Free Screenings Aren’t Enough: Singapore’s Flagship Health Programme Leaves Groups Behind

Singapore’s most ambitious primary care overhaul was built on a simple promise: make preventive care easy, continuous and affordable, and people will show up for it. Healthier SG, launched in 2023, offers residents a voluntary, long-term relationship with a family doctor, subsidised screenings and vaccinations, and a personalised health plan. Yet a new study suggests that removing financial barriers is only the first step. Analysing responses from nearly 4,000 adults, researchers at the Saw Swee Hock School of Public Health at the National University of Singapore found that half of eligible residents were still unaware the programme existed, and that the people most likely to benefit from early detection were often the least likely to enrol. The findings, published in the International Journal for Equity in Health, reveal persistent socio-economic and ethnic gaps at every stage of engagement, from simply hearing about the programme to completing a screening, even though eligibility is universal and the services are subsidised.

Healthier SG represents a deliberate shift in how the city-state approaches health. Rather than paying clinics to treat illness after it appears, the programme asks residents to empanel, formally register, with a general practice clinic or a polyclinic, creating a continuity of care relationship intended to catch chronic diseases early and manage them better. It opened to adults aged 60 and above in mid-2023, and eligibility was extended to those aged 40 and older by late the same year. Voluntary empanelment of this kind has been adopted by health systems around the world as a strategy for strengthening primary care, but researchers note that its equity implications, particularly in multi-ethnic Asian populations, have rarely been examined in detail. The Singapore team set out to fill that gap, asking not just whether people enrol, but who makes it through each step of the journey, and who is left behind along the way.

To answer that question, the researchers turned to the Singapore Population Health Studies, drawing on a sample of 3,899 residents aged 40 and above. They framed the analysis using Andersen’s Behavioural Model of Health Services Utilisation, a longstanding framework in health services research that organises the drivers of care use into three categories: predisposing factors such as age, sex, education and ethnicity; enabling factors such as income, housing type and employment; and need factors such as the burden of chronic disease. Engagement with Healthier SG was classified into four sequential stages: people who were unaware of the programme and not enrolled, those who were aware but had not enrolled, those who had enrolled but not completed a screening, and those who had both enrolled and been screened. Using multinomial logistic regression, the team estimated odds ratios and marginal effects, the predicted probabilities of occupying each stage, for every factor.

The headline numbers are striking. Half of the respondents, 50.5 per cent, had never heard of Healthier SG, despite the programme’s nationwide promotion. Only 36.1 per cent had either enrolled or completed at least one of the preventive screenings the programme offers. In other words, barely more than a third of the eligible population had moved beyond the starting line of a scheme designed to reach everyone. For a programme that strips away most of the cost of preventive care, that level of disengagement is a signal that something other than money is shaping behaviour, and the statistical analysis pointed clearly at what.

Socio-economic advantage left a visible fingerprint on every stage of engagement. Older adults, people with higher educational attainment, retirees, and residents living in higher-tier housing were all significantly more likely to both enrol in the programme and complete their screenings. The housing gradient is particularly telling in Singapore’s context, where housing type serves as a widely used proxy for socio-economic status. Residents in larger, higher-value public and private flats navigated the programme more successfully than those in smaller units, suggesting that differences in health literacy, digital access, time flexibility and familiarity with the healthcare system continue to operate even when the price of care has been heavily subsidised. Education, similarly, appeared to function less as a route to affording care than as a route to understanding and trusting it.

Ethnic disparities emerged in a more nuanced pattern. After the researchers adjusted for socio-economic factors, respondents of Indian ethnicity showed lower odds of enrolling in the programme, a gap that persisted even when financial and educational differences were accounted for. Malay respondents, by contrast, showed higher odds of being aware of Healthier SG without actually enrolling, a pattern the authors describe as awareness without conversion. That distinction matters: it suggests that for some communities the barrier is not information but something that happens at the point of deciding to sign up, whether that involves trust in primary care institutions, cultural fit of communication materials, differing health beliefs, or practical frictions in the enrolment process itself. The findings point to the need for culturally responsive outreach rather than a uniform national campaign.

One of the study’s most consequential findings concerns need, the factor that health policy most wants to drive preventive care use. People carrying a higher burden of chronic disease were more likely to complete screenings once they had enrolled, which is exactly what the programme is designed to achieve. But a higher chronic disease burden did not make people any more likely to enrol in the first place. The residents with the greatest clinical need were not gravitating toward the programme on their own. In a voluntary system, the people who stand to gain the most from early detection and continuous management are, it turns out, no more likely to sign up than anyone else, and in some socio-economic groups considerably less likely.

Methodologically, the study’s strength lies in treating engagement as a sequence rather than a single yes-or-no outcome. By modelling four distinct stages with multinomial logistic regression and reporting marginal effects alongside odds ratios, the researchers could show where in the funnel different groups stall. Older, better-educated, more advantaged residents flow through the entire pipeline from awareness to screening. Disadvantaged residents and some ethnic minority groups drop out earliest, most often at the awareness stage itself. That granularity matters for policy, because the remedy for an awareness gap, targeted, culturally attuned communication through trusted community channels, is entirely different from the remedy for an enrolment gap, which may require simplifying registration, offering assistance with sign-up, or building trust through community partnerships.

The authors are careful about what their cross-sectional data can and cannot show. Because the study captures a single point in time during the programme’s early rollout, it cannot establish whether today’s engagement gaps will harden into tomorrow’s health disparities, and they call for longitudinal research to track whether early differences in enrolment and screening translate into differences in disease outcomes over the years ahead. The cohort also represents the population aged 40 and above, the group targeted by the programme, rather than the entire adult population. Still, the direction of the findings is consistent with a growing international literature showing that voluntary, incentive-based preventive care programmes tend to reproduce existing social gradients unless they are actively designed not to.

The broader lesson reaches well beyond Singapore. As health systems worldwide pivot toward prevention, from the United Kingdom’s emphasis on continuity of care to community-based primary care reforms across Asia, voluntary empanelment is becoming a default strategy. Singapore’s experience offers an early warning: universal eligibility and generous subsidies are necessary but not sufficient. Reaching the residents who rarely see a doctor, who live in smaller flats, who have less schooling and who may distrust or simply not encounter official health messaging, requires deliberate, targeted and culturally informed effort. Equity in preventive care, the study concludes, is not achieved at the moment costs are eliminated. It is achieved, or missed, in the accumulation of small frictions and quiet barriers that determine who walks through the door. The measurement of those barriers, stage by stage, is where reform begins.

Subject of Research: Socio-economic and ethnic disparities in preventive care engagement under Singapore's Healthier SG voluntary primary care empanelment programme

Article Title: Beyond financial access: socioeconomic and ethnic disparities in preventive care engagement under Singapore’s Healthier SG programme

Article References: Beyond financial access: socioeconomic and ethnic disparities in preventive care engagement under Singapore’s Healthier SG programme. (n.d.). https://doi.org/10.1186/s12939-026-03028-1

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03028-1

Keywords: Healthier SG, Singapore, preventive care, health equity, primary care reform, voluntary empanelment, Andersen Behavioural Model, socio-economic disparities, ethnic disparities, screening, health policy, public health