27 Apr 2018
Topics Health

Demystifying the Difficulty of Addressing Diabetes and Fertility

As the Singapore Parliament re-convenes in May and articulates its policy priorities for the remainder of this term of government, it is an opportune time to take stock of some of the complex challenges that the nation-state faces today.

While pressing issues such as economic transformation to enhance productivity and growth, and the security threat of terrorism, have rightly taken centre-stage in public discourse, it is critical to remember two social issues that continue to lurk ominously in the background diabetes and fertility. Both of these issues require shifting behaviours which can be extremely difficult.

Dual Threats of Diabetes and Declining Fertility

In 2016, the Minister for Health Gan Kim Yong announced the War on Diabetes, revealing the bleak projections that about a million Singaporeans would be afflicted with diabetes by 2050 if the health issue was left unmitigated. During the 2017 National Day Rally, Prime Minister Lee Hsien Loong took the unprecedented step of making diabetes prevention one of the cornerstones of his speech signalling the high importance that the Singapore Government places on this escalating health problem.

The second social issue is fertility during this year's Committee of Supply Parliamentary debate, then-Minister in the Prime Minister's Office Josephine Teo said that Singapore's total fertility rate (TFR) has declined to 1.16 in 2017, the lowest figure since 2010 and the second lowest ever recorded. Juxtaposed with the mathematical reality that the replacement rate to maintain a stable citizen population size without immigration is a TFR of 2.1, the 2017 figure is abysmal.

Fundamental Difficulty in Addressing Diabetes and Fertility

Tackling the prevalence of diabetes and a declining fertility rate both require shifting behaviours for the former, it is about promulgating exercise and keeping to a healthy diet, while the latter is about changing deep-seated mindsets toward marriage and procreation.

Existing policies already try to do this. For example, the Health Promotion Board works with food suppliers to develop healthier ingredients and beverages, also launching the National Steps Challenge to encourage exercise via monetary incentives. On the other hand, the National Population and Talent Division encourages Singaporeans to have children through policies like tax incentives to reduce the financial burden on would-be parents, and increasing the number of child-care centres.

These measures are pragmatic, rational policies aimed at addressing key pain points' causing diabetes and low fertility. Indeed, many of these policies such as financial incentives for having children are proven to work in several other developed nations.

However, shifting behaviour through policy in these two areas is incredibly difficult because it requires people to proactively do something, compared to the easier task of deterring action.

For example, mitigating diabetes involves a concerted recognition that exercise is beneficial, thereby encouraging proactivity toward exercise. Fertility is also about encouraging the desire to have children. Compared with past policies like the Stop at Two fertility policy in the late 1960s that serves to deter' child-bearing today's policy objectives require action, instead of inhibiting action.

Therefore, traditional policy measures will not and cannot suffice to promote behavioural changes critical to addressing diabetes and fertility. The question is how current policies can be augmented to achieve the desired social outcomes.

Three Policy Suggestions

First, it is critical to ask whether existing policies have worked here through evidence-based policy analysis and outcome evaluations. After certain policies were implemented, was there an observed slowing in the number of diabetics, or has there been a rise in the TFR?

Through robust quantitative analysis techniques, it is possible to determine if specific initiatives have been more successful than others. These policies should therefore be expanded, and other ineffective initiatives discontinued, to concentrate resources on cost-effective policies proven to work. This recognizes that policies intended to change behaviour are highly context-specific and their effectiveness must be regularly evaluated and not stay wedded to certain policy measures even if they have worked somewhere else.

Second, the top-down approach to policy-making for social issues such as diabetes or fertility needs to give way to a ground-up, community-led effort toward desired objectives. The state should act to foster such efforts. This involves a realization that on sensitive social matters like health and having children, it is far more effective to rely on community and family units to achieve desired outcomes.

For example, a son who gently admonishes his parents against consuming too much sugared beverages, or a mother who expresses her wish to see her child get married and have children, would likely produce far better outcomes than any government-led incentive or public awareness campaigns can dream of achieving.

Third, there is a need to highlight to Singaporeans the trade-offs of their (non)actions, if they so choose to pursue diabetes-inducing behaviour or not to have children.

Just like how there is legislation enforcing the placement of warning labels on cigarette packs, the consequences of long-term consumption of high-sugar foods and the health repercussions of diabetes should be made plain to all through outreach and communications efforts.

For fertility, there is a need to have a broad societal discussion on the economic and social consequences of having consistently low TFRs. For example, it could mean having to accept more naturalized Singaporeans or Permanent Residents, or increase the number of expatriates to fill local jobs due to the labour shortfall. Otherwise, economic growth could falter, and standards of living for Singaporeans could decline.

This reality and the associated trade-offs should be made clear not as a top-down veiled warning' to raise fertility per se, but to raise public consciousness of the stark choices that the government of the day must make.

There are no easy solutions to the social issues of diabetes and fertility. What is clear, however, is that traditional policy measures are increasingly limited in addressing them. Through robust outcome evaluations of policies, creating a ground-up effort and clearly articulating the consequences of non-action, there may yet be hope of reversing current trends.

Jansen Tham is a 2nd year Masters in Public Policy (MPP) student at the Lee Kuan Yew School of Public Policy, National University of Singapore.

Topics Health