A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Concern #1: Singapore’s workforce is ageing rapidly Singapore’s population is ageing rapidly. The number of older residents aged 65 years and above will double from 440,000 in 2015 to over 900,000 in 2030. Coupled with Singapore tightening foreign labour policy, there is a greater impetus to extend the employability of older workers to sustain the labour demands of the economy. Good health and well-being is important to ensure workers can remain in the workforce as long as they want to. Singapore’s National Health Survey (2010) revealed that older Singaporeans aged 40 to 69 had a higher prevalence of chronic disease than the general population. In particular, transport workers, especially taxi and bus drivers who are on average around 50 years old, fare worse in health than the general population. Concern #2: A significant percentage of older workers in the transport sector remain under-served and have limited access to health Beyond keeping older workers healthy to allow them to remain employable, we can achieve better health outcomes via helping them detect and manage their chronic conditions well through early detection, treatment and control. HPB’s research has shown that companies with mature workplace health promotion managed to save about $390 per employee per year relative to companies that have just started on such programmes. However, past workplace health promotion efforts in Singapore focused on individual companies conducting conventional health activities at central locations and had limited penetration of health programmes beyond office-based workers. There was limited access to health activities in workplaces where it was difficult to accommodate workers scattered across multiple sites, or work shifts. In addition, the use of conventional plug-and-play programmes was unable to sufficiently take into account operational schedules, differing job natures, individual lifestyle habits, and health literacy. To complement workplace health programmes, community health services are provided in the community for older residents. These are however, commonly held over weekends at high-traffic locations like malls, community clubs and residential centres. However, weekends are peak ‘business’ periods for taxi drivers and bus drivers, and taking time out to attend health programmes or even follow-up with a doctor would incur not just payment for these activities, but also income lost from taking time out from work. Given the nature of their work and operational considerations, social media platforms were also not a feasible option to reach out to older workers in the transport industry. Clearly, these hard-to-reach workers who needed health access most were under-served.

B. Strategic Approach

 2. What was the solution?
‘Industry-Specific Solutioning’ through 4R’s: (i) Right Siting, (ii) Right Timing, (iii) Relevant and customised health programmes and (iv) Rapid scale-up to make it convenient for older workers to participate in sustained health promoting activities resulting in behaviour change and health impact . This meant bringing customised health to the doorstep of workers by identifying key contact times, conducting health activities at non-conventional sites at unusual hours, modifying ecosystems to support and sustain behaviours, customising programmes to the needs of older workers and refining programmes through learning from smaller pilots before rapidly scaling-up to the industry.

 3. How did the initiative solve the problem and improve people’s lives?
We identified where these under-served older workers could be found (Annex 1) Through the conduct of landscape analysis across employment and health statistics, we identified seven key sectors to target. These seven key sectors employed 40% of Singapore’s older workers who: are generally of lower-wage and less likely to prioritise health over finances as they need to first fulfil their basic needs have low to moderate levels of health literacy may not work at fixed locations, making it difficult to participate in structured programmes work across multiple shifts with challenging operational requirements and constraints. We leveraged on key influencers to reach out to workers quickly (Annex 1, Step 3) Instead of working alone as a single government agency, we leveraged on three groups of key influencers to “open doors” and act as multipliers: Workers’ unions, especially those supporting workers from security and cleaning sectors who receive little company support and work in dispersed locations. Workers’ unions are influential in getting companies to establish equitable workplace health initiatives. Market leaders within each sector, who employ a sizeable number of older workers and set the benchmark for smaller companies in terms of health and employment benefits. Service buyers such as Town Councils or Schools who employ older workers sub-contracted workers. We work with service buyers to influence demand for workplace health programmes. We increased health access via workplaces by ensuring Right siting and Right timing (Annex 2) Companies in the seven key sectors often find it difficult to implement workplace health promotion efforts due to these workers being scattered across multiple sites, or across different shifts. This initiative increased access by operating around operational constraints: Right siting: Healthcare was provided on-site so that workers could receive timely attention on their abnormal health screening results. This required working with companies to carve out space within work sites, and using non-conventional sites such as taxi repair workshops and supermarket back-of-house storage areas. Right timing: We provided access and convenience by working around operational constraints. We fitted health into the work routine e.g. health screening was conducted at 4am before bus drivers start work; follow-up health coaching was conducted during the monthly taxi servicing downtime and before or after the shift for bus drivers. We addressed real health needs by using Relevant and customised programmes (Annex 2) Rather than implement conventional health programmes intended for the general public, we ensured that critical health needs of these under-served older workers were well addressed. This was achieved through: Conduct of rigorous ground-sensing with workers to understand both age and work-related health concerns. These concerns were then addressed through worker-centric holistic health packages customised for each sector, covering areas such as chronic disease management, functional health, driving ergonomics, vision, hearing and fatigue management. Use of “Learn and Apply” techniques to help break down difficult health concepts for workers, complemented by teaching aids to put theory into practice. Examples include hardcopy health booklets for tracking health goals, ensuring workplace canteens serve healthier food by default, easy adoption through making choices based on healthier choice symbol. (Annex 3) Continuous programme enhancement through behavioural analytics to influence adoption of healthier practices. We reach out to large numbers of workers through Rapid scale-up (Annex 2) Conducting small pilots allowed us to establish important proof-points at both health-impact and operational levels. Such proof-points were used to convince senior management of companies, thereby opening more ‘doors’ for us to rapidly scale-up to the rest of the industry. We have since become the first in Singapore to conduct a large-scale customized sustained health initiative for transport workers.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
We looked through the lens of the older worker We used a person-centric approach through staying close to the ground, walking a mile in the shoes of our older workers through job-shadowing, conducting focus group discussions and in-depth interviews. This allowed us to sense the deeper concerns before customising relevant holistic health packages. Moving beyond programme-centric to operationally-ready models Instead of attempting to forcefully fit plug-and-play programmes, we designed new health packages around operational schedules. We involved worker’s unions and companies from the onset to design sector-specific health models that would fit seamlessly into operational schedules. We then tapped on the Public Transport Tripartite Committee as a lever to push transport companies to adopt these models. Making business sense, not just health sense Companies are ultimately driven by profit margins. An intentional effort was made to translate health efforts into measures on staff engagement, retention and worker productivity. Such value propositions were necessary to persuade companies to invest in workplace health for their older workers. Since the pilot, all local bus companies have co-funded health initiatives as a way to retain their workers and to be seen as a more caring employer.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
As part of the SGD$3 billion Action Plan for Successful Ageing chaired by Singapore’s Ministerial Committee for Ageing, the Health Promotion Board (HPB), Singapore, was tasked to administer the initiative, bringing customised health to the doorstep of older workers across seven key sectors (Annex 1). HPB is a statutory board under the Ministry of Health (MOH), Singapore, aiming to empower the people of Singapore to attain optimal health, increase the quality and years of healthy life and prevent illness, disability and premature death. Through this initiative, HPB has since impacted more than 31,000 older workers in a short span of two years since 2014. By 2025, MOH and HPB aim to impact 120,000 older workers (~10% of Singapore’s current mature workforce) aged 40 and above through customised and sustained health efforts. For more information on Singapore’s Action Plan for Successful Aging, refer to (Annex 6)
 6. How was the strategy implemented and what resources were mobilized?
Element 1: Established clear responsibilities, funding and performance indicators at Ministerial level A strategy paper approved by the Ministerial Committee on Ageing spelt out the key tenets of the “Workplace Older Workers’’ Health Programme” including HPB’s role as Programme Manager and approved a government budget of SGD$29 million over 10 years to ensure older workers in the identified sectors would receive customised health programmes. As Programme Manager, HPB is responsible for delivering on key performance indicators to MOH on a 6-monthly basis, as part of a clearly established performance management and accountability framework. The indicators monitored include: Number of unique older workers impacted Number of companies which adopted interventions Tracking of improvement in workers’ health biometric indicators Element 2: Developed human capital to meet industry demands We conducted industry briefings with workplace health consultants and service providers to understand their current capabilities and identify gaps. It was noted that service providers were (i) only used to conducting general population mass market activities and did not have content knowledge especially in health needs associated with aging (ii) not equipped to implement high impact activities such as health coaching with sustained follow-up (iii) unable to find suitable manpower to conduct on-ground activities To address gaps related to points (i) and (ii) in service provision, HPB conducted compulsory training sessions to up-skill service providers and developed toolkits incorporating information on both age and work-related health needs. Further, to address gaps relating to point (iii), HPB is working upstream with educational institutions and re-employment agencies to groom a pipeline of trained manpower to meet the growing demands for workplace health services. Element 3: Determined programme funding cost We conducted a landscape sweep to determine existing market prices to develop and deliver targeted programmes for older workers. This was benchmarked against high-impact programmes in the community and in clinical settings. As a result we derived a subsidy cost of $200 per worker.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
For a flowchart of stakeholders involved, see Annex 1 Aging Planning Office: Oversees initiative Singapore’s Ageing Planning Office is the Secretariat of the Ministerial Committee on Ageing. It oversees and provides guidance on the delivery of this health initiative, as well as monitors achievement of performance indicators by HPB. Health Promotion Board: Implements initiative HPB is the appointed Programme Manager, with a team of seven officers leading the implementation of this initiative. It is the main agency to design relevant holistic health packages, building in-roads with downstream stakeholders (unions and companies) and service providers for implementation, and ensure that the initiative is rolled out to workers. Unions: Bridge between companies and HPB HPB collaborates with workers’ unions in Singapore to publicise initiatives to companies. The unions also act as a platform for sharing of best practices to influence companies in establishing equitable health initiatives. Private Sector Companies: Co-implements initiative Companies act as co-implementers of the initiative together with HPB, advising on operational needs and managing day-to-day ground efforts. For example taxi company, ComfortDelGro has since scaled-up the initiative to all their taxi service centres island-wide and has been running the programme on its own. Workers: Co-design initiative HPB ensured the workers could act as co-designers of programmes. Candid feedback from workers during focus group discussions were critical in the design of relevant programmes, by informing HPB on their health worries and needs.

 8. What were the most successful outputs and why was the initiative effective?
At population level: Benefiting large numbers of older workers The initiative impacted more than 31,000 older workers in a short span of 2 years. We expect another 12,000 to have participated by March 2017. Aggressive outreach to the companies resulted in HPB reaching workers from all seven key sectors. At industry level: Workplace health is now a norm for companies in the transport industry In two years, we have piloted and scaled-up the health programmes for taxi and bus drivers, from 2 to 5 taxi service centres across 3 taxi anchor players collectively covering 80% of the market, and from 3 to 24 bus interchanges across all 4 public transport operators covering 100% of the market. We have also garnered commitment from all rail transport companies and major supermarket chains in Singapore to implement the initiative for rail and retail workers respectively. At company level: Equipping companies with skills to sustain workplace health initiative Companies were equipped to expand pilot success to a larger scale, with the desired outcome of reaching out to all employees. Sustainability frameworks were also in place to ensure that impact would be maintained beyond the first year of implementation (Annex 5). Companies now have at least one personnel equipped with the capability to manage the day-to-day on-ground implementation of the initiative, in order to build long-term ownership. At worker level: Workers’ see real improvements to health Participants benefited from improved access to workplace health programmes because of greater inclusiveness. They have also improved based on measurable health outcomes. For example, attributing his health improvements to health coaching sessions brought down by HPB to his company, 67-year-old bus driver Mr Lee achieved his weight goal of 60kg, lowered his blood pressure and brought his cholesterol level down to normal over a span of 9 months. He now makes better food choices and practices stretches in between shifts. See Annex 5 for overview of impacts made with workers. For more testimonials, view Testimony to the initiative’s effectiveness, HPB was awarded ‘Most Innovative Project/Policy (Gold Award)’ in 2016 by the Singapore Public Service, standing out from more than 100 entries. The initiative was well covered with at least 77 media mentions, resulting in increased interest in workplace health by companies who did little or none before. Citizens’ confidence in the public service is enhanced when they view us doing sincere real work impacting the under-served.

 9. What were the main obstacles encountered and how were they overcome?
Scarce nursing manpower To prevent taxing Singapore’s scarce nursing manpower, we grew a new pool of health coaches from non-medical staff. This was a planned and measured attempt at training non-medical staff for health promotion roles with the view of addressing the shortage of medical staff. This new pool of non-medical staff were trained in both health and motivational interviewing, to ensure that they were equipped in both hard facts and “heart wear”. Allocation of limited manpower and resources With a head count of only seven staff, we found multipliers to push the same agenda by working with new stakeholders such as workers’ unions and service buyers. To prioritize workers who need most attention, a health risk stratification system was developed to provide different pathways for those with different health risks, ensuring that those who needed more support, were able to receive it. Obtaining buy-in from workers Not being used to having such “health benefits”, the older workers were often sceptical when they first encountered the health initiative at their workplaces. For example, 20% of bus drivers waited for more than two months to take part before wanting to participate in their first workplace health activity. We had to create a notable presence of health coaches at their work site, for a sustained period for often at least six months for older workers who took a 'wait-and-see' approach. This allowed on-ground health coaches the opportunity to convince the workers to participate, and build rapport with them.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
At an individual level: By bringing activities to the workers so that they do not need to take time off work, travel to another place or pay for it, we saw higher participation rates and follow-up compared to programmes in the community setting. Of the 3,000 taxi and bus drivers in the pilot health programme, 50% discovered they had chronic disease during health screening. Their condition would otherwise have gone unnoticed if we had not brought this programme to them. Further to this, about 50% of those with abnormal health screening results improved in at least 1 chronic condition one year later as measured through a pre-post health screening. More importantly, 1 in 4 workers improved from abnormal to normal health status. To help these workers benefit from other efforts by the Singapore Government, we incorporated such information into our initiative and built pathways for workers to sustain their healthy living endeavours. For example, as bus drivers are highly sedentary due to their nature of work, physical activity was incorporated as part of the HPB workplace health initiative for bus drivers. In addition, HPB also collaborated with ActiveSG (an all-encompassing and inclusive national movement for sport providing exercise programmes and facilities nation-wide) to orientate workers to nearby ActiveSG sports facilities and helped workers activate their free ActiveSG credits to access community-based exercise programmes. At a family level: We are beginning to see a ripple effect of influence as these workers bring their newly learnt health knowledge home and share it with their families. For example, Mr Nordin, a cleaner, told his wife to cook brown rice at home after learning it from the health coach situated at his workplace. Now his whole family, including his children, have brown rice during meals. At a company level: We deliberately groom companies to take on ownership for planning and running the health initiative at their workplace for long-term sustainability. When working with a new company, HPB not only invests effort in managing the programme but also concurrently guide companies in how to co-lead it. Our companies have quickly progressed from the 'learn and observe' stage in the first year to the 'co-leader' stage in the second year in preparation to finally drive the programme on their own thereafter. For example, transport company ComfortDelGro was a passive observer in its first year, relying entirely on the manpower resource and expertise from HPB to implement the health initiative. By the second year, they transformed into a co-leader, with a dedicated personnel to implement the initiative, built multiple health centres at taxi servicing workshops, and created a Learning Factory. In addition, they also set aside dedicated funding for the initiative. This will allow generations of taxi drivers in ComfortDelGro to continually benefit.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Increasing awareness on women’s health In female-dominated sectors like cleaning, mammograms and pap smears were introduced for early detection. Topics like menopause were also integrated into the holistic health package. Building self-efficacy As many of our participants had little education, they enjoy participating in health activities. We ensured on-ground staff were trained in both technical and communication building skills. This translated into testimonials where workers shared their appreciation on learning something new and also feeling valued. Reducing barriers to follow-up With income dependent on number of trips made, time is money to taxi drivers. Drivers defer follow-up for critical chronic conditions, not just due to direct treatment costs but also the waiting time to see a doctor. Incentive packages pegged to vehicle rental rate were established to cover such costs for drivers who followed-up with a doctor within 24hours. Our staff also explained healthcare financing schemes face-to-face to workers through workplace programmes to help them navigate the often-complicated health system.

Contact Information

Institution Type:   Public Agency  
Contact Person:   PREMA GOVINDAN
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Institution's / Project's Website:  
Postal Code:   168937

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