Putting the Nation in Singapore’s NPM Programme
By 2030, around one in four citizens in Singapore, or 23.8%, will be aged 65 and above. Naturally, when it comes to planning for the healthcare system, the implication of a rapidly ageing population is significant.
Professor Kenneth Mak, Director-General of Health (DGH), Ministry of Health, explains the intricacy involved in ensuring the resilience and robustness of Singapore’s healthcare system and how the National Precision Medicine (NPM) programme plays a part in this strategy.
What are some opportunities precision medicine offers to Singapore’s healthcare system?
As Singapore has more and more people filling up the age pyramid’s upper tiers, we can expect a greater incidence and prevalence of chronic diseases like diabetes, hypertension, hyperlipidemia as well as cancers, strokes and heart diseases. Additionally, seniors are increasingly frail with age, making them more vulnerable to falls and illnesses. Stressors in everyday living could also negatively impact their mental health.
Cumulatively, these factors increase the burden on our healthcare system—and precision medicine presents the potential for us to focus on effective and cost-efficient interventions that can stem this steady progression. For example, if we can identify those who are at higher risk of health problems or at risk of early deterioration, we could try to intervene and stave off their need for more care later on.
On the other hand, precision medicine allows us to apply more targeted interventions and treatments so that instead of providing the whole basket of treatments to a patient in the hope that something works for the patient medications and treatments providing the greatest benefit is offered. In this process, we not only reduce harm from side effects but also ensure that there is less waste in the system.
What is the significance of starting Singapore’s very own genomic bank in our journey towards embracing precision medicine?
We recognised early on that building Singapore’s own genomic bank is an essential starting point for getting the most out of precision medicine. Referencing countries who were ahead of us, we saw that much of the work done in the genomic research space took place outside Asia. Although there was a small representation of Asians within these biobanks, the research findings, insights, and recommendations predominantly catered to the western population. This means that treatments developed from these studies and promulgated as best practices in standards of care are orientated towards them.
It is questionable whether these same strategies will benefit Asians, and more specifically Singapore. But to validate them, it is necessary to have comparable information that is relevant to our demographics—which even our Asian counterparts in Thailand, Hong Kong, Japan and China could not exactly offer because populations in many of these countries are homogenous. This is where we found that Singapore’s diverse ethnic make-up—despite our small size—could actually provide useful new insights to ethnic populations that other biobanks couldn’t.
We understand you were intimately involved in SG10K. Can you share with us how the work done paves the way for SG100K and contributes to the NPM journey?
When we first embarked on the NPM programme, we had the ultimate goal of creating a healthcare system and society that could leverage the advantage of precision medicine. But before that can happen, we needed to first think through the ethics to understand what was acceptable to explore and what was not, put in place the appropriate regulations to protect the interest of the population and enhance the healthcare industry’s understanding of precision medicine. Hence in SG10K, we scripted the strategies by starting these important conversations—many of which have continued in the SG100K study.
As a first step, we amalgamated various bio-diverse repositories, tissue banks and genomic registries in Phase I. Then in Phase II (SG100K) now, we are looking to strengthen the foundation established in Phase I in a logical and natural manner by scaling up efforts and mainstreaming initiatives that were started as pilots in SG10K. These efforts lead us towards establishing a robust infrastructure and support system in preparation for Phase III.
Notably, in Phase II, we are also testing out the rudimentary structure and framework built in Phase I by looking into how the early research conducted can be applied and brought from bench to bedside—as well as empower Singapore to harness the potential and promise of precision medicine.
How does the NPM programme complement our aspirations for a Healthier SG?
At the end of the day, precision medicine is about making use of genetic and medical information from individuals and applying treatments that offer the best value. From the population perspective, this is highly relevant. Given our limited resources, how can we deliver the best care for as much of the population as possible in a manner that is cost effective?
We are always looking out for opportunities to improve our resourcing planning while mitigating costs when it comes to dealing with these health issues. For instance, some of our hard work in Phase I has started to translate into clinical application in the way diseases are diagnosed or treated in specific use cases. But, as a next step, we are interested to see how we can scale that by employing the same underlying principles for wider implementation and appraising both clinical as well as cost-effectiveness.
We are acutely aware that the treatment giving the best clinical outcome could also be more expensive or cause the cost of care to escalate. Therefore, it is critical that we define and analyse how each initiative provides value to the nation and adds to our Healthier SG aspiration—in the long run.
How far along are we in the NPM journey to realising prospective benefits?
We are certainly on the right track with good forward momentum now. But to fully realise the benefits from precision medicine, there are a few areas we will need more work on.
While the awareness of precision medicine is significantly higher now within the healthcare domain than when we first started on the NPM journey, there is more we can do with regards to education, training and building competencies. One such specific space is in our healthcare educational institutions. With the understanding that precision medicine will play an increasingly important role in the future, it is critical to look into the curriculums and embed the knowledge early—so that future healthcare professionals are better positioned as well as more confident in embracing these technologies and advances.
Another important aspect is the education of different industry and sector partners. An example is the insurance sector. In many conditions, having a gene mutation does not mean that a certain disease trajectory or adverse clinical outcomes will follow. That is why we have brokered an understanding with healthcare insurance partners in Singapore to not discriminate based on findings from genomic research. Similarly, we need other stakeholders to understand the same and conduct themselves in a responsible manner.
Finally, it is important to reach out and educate the general public on the benefits of precision medicine, and just as importantly, the dangers of irresponsible use of precision medicine and new genomic technologies.
[1] Population in Brief 2022 (September 2022). https://www.strategygroup.gov.sg/files/media-centre/publications/Population-in-Brief-2022.pdf