Commentary: How do we know Singapore’s mental health and well-being strategy is working?

SINGAPORE: “So let there be no doubt: The government is making mental health and well-being a key priority in our national agenda”. 

As an advocate and community organiser of mental health since my own brush with depression in 2006, it was impossible not to feel emotional hearing this declaration from Deputy Prime Minister Lawrence Wong earlier this month, along with a robust debate across two days in parliament on the Advancing Mental Health motion. 

Making mental health a national priority with a national mental health office was the impassioned plea I made in my 2019 Budget speech; in the following year’s Budget, I implored the government to improve accessibility, affordability and quality of mental healthcare.

These words by the incoming prime minister not only commit the government to making significant policy shifts to address one of the most existential challenges of our time but will most certainly shape social attitudes and behaviours positively towards mental health and well-being across all segments of the population. 

ARE WE INVESTING ENOUGH IN MENTAL HEALTH AS A NATIONAL PRIORITY?

Across the world, governments spent an average of just over 2 per cent of their health budgets on mental health in 2020, according to the World Health Organization Mental Health Atlas. Additionally, 66 per cent of total government spending on mental health was directed towards an outdated approach: Psychiatric hospitals. 

The World Bank deemed “all countries can be considered ‘developing’ countries in the context of mental health, as all are lagging in addressing the growing burden”. 

We are certainly guilty of that too. In 2017, Singapore’s mental health spend at S$300 million was only 3 per cent of the Ministry of Health’s total expenditure, versus 11 per cent for diabetes and 6 per cent for aged care.

In 2022, the projected mental health spend increased to S$434.6 million but stayed at 3 per cent of total healthcare expenditure (not including COVID-19 expenditures). More interestingly, only 3 per cent of Singapore’s mental health spend in 2022 was for promotion and prevention, while 97 per cent was on treatment.

The National Mental Health and Well-being Strategy launched in October last year, however, is clearly premised on a new policy narrative that mental health is a continuum, not merely the absence of illnesses - a much-welcomed shift. 

Under the new national strategy, a tiered care model will organise mental health services and support measures according to the severity of an individual's needs, along with multiple touchpoints including a new national mental health hotline and text service.

Certain goals have also been set for implementation by 2030, including making mental health services available in all polyclinics and 1,350 HealthierSG GP clinics. The number of public sector psychiatrists is also set to grow by about 30 per cent to 260, and the number of psychologists by about 40 per cent to 300. In addition, the number of Community Outreach Teams (CREST) catering to youths will be nearly doubled to 15, from eight currently.

Indeed, there is no doubt that our mental health spend will and must certainly increase beyond 3 per cent of total health expenditure in the next six years.

If one in seven Singaporeans (14 per cent) has a mental health condition according to the 2016 Singapore Mental Health Study (and likely more by now), should we not invest more than 3 per cent of the total health budget on mental health? 

I hope that we would also see a more even distribution between mental health promotion/prevention and care treatment as we take a population health approach. 

Because where, and how much, we invest is where the change will be. 

HOW DO WE KNOW IF THESE MEASURES ARE ENOUGH?

I am most heartened by the promise of a whole-of-government coordination in the national strategy through the setting up of the National Mental Health Office by 2025 “with officers from the health, social, and education sectors to oversee the implementation of the strategy, to ensure cohesive alignment of policies and programmes at the national level, and to track the progress and impact of our strategy”. 

Indeed, how do we know if these measures are enough? 

As of 2022, there were 203 registered psychiatrists and 212 psychologists in the public sector. It is difficult to fathom if having just 57 more psychiatrists and 88 more psychologists in the next six years will help reduce waiting times and improve quality in the public sector. 

At 260 psychiatrists and 300 psychologists by 2030, this works out to roughly 6.3 psychiatrists and 7.2 psychologists per 100,000 population based on 2023 resident population figures.

Compare this to 44 psychiatrists per 100,000 population for Switzerland and 28 for New Zealand versus 1.0 for Malaysia and 0.3 for Indonesia. 

According to the Ministry of Health, there is no international consensus on the optimal ratio of psychiatrists and psychologists to population. What then is the basis for our targets of 260 psychiatrists and 300 psychologists by 2030? 

Similarly, will 15 CREST teams catering to youths in 2030 be sufficient to address upstream the “worrying trend” of a surge of youth mental health issues as Mr Wong alluded to?

What is also not known is an aggregated map of all mental health efforts across the ecosystem that would augment these government measures for a fuller picture of national capacity and capability.

For example, the Community Foundation of Singapore has a project to train 1,000 community mental health champions that could supplement the effort to train 130,000 frontline personnel and volunteers.

Aside from the state-directed online initiatives such as MindSG and Mindline.sg, there are also homegrown mental health platforms like Intellect that use their business technologies for individuals to access support. 

This partnership between the government and all stakeholders would need to be even more intentional and coordinated, as DPM Wong also affirmed.

I hope that we will know more about the explicit targets of and dedicated resources allocated to the national mental health office in the upcoming Committee of Supply debates.

WHAT DOES SUCCESS LOOK LIKE FOR A MENTALLY HEALTHY AND THRIVING SINGAPORE?

The National Mental Health and Well-Being Strategy aims to work towards “improving a mental health ecosystem in Singapore where individuals with mental health needs can seek help early without stigma and will receive help readily for their recovery”. 

We have committed decisively on the actions, but have we committed explicitly to clear outcomes? How do we know we are moving in the right direction with the strategy if we don’t know where we are going? 

For instance, are we working towards reducing waiting times by X per cent by 2030 with these strategies? Or do we want to see suicides reduced to Y and stress-related illnesses to Z in six years? What do we hope to see as the mental health prevalence in 2030 with these measures to create a more effective mental health ecosystem? 

The national strategy aims to close the treatment gap which is a baseline goal we must have, but can we also go further to boldly declare mental well-being as fundamental a priority as our economic well-being for sustainable and meaningful growth as a nation? 

We know without a doubt that economic success alone does not guarantee the mental well-being of our children, elderly and communities or we would be one of the last places to have a mental health challenge, given the economic growth that we have had since independence. 

In fact, anxiety and depression collectively cost Singapore’s economy S$15.7 billion in productivity every year, according to a study by Duke-NUS and the Institute of Mental Health. This works out to 2.9 per cent of our gross domestic product (GDP) for 2022. 

So mental health and well-being are inextricably tied to economic performance. Imagine celebrating success equally in our “gross well-being progress (GWP)” alongside gross domestic product (GDP). 

We must be the change we want to see around us. Our present circumstances don’t determine where we go; they merely determine where we start. 

I look forward to the day when we embrace our mental well-being and personal thriving as a life goal individually and a sustainable growth imperative as a nation. 

Anthea Ong is a former Nominated Member of Parliament, a leadership and life coach, a social entrepreneur and author. She founded SG Mental Health Matters, a community-led initiative that aims to educate the public on mental health policies through parliamentary tracking, public consultations, and policy recommendations.