Connecting the dots: The state of arts and health in Singapore

ABSTRACT Background: This article examines the state of the field of arts and health in Singapore and identifies the drivers that have shaped its development to date, adding new insights from Asia to the growing international literature in this area. Methods: Various methods, including an online survey and in-depth focus groups were used. Results: We find that the field in Singapore is rapidly growing, with a proliferation of activities across the arts and culture, healthcare, and social care sectors in recent decades fostered by various policy developments, increased funding and new peer-to-peer networking. Nevertheless, several issues persist, including inconsistent understanding and conceptualisation of the field as a whole across multiple stakeholders, limited research capacity and training platforms, and lack of professional recognition. Conclusions: We provide recommendations for further action, including developing arts and health literacy and research capacity, investing in efforts to bridge education and practice, and focusing on formalising and elevating professional standards.


Introduction
The use of artistic media to support health and well-being is growing around the world (Clift et al., 2009;Sonke et al., 2009;Wreford, 2010;Cox et al., 2010;Laitinen et al., 2020). The dynamic field of "arts and health" integrates the domains of healthcare, social impact and cultural life through artistic practice and experience in many forms, ranging from creating and appreciating the arts as a form of therapy to actively using the arts as a platform for health communication and promotion. However, studies that document the development of the field in Asia have largely been absent from the present literature.
We provide a landscape review of the field from Singapore to address this gap in the literature and to provide new insights about the past and potential future developments for both policymakers and practitioners. We briefly introduce Singapore and some relevant contexts related to the role of policy in shaping public life as well as key background population trends. Drawing on data gathered from primary and secondary data collection, we construct a narrative of recent developments and map the existing range of arts and health activities in Singapore while exploring the drivers that have encouraged its growth. Lastly, we highlight the underlying issues in this burgeoning field and provide recommendations to guide stakeholder decision-making for the future.

Research approach and methodology
We adopted various methods for primary and secondary data collection. First, we conducted a desk review of the arts and health sector and related policies in Singapore, searching both the existing academic literature and the grey literature and policy documentation from relevant government and non-governmental entities. Second, to chart the scope of arts and health practice in Singapore, key informants were recruited between mid-November 2019 and mid-June 2020. An initial sample of respondents was purposively identified by the research team to ensure representation, while further respondents were recruited using snowball sampling by direct referral through word-of-mouth and via the circulation of printed leaflets and electronic direct mailers on social media through these extended networks. Seventy-eight final respondents were enrolled in the study. Our respondents include art practitioners, creative therapists, administrators and professionals from the arts and culture, healthcare, social care, education, and research sectors. All completed a brief standardised online survey describing their activities, experiences and perceptions of the sector and subsequently participated in focus group discussions to provide more in-depth reflections, moderated by members of the research team. The themes derived from the findings were organised and further corroborated via data, methodological, and investigator triangulation. The study protocol was reviewed and approved by the Nanyang Technological University Institutional Review Board (IRB-2018-12-014-02).

Context: key stakeholders and policy background
Singapore is an island city-state in Southeast Asia. Having achieved self-governance from the British Empire in 1959, it subsequently became a sovereign city-state in 1965 following separation from the Malaysian Federation. With no significant local or regional governance, the centralised national government sets the policy agenda. Moreover, Singapore's unicameral parliamentary political system has no upper house or senate and has been dominated since 1965 by a single party, the People's Action Party. Throughout its brief modern history, the Singapore government has taken a relatively interventionist approach towards shaping public life, emphasising the role of state-led national plans and blueprints. For example, Singapore's population of approximately 5.6 million is racially diverse, consisting of Chinese (74.3%), Malay (13.5%), Indians (9%) and other minor ethnic groups (3.2%) (Singapore Department of Statistics, 2019). An explicitly multi-ethnic approach to promoting social cohesion began in 1956, with proposals to organise an education system based on four official languages (Mandarin, Malay, Tamil, and English) (Rocha, 2011), and was then further reinforced by subsequent imposition of quotas in public housing and other social policies to promote mixing and prevent the formation of ethnic enclaves (Ng, 2017).
To that end, the arts and cultural sector has traditionally been called upon to support the imperatives of public policy, reflecting the nature of the times from early nationbuilding to the present day (Chang, 2016;Chong, 2010Chong, , 2018Kong, 2012). The Report of the Advisory Council on Culture and the Arts (ACCA) released in 1989 was the first blueprint for Singapore's arts and culture development, providing acknowledgement of the ability of arts and culture to enhance people's quality of life, deepen sensitivities, and promote social bonds alongside the economic benefits of developing the arts and culture landscape in Singapore (such as a platform for establishing international tourism) (Advisory Council on Culture and the Arts, 1989). Under the auspices of the National Arts Council (NAC), a statutory board formed in 1991 by the Ministry of Culture, Community and Youth (MCCY), three Renaissance City Plans (RCPs) were launched in 2000, 2005 and 2008 to guide the development of Singapore's arts and culture locally and internationally (National Arts Council, 2000, 2002, 2008. With each of these plans, arts and cultural policies have continued to shift beyond focusing on the political or economic value of the sector, towards emphasising the value of the arts to society (Hoe, 2018;Kong, 2012).
In recent years, the fundamental driver of social change has been ageing and its related challenges. Rapid developments leading to improvements in income, housing, education and healthcare have hastened the demographic transition, lowering mortality and boosting the life expectancy of Singaporeans from 75.3 years in 1990 to 83.2 in 2019 (Singapore Department of Statistics, 2019). With falling fertility rates, this has led to a ballooning elderly population share and a rise in chronic or noncommunicable disease. This transition has been progressively accompanied by new attention to previously underemphasised related issues such as long-term disability as well as the invisible burden of mental health disorders (Chong et al., 2012;Ong, 2017;Subramaniam et al., 2020), which accounted for 10.3% of total disease burden in 2017 (Institute for Health Metrics and Evaluation, 2019).
Guided by this more holistic view of ageing, Singaporean policymakers across the board were compelled to explore new ways to sustain their trajectory of growth while supporting the economic, physical, mental and social wellbeing of a greying population (Yuen & Kong, 2018). There are multiple actors in this space, as Singapore's health and social care sector is highly complex. In healthcare, the private sector dominates primary care, while acute tertiary care is largely the province of the highly subsidised public sector and long-term care is provided by a mix of private, public, and non-profit organisations. The Ministry of Health (MOH) regulates the overall sector, complemented by the Health Promotion Board (HPB) and the Agency for Integrated Care (AIC), the national care integrator which provides community mental health and dementia support, coordinates aged-care services, and supports capacity building (Agency for Integrated Care, 2019). Meanwhile, the social service sector is governed by the Ministry for Social and Family Development (MSF), with the National Council of Social Services (NCSS) serving as a statutory board that develops and enhances the capabilities of social service agencies (National Council of Social Services, 2019).
For these stakeholders, the demographic and epidemiological shift has created an ongoing need for sustainable and inclusive health and social care policy that addresses a broader wellbeing agenda. Early efforts included the setting up of the Ministerial Committee on Ageing in 2007, which currently oversees the Action Plan for Successful Ageing (Ministry of Health, 2016) with the Ministry of Health's Ageing Planning Office acting as its secretariat. Similarly, the National Mental Health Blueprint was formulated in 2006 to guide and develop approaches to promote the mental wellness and awareness (Institute of Mental Health, 2010). An Enabling Masterplan for persons with disabilities (PWD) in Singapore was launched in 2007 (Disabled People 's Association Singapore, 2015) to foster the quality of life for both PWD and their caregivers. The masterplan was bolstered by the signing of the United Nations Convention on the Rights of Persons with Disabilities in 2012 (Wong & Wong, 2015) and extended from 2017 to 2021. Most significantly, these goals have now begun to be integrated into mainstream sectoral planning to support more person-centric care. Under the Healthcare 2020 Masterplan, the need to divert chronic care towards the community was acknowledged (Ministry of Health, 2015) and the present Beyond Healthcare 2020 Plan strongly emphasises preventive care and community-based care, further leveraging on local resources within the existing geographically based Regional Health Systems (RHS). In 2017, the National Council of Social Services (NCSS) published the Social Service Sector Strategic Thrusts (4ST), a 5-year roadmap outlining the vision where "every person is empowered to live with dignity in a caring and inclusive society" (National Council of Social Service, 2017).
Understanding these key parties and this increasingly convergent set of priorities, as well as the underlying relationship between the state and the arts and cultural sector in Singapore, is an important precursor to understanding how the field of arts and health has come together in recent years.

The development of the arts and health field in Singapore
Our data collection suggests that the development of the arts and health field in Singapore can be broadly divided into two phases, before and after the 2000s. The earliest effort that we identified as bringing the creative arts into health and social care can be traced back to 1993 with the launch of Very Special Arts (VSA) Singapore, a program to nurture creative talent in people with disabilities (Very Special Arts, 2016). Subsequently, the first art-in-hospitals programme, Arts for Health, was established at the Singapore General Hospital in 1998. In 2002, the now-defunct Singapore Creative Arts Therapist Network (SCATN) was set up to connect the growing number of music and art therapists. Thereafter, the Social Service Institute began offering introductory art therapy training programmes in 2003. These early efforts were valuable but relatively uncoordinated and focused on using the arts as an adjunct to or part of formal therapy.
In contrast, the number of reported initiatives has grown considerably since 2000, with a significant expansion in the range of arts and health-related activities currently undertaken and developed by independent artists, creative arts therapists, arts organisations, arts and cultural institutions and national agencies. This proliferation may be partly attributed to new demand for these activities generated by changing population demographics, and new interest from creative practitioners and organisations, but is also largely directed by the strength and nature of policy support in more recent times.

New developments within the arts and cultural sector
Within the arts and culture sector, an explicit cross-sectoral approach to planning was first marked by the Renaissance City Plan III released in 2008, which proposed bringing the arts into healthcare settings and ageing-related programmes (National Arts Council, 2008). This was reiterated in the 2010 Arts and Culture Strategic Review, which focused on promoting access to the arts for seniors and specifically mentioned working with social sector agencies "that use arts and culture as a tool for rehabilitative therapy, wellness, and active ageing" (National Arts Council, 2012) and a 2015 Ministerial Committee on Ageing statement on expanding the arts and culture activities that promote the health and wellbeing of the elderly as part of healthy ageing (Ministerial Committee on Ageing, 2015). In 2016, the National Heritage Board launched the HeritageCares initiative to codevelop age-friendly programmes (e.g. heritage trails) for the beneficiaries of Social Service Organisations, followed by the 2018 launch of Our SG Heritage Plan, supporting museums and heritage institutions to increase accessibility and roll out new wellnessrelated programmes. The most recent high-level sectoral master plan, the Our SG Arts Plan emphasises inclusivity and accessibility through the arts for under-served communities as well as the emerging need for research on the impact of the arts on health and wellbeing (National Arts Council, 2018).
Together, these plans provided a background policy framework that successfully impacted the behaviour of institutions and practitioner organisations. Table 1 highlights the range of arts and health-related practices and initiatives that can be linked to these developments in arts and cultural policy.

New developments within the healthcare sector
While there remains no specific masterplan for the arts in healthcare, the shift towards more holistic health and social care with a strong community base has given rise to opportunities for pioneering new approaches for both government and non-governmental actors in the sector, particularly in the areas of healthy ageing, elder caregiving, mental health and disability (Ministry of Health, 2015). Among the various government agencies, the AIC has been a leading champion of the arts and health via the AIC Wellness Programme. Launched in 2014 as a deliberate effort to promote arts-based activities into the Community Care sector, this also marked an unprecedented cross-sectoral partnership between the AIC and the National Arts Council (NAC).
Recent years have also seen the growth of creative arts therapy as a professional field. Art therapy and music therapy are the most prevalent types of creative arts therapies, each having its professional association (i.e. Art Therapists' Association Singapore and Association for Music Therapy Singapore respectively). Other creative therapies such as dance and movement and drama therapies are also emerging. Table 2 provides examples of the current range of arts and health practices and activities in the healthcare sector.

New developments within the social service sector
Organisations in the social service sector have actively integrated the arts into social work or care practices to promote a better quality of life. Under the directives of the 4ST, various public or non-profit organisations launched community-based arts programmes, such as the YMCA's Y Arts Challenge and the NCSS's Empowering Seniors projects, to enhance the experience and wellbeing of their beneficiaries. These changes also saw the adoption of Ageing, convalescence Artsolute (est. 2011) uses visual arts, drama, puppetry, and music to engage communities of various needs, in Singapore and other Southeast-Asian countries. They have developed projects to foster relations between persons with dementia and their caregivers, and to alleviate the loneliness and pain of patients.
End-of-Life Both Sides, Now, an art-based community engagement project developed by ArtsWok, an arts-based community development organisation and Drama Box, a socially engaged theatre company have led discussions on caregiving and end-of-life matters using forum theatre, puppetry, participatory arts activities, and exhibitions since 2013.

Dance and Movement
Ageing Art Fission (est. 1994) is the longest incorporated contemporary dance company in Singapore. The company was amongst the first who ventured to partner with healthcare organisations. They developed Everyday Waltzes for Active Ageing (2013), a creative movement programme for use in nursing homes and rehab centres.
Mental wellness, convalescence Danspire is one of the few somatic arts for health and wellness organisations in Singapore. It offers somatic movement wellness/therapy programmes and flow ballet for the general public and cancer survivors.
Children body safety, family bonding Derring-Do Dance is a dance, movement, improvisation organisation offering a variety of programmes to promote body positivity, boundaries and safety skills to children and familial bonding.

Music and Sound
Ageing, youth at risk, special needs OneHeartBeat Percussions is a leading percussion music-making organisation that uses rhythm-centric programmes for Senior Activity Centres, At-Risk Youth Agencies, and Special Needs Schools to promote wellness, intergenerational interaction and community bonding.
Ageing, migrant labourers Music for Wellbeing set up by musician and ethnomusicologist Neil Chan has organised numerous music playing activities at hospital wards, memories cafes by the Alzheimer's Disease Association, migrant worker food distribution events.
Writing, Applied Theatre, Drama and Reminiscence Art

Mental wellness
The Tapestry Project SG (est. 2014) is a voluntary ground-up initiative, run by persons-in-recovery. It champions mental health recovery through the power of first-person stories and promotes mental health awareness, education and empowerment.
Mental health, self-care Rosie McGowan combines her training in applied theatre and counselling to create arts-based, experiential workshops in schools, to promote understanding of mental health and self-care; as well as drama workshops for people in recovery and transgender youth.

Ageing
Reminisce Connect (est. 2017) was developed to foster meaningful engagement amongst elderlies and their caregivers. Guided by Curated Archives of Person's belongings (CAP), their programmes aim to improve wellbeing and bonding through sharing and creation of life stories.

Ageing
The Glowers Drama Group (est. 2003) is Singapore's pioneering seniors' theatre group. It offers seniors an avenue to develop and showcase their talent, and to socialise. The group has created multilingual performances and showcases its work locally and internationally.
Arts, Creativity and Technology for Seniors.

Ageing
Happy Kopi (2017) is an interactive multimedia project developed by Moses Sia during his art residency at a nursing home. The project captured the residents' stories and memories of kopitiams (local coffee shops) and embedded them in an interactive diorama.
Ageing magic mARkers (2018) is a community art project by Lee Sze-Chin, Woon Tien Wei and Nigel Chen that uses augmented and virtual reality tools to engage seniors to create interactive narratives on memories of their neighbourhood.

Museums and Heritage Institutions Mental Wellness
National Gallery Singapore developed Silent Tour (2019) to help cultivate mindfulness by providing participants with a reflective and introspective experience while interacting with displayed artworks in the exhibition to draw relations between the self and art.
Youth, mental wellness Singapore Art Museum collaborated with the Singapore Association for Mental Health to develop Project Happiness which uses the museum's contemporary art collection to engage secondary students to discuss issues on mental health.
Ageing, special needs Sun Yat Sen Nanyang Memorial Hall's Be My Robo-Date (2019) provides access for individuals who are unable to physically visit the heritage institutions with an interactive virtual museum tour through a remote-controlled mobile monitor robot accompanied by a museum guide.
creative-based therapy and activities amongst social care providers and social support organisations in the community, e.g. Creative Services by the Singapore Association of Mental Health. These policy changes also fostered growth in the area of disability, with more dialogues such as the Arts and Disability Forum (est. 2016), the mainstreaming of inclusive programming in the arts and cultural institutions and ground-up activities for PWDs (Access Art Hub, 2018). Table 3 highlights the existing range of arts and health practices and activities in Singapore's social care sector.

Key drivers of development
This expansion of arts and health initiatives and activities can be attributed to a combination of both top-down and ground-up factors.

Strengthened commitment -cross-sectoral goals and collaborations
The specific principles and approaches adopted in the policies mentioned above have encouraged interaction and facilitated collaborations amongst previously siloed practices in arts and culture and in health and social care. Most importantly, commitments were articulated at the highest level across all relevant sectors simultaneously, allowing for clear and unambiguous alignment. A common set of policy objectives -to develop an inclusive, healthy and resilient society in the face of ageing -and the common need to identify more sustainable, scalable population-level solutions helped to further drive cross-or even multi-sectoral initiatives forward. Table 2. Current arts and health practices and activities in the healthcare sector of Singapore.

Context Exemplars Art-in-Hospitals
Arts and Health (est. 2014) at Ng Teng Fong General Hospital has an extensive and active art-inhospitals programme that brings creativity into different care and community settings for therapeutic, educational, and expressive purposes. Besides offering its regular programme it also runs an annual Arts and Health Festival. Project DreamCatcher (est. 2011) is a unique peer support group programme developed by the Department of Paediatrics at the National University Hospital to empower adolescents with chronic illness. The project engages artists to mentor the youths to develop artworks to raise awareness on childhood chronic illnesses. Centre for Health Innovation (CHI) (est. 2016) at Tan Tock Seng Hospital runs CHI Living Lab (CHILL) to connect innovators with resources such as designers, researchers and medical technologists, to innovate processes and products, and enhance patient care and experience. Integrated Care Agency for Integrated Care (AIC) -Wellness Programme (est. 2014) has played a pivotal role in promoting and supporting the use of art for wellness in community care. Some of the milestones include; piloting museum-based activities for senior with the National Heritage Board and The Peranakan Museum (2015); implementing the first arts residency in nursing homes in partnership with the National Arts Council (2017); developing toolkits to support the implementation of creative activities in community care facilities.

Creative Arts Therapies
Association for Music Therapy (Singapore) formed in 2007 is the professional association for music therapists in Singapore. Art Therapy Association Singapore (est. 2008) is the professional association for art therapists in Singapore. Psycho Drama Singapore offers Experiential Therapy targeting stress management, grief work, relationship trauma repair for individuals in the prison, special needs schools, children's homes and hospitals.

Strengthened resources -funding and networking platforms
In addition to a coordinated framework for action, the development of arts and health in Singapore can also be attributed to a corresponding increase in support, both tangible and intangible. Alongside policy changes, increased funding from government agencies and philanthropic organisations have also been catalytic in supporting the development of arts and health-related works. Some examples include the provision of new grant funding for arts as a part of core service provision (e.g. Community Chest, WeCare Arts Fund, PAssionArts), for youth in the community (e.g. Young Changemakers), and for community eldercare (e.g. Tsao Foundation). The sector has also gained from the introduction of networking platforms that have promoted the development of an active arts and health community of practice. The Arts for All initiative (est. 2008) by the NAC has been instrumental in facilitating and supporting cross-sector collaborations amongst professionals from the arts and culture, health, and social care sectors through its effort to expand the outreach of the arts to various segments of society. Subsequently, several forums and other resources have emerged dedicated to exploring arts and health over the years (See Table 4), including the recent development of the Arts and Health Repository Singapore, an online community-driven database charting arts and health activities in Singapore.

Persistent problems and emerging issues
While the surge in arts and health-related activities is encouraging, our survey and qualitative findings also revealed several issues confronting policymakers and practitioners in the field. Notwithstanding the therapeutic and healing qualities observed in Disease Association (ADA) Singapore) has been partnering with various arts and culture organisations since 2013 to offer a variety of community-based arts programmes for persons with dementia and their caregivers. TOUCH Centre for Independent Living is a day activity centre set up by TOUCH Community Services. It offers competency-based training and enrichment programmes for adults with mild intellectual disabilities to learn new skills that enable them to gain financial independence and improve their quality of life. In addition, its TOUCH SpecialCrafts uses visual art as an alternative way to bridge learning for persons with intellectual disability. Arts, Disability and Social Inclusivity Extraordinary Horizons (EO Horizons) is a deaf run enterprise established in 2011 to support and empower the deaf to integrate into mainstream society and promote deaf awareness. Superhero Me is a non-profit ground-up inclusive arts movement that empowers children with disabilities, special needs and those from less-privileged backgrounds. The initiative also provides arts training workshops for artists to promote inclusive art programming. Esplanade -Theatres on the Bay's Dance for Joy offers youths with autism opportunities to interact and bond with their family through creative movement sessions led by professional instructors.
the arts, buy-in and integration of the arts in health still faces resistance during planning and barriers during implementation. Key themes included inconsistent understanding of arts and health among the general population and even within the community, inadequate capacity to conduct research, limited training platforms, and a lack of professional recognition.

Uneven arts and health literacy
Although the growth in arts and health-related activities in the past decades is encouraging, appreciation and understanding of the field remains uneven amongst the sectors and may result in several challenges on the ground. Even among creative practitioners, varying perspectives on what it means to integrate arts and health and the value of such approaches have hindered discussions and progress towards getting buy-in from new partners, particularly those with limited exposure to the field. Likewise, health and social care administrators have expressed encountering resistance from their management when requesting the allocation of more resources for the arts in their setting. The inconsistent use of terms or inherently ambiguous terminology has also caused confusion amongst stakeholders, especially at the early stages of discussion. For instance, art or music therapy by qualified therapy professionals as part of a client/therapist relationship may be confused with the practice of therapeutic arts led by an art instructor. While both are skilled professionals, the experience itself and the nature of the training and oversight required are significantly different, leaving considerable room for misunderstanding.
Our findings also indicate that, ironically, while cross-sectoral forums have grown, opportunities for detailed, role-specific knowledge exchange within sectors have been scarce. For instance, even though art-in-hospitals programmes have grown in the past decades, arts-in-hospitals administrators reported virtually no sharing of best practices or Table 4. Forums and networking events supporting arts and health in Singapore.

Context
Exemplars Arts and Social Community Care Arts and Ageing Forum, previously named Arts in Eldercare Seminar (est. 2013), is an annual seminar organised by the NAC which aims to bring together local and international social and healthcare practitioners, artists and aged care policymakers to discuss and develop approaches to promote the wellbeing of seniors with the arts. AIC Up and Up: A Forum on Community Care (est. 2013) is a cross-agency forum by the AIC to connect professionals from healthcare, social care and the arts sectors and encourage cross-sector collaborations to enhance local health and social care services.

Interdisciplinary Discussion of Arts and Health
Roundtable Series at SAM: Arts, Health and Wellbeing Connections and Conversation is the first of its kind event organised by the Singapore Art Museum and Dr Michael Tan in 2014, focusing on conversations concerning arts, health and wellbeing with industry experts and how artistic creativity contributes to the overall wellbeing of individuals from diverse communities. Arts and Health Singapore Repository (est. 2020) is an online database set up to actively documents and provides updates on the state of arts and health field in Singapore through a listing of practice, policy, research, and capacity development.

Arts, Disability and Social Inclusivity
Art and Disability Forum was jointly organised by the British Council, NAC and Singapore International Foundation in 2016 to highlight the arts as an avenue for empowering individuals with disabilities and promoting their wellbeing.
avenues to discuss further developments with one another. Similarly, museum and cultural venue administrators indicated a lack of opportunity to pursue in-depth discussion on arts, health and wellbeing within the cultural sector.

Limited research capacity for evidence-based policy and practice
Interest in arts and health has also brought new demand for critical evaluation of the effects and value of arts on health and wellbeing, as emphasised in the Our SG Arts Plan (National Arts Council, 2018). Some local arts and health-related research has begun to emerge in recent years. Most have focused on arts and ageing; examining the effect of arts engagement on community-dwelling older adults (Ho, Ma et al., 2019;Yuen & Kong, 2018); evaluating the value of the arts in dementia care (Fong, et al., 2021;Tan, 2020Tan, , 2018Tan et al., 2018); supporting transitions to residential care (Pang et al., 2015;Tan & Tan, 2020); and promoting resilience among end-of-life care professionals (Ho, Tan-Ho, et al., 2019). However, such studies are still relatively rare, and their coverage is limited. The lack of localised, evidence-based support to substantiate efficacy has made it hard for arts practitioners and administrators from the various sectors to convince management to buy into the arts and secure the long-term future of programmes in this field over other competing alternatives.
Despite the demand from policymakers and increased opportunities for research, arts practitioners, healthcare, and social care administrators running arts and health-related programmes also identified strong practical constraints. These include a lack of researchrelated knowledge and skills, insufficient personnel, lack of budget and limited time, particularly for smaller organisations for which investment in research may not be feasible and represents significant opportunity costs.

Limited education sector capacity to meet formal training needs
Despite the growing call for artists to be involved in arts and health-related work, administrators, arts producers, and veteran community arts practitioners expressed difficulty finding artists with the appropriate skills, training, and, crucially, disposition to lead arts and health-related projects. From this perspective, educational institutions have an essential role to play in developing competencies amongst creative practitioners.
However, presently, LASALLE College of the Arts and Singapore University of Social Science are the only higher learning institutions providing graduate programmes in Art Therapy. In addition, the Singapore Polytechnic offers a three-year diploma course in Applied Drama and Psychology. A few initiatives/modules have also emerged to encourage exploration of the intersection of arts and health, such as the Digital Wellness and Design for Medicine clusters at the School of Design and Environment at the National University of Singapore, and the Arts, Ageing and Wellbeing module in the M.Sc. in Applied Gerontology programme at the Nanyang Technological University. However, there are currently no courses offering formal education and training on arts and health practices or community arts practices.

Under-recognition of professional status
A key concern is the appropriate treatment of practitioners in line with their status as professionals in the field of arts and health. For instance, even as the use of creative art therapy increases, creative art therapists are currently not recognised as a protected profession by the Allied Health Professional Council (AHPC), the professional board that governs and regulates allied health professionals in Singapore. This predicament points not only to the issue of including art therapists as part of the allied healthcare profession in line with international practice but also has strong implications for their eligibility for healthcare subsidies, limiting their accessibility, and affordability of creative arts therapies.
Compensation issues are an important part of this discussion. Arts practitioners often rely on mixed sources of funding that range from formal to alternative funding sources. Our respondents related to instances where, in light of the "social" value of arts and health, artists were asked to provide pro bono services or were simply given a token sum that does not reflect a professional rate. Moreover, payment rates can be dissimilar amongst creative practitioners and are dependent on several factors such as the art forms, "reputation" of the artist, duration and complexity of the project, and the budget pool of project partners. There are currently no official published rates for artists, let alone artists in the field of arts and health.

Uncertainty about long-term project sustainability
Finally, current grant calls and funding sources to encourage cross-sectoral collaboration and kick off pilot projects are felt to be highly adequate. However, many practitioners expressed concerns about the sustainability of their practice and programmes beyond the typical initial pool of pilot funds, which generally lasts only a few years, and whether selfsufficiency should be a realistic goal.

Conclusions and implications
In summary, over recent years, the field of arts and health has seen considerable growth in Singapore, demonstrating new synergies amongst the domains of policy, practice, research, and capacity development. The policy shift towards the "social" and "community" observed in arts, health, and social care has promoted exchanges between seemingly unrelated sectors and created new opportunities for collaboration, resulting in a comprehensive range of new arts and health-related activities by different stakeholders in a variety of settings. At the same time, our research highlights several systemic issues that remain to be resolved.

Policy recommendations
Below, we suggest several policy recommendations for consideration, drawn from our analysis as well as stakeholder perspectives, in order to bring about a more integrated and sustainable arts and health ecology.

Extend existing efforts to expand public awareness and knowledge exchange
The arts and health field in Singapore has grown tremendously but requires continued exposure and advocacy. Our respondents felt that more frequent and more regular forums that support discourse on arts and health would be widely desirable and contribute to growing literacy about arts and health both within and across sectors. Such forums would also facilitate practitioners' ability and motivation to learn from one another.

Expand the education sector to meet new demand
Considering future demand for artists in the arts and health community, increasing the quantity, scope and quality of training programmes while keeping costs affordable is critical. Administrators and producers felt that local educational institutions should consider and be supported in expanding current offerings, including courses for aspiring individuals to explore practice in arts and health or related areas such as community arts and community cultural development. Similarly, the growing interest amongst cultural institutions and their shift towards promoting wellness and access also indicate the need for continuing education of the existing cohort of professionals and managers. For example, this could include courses for administrators with experience only in the arts or health sector to develop the appropriate competency and knowledge to support arts and health-related projects.

Bridge education and practice to further promote capacity-building
To keep up with the field, the current forms of formal training are necessary but not sufficient. Administrators and practitioners in our study recommended exploring models where educational institutions collaborate with experienced organisations or artists in the field to offer placement opportunities for students to gain practical experience and prepare them to undertake arts and health-related work.
The need to develop locally sensitised context-awareness as part of this bridging experience is key. For instance, the growing music therapy community in Singapore points out the need to develop formal music therapy training locally that caters to culturally relevant practices because most of them receive their education and training from overseas institutions in the USA, UK, Australia, and Korea.

Actively support research collaborations
Increasing research and evaluation is a critical priority for the field. However, the strategy of developing in-house research capacity may not be optimal or feasible for all. Growing partnerships between researchers and creative practitioners can help strengthen research capacity to help build evidence and enhance practice to expand the field further.
Moving forward, practitioners and administrators felt that the field could benefit from match-making opportunities with academics and research organisations. Such platforms might connect programs with researchers who could help measure their impact and develop insights to improve their efficacy while yielding evidence that might benefit the field as a whole. Robust independent scientific research in this area would also increase visibility and understanding of the impact of arts on health and well-being while broadening and diversifying the scope of the knowledge base on arts and health.

Continue to drive professionalisation in the field
It is imperative to build shared resources to coordinate and support the diverse array of practitioners that exist. Some resources may be relatively straightforward: for instance, administrators have expressed the need for a consolidated directory with information on experienced creative practitioners and organisations in the arts, cultural and health sector that could aid organisations and practitioners in finding suitable partnerships.
Recognition of the professional contributions of practitioners as well as promotion of financial stability for practitioners and partners is also key. Producing effective resources that address these areas requires more sectoral commitment and coordination but offers high potential value. Practitioners felt in particular that transparent standards around payment arrangements would help cement the position of arts and health practitioners or community arts workers as a recognised profession, and that audited professional guidelines would ultimately be mutually beneficial to both artists and their employers.

Study limitations and future work
This study reflects our best efforts at conducting a scoping review of the arts and health field. We are aware that the variety of arts and health-related work in Singapore goes beyond the content presented in this report. Thus, this account is unavoidably selective. We convey apologies to any practitioners and organisations, whose work has not been mentioned above. We look forward to connecting with them via the Arts and Health Singapore Repository (www.artshealthrepository.sg), which we have developed alongside this study. Data collection and review for this study were also concluded prior to the COVID-19 pandemic, which we acknowledge have implications for the field of arts and health that are not meaningfully captured in this discussion and are left for future work.
Developing arts and health in Singapore has been a complex and challenging enterprise involving multiple stakeholders. While significant progress has been made in connecting the dots to date, gaps and unmet needs remain. Our findings also uncovered strong interest to address these issues collectively and collaboratively amongst stakeholders in this sector. Future development requires continued dedication at all levels of the policy process, particularly if Singapore wishes to fully realise the potential of its arts and health field in the future to achieve truly holistic personcentric care.

Data Availability Statement
The data that support the findings of this study are openly available in DR-NTU (Data) at https://doi. org/10.21979/N9/VFOACC.

Disclosure statement
No potential conflict of interest was reported by the author(s).