Tackling low-value care in Singapore: progress, pitfalls, and prospects

1 Introduction

Low-value care, defined as the delivery of interventions for which the added resources do not provide proportionally significant benefits (1), is a major issue for healthcare systems globally. This is particularly the case in Singapore where high levels of private sector provision, and fee-for-service incentives have contributed to concerns about overuse and inefficiency (2). While the concept of value-based care has gained prominence in Singapore (3), specific efforts to reduce low-value care in the past decade have been limited, possibly because healthcare as a percentage of GDP in Singapore remains lower than many high-income countries.

2 Potential drivers of low-value care in Singapore's healthcare system

Singapore is a small nation state with a high-performing healthcare system. Healthcare is widely accessible and consists of dual public-private sectors. Singapore consistently ranks well in life expectancy (84 years), infant and maternal mortality, disability-adjusted life years, and healthcare spending (4.9% of GDP in 2022) (4). However, she faces challenges such as resource limitations including finite space and manpower, and a rapidly ageing population. If healthcare expenditure grows along the current trajectory, healthcare as a percentage of GDP could increase by up to 9% by 2030 (5). Reducing low-value care is pertinent in ensuring sustainability while tackling these hurdles.

Local evidence on the prevalence of low-value care is limited, though studies have documented practices constituting low-value care. For example, an analysis of health screening packages found that 12 of 14 providers offered tests not recommended for routine screening, such as tumour markers, treadmill testing and magnetic resonance imaging (6). Recent multicentre data from public primary care clinics found low guideline concordance among antibiotic prescriptions for upper respiratory infections (7). These examples illustrate manifestations of low-value care locally, although their prevalence across the wider healthcare system has not been systematically characterised.

Mechanisms underlying low-value care in Singapore are also not well established. International literature identifies patient expectations, fear of missed diagnoses, information asymmetry, fee-for-service incentives, defensive medicine, time pressure and organisational factors (8, 9) as potential contributors to low-value care. Some of these mechanisms have also been described in Singapore healthcare research. For example, defensive medicine practices are common in Singapore due to medico-legal concerns (10), and time pressures are a frequent source of stress in clinics and hospitals (11). Organizational and system-level barriers such as lost revenue concerns (12) and inadequate decision-support infrastructure also sustain the continued provision of low-value care. There are also guideline adherence gaps and lack of standardization of care protocols between different places of practice (13). Finally, limited engagement and training in shared decision-making means patients often struggle to distinguish between necessary and unnecessary interventions (14).

3 Progress and pitfalls

Singapore has introduced national and institutional initiatives that aim to increase value in healthcare, although they vary in scope and extent to which reducing low-value care is an explicit objective. The national Value-Driven Care programme was instituted in 2017 and involves employing value-based methodologies to 19 high-impact conditions such as community acquired pneumonia and total knee replacements for osteoarthritis. Reported programme-level outcomes include reductions in adverse outcomes and healthcare utilization such as readmissions and reoperations (15). More recently, the Ministry of Health has positioned Appropriate and Value-Based Care as a broader system-wide priority aimed at ensuring care is clinically appropriate, evidence-based, and sustainable (16).

On the institutional level, the National University Health System has an Appropriate Care programme initiated in 2024 that aims to reduce low-value interventions through periodic educational emails sent to physicians. Singapore General Hospital also has a Value Driven Care team to analyse outcomes and costs for conditions of priority to national healthcare needs and implement best practices. Given the limited published literature describing low-value care initiatives in Singapore, the initiatives presented here are illustrative rather than an exhaustive or systematically identified set of examples.

Existing initiatives focus largely on public, hospital-based care, despite a large proportion of patients seen in primary care and the private sectors, which are areas where low-value care clearly needs to be addressed. Efforts also tend to be “top-down” where authorities implement methodologies or ideas for healthcare staff to follow. There is a lack of patient and public involvement, and behavioural interventions. While programmes such as Value-Driven Care have reported improvements in clinical and utilisation outcomes, there has been limited evaluation of interventions explicitly designed to identify or reduce low-value care as a distinct phenomenon. Empirical research characterising the prevalence, drivers and consequences of low-value care across Singapore's healthcare system remains limited.

4 Discussion—prospects

Healthier SG, launched by Singapore's Ministry of Health in 2023, is a long-term healthcare reform aimed at shifting the focus from hospital-based treatment to preventive and chronic care (17). Central to the initiative is the enrolment of residents with a chosen primary care provider, who develops a personalised health plan. While primarily preventive in nature, Healthier SG also offers opportunities to reduce low-value care. Its financing reforms operate at different levels: public healthcare clusters receive population-based funding, while participating GP clinics receive an annual service fee for each enrolled resident, tiered according to care needs, and preventive and chronic disease management. The latter may help align incentives towards longitudinal and preventive care rather than service volume.

Continuity of care with a regular primary care provider fosters trust, which enhances the effectiveness of right-siting and strengthens the gatekeeping role of primary care. It also reduces GP-hopping, a practice associated with duplicative and fragmented care, while facilitating patient education on the appropriateness and necessity of medical interventions. Preventive services like vaccinations and screenings are subsidised when clinically appropriate. With health plans managed electronically, low-value care metrics could be integrated into provider performance evaluations, further incentivising appropriate, high-value care. However, whether these features translate into reductions in low-value care remains to be established. Evaluation should assess reductions in low-value services alongside appropriate care, patient outcomes, access and equity, while monitoring for unintended consequences such as underuse of appropriate care, reduced access, and widening inequities.

Singapore can also draw lessons on how to reduce provision of low-value care from other high-performing healthcare systems. International examples from England, Australia, and South Korea were purposively selected, rather than identified through a systematic search, to illustrate different mechanisms for reducing low-value care operating across levels of the healthcare system, including evidence-based guidance, clinician-patient shared decision making, monitoring and accountability, and payment reform.

Choosing Wisely campaigns which are implemented in more than 20 health systems globally (18), demonstrate an approach centred on clinician-patient conversations about unnecessary tests and treatments. England's Evidence-Based Interventions (EBI) programme monitors activity for low value interventions and introduces provider and commissioner level targets to reduce provision (19). In Australia, national initiatives such as EVOLVE (20) and Better Care Everywhere (21), identify low-value practices and support clinician behaviour change across disciplines and care settings, while health services research has evaluated potentially unnecessary prescribing across different settings (22). In Asia, efforts specifically targeting low-value care remain limited (23). Broader payment reforms may nevertheless offer relevant mechanisms for addressing overuse. In South Korea, diagnosis-related group (DRG)-based payment has been implemented for selected conditions, partly to address incentives for excessive service provision under fee-for-service payment, with evaluations reporting reductions in length of stay and readmissions (24).

These approaches offer mechanisms rather than directly transferable programmes for Singapore. Their application would need to account for differences in financing, governance and delivery across public and private sectors. Table 1 translates these international lessons into potential implementation strategies for Singapore, specifying the mechanism, potential applications in Singapore Singapore, low-value care targeted, responsible actors and settings, evaluation measures, patient and public involvement, and potential unintended consequences.

Table 1. Potential strategies for reducing low-value care (LVC) in Singapore informed by international approaches.

Given the multiple drivers of low-value care, no single intervention is likely to be sufficient. A coordinated, multi-component approach addressing both supply- and demand-side drivers, supported by sustained policy commitment and collaboration across Singapore's public and private healthcare sectors, is therefore likely to be needed (25). The approaches considered here suggest potential value in combining interventions targeting clinician and organisational practices with patient and public engagement. Evaluation of such strategies could consider their effects on low-value care alongside appropriate care, patient outcomes, access and equity, including potential unintended consequences such as underuse.

5 Conclusion

Singapore has established initiatives promoting value and appropriate care, but low-value care remains incompletely characterised, with limited empirical evidence on its prevalence and drivers. Existing initiatives have largely centred on public and hospital-based care, with comparatively limited attention to primary care and the private sector. Healthier SG introduces financing and continuity-of-care mechanisms that may influence low-value care, although their effects on unnecessary service use remain to be established. International experience highlights potentially relevant mechanisms, including evidence-based recommendations, shared decision-making, monitoring and feedback, and payment reform, but their applicability and effectiveness in Singapore require local evaluation. Further research is needed to establish which approaches are effective and appropriate within Singapore's healthcare context.

Generative AI statement

The author(s) declared that generative AI was used in the creation of this manuscript. ChatGPT (GPT-5.6 Luna) was used in the preparation of this manuscript to support language refinement, editing, and review of the manuscript structure. All content was reviewed and verified by the authors, who take full responsibility for the final manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

Edited by: Le Khanh Ngan Nguyen, University of Strathclyde, United Kingdom

Reviewed by: Sanghyun Ahn, Dankook University Hospital, Republic of Korea