Chronic disease management: Preventive care framework for migrant workers in Singapore

Chronic diseases, if unmanaged, can contribute to significant premature mortality and morbidity. Before the COVID-19 pandemic, there was limited data on chronic disease prevalence amongst migrant workers (MWs) in Singapore. The antecedent episodic and fragmented primary care for migrant workers also affected care continuity for common chronic diseases. In April 2022, a Primary Care Plan (PCP) was developed for migrant workers to improve access and affordability which included chronic disease detection and management and risk factor reduction. In addition, chronic disease screening was also enhanced in migrant workers’ pre-employment medical screening for those with risk factors or above 40 years old. Beyond disease management, interventions to address health gaps and strengthen the healthcare resilience of MWs are incorporated into a population-health based “Management of Oral and Chronic Conditions and Ailments - MOCCA” framework, anchored on three thrusts: 1. Address knowledge gaps and inculcate healthier habits - Improve health literacy via outreach programmes and culturally nuanced health materials 2. Mitigate risk factors - Build primary care providers’ capabilities to deliver alcohol/tobacco interventions 3. Treat and control disease progression - Set up referral pathways between primary and tertiary healthcare institutions including for post-discharge case management MOCCA was implemented in December 2022 through the collective efforts from the government, community, social service agencies and their employers. KEY MESSAGES: • Migrant workers have been receptive to interactive health programmes, regular health screening, follow up on chronic disease under the PCP and 324 workers attended basic dental screening. • The MOCCA framework is integral to the provision of care for MWs, through risk factor identification, empowerment of health ownership, and periodic assessment of health and behavioural outcomes.