Webinar: Healthy ageing and adult vaccination in Singapore and Hong Kong

Healthy ageing and adult
vaccination in Singapore and
Hong Kong
Join the conversation: @ilcuk
#HealthyAgeing

Welcome and
introduction from Chair
Susana Harding, Senior Director, ILC
Singapore
#HealthyAgeing

Presentation: Singapore
perspective
#HealthyAgeing

Dr Ng Wai Chong
Clinical Programme Consultant,
Tsao Foundation,
CEO, NWC Longevity Practice Ltd
#HealthyAgeing

Findings from ILC Singapore Public Seminar and Roundtable Discussion
14 - 15 Oct 2019
Policies and Practices, Challenges and Way
Forward for Older Adult Vaccination in Singapore
Dr Ng Wai Chong
1 Oct 2020

© All Rights Reserved
• Roundtable discussion conducted on 15 Oct 2019, representatives
from
• Public-sector and private family medicine clinics
• Public-sector (‘Restructured’) hospitals
• Geriatricians
• Infectious Disease Physicians
• Intermediate and Long Term Care sector
• Public Health Practitioners
• Non-profit Sector
• Rsearch and policy workers

Policies and Practices
• National Adult Immunisation Schedule established in Nov 2017 by
MOH
• Medisave500 scheme
• FlexiMedisave
• Non-mandatory
• Individuals own the responsibility; advised, recommended and
prescribed by doctors
• Enhanced subsidies starting 1 Nov 2020

Eligibility PG MG/CHAS Blue and Orange CHAS Green/ Non-CHAS
INF (tri or Qua-valent) S$9 S$18 S$35
PCV13 S$16 S$31 $63
PPSV23 S$10 S$20 $40
MMR S$9 S$18 S$35
Hep B S$9 S$19 S$38
Source: https://www.moh.gov.sg/resources-statistics/nationally-recommended-vaccines

Challenges
• Low uptake
“In each clinic, we cater to 60-70k patients; however, we only vaccinate around 2-5% of
these patients against influenza and pneumoccocal disease”
• 2016/2017 est. 12% and 14% of adults 65-74 received pneumococcal and influenza
vaccines respectively
• Low public awareness
“we don’t have a culture of vaccination. It’s a good to have, rather than a must have.”
• Survey of adults 21-70 yrs, 20% reported willingness to consider vaccination against
influenza or dengue
• Singaporean study on HCW found many wrong beliefs that influenza vaccine can lead
to influenza, vaccination is not efficacious; they are not vulnerable to influenza etc

• Underuse of allied health professionals
“Doctors are the worst at asking patients to do extra things as they are so busy.”
• Pharmacists and nurses are most often the ones to recommend vaccinations.
Legislation does not allow them to prescribe.
• A lack of data
“Is it better to over or under vaccinate?”
• Vaccination history sit in multiple medical records silos across private, public
and charity silos, NEHR notwithstanding, challenging informed policy
decisions.

Way Forward
• Investing in financial incentives and care packages to overcome
financial barriers to those most at risk
• Investing in top down and bottom up educational efforts to normalise
adult vaccination and improve health literacy:
• regular public education campaigns,
• older ambassadors,
• increased training and simplified guidelines for HCW

• Expanding use of team-based models of working to divorce patients
from a GP-centric view of healthcare, while investing in allied health
professionals to play a greater role
• Expanding to scope of national data collection on adult vaccination to
better inform policy and medical decisions on adult vaccination.

Special thanks to Participants of the Roundtable
• Dr Ng Wai Chong (Moderator, Tsao Foundation)
• Dr Mark Chan (TTSH)
• Dr Christopher Chong (NHGP)
• Dr Elaine Chua (Bedok Medical Centre)
• Ms Susana Harding (Tsao Foundation)
• Dr Chia Tee Hien (SLH)
• Dr Kala Kanagasabai (Ren Ci CH)
• Ms Low Mui Lang (Peacehaven Nursing Home)
• Dr Lim Poh Lian (TTSH)
• Dr Edwin Lim (Tzu Chi Foundation Singapore)
• Dr Chikul Mittal (Tsao Foundation)
• Dr Barbara Rosario (CGH)
• Dr Mary Ann Tsao (Tsao Foundation)
• Dr Hsu Li Yang (NUH)

Response on Singapore
perspective
#HealthyAgeing

Yeo Wan Ling
Director of Women and Family Unit,
National Trades Union Congress (NTUC)
#HealthyAgeing

Presentation: Hong Kong
perspective
#HealthyAgeing

David Sinclair
Director, ILC-UK
#HealthyAgeing

Key findings
• The health system focussed on cure not prevent
• There are relatively few public primary care services to meet the
needs of its ageing population
• A greater focus on preventing ill health is happening but the
approach is not strategic or holistic
• Adult vaccination is an important element of preventative
healthcare, however, uptake rates are low

Approach
Desk research
13 interviews with experts on ageing and
health in Hong Kong in March 2019
The views remain ILC’s
“When I first started
looking after older
people they weren’t
so old”

Hong Kong is wealthy
BUT
30% of people aged 65 and
over classed as in poverty
in Hong Kong

“It’s not easy to die in Hong Kong”
image goes here
In 2014, 15% of the population
was 65 and over, a figure which
will more than double by 2064
Life expectancy sits at 84.7
years, the longest life
expectancy of local citizens in
the world
A consistently low fertility rate
over the past twenty years

Hong Kong isn’t ageing well
• Chronic health conditions have been diagnosed
in 44.5% of 55-64 year olds and 74.3% of those
65 and over.
• Chronic illness is being experienced at an
earlier age by later population cohorts.
• The number of people aged 60 and above with
dementia will increase by 222% between 2009
and 2039, with a large proportion of those
living in institutions.

And healthcare is very good
Health system has been ranked as the
most efficient in the world.
But it is coming under increasing strain as
the population ages.
More older people means more spending
projected on health

Prevention – a missing part of the picture
Hong Kong’s healthcare system is currently
organised to focus on curative care
Underinvestment in public primary care has
resulted in inadequate services being available in
the community.
Only 73 public general outpatient clinics exist in
Hong Kong to provide primary care to its
population of nearly 7.5 million people.
The public primary care shortage is increasing
pressure on A and E departments as they become
the primary health contact point for those unable
to afford private healthcare

And there aren’t enough primary care staff
In 2017 it was reported that there were
just 1.91 doctors for every 1,000 people.
By 2030, it has been projected that a
shortfall of 1,007 doctors and 1,669
nurses will exist.
While foreign healthcare professionals
could potentially fill these gaps, this is
made more difficult by strict registration
requirements.

Many people pay privately for health
High levels of out-of-pocket (OOP) spending exist, despite
the existence of subsidised healthcare, as people pay to
access private practitioners based in the community.
In 2015/2016, OOP spending represented 34.6% of
total health expenditure in Hong Kong.
However, not all older people are able to afford these
payments which is putting greater pressure on Accident
and Emergency departments as these wards become
the primary health contact point for many people.
In the public sector, 46.8% of hospital admissions of
older adults are ambulatory care sensitive conditions
which could be dealt with in primary, community or
ambulatory care settings.

“We have a lot of money so can do a lot of
pilot projects”
In 2009, the Department of Health funded an ‘Elderly Health Care Voucher Scheme’ to shift
demand for primary care services over to the private sector
Under the scheme, people aged 65 and above are given an annual amount of HK$2,000
(£200) to spend on primary preventative services
But
• low enrolment by private medical practitioners (32.4%)
• an uneven distribution of those who have enrolled
• Vouchers are used to manage acute episodic conditions rather than for preventive
services
• the scheme is being abused by some health professionals who charged more for services
paid for with vouchers.
• the government collects data on how the Elderly Health Care Vouchers are being used, but
does not actively monitor the data to see if the scheme is having the desired effect on the
uptake of preventative services.
• Communication campaigns on the Elderly Health Care Vouchers have not occurred.
Interviewees suggested that this had resulted in many older people being unaware of the
scheme, and contributed to the use of the vouchers for non-preventative services.

District Health Centre Pilot
In early 2019, the Food and Health
Bureau (FHB) took an encouraging
step towards increasing the
availability of preventative care in
the community by setting up a pilot
District Health Centre (DHC).
The FHB intends to open additional
centres in each of the 17 remaining
Hong Kong districts if the pilot
proves to be successful.

Healthy ageing on the agenda
‘Healthy ageing’ as a policy initiative has also been
taken up by a range of government departments, with
the idea of ‘ageing in place’ central to many of these
policies
The Hong Kong Housing Authority (HKHA), for example,
has organised ‘Healthy Ageing in public rental housing
(PRH) Estate initiatives in response to about a quarter
of PRH tenants being aged 60 or above.18
The HKHA has arranged health visits to PRH estates to
provide free health checks, along with follow-up and
referral services for older tenants and free health talks
addressing healthy diet, proper exercise techniques and
oral health.

“Everyone is doing something but this is not
happening in a concerted manner to have
the best impact”
Hong Kong is still taking a scattergun approach to
preventative healthcare and lacks overall strategic vision
and targets.
While an Elderly Services Programme Plan was released
201422 which has ‘ageing in place’ as one of its goals,
interviewees viewed this a ‘checklist’ strategy rather than
the holistic effort needed to improve preventative care.23
Interviewees also highlighted a lack of appropriate
monitoring and regulation of the preventative initiatives
as a barrier to improvement. Interviewees also suggested
that effective promotional campaigns related to
preventative efforts are often lacking.

Adult Vaccination Case Study
• Adult vaccination is a key element of preventative healthcare which is being utilised by Hong Kong
through government-funded schemes.
• Vaccination can play a significant role in preserving older adults’ health and independence,
helping to delay the inevitable age-related increase in healthcare utilisation.
• Two government schemes exist in Hong Kong which provide free or subsidised influenza and
pneumococcal vaccinations to designated groups of high-risk adults, including all adults 65 and
over
• The Vaccination Subsidy Scheme (VSS) provides subsidised annual influenza vaccination and
pneumococcal vaccination to a range of high-risk groups in private clinics and through outreach
vaccination activities in non-clinical settings.26
• The Government Vaccination Programme (GVP) provides free annual influenza vaccination and
pneumococcal vaccination to a range of high-risk groups through public healthcare facilities.

Cost and access challenges
While free vaccination is available to older adults through
the Government Vaccination Programme, the limited
network of public GPs is restricting older adults’ access to
this service.
With just 73 public general patient clinics across Hong
Kong, options for older adults are limited and they
potentially face long waiting times for an appointment.
There is also limited financial incentive for public GPs to
offer the vaccines.
While access has been increased through subsidising
private clinics to provide vaccines, patients have to pay any
difference in the vaccine’s cost. Patients also have to pay a
service charge for the vaccine’s provision.

And low awareness
These low uptake rates may be symptomatic of a low awareness of
immunisation beyond childhood in Hong Kong both at a policy and individual
level.
The likelihood of adults seeking out vaccination is further reduced by a low
public awareness of the risk of vaccine preventable diseases.
Government advocacy efforts around vaccination are limited, which is
contributing to the low public awareness on vaccination.
Ethnic differences have also been recorded, with Nepalese older adults being
found to have a lower awareness of the Government Vaccination Program in
comparison to Chinese older adults, and a resultant lower uptake rate of the
influenza vaccine

Data is weak
There is a need for the collection of more data around vaccination to inform
policy decisions on immunisation.
Interviewees highlighted that few Hong Kong based cost-effectiveness
studies of vaccines and vaccine strategies exist to inform decision making.

And healthcare professionals don’t
vaccinate themselves
“Why should I get vaccinated if the doctor doesn’t?”
2012/13 season flu vaccine uptake by healthcare workers ranged from 28.6 -
44.9%.30
Only around half of GPs would actively recommend pneumococcal
vaccination to patients aged 65 and over, and only 18.8% would recommend
it to those aged 50-64.39
Social marketing may offer a solution to improving vaccination uptake
amongst older adults. Interviewees highlighted that when the subsidised
influenza scheme began it was successfully publicised through an insert
posted with electricity bills; however, this has now stopped.41

There are some cultural and cohort
barriers
“Older people don’t have a positive image of vaccination:
they say it’s intrusive and can make them sick.”
Vaccinations have not been a part of many older people’s
lives as they were born before the launch of Hong Kong’s
Childhood Immunisation Programme (HKCIP) in the
1950s.
Older people may also see traditional Chinese medicine
as a viable alternative to vaccination.
There are low levels of literacy amongst the oldest old.
In 2016, 32.7% of women 65 and over and 12.5% of
men had no schooling or had only received pre-primary
education.42

There could be a greater role for pharmacy
in prevention
Pharmacists could play a greater role in preventative care
Pharmacists are far more accessible than public GPs, with
around 640 pharmacies and 2700 pharmacists existing in Hong
Kong
They are often based in the communities where older people
live.
Currently, pharmacists are not authorised to either prescribe or
administer vaccines; however, initiatives are occurring which
could lead to them taking on more responsibility.
From September 2019 a pilot programme will trial the use of
private pharmacists to provide flu injections in schools.45 The
scheme could be expanded to older people and the provision of
additional vaccines, with the service paid for using the Elderly
Health Care Vouchers

Policy recommendations
• Greater data collection around vaccination to ensure that policy decisions
fully realise the potential of adult vaccination, and the role it can play in
health ageing.
• The use of older “ambassadors” to improve health literacy and vaccination
rates amongst older people. Given the importance of families to older people
in Hong Kong, health education could also be focussed on adult children as
these people can play an important role in influencing health decisions made
by of older people.
• Pharmacists playing a greater role in vaccination to increase the accessibility
of adult vaccines and to relieve pressure on public general outpatient clinics.
This could be through identifying eligible patients; pointing people towards
vaccination services and using nurse practitioners to actually deliver services
in community settings.

Thanks to
• Grace Chan Man-yee, Chief Officer, Elderly Service,
Hong Kong Council of Social Service
• Professor Ben Cowling, School of Public Health,
The University of Hong Kong
• Professor Stuart Gietel-Basten Associate Dean
(Research), School of Humanities and Social
Science, The Hong Kong University of Science and
Technology
• Professor David Phillips, Chair Professor of Social
Policy, Lingnan University
• Dr Vivian Lou, Director, Sau Po Centre on Ageing
• Tim Pang, Community Organizer, Society for
Community Organization
• Scarlett Pong, President of The Pharmaceutical
Society of Hong Kong
• Dr Judy Siu, Assistant Professor, Department of
Applied Social Sciences, The Hong Kong
Polytechnic University,
• Jeff So, Aging2.0 Ambassador for Hong Kong
Chapter
• Dr ZENG Wen, Vice-President, Macau Sun Yat-Sen
Association of Medical Sciences
• Professor Jean Woo Director, CUHK Jockey Club
Institute of Ageing
• Professor Paul Yip, Chair Professor, Department of
Social Work and Social Administration, The
University of Hong Kong
• Rebecca Yung, Golden Age Foundation Founder &
Chair

David Sinclair
Director
ILC-UK
@ilcuk

Response on Hong
Kong perspective
#HealthyAgeing

Pamela Tin
Head of Healthcare & Social Development,
Our Hong Kong Foundation
#HealthyAgeing

Healthy Ageing in HK
1st October 2020
Webinar: Healthy ageing and adult vaccination in Singapore and Hong Kong
ILC UK, ILC Singapore, Global Alliance International Longevity Centre

Our Challenges
Challenges
Slow primary care
development
High OOP spending
is unachievable to
many
Limited
comprehensive
strategy
Fragmentation
between public and
private sectors
Medical-social
segmentation
Hospital-centric
orientation
(Census & Statistics Dept, 2011; Yeoh, 2018)45

© Our Hong Kong Foundation Limited. All Rights Reserved.
46
Release of “Health for All
– The Way Ahead” in
1990
To promote primary care,
establishment of:
Women Health Service in
1994
Elderly Health Service in
1998
Launch of the Elderly
Health Care Voucher
Scheme in 2009
Creation of a Primary
Care Office (PCO) in
2010
The Primary Care
Directory was launched
in 2011 to facilitate the
public to search for
primary care providers
The Steering Committee
on Primary Healthcare
Development was
established in 2017
“Towards 2025: Strategy
and Action Plan to
launched in 2018
Smaller scale efforts to
target NCDs, including
Hong Kong Cancer
Strategy (2019)
The first District Health
Centre (DHC) launched
in Kwai Tsing District
Efforts to create additional
6 DHCs and 11 “DHC
Express” stations
throughout HK
Primary Care Development in Hong Kong
(HK Gov, 2020)

District Health Centre
(Yeoh, 2018; FHB DHC, 2020)47
• Roll out DHCs in 6 other districts by 2022
• “DHC Express” will be set up in 11 districts
to provide district-based primary care
services to the community
Stakeholders’ Concerns:
• Ineffective set-up of DHCs:
o Top-down approach of DHC leaves little room for change in service model
o Insufficient use of patient information and data to inform service model
o Service model limitations (limited subsidy; unable to leverage external resources)
• Communication issues:
o Insufficient promotion of DHC within the community
• Community resistance to non-specialist trainees/nurses in DHC
• DHC fails to propel primary care in a more cohesive manner
Kwai Tsing District Health Centre

Elderly Health Care Voucher Scheme
65 68 68 69 66 61 58
23 20 23 18 20 26 28
7 8 6 6 8 9 9
6 4 4 7 6 4 5
0%
20%
40%
60%
80%
100%
Year
Voucher Claim Transactions by
Reason of Visit (2009-2015)
Reha
bilitati
on
(419) (659) (848)
(1,182) (2,059) (3,502)
No.
of
(Yeoh, 2018)
Vouchers are mainly used for acute episodic conditions
48
Did you usually consult public doctors or private doctors or
both for general illness? (n=905)
49
61
24
17
22 19
5 3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Before using
voucher
After using voucher
Seldom/
never
seen
doctors
Private
doctor
only
Prior to their use of voucher
Publ
ic:
(73%
)
Publ
ic:
(78%
)
Voucher did not alleviate public sector burden
(Data from repeated cross-sectional
survey)

Goals and
Eligibility
Identify
asymptomatic
carriers in the
community to cut
virus transmission
chain
Participation is
voluntary and free
for eligible
individuals without
symptoms
Results
1.78 million people
were tested
(~24% of the total
population)42 COVID
carriers/infections
were identified
Free and centralised treatment in public hospitals Universal Community Testing to identify silent carriers
HK’s Response to COVID-19 Pandemic
(RTHK, 2020; Gov, 2020)
49
Leveraging private sector for non-COVID care
Hospital Authority added additional PPPs to the 8 existing prior:
• Phototherapy for babies with jaundice
• Radiotherapy for cancer patients
• Caesarian section
• Treatment of limb fractures

Community Efforts during the COVID-19 Pandemic
“United to Fight Virus, Send Love to the Community”
• 5 month duration, reached over 80,000 elders
• Distributed nearly 300,000 items of emergency
necessity, including surgical masks, hand sanitizers
• Social workers and registered nurses teams provided
care to over 42,000 elders
HIA COVID-19 Work
• Provided health information to ethnic minorities in
Hong Kong without English or Cantonese fluency
• Distributed personal protective gear to individuals
without financial means
Senior Citizen Home Safety Association (SCHSA) Health in Action (HIA)

Q&A
#HealthyAgeing
Please submit your questions to panellists
via the Q&A tab

Close remarks from
Chair
Susana Harding, Senior Director, ILC
Singapore
#HealthyAgeing

Please join us for the upcoming COVID-19 & Older People Webinar Series:
Older People and Function in the Times of COVID-19
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Presentation: COVID-19, Older People and the New Normal
24 November 2020, Tuesday
Scan QR code to register for the Older People and Function in the Times
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All attendees will also be receiving a complimentary Festival Fringe Activities Ticket at
the 11th International Ageing Asia 2020: World Ageing Festival (The hybrid edition).
Keynote Speaker: Dr. Mary Ann Tsao
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Co-President, ILC Global Alliance
COVID-19 & OLDER PEOPLE WEBINAR SERIES
A collaboration on COVID-19 Intelligence | A Step Towards Ageing Asia 2020: World Ageing Festival (The hybrid edition)
9 SEPTEMBER 2020
8:00PM – 9:30PM (SGT)
A collaboration on COVID-19 Intelligence | A Step Towards Ageing Asia 2020: World Ageing Festival (The hybrid edition)

Future of Ageing 2020:
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better society for all generations
Date: Thursday, 3 December 2020
Time: 9.00am (for 9.30am) - 5.30pm
Make the most of our early bird rate until 11
October 2020.
Register at: futureofageing.org.uk
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futureofageing.org.uk
#HealthyAgeing

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