (or in a familiar
Services Promotive & Social environment)
Care
• Caregiver support to enhance family cohesion

Health Policy 125 (2021) 351–362

Day Care Centers for Hong Kong Public & Organizational Primary Rehabilitative, • Providing care and support during daytime on • Long waiting time
the Elderly Private & Operational Promotive & Social weekdays and Saturdays
Care
• Providing services to elderly suffering from moderate • Lack of staff
to severe level of impairment
• Options for services vary with enrolment according • Varying service quality
to needs
• Providing support and training for caregivers
Care and Attention Hong Kong Public & Organizational Primary Preventive, Promotive • Providing communal living for the elderly requiring • Long waiting list
Homes Private & Social Care more assistance in daily functioning (with physical or
mild mental impairment)
 A.J. He, V.F.Y. Tang
• Providing integrated services including social care • Lack of staff
• Regular visits by medical practitioners • Varying service quality
Community Health Singapore Public & Organizational Primary Curative • Extending healthcare subsidies to patients visiting • Not eligible for every
Assist Scheme Private private general practitioners resident in need
• Through means testing, providing a range of curative
care services to reduce utilization of public hospitals
• Bridging continuum of care in community
Geriatric Service Hub Singapore Public Organizational Primary & Preventive, Curative, • Holistic and seamless care for complex conditions • Limited service providers
& Operational Secondary Rehabilitative, between community, polyclinics, and hospitals
Promotive & Social
Care
• Co-locating a family medicine clinic, community
health center, and senior care center
Primary Care Networks Singapore Private Organizational Primary Preventive & Curative • To achieve economies of scale and maximize • Higher OOP as not all
(PCNs) & Operational resources among private practitioners citizens are eligible for
subsidies
• Multidisciplinary team managing patients with
chronic conditions
• Bringing services closer to home through
government funding and support
Integrated Care and Hong Kong Public Operational Primary Rehabilitative & • Integrated care services for patients aimed at • Lack of sustainability of
Discharge Support Promotive reducing unnecessary hospital admissions discharge program
• A multidisciplinary team providing care, support and
training for patients and caregivers for 8 weeks
359

Community Geriatric Hong Kong Public & Operational Primary Preventive, • A multidisciplinary team ensuring elderly patients’ • Differing
Assessment Team Private Rehabilitative & smooth transition back into the community and decision-makers, resulting
Promotive maintaining quality of life in confusion on the ground
• Serving as gatekeeper for readmission and safe
discharge
Enhanced Community Hong Kong Public & Operational Primary Preventive, • A multidisciplinary team ensuring a smooth • Differing
Geriatric Assessment Private Rehabilitative & transition back into the community and maintaining decision-makers, resulting
Service for Promotive quality of life for elderly patients living in residential in confusion on the ground
End-of-Life Care care homes
Regular visits conducted by nurses for semi-urgent • Varying concept of
clinical problems end-of-life care among
providers
• Supporting end-of-life care within the community
Direct admission to designated convalescent beds to
avoid long waiting times
Community Health Indonesia Public Organizational Primary Preventive, Curative, • To improve supply and quality of care in remote areas • Shortage of manpower
Center (Puskesmas & Operational Rehabilitative &
Santun) Promotive
• Services such as simple laboratory tests and • Lack of support from local

Health Policy 125 (2021) 351–362

examinations, together with programs on preventing leaders
illness and promoting optimal health

Source: Nurjono, et al. (2018); Yeo, Harris & Majeed (2012); Lim, et al. (2017); Ho (2009); Yap & Gee (2015); Liu et al. (2015); Tan (2014); Tan & Lee (2019); Low et al. (2015); Rozario & Rosett (2012); Lau et al. (2018); Wong et al.
(2015); Yam et al. (2011); Lai et al. (2017); Yam et al. (2019); Christiani et al. (2016); Kadar et al. (2012); Pratono & Maharani (2018); Nursalam et al. (2017).
A.J. He, V.F.Y. Tang
management and counselling services to educational training for
patients and caregivers [24,36,68,69]. In Singapore, under the
framework for frail elderly care, authorities are given to nurses in
providing innovative services, and they helmed specialist services
such as ‘Geriatric Resource’ and ‘GeriCARE’ based on their trainings
[36]. In Hong Kong, lay extenders are instrumental in the CGAT and
Enhanced CGAT programs to ensure smooth transition of elderly
patients back into the community [74]. With active involvement of
nurses and lay extenders, care integration can be carried out in a
more coordinated manner. Social support and social connectedness
are crucial for the health and well-being of the elderly population
[28]. Bridging the gap between the health care system and the
social support system, good social care also promotes the use of
LTC services within the community through recreational activities.
To note, social participation in recreational activities helps promote
and improve integrated care services [25,28,33,65].
A financing initiative that aims at leveraging integrated care in
Hong Kong is also worthy of discussion. Hong Kong has adopted
an elderly healthcare voucher scheme in order to recalibrate the
public-private imbalance. These cash vouchers are supposed to
enable the elderly, the chief users of the public system, to seek
care from private facilities, mainly for preventive services [72]. Two
empirical studies, however, have found that most elderly people
still use their vouchers for curative purposes [73,74]. This suggests
that although vouchers can be employed as a financial instrument
to promote care integration, demand-side issues may substantially
limit their potential. Therefore, in a free-market economy such as
Hong Kong, a combination of multiple high-powered policy instru-
ments is necessary to achieve the goal of care integration.
4. Discussion
A noteworthy theme arising from this scoping review points
to the increasing irrelevance of the traditional disease-centric,
hospital-based, and fragmented provision of health services in this
region. Even the established chronic disease management mod-
els that emphasize care coordination have become increasingly
inadequate in the face of confluent multiple morbidities and ill-
defined geriatric syndromes that do not fit the single-disease model
[36]. A paradigm shift towards fully integrated health services
for the elderly must therefore be supported by a collaborative
mindset, coupled with strong internal and collective capabilities
among organizations and practitioners at all levels. The realiza-
tion of this goal rests on the orchestrated efforts of policy-makers,
health service funders, practitioners, health educators, and service
users. Some studies in this review suggest that the unsatisfactory
outcomes seen in many existing integration models often result
from a poor appreciation of the needs and preferences of elderly
users themselves. An elitist top-down approach to integration must
therefore be reformed to encourage consultation, participation, and
coproduction with the elderly. Public education programs aimed at
increasing health literacy and awareness are pivotal to this agenda.
With a few exceptions, the majority of publications reviewed
concentrate mainly on integration at the organizational or
operational levels, paying insufficient attention to financing
arrangements. As most elderly people face varying degrees of
financial constraints, the affordability of integrated services thus
becomes an important policy issue. In societies where public sys-
tems are overwhelmed or underdeveloped, the planning of private
services has to pay particular attention to financing issues. Without
substantial financial resources being injected into the private sys-
tem, the development of community and LTC services will continue
to be bottlenecked. Therefore, financing initiatives should aim at
nurturing the growth of the private system while keeping services
affordable.
360
Health Policy 125 (2021) 351–362
To be more specific, the adaptability of existing health financ-
ing systems should be improved in order to pool resources from
disease-centric episodic hospital settings and enable care services
to conduct follow-up with patients and incentivize continuity of
care after discharge [27]. In health financing systems that are dom-
inated by social health insurance, there is evidence for perverse
incentives encouraging the use of curative care [51]. Govern-
ments should therefore actively pursue provider payment reforms
to move away from fee-for-service models and adopt alterna-
tive payment methods such as capitation, bundled payment, and
so on. All financial incentives should be aligned in such a way
that cost-effective preventive, promotive, and community care are
encouraged. Vouchers could be a useful financing instrument to
induce behavioral change among elderly users, but the experi-
ence of Hong Kong indicates that this alone may be insufficient to
promote primary care or public-private partnership. Supply-side
interventions should therefore be introduced alongside financing
innovations.
This review has encompassed a very wide constellation of inte-
gration practices and models, embodying various approaches and
levels of integration. Clearly, the path-dependent nature of health
systems has made reforms in high-income societies such as Hong
Kong and Singapore a rather formidable task. Deeply entrenched
concepts of professional autonomy, coupled with considerable
technical complexities, have made it difficult to undertake even
piecemeal reforms, as can be seen in Hong Kong. Middle- and
low-income societies with younger populations are thus in a more
favorable position to plan ahead before a bigger “silver wave” hits
their health systems. A key policy implication emerging from this
review is the crucial necessity of building capacity in such middle-
and low-income societies. Training a large team of professionals
who are not only clinically competent in medical care but also
adept at social care is a critical success factor. Professional edu-
cation programs should be reoriented to train a growing number of
skilled nurses, dieticians, occupational therapist, pharmacists, psy-
chologists, and other allied health personnel to manage the chronic
conditions of elderly people with complex needs.
Clinical guidelines, discharge pathways, post-discharge care
plans, case management protocols, and community care standards
should be proactively developed by drawing from evidence-based
multidisciplinary research, and be regularly updated with refer-
ence to users’ feedback. Such progress in the system “software”
should also be accompanied by “hardware” development especially
in terms of electronic health records systems and enable wider
information interconnectivity among practitioners. It is apparent
that integrating health services for the elderly is an endeavor that
will be highly contingent on local circumstances and that differ-
ent health systems will inevitably manifest varying characteristics.
Nevertheless, we believe that the common principles laid out above
are essential aspects of the reform process, irrespective of the con-
text.
5. Conclusion
This report synthesizes the findings of a scoping review of the
emerging literature on integrating health services for the elderly
in four Asian societies. Clearly, both research and practice are at
a preliminary stage of development, except for the more compre-
hensive reform package currently being rolled out in Singapore.
The majority of studies included here focus on the deficiencies
of existing health service delivery arrangements and explain why
integration is necessary. There is a lack of rigorous evaluation of
integration models, partly because the models themselves are very
new and quantitative data are not yet available. We note a marked
trend in seeking to integrate long-term elderly care with curative
A.J. He, V.F.Y. Tang
and preventive care, especially in community settings. ageing -in-
place and active ageing seem to have been embraced as important
principles, although the progress of implementation varies. Inte-
gration is demonstrated not only horizontally but also vertically,
transcending public-private boundaries. The central role of primary
care is highly prominent in almost all the integration models stud-
ied here. However, these models have many drawbacks in relation
to capacity, perception, and operation, indicating the robustness
and persistence of siloed healthcare practices. The full integration
of health services is a challenging task. Cross-jurisdictional com-
parative studies are particularly helpful in fostering health policy
learning and transfer.
Declaration of Competing Interest
None.
Acknowledgements
This study was generously funded by the Asia-Pacific Observa-
tory on Health Systems and Polices (APO). The authors are very
thankful to Professor Rama Baru for her project leadership and Dr
Madhurima Nundy for excellent project coordination. Constructive
comments from Dr Nima Asgari-Jirhandeh of the WHO and the two
anonymous reviewers are also gratefully acknowledged.
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