John P. Ansah

Implications of long-term care capacity response policies for an aging population: A simulation analysis

INTRODUCTION The demand for long-term care (LTC) services is likely to increase as a population ages. Keeping pace with rising demand for LTC poses a key challenge for health systems and policymakers, who may be slow to scale up capacity. Given that Singapore is likely to face increasing demand for both acute and LTC services, this paper examines the dynamic impact of different LTC capacity response policies, which differ in the amount of time over which LTC capacity is increased, on acute care utilization and the demand for LTC and acute care professionals. METHODS The modeling methodology of System Dynamics (SD) was applied to create a simplified, aggregate, computer simulation model for policy exploration. This model stimulates the interaction between persons with LTC needs (i.e., elderly individuals aged 65 years and older who have functional limitations that require human assistance) and the capacity of the healthcare system (i.e., acute and LTC services, including community-based and institutional care) to provide care. Because the model is intended for policy exploration, stylized numbers were used as model inputs. To discern policy effects, the model was initialized in a steady state. The steady state was disturbed by doubling the number of people needing LTC over the 30-year simulation time. Under this demand change scenario, the effects of various LTC capacity response policies were studied and sensitivity analyses were performed. RESULTS Compared to proactive and quick adjustment LTC capacity response policies, slower adjustment LTC capacity response policies (i.e., those for which the time to change LTC capacity is longer) tend to shift care demands to the acute care sector and increase total care needs. CONCLUSIONS Greater attention to demand in the acute care sector relative to demand for LTC may result in over-building acute care facilities and filling them with individuals whose needs are better suited for LTC. Policymakers must be equally proactive in expanding LTC capacity, lest unsustainable acute care utilization and significant deficits in the number of healthcare professionals arise. Delaying LTC expansion could, for example, lead to increased healthcare expenditure and longer wait lists for LTC and acute care patients.

Projection of Young-Old and Old-Old with Functional Disability: Does Accounting for the Changing Educational Composition of the Elderly Population Make a Difference?

This study compares projections, up to year 2040, of young-old (aged 60-79) and old-old (aged 80+) with functional disability in Singapore with and without accounting for the changing educational composition of the Singaporean elderly. Two multi-state population models, with and without accounting for educational composition respectively, were developed, parameterized with age-gender-(education)-specific transition probabilities (between active, functional disability and death states) estimated from two waves (2009 and 2011) of a nationally representative survey of community-dwelling Singaporeans aged ≥60 years (N=4,990). Probabilistic sensitivity analysis with the bootstrap method was used to obtain the 95% confidence interval of the transition probabilities. Not accounting for educational composition overestimated the young-old with functional disability by 65 percent and underestimated the old-old by 20 percent in 2040. Accounting for educational composition, the proportion of old-old with functional disability increased from 40.8 percent in 2000 to 64.4 percent by 2040; not accounting for educational composition, the proportion in 2040 was 49.4 percent. Since the health profiles, and hence care needs, of the old-old differ from those of the young-old, health care service utilization and expenditure and the demand for formal and informal caregiving will be affected, impacting health and long-term care policy.

Future requirements for and supply of ophthalmologists for an aging population in Singapore

BackgroundSingapore’s population, as that of many other countries, is aging; this is likely to lead to an increase in eye diseases and the demand for eye care. Since ophthalmologist training is long and expensive, early planning is essential. This paper forecasts workforce and training requirements for Singapore up to the year 2040 under several plausible future scenarios.MethodsThe Singapore Eye Care Workforce Model was created as a continuous time compartment model with explicit workforce stocks using system dynamics. The model has three modules: prevalence of eye disease, demand, and workforce requirements. The model is used to simulate the prevalence of eye diseases, patient visits, and workforce requirements for the public sector under different scenarios in order to determine training requirements.ResultsFour scenarios were constructed. Under the baseline business-as-usual scenario, the required number of ophthalmologists is projected to increase by 117% from 2015 to 2040.Under the current policy scenario (assuming an increase of service uptake due to increased awareness, availability, and accessibility of eye care services), the increase will be 175%, while under the new model of care scenario (considering the additional effect of providing some services by non-ophthalmologists) the increase will only be 150%. The moderated workload scenario (assuming in addition a reduction of the clinical workload) projects an increase in the required number of ophthalmologists of 192% by 2040.Considering the uncertainties in the projected demand for eye care services, under the business-as-usual scenario, a residency intake of 8–22 residents per year is required, 17–21 under the current policy scenario, 14–18 under the new model of care scenario, and, under the moderated workload scenario, an intake of 18–23 residents per year is required.ConclusionsThe results show that under all scenarios considered, Singapore’s aging and growing population will result in an almost doubling of the number of Singaporeans with eye conditions, a significant increase in public sector eye care demand and, consequently, a greater requirement for ophthalmologists.

Emergency department crowding in Singapore: Insights from a systems thinking approach

Objectives: Emergency Department crowding is a serious and international health care problem that seems to be resistant to most well intended but often reductionist policy approaches. In this study, we examine Emergency Department crowding in Singapore from a systems thinking perspective using causal loop diagramming to visualize the systemic structure underlying this complex phenomenon. Furthermore, we evaluate the relative impact of three different policies in reducing Emergency Department crowding in Singapore: introduction of geriatric emergency medicine, expansion of emergency medicine training, and implementation of enhanced primary care. Methods: The construction of the qualitative causal loop diagram is based on consultations with Emergency Department experts, direct observation, and a thorough literature review. For the purpose of policy analysis, a novel approach, the path analysis, is applied. Results: The path analysis revealed that both the introduction of geriatric emergency medicine and the expansion of emergency medicine training may be associated with undesirable consequences contributing to Emergency Department crowding. In contrast, enhancing primary care was found to be germane in reducing Emergency Department crowding; in addition, it has apparently no negative side effects, considering the boundary of the model created. Conclusion: Causal loop diagramming was a powerful tool for eliciting the systemic structure of Emergency Department crowding in Singapore. Additionally, the developed model was valuable in testing different policy options.

Causal Analyses of Public Debt and Structural Adjustment

The impact of structural adjustment program on the economic situation in many African countries can not be overemphasised. Over two decades of implementing neo-liberal economic policies by the Bretton Woods institution, it is of great importance to document the lessons learnt. This paper elicits the structural mechanism representing the intended effect of structural adjustment policies and the unintended effects observed from the implementation of the structural adjustment policies. The assumptions and hypotheses implicit in the main structural adjustment policies, as well as the observed unintended effect of the policies are clearly elicited with a causal loop diagram.

Projecting the effects of long-term care policy on the labor market participation of primary informal family caregivers of elderly with disability: insights from a dynamic simulation model.

BackgroundUsing Singapore as a case study, this paper aims to understand the effects of the current long-term care policy and various alternative policy options on the labor market participation of primary informal family caregivers of elderly with disability.MethodsA model of the long-term care system in Singapore was developed using System Dynamics methodology.ResultsUnder the current long-term care policy, by 2030, 6.9 percent of primary informal family caregivers (0.34 percent of the domestic labor supply) are expected to withdraw from the labor market. Alternative policy options reduce primary informal family caregiver labor market withdrawal; however, the number of workers required to scale up long-term care services is greater than the number of caregivers who can be expected to return to the labor market.ConclusionsPolicymakers may face a dilemma between admitting more foreign workers to provide long-term care services and depending on primary informal family caregivers.

Healthcare human resource planning

Healthcare human resource planning is an important aspect of health policy. Its importance arises in particular from the long time-delays, high-costs for training, and high proportion of healthcare expenditure allocated to it. Many countries experience workforce shortages in the healthcare sector, especially among nursing staff. This also has huge implications for population health; morbidity and mortality can increase in the face of inadequate healthcare human resources. Yet, the high degree of uncertainty related to policies, costs and patient behavior makes long-term planning a significant challenge. In this light, this chapter will discuss different analytical techniques used in healthcare human resource planning. Two case studies are presented to provide examples of real-world applications across different institutional context. One employs a systems methodology, while the other uses a linear programming method. Specifically, they aim to demonstrate the importance of adequate planning, and the various elements that need to be accounted for when planning healthcare human resources.

Modeling to Inform Long-Term Care Policy and Planning for an Aging Society

Demographic changes such as increasing longevity, declining family sizes, and increasing female participation in the labor market have implications for long-term care (LTC) planning for the elderly. As the population in both developed and developing world ages, the prevalence of health conditions such as chronic diseases and disabilities increases. Consequently, the proportion of elderly adults who require assistance with their daily activities rises. Further, the potential decrease in family members available as caregivers implies an increase in the demand for alternative LTC arrangements. Planning of LTC services is fraught with dynamic complexities. Various issues, such as projecting future need, cost, capacity, and quality of care and caregivers—formal and informal—can influence the effectiveness and efficiency of LTC services. The trends outlined point to the need for a comprehensive LTC planning that accounts for all these dynamics changes. This chapter aims to demonstrate the use of simulation modeling as a communication tool that allows for the LTC complexity to be reduced to its essential elements to inform policy for an aging society. The forms of simulation techniques used in the planning of LTC policy and services and real-world applications across different institutional contexts are discussed. Of particular focus is the application of the system dynamics methodology in LTC planning. Three LTC projects using system dynamics methodology are presented. Specifically, these LTC projects comprise the methodological process in the projection of the number of disabled elderly in Singapore accounting for changing educational attainment, the impact of various LTC policies on informal eldercare hours and labor force participation of informal caregivers, and the impact of LTC capacity expansion policies on acute care.

Simulation modeling for primary care planning in Singapore

Singapore is undergoing an epidemiological shift and has to provide services for an aging population with a higher burden of chronic disease. In order to address this challenge, enhancing the provision of primary care by improving the ability of more primary care providers to offer care to more complex patients over the continuum of needs is seen as a promising solution. Developing capabilities and capacities of primary care services is far from straightforward and requires careful analysis of how increasing the number of primary care providers with enhanced capabilities influences the multiple objectives of the health care system. The paper demonstrates how group model building can be used to facilitate this planning process, and provides potentially valuable initial insights regarding the tradeoffs engendered by policies aimed at meeting the health care needs of a more complex population.

System dynamics model of debt accumulation in developing countries: The case of Ghana and Pakistan

Purpose - – The purpose of this paper is to present a dynamic macroeconomic framework that identifies the fundamental structure of public debt accumulation process in developing countries and its two way linkages with economic growth and public finances. Within this framework, the objective of this study is to identify leverage points that may be utilized to slow down debt accumulation process without slowing down economic growth. Design/methodology/approach - – The paper uses the system dynamics (SD) method to model and analyze the debt accumulation process. This method allows us to analyze the relationship between structure and behaviour of complex dynamic systems. This paper considers fiscal policy as the strategic element of the debt accumulation process and hence it considers seignorage and consequent inflation to be outside the model boundary. In other words the paper assumes that there exists an effective monetary policy that satisfies the objectives of the fiscal policy. Findings - – Capping debt servicing (debt relief) increases the debtor countrys capacity to invest and the higher investment will raise capacity to pay debt in the future, with some of the rewards going to the creditor. Financing public investment through borrowing produces the highest Debt-GDP ratio compared to all other polices considered. Widening of the tax base to include this informal sector without increasing the tax rate and reducing the extravagant non-debt current expenditure are effective endogenous policy options that help reduce considerably the Debt-GDP ratio. The best composite policy demonstrates that a reduction in the Debt-GDP ratio does not only require exogenous assistance (debt relief) but endogenous government and private sector responsibility to maintain fiscal discipline and generate growth. Originality/value - – The unique characteristic of this model is the transparent way in which it represents the two-way feedback relationship between the debt, public finance and economic development taking into consideration the delays and non-linearities involved in this process.