Structural characteristics of the LTC system, impact of the pandemic, measures adopted and new reforms
This country profile brings together information on the experience of the long-term care sector (focussing on people who use and provide care) during the COVID-19 pandemic in Singapore from a living international report on COVID-19 Long-Term Care. It also provides links to research projects on COVID-19 and long-term care, to key reports, and lists key experts on the impacts of COVID-19 on the long-term care sector in Singapore.
Experts on COVID-19 and long-term care in Singapore that have contributed to this report:
Kai Leichsingering, Andrea Schmidt
Living report: COVID-19 and the Long-Term Care system in Singapore
PART 1 – Long-Term Care System characteristics and preparedness
- 1.01. Population size and ageing contextIn 2021 there are 5.4 million people living in Singapore, of whom 3.9 million are residents (comprising 3.5 million Singapore citizens and 488,700 permanent residents). Singapore’s population is ageing rapidly, in the population aged 65 and over was 639,000 (15.9%) out of its 4 million resident population. This is expected to rise to 23.8% of the population of residents by 2030. Sources: Department of Statistics Singapore
- 1.02. Brief description of the Long-Term Care system
Singapore’s approach to Long-Term Care (LTC) focuses on integrated care and active care management and coordination, aiming to reduce unnecessary utilization of institutional care. The approach is nested with an overarching Action Plan for Successful Ageing, as part of a policy shift towards a population health approach.
Singapore’s LTC policies are based on the principle of ‘Many helping hands’ that calls for individuals, families, communities, civil society, the private sector, and government to all play a role in ensuring the wellbeing of older people.
The system is designed with the aims of maximising prevention, promoting individual and family responsibility and reduce inefficiencies, with LTC as part of a wider integrated system covering public health, primary care, acute care, rehabilitation and long-term and palliative care.
- 1.03. Long-term care financing arrangements and coverage
Financing for LTC and support to older adults exists within an overall health-care financing that, in turn, is linked to the way in which social care and pension funding is organized. There are three complementary insurance schemes for disability cover: ElderShield and ElderShield Plus, and CareShield. ElderShield is a severe disability insurance scheme under which all citizens and permanent residents born before 1979 who have a MediSave account are automatically covered from 40 years of age (opt-out is possible). To be eligible for the scheme, individuals must be unable to carry out at least three out of six basic activities of daily living. ElderShield Plus offers higher monthly payouts or payouts for a longer period or a combination of both. CareShield Life is a compulsory insurance policy introduced in 2020 that provides payouts for people who are severely disabled. Everyone born between 1980 and 1990 is enrolled automatically and younger cohorts will be enrolled as they turn 30. Another funding scheme introduced in 2020, ElderFund, provides financial support for low income, severely disabled Singaporeans. Additional subsidies and schemes exist to finance LTC. Some schemes focus on financial support to informal caregivers and home-based care (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf).
- 1.04. Long-term care system governance
The Ministry of Health is responsible for governance over the entirety of the health and LTC systems, including setting policy direction, projection of national-level service demand, health and LTC financing, regulatory frameworks, standards, oversight, and coordination of related bodies. The Aging planning Office is responsible for setting policy direction and implementation for successful aging across sectors; Agency for Integrated Care is responsible care integration for health and social care systems (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf).
- 1.06. Approach to care provision, including sector of ownership
LTC in the community is mostly provided informally by family and surrogate carers. Formal community services (e.g. day care) and residential care are largely provided through Voluntary Welfare Organisations or Social Service Agencies. In 2019, Singapore had 7,600 day care places, 10,300 home care places, 1,986 community hospital beds and 16,059 nursing home beds. Of the available nursing home beds, 75% were supplied through the Social Service Agencies and the government and 25% through private providers (source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
- 1.07. Care coordination and personalization
Care integration is high on the policy agenda in Singapore. For example, to facilitate integrated delivery of support and services, Singapore has consolidated aging, health, and LTC under the Ministry of Health (MOH) with inter-ministerial remits, where relevant (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf).
The Agency for Integrated Care has taken on the role of a National Care Integrator in 2009. It is the agency’s role to match people with LTC needs with available services. The agency further is ‘responsible for supporting community care service partners in manpower development, quality improvement, programme development, and crisis management’.
In 2012, a Regional Health System model was introduced by the Ministry of Health to support the provision of ‘seamless integrated care based on geographic location’. This model facilitates local collaboration and transition between care settings and has been reported to strengthen management capabilities and continuity of care. Key actors are designated anchor public acute hospitals as well as ‘primary, chronic health and social care’ services in the different geographic areas (source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
- 1.09. Care home infrastructure
Singapore relies heavily on community-based care, however older adults who cannot receive care appropriate for their needs at home are able to seek accommodation in a LTCF. Singapore has over 16,000 LTCF places as of 2019 of which 40% are run by the government, 37% by non-profit organisations and 23% by the private sector (source: ageingasia.org).
- 1.10. Community-based care infrastructure
Singaporean LTC relies heavily on home-based and community care services and aims to reduce unnecessary utilization of institutional care (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf). In 2019, there were 7,600 day care places, 10,300 home care places and 1,986 community hospital beds in Singapore (source: Analysis of variable COVID-19 mortality among older people in Asia Pacific, by forms of long-term care (ageingasia.org).
There are different types of day care services in Singapore. These include: ‘senior care centres, day rehabilitation centres, general and enhanced dementia day care and day hospices’. Home care services for bed-bound older people living in their own homes include ‘medical, nursing, therapy, personal care and hospice’ are. In addition, there are meals-on-wheels services and Medical Escort and Transport Services available. Community hospitals offer short-term (2-4 weeks) rehabilitative inpatient care for people who experienced acute medical care needs. It is their role to facilitate transition back into the community (source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
- 1.11. Workforce conditions: pay, employment conditions, qualification levels, shortages
The country operates with shortages of workers in LTC sector, which poses challenges to staffing facilities (source: Responding to COVID-19 in Residential Care: The Singapore Experience – Resources to support community and institutional Long-Term Care responses to COVID-19 (ltccovid.org).
- 1.14 Pandemic preparedness of the Long-term care sector
Singapore drew many lessons from the SARS-CoV outbreak of 2002, which exposed the ill-preparedness of the country to deal with pandemics. Following the 2002 outbreak, the government established 900 rapid response public health preparedness clinics (PHPCs) across the country, ear-marked for improved response to pandemics and outbreaks. The PHPCs serve as an intermediary between the community and hospitals, screening all patients with flu-like or pneumonia symptoms into low-risk and high-risk groups. The high risk group is referred to an infectious disease hospital for further assessment and management (https://www.liebertpub.com/doi/10.1089/omi.2020.0077).
PART 2 – Impacts of the COVID-19 pandemic on people who use and provide Long Term Care
- 2.02. Deaths attributed to Covid-19 among people who use and provide Long-Term Care
As of January 24, 2021, there had been 59,308 cases of COVID-19 infection (the majority, 54,508, in dormitories of migrant workers) and 29 deaths (Source: https://www.moh.gov.sg/covid-19/situation-report). As of January 24, 2021, there have been 4 COVID-19 related deaths in nursing homes, which represents 12% of all deaths. There are 16,059 nursing home beds in Singapore. Therefore, the number of COVID-19 related deaths in nursing homes would represent 0.02% of all beds (Source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
PART 3 – Measures adopted to minimise the impact of the COVID-19 pandemic on people who use and provide Long-Term Care
- 3.01. Brief summary of the overall pandemic response (not specific to Long-Term Care)
Singapore has put in place a multi-pronged strategy with an emphasis on epidemiological surveillance, case finding, testing, mandatory reporting, contact tracing and containment.
There is a strict isolation policy for people who test positive. If they are clinically unwell according to a set clinical protocol, they are hospitalised. If they are clinically well are housed and cared for in designated community isolation facilities. These community facilities include hotels, army barracks, stadiums, and exhibition halls which have been repurposed. Clinically well individuals are closely monitored by designated healthcare professionals at these facilities.
Extensive contact tracings done for all positive cases, in April 2020 there were more than 1,300 Singapore Armed Forces personnel and civilians deployed to contact tracing. This is complemented with the use of technology.
The country has a Disease Outbreak Response System Condition (DORSCON) framework. The severity of an outbreak and associated actions are highlighted through a colour-coded system
- 3.02. Governance of the Long-Term Care sector's pandemic response
The long-term care sector in Singapore was first advised on January 23, 2020, against traveling to Wuhan (China) (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
- 3.02.02. Measures to improve coordination between Health and Social Care in response to the pandemic
The Regional Health System model, and the collaborative relationships that were formed through this model prior to the COVID-19 pandemic, was reported to have contributed to the ‘allocation and sharing of infection control resources and training, and the safe transfer and management of patients between acute and community care settings’ (Source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
- 3.06. Support for care sector staff and measures to ensure workforce availability
Singapore recognised the limitations of their lean workforce in residential LTC and the need to protect it. ‘The implementation of split zones and full contact precautions’ protected facilities from acute staff shortages.
To ensure the functioning of split zones, housing was organised for LTC workers who shared accommodation with staff assigned to different zones, workers in different (health and LTC) care settings, or in dormitories that did not allow for safe distancing. Many care workers working in nursing homes lived in hotels and serviced apartments, others lived on-site (adhering to split zone arrangements) between April 7 and June 1, 2020, during the Circuit Break period. The government paid for meal delivery and dedicated transportation between home and work. Health and LTC workers that were moved into temporary accommodations received $500 to facilitate the transition.
In addition to public recognition, the workforces received care packages and message of support from care facilities and could access ‘professional counselling and emotional support services’. (Source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
- 3.07.01. Measures in relation to transfers to and from hospital, from community to care homes and between settings
As the DORSCON level reached orange in February 2020, elective surgical procedures and non-essential health/dental services were suspended. Hospitals continued to discharge residents to nursing homes throughout the Circuit Breaker period. The referrals were coordinated by the Agency for Integrated Care. At first, residents could be discharged if they did not have an acute respiratory infection and COVID-19 related symptoms. Those with an acute respiratory infection or pneumonia were required to provide a negative test. In May the policy changed as knowledge of asymptomatic COVID-19 increased. From then onwards, all patients discharged from hospital to nursing homes had to be tested (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
- 3.07.02. Approach to isolation of people with confirmed or suspected Covid-19 infections in care homes
In comparison to other countries, there were only very few cases in nursing homes in Singapore. All of the residents with COVID-19 were transferred to acute hospitals.
Nursing homes introduced mandatory split zones to reduce the number of contacts for residents and staff. The zones cannot house more than 100 residents, a fixed set of staff and need to have dedicated entry and exist points. Communication between staff in different zones should take place remotely via text messages, phone or video conference. Shared spaces, such as pantries and lifts should have staggered access that allows for cleaning between the use from different zones. Medical staff needing to move across split zones are recorded for contact tracing and have to adhere to increased infection prevention and control measures (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
- 3.07.03. Care homes: visiting and unpaid carer policies
In-person visits to nursing homes were suspended for just over two months during the Circuit Breaker Period (April to June 2020). In July 2020, nursing home residents could ‘receive one of two designated visitors for 30 minutes each day.’ Visitors have been asked to make appointments so that nursing homes can manage the number of people present (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
In response to the national situation, visiting guidelines are regularly updated. When there are increased cases in the community, guidelines are adjusted and updated, lowering the number of visitors that a resident can receive from two to one per day. Outings are not permitted for residents following an inpatient hospital stay. As of June 2021, there is currently no mandate for visitors to be vaccinated (https://ltccovid.org/2021/08/05/current-situation-in-relation-to-visiting-in-care-homes-and-outings-for-residents-ltccovid-international-overviews-of-long-term-care-policies-and-practices-in-relation-to-covid-19/)
- 3.07.04. Deployment of "squads" or rapid response teams to support care homes with outbreaks or staff shortages
If a resident in a nursing home receives a positive COVID-19 test, a COVID-19 Incident Response Team (CIRT) is called in immediately by the AIC. These response teams consist of ‘representatives from the nursing home, the supporting regional hospital, the Ministry of Health, the Agency for Integrated Care, National Public Health Laboratory as well as the National Centre for Infectious Diseases. The response teams work on containing the number of positive cases, stepping up infection control, carrying out swabbing and testing operations, contact tracing, heightening vigilance (health monitoring of staff and residents), communicate with residents’ relatives and media, develop a service continuity plan and maintain adherence to the IPC measures, ensure workforce recovery after quarantine (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
- 3.08. Access to testing and contact tracing for people who use and provide Long-Term Care
In April 2020 Singapore started routine testing of residents who showed COVID-19 relevant symptoms. At the end of April 2020 routine testing of all staff and residents began. Testing and follow-up treatment for those with positive results identified through this surveillance mechanism were provided for free by the government.
In addition, the Ministry of Health and the Agency for Integrated Care have ‘worked with the regional hospitals to train nurses in care facilities and nurses in three home care providers in testing and to support the development of ‘mass swabbing workflows’. The Agency for Integrated Care took on the coordination of sending the samples to the National Public Health Laboratory (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).
- 3.09. Access to Personal Protection Equipment (PPE) in the Long-Term Care sector
Already in 2018, Singapore introduced National Infection Prevention and Control Guidelines for Long Term Care Facilities. In addition, the Agency for Integrated Care provided webinars to review practices outlined with care providers and to provide up-to-date guidelines. In addition, the Ministry of Health issues current advisories.
The Agency for Integrated Care also drew on the national stockpile to ensure that all nursing homes, irrespective of provider, had sufficient levels of PPE. The supply of PPE was provided based on ‘the facilities’ staff size and level of precaution required of specific care services’.
- 3.11. Vaccination policies for people using and providing Long-Term Care
Covid-19 Vaccinations have been voluntary for the whole healthcare sector (and country), but Care Providers proactively educate their staff and regularly report vaccination rates. As of Mid-February, already 73% of healthcare workers had been vaccinated with at least 1 dose (the vaccination campaign started around Mid-Jan, so the coverage is likely much higher now) (https://www.moh.gov.sg/news-highlights/details/progress-of-covid-19-vaccination-programme/).
On the 3rd September 2021, the Expert Committee on Covid-19 Vaccination recommended that people aged 60 and over, as well as those who live in aged care facilities, should receive a booster dose of an mRNA vaccine six to nine months after the completion of vaccination with two doses.
PART 4 – Reforms to strengthen Long-Term Care systems and to improve preparedness for future pandemics and other emergencies
Printable version of this country profile:
To cite this report:
TBC. LTCcovid country profile – Singapore. In: Comas-Herrera A., Marczak J., Byrd W., Lorenz-Dant K., (editors) International living report on COVID-19 and Long-Term Care users and providers: context, impacts, measures and lessons learnt. LTCcovid, Care Policy and Evaluation Centre, London School of Economics and Political Science. Available at: https://ltccovid.org/country-questions/
Most recent LTCcovid report for Singapore (July 2020):
Acknowledgement and disclaimer
This report has been initially developed by the team working on the Social Care COVID Recovery and Resilience project and questions will be added to and validated by LTCCovid contributors who are experts on Long-Term Care in their respective countries. This study is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.