I am personally impressed by the work that the HPB and its predecessor Training and Health Education Dept, Ministry of Health, has quietly undertaken these last decades. At the risk of appearing jingoistic, I thought it worthwhile to highlight the HPB approach to encouraging health. Of particular interest is the ‘systems thinking’ philosophy and the pragmatic recognition of human nature. And much as I am often skeptical of many government initiatives, credit must be given where credit is due and the commitment to health promotion amongst politicians and policy makers has been impressive.
Making it easier for S’poreans to be healthy (TODAY 19 Sept 2013)
Singapore enjoys the world’s fourth-highest life expectancy and its rates of disease risk factors, like smoking and obesity, are lower than those of many other developed countries. In fact, it was crowned last year by Bloomberg Media the world’s healthiest country.
However, dark clouds gather. With Singapore having one of the fastest-ageing populations globally and facing an explosion in non-communicable diseases (NCDs), more needs to be done.
For many years, health promotion had centred on public education, especially among the young. The School Health Service, launched in 1964, initially focused on childhood immunisations but rapidly expanded into other aspects of health including dental hygiene and nutritional supplementation.
Many Singaporeans in their 40s and 50s will remember the dental drills of yesteryear, standing in neat rows by school drains brushing their teeth; or when children were offered subsidised milk to enhance early nutrition. Later, programmes in breast, cervical and colorectal cancer were launched, highlighting the importance of early screening and detection.
However, even as the Health Promotion Board (HPB) led public education campaigns and worked with partners to establish screening programmes, it also quietly went about transforming health promotion in Singapore. While many health agencies primarily concentrate on education, the HPB has made great strides in advancing health upstream — going to the source.
ENGINEERING BETTER HEALTH
Singaporeans are justifiably proud of their food, and we eat out and often. The National Nutrition Survey 2004 revealed that a third of adult Singaporeans eat in hawker centres two to five times a week, while 27.3 per cent do so more than eight times a week. The 2010 edition of the survey found even higher numbers: 60.1 per cent eat out regularly (compared to 48 per cent in 2004) due to easy access to cooked food.
The HPB, recognising that it would be futile to swim against the tide, engaged with food manufacturers to create healthier yet still tasty options.
One in five Singaporeans consumes insufficient amounts of dietary fibre, and so, a local manufacturer was roped in to co-develop wholegrain noodles, to substitute for the traditional white rice-based ones in hor fun. It is gaining popularity among hawkers and patrons. The HPB worked with another manufacturer to create a blend of vegetable oil with 20 per cent less saturated fat than palm oil, but at comparable prices.
While Singapore has advanced legislation in restricting tobacco and alcohol, HPB CEO Zee Yoong Kang believes more can be done in the field of creative regulations.
He is especially interested in workplace health. “I see untapped potential to build on existing government initiatives,” he says. “For example, we could reach out to the workplace in collaboration with other agencies outside the healthcare system.
“The Ministry of Manpower owns the Workplace Safety and Health Act (WSHA). But if you look at the ‘H’, it is a narrow definition as it focuses on occupational health, like not falling from heights, wearing masks and particulate matter in the air.
These are less relevant to office workers who form the bulk of the Singaporean workforce.
“I believe that the HPB has a role in helping to widen the definition of ‘Health’ in WSHA by getting employers to look at chronic disease management in the workplace, ergonomics, mental well-being and so on.”
STICKER PERMISSION TO DO RIGHT
The behavioural sciences have enjoyed tremendous policy attention in recent years. At the heart of behavioural science? Making it easier to do the right thing.
The HPB’s ‘Healthier Choice’ logo is a simple display to make it easy for consumers to elect, at the point of ordering, healthier choices. The sister ‘Ask For’ programme empowers consumers to request hawkers to cook their food with less oil, less sugar, less salt or more vegetables. The ‘Ask For’ sticker is essentially a visual ‘permission’.
The latest initiative is a ‘Healthier Hawker’ programme launched in 2011, under which the entire hawker centre commits to offering healthier options. Yuhua Hawker Centre, a pioneer in this scheme, reported a tripling of sales of dishes made with brown rice and wholegrain noodles. Importantly, earnings went up by at least 10 per cent, thus encouraging hawkers to stick to the programme.
This year, the health ministry announced another 40 food outlets would be included.
AWARDS AND SMART SUBSIDIES
At the corporate level, Mr Zee surfaces an idea that plays on Singaporeans’ penchant for pursuing awards. Referring to the Singapore Quality Class and Singapore Quality Award, he wonders: “Health should also be a component for assessing this. As part of the SQC/ SQA requirements, why not include health? The goal is not to create new awards. There is potential here.”
He is also keen for the HPB to do more in terms of “smart subsidies”. Referring to the ‘Healthy Hawker’ initiative, Mr Zee questions: “Are we smart about how we go about this? Right now, we have to persuade each individual hawker, which is time-consuming and requires a lot of effort and resources. So we are starting to look into using smart subsidies.
“In the past, we changed salt and put potassium iodide in the salt. If you try at the retail level it won’t work. You’ll need to do it at source. Can we work with the manufacturers?
“At the retail level, think about how much oil costs for each individual bowl of noodles — hardly anything. You need to intervene at the appropriate juncture in the supply chain. So, there is no point taxing sugar, you won’t really modify consumer habits. But if you subsidise peanut/canola oil instead of palm oil, you can shift behaviour on the part of the hawkers.”
MARKET AND POLITICAL WILL
Going far beyond health education, the HPB is trying to embed health in society, in the ecosystem of the market. Using tools far more familiar to market research companies and vendors of fast-moving consumer goods, the HPB wants to make health easier, more natural and mainstream.
Why has not this notion taken root around the world? Mr Zee describes the strong support that health promotion has from the highest echelons of government. In Singapore, the Prime Minister fronts the annual National Healthy Lifestyle Campaign and it is expected that political leaders lead by example — often not just flagging off runs but also taking part.
Asked what lessons the board can offer to other countries, the CEO demurs, saying every country is different.
His parting words, though, are: “Political will is the secret sauce”.
ABOUT THE AUTHORS:
Dr Jeremy Lim is a Founding Member of the ASEAN Non-Communicable Diseases (NCD) Network and Fatimah Z Alsagoff is with its Secretariat. The Network is an informal grouping of healthcare experts with a shared passion and commitment to improving care for NCDs in Southeast Asia.