The World Health Organization ranks Singapore’s healthcare system to be the sixth in the world, the only Asian country apart from Japan among the top ten countries. Yet, even in the stellar lion city, the highly preventable pneumonia disease claims more than four thousand lives each year. It is the third leading cause of death in the country due to one simple reason: the low rate of adult vaccinations.

Over a quarter of pneumonia cases are estimated to be caused by the pneumococcus bacteria, which can be easily prevented with the pneumococcal vaccine. But only about 14.4 per cent of Singaporean residents aged 65 to 74 years old have received at least one dose of the vaccine.

Together with the Ministry of Health and the Health Promotion Board (HPB), Open Government Products is on a mission to prevent these very preventable deaths. They have launched a new Health Appointment System (HAS) to link senior citizens up with hundreds of General Practitioner (GP) clinics to facilitate a higher rate of vaccination appointments, beginning with pneumococcal vaccines. This comes without the need for additional administrative manpower in the already strained healthcare sector.

Open Government Products (OGP) is an experimental tech team with the Singapore government which aims to build technology for the public good. The same team built the Vaccination Appointment Booking system during the Covid-19 pandemic, and is now riding the wave of vaccine awareness to expand citizens’ access to preventative services.

“We are trying to solve the ‘last-mile’ problem for preventative care services,” said Mr Kenneth Sng, Product Manager of the appointment system. Sng pointed out that while Singapore was swift in expediting vaccinations for the pandemic and is on track with its childhood immunisation schedule, the uptake of adult-recommended vaccines such as pneumococcal, flu, and HPV vaccines remain low at less than 20 per cent.

“We are trying to move closer towards a society that’s free of highly preventable diseases. If you think about it, vaccines are the cheapest way to prevent healthcare issues further down the line,” said Sng.

Intended impact of pilot phase

The current pilot phase will run from August to October 2022, where the 650,000 seniors will be nudged to book their pneumococcal vaccination appointments through HAS. If the pilot is successful, HAS will expand to other vaccinations recommended under the National Adult Immunisation Schedule, which includes the flu and HPV shots.

“With HAS, I think I will definitely go for the pneumococcal vaccination. It is quite simple to use – I just key in my postal code to find the closest clinic, then choose the timing I want. I can reschedule also, fron the SMS link,” said 65-year-old Albert Yeo, on whether HAS will change his current experience with vaccine appointments.

Dr Shawn Tan, GP at Loh and Loh Clinic and Surgery shares that HAS is easy to use as “clinic assistants just have to set the ‘Opening Hours’ once and leave everything else to the system, greatly increasing their productivity and freeing up time for other clinic duties.”

The ‘last mile problem’: Accessibility

Through interviews with more than a dozen GPs, clinic assistants, and senior citizens, OGP found that the key reason for the low uptake in adult vaccines was the lack of easy access and convenience in finding a nearby GP clinic that offered the pneumococcal vaccine stock on-hand.

“After the pandemic, we found that people were more willing to be vaccinated. The government put out nationwide educational campaigns such as the ‘Uncle Lee’ video, but during our research, we found that the biggest problem was that there was no [effective] call to action following these campaigns,” said Ms Lai Jing Yi, Product Designer at OGP. The ‘Uncle Lee’ video was an awareness video campaign nudging citizens to “stay one step ahead” of vaccine-preventable ailments by keeping up-to-date on their vaccinations.

But after the awareness-building phase, the highest dropout rates happen, according to Lai. Many citizens do not find proper channels to translate their awareness into action. The team heard the anecdote of a senior citizen who visited three separate GP clinics but could not find one that offered the vaccine. In another instance, a mother of three daughters took leave from work to take the HPV vaccine, but the clinic she visited only had two vaccine doses.

“I think these stories illustrate how difficult it is for even the most motivated citizens to get a vaccine in Singapore. You can only imagine how it is for most other senior citizens who might possess more reservations or are less vigilant about getting vaccinated,” said Sng.

HAS aims to provide a highly intuitive system for clinic assistants to update the availability of their vaccines, so that citizens do not waste their efforts showing up at a clinic that fails to offer their vaccine of choice.

The team identified four key stages that might deter citizens from getting vaccinated, and narrowed it down to the final stage: accessibility. Diagram: Open Government Products

The idea of a health appointment system is not a novel one, Sng said. Many healthcare teams might have had their own appointment systems before – but existing applications might be quite difficult for the elderly population to navigate, or simply operate within their own healthcare clusters. “It’s like turning on your Grab or GoJek, but only seeing a very limited number of drivers,” added Lai.

Hence, the team sought to unify the currently fragmented vaccine appointment landscape for GP clinics islandwide, so that Singaporeans have a one-stop shop to make appointments at hundreds of clinics. This hopefully creates a “virtuous cycle” of uptake, wherein a more robust supply of GP clinics will attract more users, and even more GP clinics will be incentivised to join HAS in turn.

To date, almost 700 out of 1242 vaccine providers, such as clinics and hospitals, in the country have already been onboarded onto HAS.

Behind the design

The key demographic HAS is targeting are senior citizens aged above 65, hence the app was designed to be as intuitive as possible without the need for much digital savviness.

Additionally, the team also focused on a “proxy booking” approach – where seniors’ loved ones can book appointments for them. “We built it such that it’s easy for them to ask for help from their children, grandchildren, or even at community centres,” said Suhaila Roslan, Product Operations Specialist at OGP.

But the elderly are not the only tech-averse end users involved, according to Suhaila. “Many clinic assistants might be medically trained but not technology trained, but they end up having to navigate these complicated back end systems. We are working very hard to make sure that even if one hasn’t gone through any formal training, they’ll know exactly how to use the app,” she said.

Finally, the team built the system for eventual scalability, designing the components of the app such that it was easy to reuse for future vaccine campaigns, and possibly health screenings in future. “We tried to decouple [graphics] that were used for specific vaccine campaigns from the actual appointment booking,” said Ian Chen, Software Engineer at OGP.

“Seniors should be able to make their pneumococcal vaccination appointment in sixty seconds. We hope that HAS will be a catalyst for saving lives and take us one step closer to our vision of a society largely free from major vaccine-preventable illnesses,” said Sng.