Analyzing National Health Financing Reform Strategies and Health System Governance Challenges in Singapore: A Modelling Study

Health systems worldwide are under increasing pressure to reconcile rising healthcare costs, population ageing, and prevalent chronic diseases while maintaining universal access and high-quality care. In response, Singapore has recently launched the Healthier SG (HSG) initiative that shifts the emphasis away from reactive and treatment-oriented care toward preventive and population-based care. A cornerstone of HSG is the transition from fee-for-service (FFS) to capitation (CAP) funding mechanism. As such, this thesis aims to investigate the implications of CAP payment reform for both health financing and system governance under HSG. Grounded in systems thinking and complexity theory, the study seeks to understand how payment reform reshapes financial incentive, resource allocation, service delivery, and population health. It addresses four central research questions: (1) what roles stakeholders play in Singapore’s health system governance; (2) how different payment models influence physicians’ provision behavior; (3) what unintended consequences might emerge from the transition to a capitated system; and (4) how governing policies can be designed to support the long-term viability of CAP payment reform.Methodologically, the study adopts an instrumental case study approach that integrates qualitative and quantitative modelling methods. Qualitative frameworks, including Viable System Model (VSM) and Dynamic Performance Governance (DPG), are employed to examine institutional structures, governance arrangements, and stakeholder roles within Singapore’s health system. These frameworks are further complemented by simulation models, including Generative Agent-Based Model (GABM) to explore individual physicians’ provision behavior and System Dynamics (SD) model to capture population-level impacts on health outcomes, service utilization, and public expenditures. Collectively, these models form a coherent analytical architecture that enables experimentation with alternative health financing policies and informs an integrated health system governance design.The findings highlight that while CAP payment reform can strengthen incentives for population health promotion, chronic disease management, and medical cost control, its effectiveness is highly contingent on other factors, such as HSG enrollment progress, financial risk management, provider service capacity, and collaborative governance efforts. Poorly calibrated CAP funding model may expose providers to disproportionate risks, elicit policy resistance, or even cause system failure. Conversely, CAP reimbursement method holds the potential to mitigate all levels of waste, improve population health outcomes, and enhance the sustainability of health systems when supported by robust health financing and governance arrangements.To conclude, this research contributes to the literature by offering a holistic, dynamic, and context-specific analysis of payment reform that moves beyond static or siloed evaluations. By integrating multiple modelling paradigms, the thesis advances methodological innovation in the study of complex health systems. Practically, it provides policy-relevant insights for Singapore and other health systems undergoing similar transitions toward CAP payment and accountable care. Ultimately, the study demonstrates that payment reform is not merely a technical adjustment of reimbursement method. Rather, it indicates complex health financing and system governance challenges that necessitate coordinated institutional design, adaptive policy management, and long-term strategic oversight.