Put 'Smart Nation' to work on diabetes care

The current model has patients queueing hours to see a doctor four times a year for a follow-up. Use self-tracking apps and games to engage patients year-round.

Diabetes has captured policy attention at the highest levels in Singapore.

In last Sunday's National Day Rally address, Prime Minister Lee Hsien Loong urged Singaporeans to change our lifestyles as well as go for regular health screenings. He said that the Government would subsidise 95 per cent of the usual $100 health screening charges.

This is a good start, but is it enough?

The data suggests not. Across the continuum of diabetes care, we face challenges and we need to improve in three areas - ensuring screening is available to all Singaporeans, ensuring Singaporeans with abnormal findings on screening are not "lost to follow-up", and finally ensuring Singaporeans diagnosed with pre-diabetes or diabetes are supported in effectively changing their lifestyles.


The 2010 National Health Survey has good news and bad news. The good news is that screening adoption is relatively high at 63 per cent for diabetes; the bad news is that screening is much higher for those with higher education (70 per cent versus 58 per cent for those with primary education or less), and only half of Malays have been screened for diabetes. How can we reach out to the nearly four in 10 Singaporeans who are missing out?


The same issues that impact willingness to attend screening affect follow-up. Earlier this year, The Straits Times carried a report drawing attention to this. Disappointingly, one in four screened and found to have abnormalities was "lost to follow-up", which means they didn't see their doctors to follow up on their conditions.

Getting Singaporeans screened and then ensuring those with abnormalities see through to diagnosis is crucial. The impact of the "lost to follow-up" is substantial - data from the National Health Survey shows that only half of those Singaporeans with diabetes even know they have diabetes!


PM Lee suggested "four simple things each one of us can do: get a check-up, exercise more, watch your diet, cut down on sugar".

Technology can be supportive in engendering adherence. Inexpensive reminders via SMS or WhatsApp can help shift behaviour and, coupled with incentives and perhaps even disincentives, would be very effective. Yes, this could be considered "intrusive" but we are in a war, and stronger measures are warranted.

Sadly, it's not that simple, even for Singaporeans presumably motivated by the diagnosis of diabetes. As PM Lee noted wryly, when it came to diabetes rates, "Singapore is almost world champion - just behind the US".

What is even worse is that we are also world champions in complications arising from diabetes. We have one of the highest rates of amputations globally and also one of the highest rates of kidney failure; both are directly attributable to poorly controlled diabetes.


It might be mere coincidence, but immediately after speaking about diabetes, PM Lee went on to emphasise the need for Singapore to be a "Smart Nation". Can Singapore make virtue of necessity?

Screening all Singaporeans and ensuring appropriate follow-up is firstly a logistical challenge.

One radical idea: Why not establish a national screening programme including database tracking, and entitle every Singaporean to regular screenings and follow-ups?

Given our "Smart Nation" ambitions, surely a national database that flags which Singaporeans need what types of screening would not be difficult? This would minimise "abuse" or over-servicing and, more importantly, Singaporeans who are not attending screening or follow-up can be systematically identified and encouraged to attend.

Technology can be supportive in engendering adherence. Inexpensive reminders via SMS or WhatsApp can help shift behaviour and, coupled with incentives and perhaps even disincentives, would be very effective. Yes, this could be considered "intrusive" but we are in a war, and stronger measures are warranted.

Singaporeans who are home-bound are at highest risk for not being screened, and home-care providers such as Jaga-Me or Homage (disclosure: I am an adviser to both) could bring screening services directly into the homes of those currently unreached. In the workplace, use of tele-consultations post-screening also is invaluable; MyDoc, which offers tele-consultation services, has reported improved follow-ups to as much as 85 per cent.

The costs of screening could be greatly reduced by technology allowing identification and matching to home-care providers' schedules. (Patients will continue to pay the highly subsidised fee of $5.) Healthcare professionals' time is the highest cost component of screening, and minimising extra travel time will be invaluable in managing costs efficiently.


PM Lee, in encouraging screening, explained that post-diagnosis support was important, saying: "In the early stages, it is an invisible disease. You do not feel sick; there are hardly any symptoms." This reality is also why Singaporeans, even after diagnosis, do not treat diabetes with enough seriousness.

In fairness, our current model is probably one that creates little incentive for those who "do not feel sick" to go for a follow-up.

You have to be quite motivated to queue for hours in a busy polyclinic to see the doctor for a few minutes. Besides, most patients would consult about four times a year, but that leaves the other 361 days in a year void of follow-up activity.

Our current model of diabetes care is too physician-centric and health facility-centric. It lacks the ongoing engagement of patients which is what is needed to drive behaviour change.

Convenience, "personalisation" and timeliness are also critical for patients who "do not feel sick".

Here, new smartphone app-based models of care such as GlycoLeap are good examples of what could be offered.

In GlycoLeap, patients record their diet through taking photos of foods eaten, which are then uploaded through their smartphones to an app. This information is coupled with other data such as activity and blood results which dietitians then use to advise and encourage in a very personal and customised manner, virtually and inexpensively.

Dr Yau Teng Yan, chief medical officer of Holmusk, the company that developed GlycoLeap, describes the current model as "high intensity, low frequency".

Behavioural science informs us that this would not create the stickiness needed for sustained behaviour change. Instead, we need to go for "low intensity, high frequency" interactions that encourage and motivate.

GlycoLeap-type offerings could be a standalone for pre-diabetes and a complement to traditional medical care for established diabetes. In future, the use of artificial intelligence can further boost productivity of the dietitians and introduction of "gamification" and social elements may lower costs and further improve clinician outcomes.

Singapore has a very good track record in dealing with existential issues such as security and water.

Now that we realise diabetes is likewise an existential issue, we can be emboldened to take strong measures to win this war. Screening, early detection and effective, inexpensive support for lifestyle changes are critical battlefields where we must prevail.

Technology coupled with iron resolve to remove regulatory, policy and financial barriers can allow us to leapfrog our current inefficient models and create new paradigms of care not just to serve Singaporeans but also the world. In a healthy "Smart Nation"- we can make a virtue of necessity.

• Jeremy Lim is partner and head of health and life sciences for the Asia-Pacific at management consulting firm Oliver Wyman.

A version of this article appeared in the print edition of The Straits Times on August 30, 2017, with the headline 'Put 'Smart Nation' to work on diabetes care'. Print Edition | Subscribe