Heng Chiang Meng
Singapore
“Mr Speaker, Sir, whilst I agree with the approach taken by the Government, especially when I personally think that the economy may well recover in the second half of next year, I would like to ask the Minister whether he could take steps to rectify the situation on the ground, of which I am very deeply concerned.”
“Witness the prices of PCs when they first appeared and the prices of PCs now. Also, without an extensive infrastructure, motoring with a hybrid car will cause more inconvenience for the owner.”
“Sir, I did address you as Chairman. I only once, earlier on, addressed you as Deputy Speaker. Most of the comments I am going to say have been covered by the two earlier speakers. I just want to add that I understand that Newater is biologically very clean.”
“I dare say that Singapore is kept litter-free by the street cleaners, and not because there are no litter bugs. So the real long-term solution is to inculcate good environmental behaviour as part of our habits.”
“For example, one way could be to rank the distance of each household from the school, and the ranking to be used to allocate the available places based on the household nearest to the school having the pole position.”
“Sir, I find it difficult to understand why the Senior Minister of State should bring in other people's arguments, like people being sick, one parent looking after so many children. We are talking about distances away from the school. Let us not bring in other factors. But, in any case, her mind is already made up.”
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“It is incidental and not the main purpose.”
“I have some points of clarification because I think the Minister has misunderstood me on some points. Sir, on the question of subsidy, I am aware of the various forms of mini-help that has been given to the bus services. But I am talking about a major one like if the Ministry were to tell SBS and say, "Look, we like you to air-condition all your buses. We like you to provide better frequency. How much will it cost?" Say maybe $100 million. If so, the Ministry could say: "However, we like you to only charge $60 million to commuters and the other $40 million will be subsidized by us". I am talking about that type of subsidy so as to encourage better usage of buses. Sir, on the other point about (10-X) years, again I think the Minister has misunderstood me, because I am not talking about all vehicles. I am talking about car owners with vehicles having the PARF value, which means that if they opt for the full 10-year grace period, they lose their PARF. So it is not a more generous concession. The concession depends on whether the owners of these cars want to take advantage of it or not. Finally, I am aware that the revenue figures would be available in the annual report. But I did say that I hope the Minister will give to Parliament the revenue figures as soon as they are available, and not to wait until the following year when the annual report comes out. I think he has also missed out the question on inflation.”
“The fourth question, Sir, is: would the Minister permit the existing owners of cars with PARF a grace period of 10 years, instead of (10-x) years, and let them decide at the end of the tenth year of the life of their car, whether they want to scrap their vehicle, take advantage of the PARF value and bid for a new car, or to continue retaining their vehicle until the end of the grace period, so that they do not have to pay for the quota premium and lose, in that case, the PARF value? If these owners opt for the first alternative, effectively they are back to the (10-x) years system. The fifth question is: would the Minister tell Parliament the additional revenue to be collected as soon as it is feasible or as soon as the information is known to the Ministry? Could he also tell Parliament the effect on inflation for this year as a result of this new quota system, although he did, Sir, stress that the effect will be minimal. I am sure most Parliamentarians here would like to know the actual effect.”
“Here the Minister said: "The Government does not intend to use the transport policy as an excuse to collect more revenue." I believe he said that twice. In that case, would the Minister be prepared to consider the concept of direct subsidy for bus services as a very, very special case, and that is, perhaps to ask SBS and TIBS to provide a better, more comfortable, and really a first-class service, at very affordable prices, so that the difference in the revenue and cost could be subsidised from the quota premiums collected? Sir, the second question is: would the Minister consider another system of tender bids other than the Dutch system of the lowest successful bid? Because I believe that the proposed system would encourage irresponsible sky-high bids by persons who think that they would not be the highest. And if sufficient number of people think that way, then the lowest successful bid could be very high. Sir, the third question is: when the quota system is in place, and since the quota premium will be double for company and commercial vehicles because of tax benefits, would the Minister consider the removal of the $35,000 limit ratio for tax deductible items for all expenses relating to such vehicles or, at least, increase it? The rationale for the $35,000 may no longer be there since it is not a tax collection item, but more for control of loopholes.”
“Sir, I have several questions. I think here I would like, with your indulgence, just to preface one question with a suitable quotation from the Minister's statement.”
“I support the rest and would like to comment on two of them. One is on city parking. City parking charges should be drastically increased and perhaps one way to encourage this would be to allow, without extra cost or at low cost, owners of office blocks to convert some car parks into offices. After all, it would also help to alleviate the office space shortage presently being experienced in the city. Second, on public transport. I fully support the concept of looking at various modes of land transportation system as complementary and not competitive. In particular, I fully support the suggestions on how to divert more commuters to the MRT. In addition to this, I would also like to renew my earlier appeal for a reconsideration of building car parks, wherever possible, next to MRT stations.”
“There is, however, one more important factor in my proposal and that is the system of increased operating costs translates into extra revenue for the Government. On the other hand, increased price content, whether through increased ARF or quotas, translates into windfall gains for existing car owners. Normally, this would not be too bad. After all, enabling our people to be richer is not really a bad thing. However, we must remember that car owners are still a minority in Singapore. Should we therefore tolerate a land transportation policy which enriches the minority who are, in general, already the richer segment of the population? What of the majority of Singaporeans who are not car owners? Who speaks for them? Though seemingly uninvolved, Sir, I believe they pay a very high price to enable car owners to enjoy a higher quality of life in land scarce Singapore. Some of the high price paid are noise pollution, especially for those living near roads, breathing in air contaminated by leaded exhaust fumes produced by cars, and loss of public land which could be used for everybody's enjoyment, such as parks, because such lands are used instead for roads and car parks. At least, Sir, with the higher revenue for the Government, the majority non-car owners can have some benefits in return through better housing, education, medical services and a host of other public services provided by the Government at a subsidised cost. Moreover, let us also not forget that the lowering of income tax rates all these years is only possible through increases in indirect revenue, such as those from car ownership. Sir, as for the other recommendations, it is clear that I do not agree with any easing of the ALS hours, even those in the evening.”
“But since the electronic road pricing system is still some way off, I would like, for the time being, to propose the concept of increasing "operating costs of car ownership" as a proxy. To put it in another way, until the ERP is available, I would like to advocate a policy based not on increasing the "price content of cars" but rather on increasing the "operating costs of cars". Sir, as long as the demand for cars is more than what can be supplied, whatever the reasons for the restriction of supply, the economics of scarcity will prevail, ie, the price content of cars will go up, whether through a quota system or an increase in ARF. This means that for most purchasers, cars will be viewed as a partial investment. Hence, high prices are not really a deterrent because an owner can expect to recover the investment in the future. This, in general, has summed up the situation in the past where increasing prices do not really deter ownership. However, Sir, if a potential owner realises that the high cost of owning a car is through "high operating costs" which once expended will not be recovered, then perhaps the marginal owners will think twice before embarking on ownership. Some measures of such "high operating costs" policy could be higher road taxes, higher ALS fees, higher petrol duty and much higher city parking fees. Here, I must stress that these measures should be used to encourage Singaporeans to rely more on public transport rather than on private cars. Hence, such measures should not apply to public transport. If they do, they would not be effective as the cost differential would not be great enough to encourage switching from private cars to public transport.”
“I remember the prices of used cars then dropping to very low levels but, more significantly, I also remember that the prices of new cars were effectively lower - through larger discounts, more free extras and cheaper or even interest-free financing offered by motor companies. Therefore, I would put across that the economic argument of a free market mechanism for car pricing based on a fixed quantity to justify the quota system is a spurious argument. Because even under our present system, we do and we have also seen prices fluctuating as they did between 1985 and the present time. Instead, Sir, what we may eventually get under a quota system would be a car market with a high degree of volatility in prices, speculative content, possible cornering by groups working as informal cartels and eventually an unhappy population. Experience has shown often enough that such systems normally work towards the disadvantage of the man-in-the-street. However, Sir, this does not mean that I am advocating that we retain our current system if, by that, it means perpetually increasing the Additional Registration Fee (ARF) because I believe that this will ultimately just increase the price content of the car. On the contrary, I would like to urge the Government to reduce the price content of cars while adopting a more aggressive posture on measures to restrain usage. Sir, I do not think we should restrain ownership. We should let the people own cars, if they want to and if they can afford to. Why should the Government tax this ability to own cars out of existence? After all, car ownership does not create traffic congestion. It is car usage which creates the congestion. We all know that ultimately car usage will be best served or best restrained by a system of road pricing.”
“Mr Speaker, Sir, I support the motion and I would like to commend the Chairman and his Select Committee on a job well done. Unfortunately, I have to disagree with the Report's main recommendation, i.e, the proposed quota system as a means to restrain the car population. Sir, as I listened to the very persuasive arguments put up earlier by the Member for Bedok GRC, Dr Hong Hai, the Select Committee's Chairman, I must say that I was almost convinced by him that the quota system would be the saviour of Singapore's traffic problems. Luckily, Sir, I also remember reading much material on the fallibility of governments to interfere with the free market, especially quotas, which restricts supply. Eventually, for one reason or another, such interference throws up more problems than it solves. And I believe that if the quota system is accepted, we will probably come to the same messy end. Sir, the Report tries to put across the proposition that the quota system is price-neutral, ie, it neither pushes up nor lowers prices, but that the price level will eventually depend on the demand vis-a-vis the number of new cars permitted. In theory, Sir, this is not wrong. But we all know that given the reality of the situation in Singapore, under this system, prices will increase. The argument that an economic slowdown will reduce prices under the quota system is not relevant because, in any case, under our current system without the quota, we already have seen this happening during the last economic recession in 1985/86.”
“Sir, one final question, please, with your indulgence. May I just ask why the Senior Minister of State objects to these permanent residents buying flats in the open market when these flats are no longer subsidized by the Government?”
“Sir, may I ask the Senior Minister of State whether he considers it fair to allow new permanent residents to buy flats whereas he does not allow a Singaporean with a proper family unit to buy a flat if this Singaporean happen not to have a Singapore citizen or a permanent resident in his family? I would say that this policy is not fair to that particular Singaporean.”
“Sir, in that case, may I ask the Senior Minister of State to take this particular situation into consideration? May I ask the Senior Minister of State whether he will agree with me that buying flats from the open market will not incur the element of subsidy from the Government, since it is an established point that the subsidy has been taken away in the open market. May I also ask him whether he views it equitable to treat long-serving permanent residents of more than 20-30 years in Singapore in this manner when the present policy allows new immigrants, the moment they are given PR status, PR status will also be given to all their family members so as to allow them to buy flats in the open market?”
“Sir, does this mean that if a family unit has only one Singaporean and no permanent resident, the family unit is not permitted to buy a flat from the open market?”
“Sir, may I ask the Senior Minister of State whether the present policy allows Singapore citizens, regardless of their income level, to buy flats in the open market? Because he did mention that to allow a family where only one member is a permanent resident to buy a flat from the open market would mean treating the permanent resident more favourably than Singaporeans.”
“Could he try to complete this review as soon as possible so as to give those of us who have to operate on shoe-string budgets some scope for better returns on their investments?”
“Sir, first, I would like to thank the Minister for Law for his speedy response to my request. This surely will give the Town Councils and other bodies, whose investment portfolios are controlled by the Trustees Act, greater scope in their investment decisions. Sir, although the Minister has indicated that there will be a further review of the Trustees Act, I would just like, hopefully, to hasten that review by reminding him that the purpose of this Act is primarily to provide a measure of prudence and safety to the investments of bodies who control funds, not their own funds but funds of their constituents. Traditionally, the highest rating of the investments in terms of safety are Government papers such as bonds and Treasury Bills. Next comes fixed deposits, and of course now NCDs, with banks. And the last on the list would be stocks and shares on the Exchange as well as immovable property. Sir, since the last review, the financial markets in Singapore have undergone tremendous improvements and changes. There are now available many types of papers, many types of investible instruments which I would consider to be safer and more prudent than some of the instruments permissible under the Act. For example, there are investible papers such as trade bills. These are bills arising out of trade by Singapore traders and they are in fact endorsed, similar to being guaranteed, by banks and other financial institutions supervised by the MAS. Surely, I would consider such instruments to have a higher safety rating than those instruments such as stocks and shares on the stock market. Sir, I would like to make a plea to the Minister.”
“Sir, looking at the amendment as it is worded, it looks like if the Minister so approves, the Town Council may have no choice but to accept the responsibility. It means that the officials from the Ministry of the Environment may not go to that particular Town Council to enforce the powers of the EPHA. Unfortunately, we must remember that enforcement requires and involves expenditure. I do not think Town Councils have the money for this expenditure. I will be very happy to hear from the Minister if he can tell us that the decision to accept enforcement of certain powers of the Act rests with the Town Council and not by fiat or by the wish of the Minister. I will be happier if this point could in fact be included as part of the amendment. Having said so, I would also like to ask the Minister for three points of clarification. One, if the Town Council so accepts the responsibility, will the fines collected from the composition of offences or successful prosecution of the offenders be given to the Town Council concerned? Two, could the Minister let us know that in the light of the HDB's experience whether the fines collected by the HDB are more or less than the cost of enforcement incurred by the HDB over the years? Three, can Town Councils be given Government grants to perform the duties of enforcement? In essence, this is no different from the Ministry of the Environment being allocated funds from the Consolidated Fund to carry out its duties. Since this enforcement is on behalf of public health, then I think it is up to the Ministry of the Environment to give us the money to do their job.”
“In closing, Sir, I would like to seek two clarifications from the Minister. One is the definition of 'employers' who could be caned under the new law. Sir, it is important to clarify this because, as has been said earlier, in a large organization there are chief executive officers, directors, senior people who may not be aware of the type of workers that are being employed by their personnel officers. I know that the key operative word in the amendment is "knowingly". Does this mean that if the prosecution cannot prove that a director or a company secretary or a CEO knows his company has employed illegal immigrants or overstayers, then he cannot be caned? Does this also refer to subcontractors down the line which means that if a contractor is being supplied with illegal workers by a subcontractor and he does not know it, then he cannot be caned too? The second point is a point that has been brought up by the Member for Ayer Rajah, and that is, that the Government could help by having the Immigration Department and the Work Permit Office provide a hotline, and I say "hotline", because speedy service is important. It should be a hotline information service for potential employers so that an employer wishing to employ foreign workers can verify the authenticity of the papers that they are given by the contractors, subcontractors or by the agents. Sir, with such a service, the Government will be seen to provide the industries and the employers with the necessary assistance to make sure that they have sufficient information and knowledge so as not to break the new law.”
“Hence, Sir, if because of the fear of being caned, this trade of trafficking and employing illegal immigrants and overstayers is stopped, it will also mean the removal of the main reason for illegal entry and overstaying in the first place. Hopefully, this means that there will be no illegal workers and therefore the law will never be used. Sir, I know that this is a torturous way of being harsh to be kind. But if it helps to eliminate illegal immigrants and overstayers, why not? Sir, I would like to touch on another question of labour shortage. I do agree that labour shortage is a problem that needs to be reviewed and discussed in greater detail than the time given to this particular amendment. But I would like to touch on a point which I feel must be answered. Members had earlier commented on a number of points which I must say I disagree with. One is thes question of relocation. Sir, Singapore is moving very much on to a higher level of production and certain industries that can only survive with cheap labour which Singapore cannot provide must relocate. It is not a question of being more expensive. It is a question of survival. In fact, I have examples of entrepreneurs who have relocated to Johor and they tell me that it is overall much cheaper there, despite the average time of roughly 45 minutes to an hour coming from their factory in, say, Pasir Gudang down to Singapore. If you look at examples in other countries, like in Japan, they have relocated many of their industries overseas not only in the country of consumption, like the United States or the EEC but also in places like Singapore and Thailand where their products are meant for export. Yet nobody says that the Japanese products are uncompetitive.”
“I know the name Somkid. They were probably promised a worker's heaven in Singapore, paved in gold. So they sell off some of their personal possessions, borrow money from loan sharks and pay a high price to get here. When they get here, what do they get? Sir, most probably they are given forged papers, exploitative wages and also the constant fear of arrest. Yet, Sir, the law, as it presently stands, gives them the heaviest and the most severe punishment while the other two parties are the more guilty perpetrators. As the Minister has said, this Bill seeks to redress this inequity. But, Sir, the law as I understand it is really not interested in punishment or revenge. Its primary purpose must be a deterrence, ie, it tries to prevent the offence from being committed in the first place. Therefore, if such a law, after enactment, is never used, not because the Government is fearful of using it but because nobody breaks the law, that law must be a very good piece of legislation, including its punishment provisions. Sir, therein lies the second reason for my support, because as I said earlier, I oppose caning per se. I do fervently hope that nobody, including the illegal immigrants and workers, will ever be caned. Unfortunately, as I said earlier, they may also be the victims, the persons-cheated. They may be ignorant of our laws and so without knowing the seriousness of the offence they come to Singapore. They may be caught. The same cannot be said of the employers and traffickers. The employers are the source and the trafficker provides the supply to feed the demand. Without the demand for illegal workers by employers, one can say that there will be no illegal workers.”
“Mr Deputy Speaker, Sir, I support the Bill in the name of the Minister for Home Affairs. When the Immigration Act was amended this January, I was then against it and I would like, with your permission, Sir, to explain why I now support the current amendments. I am still against caning per se for non-violent offences. If I have my rathers I would rather that this amendment be not brought up now and that we look at the first amendment in January to review other methods of solving and containing this problem of illegal immigration and overstayers. However, I do not think I will be able to have my rathers and, being a pragmatic person, I think this Bill will be perhaps the second best choice. There are two reasons. The first reason has been touched quite extensively, that is, the question of equity, the equity of punishment to fit the crime. Sir, if we look at the whole operation, there are basically three perpetrators, the traf- ficker, the employer and the illegal worker. Moreover, it was my belief, and it is now my belief, that the workers are more often the victims, as you probably have seen in the actual case of the Thai who was charged under this Act. An hon. Member: Somkid.”
“Sir, I do not really understand what the Senior Parliamentary Secretary meant by public safety because, as I said earlier, these people do satisfy all licensing requirements except that during their teen-age years they may have an adverse record but they are today cured of such ailments. So I do not understand what he meant by public safety. Unless he says it is an on-going offence; by that, if he means that the applicant continues to take drugs. That I can understand. But I am talking about ex-drug addicts, Sir.”
“I would like to know what these lesser offences are because I know of cases where people in their 40's with families are denied such licences when their only offences were perhaps drug-taking when they were 18 years old or in their teen-age years and they have been given a clean bill of health by the Central Narcotics Bureau.”
“I am not, Sir. In asking the question I am giving an example to illustrate the purpose of my question.”
“Sir, I would like to ask the Senior Parliamentary Secretary whether he is aware that if the Government's licensing authorities and departments were to adopt the same policy in the interest of public safety, let us say, Ministry of the Environment adopting this policy for hawkers, and since many jobs and vocations in Singapore are governed by licensing rules, can he tell us how these people can be absorbed into the normal stream of society if they are not given a chance to earn an honest living? In the same light I would like to ask why the ROV insist on punishing these people twice since they have already paid their debts to society and they actually qualify in all other respects in terms of licensing requirements? And should not the ROV take into consideration that they are after all the licensing department and not really the employer? Perhaps in cases like this, they should leave it to the market, ie, the employers, to decide whether they want to employ these ex-drug addicts or ex-criminals with adverse criminal records. Finally, Sir, the Senior Parliamentary Secretary mentioned about less serious offences. I would like to know what these less serious offences are? Because I do know of cases where people now in their 40's with families are denied such vocational licences.”
“Sir, we are all aware that living in a city state, such as Singapore, is a highly stressed one. Our people so far has coped with this very well. But I think stress is becoming higher and higher as we strive for greater excellence. My question to the Minister is whether our mental health programme is keeping pace with the need to treat the mentally ill at different stages of their illnesses. Sir, not only the seriously mentally ill but also those suffering from mild psychiatric disorders and stress. Sir, in this respect, I would like to ask the Minister to enlighten the House on a number of questions: (i) Besides the current outpatient facilities available at Woodbridge Hospital, the Child Psychiatric Centre at the Institute of Health, the four outpatient clinics, is the Ministry considering expanding outpatient facilities in other areas? (ii) Will the Government consider expanding the facilities for day-care treatment? (iii) Are there plans to improve and upgrade the Child Psychiatric Service in line with the plans to establish a children's hospital? (iv) What is the status on the redevelopment of Woodbridge Hospital? Will it also be restructured? and (v) Is the Ministry considering introducing an aftercare programme to better help mental patients to better integrate back into the family and the community?”
“What I meant just now when I talked about priority for willing donors is that if a normal healthy person is prepared to donate one of his kidneys to somebody for whatever reason and subsequently that person, who is still alive, needs one in future, then I am saying that perhaps there should be some scheme to give him immediate priority so that he does not have to wait, since in the past, he has actually shown his concern by willing to donate one of his kidneys.”
“Sir, as to the profit motive, he says that the hospitals must show a profit. The hospitals will have to continue to receive subsidies, like NUH, SGH. The subsidy level for financial year 1989 will be $60 million for SGH, and about $22 million for NUH. The subsidies are still very significant. Sir, Dr Wan Soon Bee has raised some very pertinent points. I agree with him that in terms of use of Medisave we have to try to ensure that Medisave account holders do not see their Medisave funds as being someone else's money but money which must be conserved because they will need it in their old age. We will be looking into how we can better communicate with the account holders and educate them more effectively.”
“This way there is still a policy setting body that would guide the hospitals on what they should be doing in terms of cooperation, in the sort of specialities that they should be developing or they should not be developing in order to avoid duplication. So whilst they have the autonomy for their day to day operations, developmental and policy decisions will still have to be vetted by a central body. Patients will still continue to be transferred as and when required. For example, radiotherapy is highly expensive. Each machine costs a million, two million, the latest one, maybe even $3 million. It does not make sense for every hospital to have a radiotherapy department. So whilst we have cancer patients spread throughout the hospitals, we will still have them ambulanced to SGH whenever they require radiotherapy. In this way, the links will still be maintained. Also, the support which is presently being given by the Singapore General Hospital to the various regional hospitals, for example, Tan Tock Seng Hospital, in terms of eye, ENT, will still continue. SGH will still continue to send the specialists and consultants to help out in the smaller hospitals. Nothing will change. As to conflict on whether a specialist would be penalized if he spends too much time with a subsidized patient, Sir, specialists are required to spend a certain amount of time with the subsidized patient. At the present moment, it is between six and seven sessions per week out of 11 sessions and we will closely monitor to make sure that they do not spend less time but if they are more efficient, they can spend more time, so be it. We will be quite happy but what we want to be sure about is that their time is efficiently utilized.”
“Anyone who prefers to have a little bit more luxury must be prepared to pay for that little bit of luxury and those who want to go all the way to an A class bed, they had better be prepared to pay for the full cost for the A class bed. He has also asked about how the restructured hospitals will achieve excellence and how do we assess them. I will address that afterwards when I come to Dr Tan Cheng Bock's questions. Sir, Dr Tan is worried that whilst he has no objection to our brining in American consultants to help us manage SGH in the interim period, he is afraid that being profit-oriented they will also bring their profit motive into SGH. Sir, there are two aspects to profit, as all accountants will tell him, maybe more, I do not know. One is the cost. The other is the revenue. If you can increase the revenue you make more profits. On the other hand, you can reduce your cost and make more profits. Our objective, Sir, is to ensure that we are able to reduce our cost or at the very least ensure that our costs do not go up rapidly. And to do that we must have all the modern management tools to allow us to monitor what is being done, what is being used, how much time is being spent, so that we can ensure that everyone is cost effective. At the same time we will have a full team of medical professionals, a medical board, which will ensure that whilst we look at costs, medical standards are not jeopardized. So these are two independent bodies. One is a day-to-day management, the other is the professional standards. How will the restructured hospitals continue cooperating with each other? How will we ensure that their self-interest does not lead them to preclude cooperation? Sir, we have ensured that by having all the restructured hospitals under one holding company.”
“The buck stops at the table of the Chief Executive Officer there, not at the Ministry of Finance or the PSC. So therefore we expect results and we expect results to be obtained relatively quickly. He talked about nursing homes. Sir, at the present moment our policy is to allow the development of private nursing homes to provide care for the convalescent and the chronic sick and the nursing homes are at present not subject to any legislation. However, they will be subjected to periodic checks by the Ministry of Health when the relevant legislation is brought into operation. In the mean time the Ministry of Health will work with the Ministry of Community Development on the licensing of nursing homes and homes for the aged and we will ensure that certain minimum standards are being complied with. Encik Abbas asked about the progress of the redeveloped hospitals. I have already replied to that. In terms of what restructuring will mean to the terms and conditions of the staff, Sir, the staff will be entitled to no lesser terms than what they are presently enjoying, except for pensions. They will have their pensions recomputed into a lump sum and henceforth they will be paid the full CPF. Mr Choo Wee Khiang has made a suggestion that we should perhaps rename the B2 into C class. I find that suggestion rather strange and in fact if he had done that earlier, I think the NCMP would have jumped on it and said, "See, you do not have to ask him. They have already done in GH." Sir, there must be the clear gradations between A, B1, B2 and C. C is a basic level of care. No frills but full medical treatment.”
“Unfortunately, because we tender, it also means we are locked in to a price for a certain time. We started off offering Hepatitis B vaccinations, for example, for newborns at $45 and in June 1988, because we had used up the old stocks we were able to obtain new stocks at a lower price, we have reduced the vaccination price to $30, and for adults we have reduced it from $120 to $90. Sir, that is not the end of the story. I am happy to inform Members that stocks are being used up. We expect when the new tender is delivered that prices for the new supplies will further go down and we would, as we have done before, pass on the savings back to Singaporeans. Sir, we do not believe in profiteering. Dr Vasoo, among his points, talked about the older hospitals losing the staff to the hospitals that have been restructured. Sir, we have made it clear and we will enforce it very strictly that a restructured hospital will not be allowed to poach staff from the other hospitals that have not been restructured. He is right. If we leave it to them all the best staff will go to the restructured hospitals and why not? Because they can expect to have better conditions of work, they can have greater authority to do what is correct, they do not have to wait months and years before their requests are approved because all the requests have to go up all the way to the Ministry of Finance for approval. So it is highly efficient and therefore highly desirable in terms of staff perceptions. Sir, we will also be ensuring that the standards in our restructured hospitals do not deteriorate. And in fact we expect the standards in the hospitals that are restructured to improve because with the authority and the responsibility being given to them, there is no other person they can pass it up to.”
“The luxury of the A class or B1 beds or for those who cannot afford it, provided we make-do with the less privacy, the B2 and the C class wards which, whilst heavily subsidized still accord them the necessary and same level of medical treatment. In our system there is very much less wastage and abuse and no one is denied medical care. Sir, let me move on to some of the other points raised by the other speakers. The NCMP made some very strong remarks. He accused the Government of playing a dirty trick on Singaporeans. He said that in SGH what we have done is to convert C class wards into B2 and call them B2. That means giving them the same C class facilities but charge them more by just a neat trick of changing the name. Sir, I guess the NCMP has not been to SGH since it was opened. If he had, he would have seen that the B2 beds in GH are highly superior to any B2 beds that we have in the other hospitals, NUH included. That is why our B2 wards in GH are so heavily utilized that we have in fact, unfortunately, turned away patients or delayed the operations until beds are available. Singaporeans are no fools, despite what the NCMP would like them to believe. They know whether they are getting value for money. If those are C class beds at such a much higher cost, those beds would be empty today. They will all be using the C class beds in the other hospitals. The NCMP accuses us of profiteering. He gave the example of Hepatitis B vaccinations. Sir, the Hepatitis B vaccincations in the Government hospitals and clinics are far cheaper than any that can be obtained elsewhere in Singapore and the reason is because we are able to use our purchasing power to tender for the vaccines and obtain extremely low prices. All these savings are passed on to our patients.”
“Sir, this is what we have already introduced way back in 1985, with the opening of NUH. As to whether the British can focus more on the target groups who require heavy subsidies, I am not too sure as to whether they can succeed in this. But I wish them well. The American system is also facing tremendous problems. They are spending over 12% of their GNP on health care and this is projected to go up to 15% within the next few years and to 18%, maybe 19%, by the turn of the century. Yet despite this heavy expenditure, over a third of all Americans cannot afford to obtain medical care. If you are involved in an accident in America and you are not covered by health insurance, your chances of getting into a hospital that is prepared to accept you are extremely slim. In Singapore our philosophy and policy is also aimed to help the needy and the under-privileged. That is our commitment. Our total expenditure on health care equals 2.7% of our GDP. But no one is deprived of medical care. Sir, the Singapore model is a far safer one and a more effective one. Our aim must be to ensure that our economy continues to grow and that everyone is gainfully employed, hopefully and preferably with ever increasing wages. This way we help them to build a safety net through their Medisave contributions and they can then choose how they wish to spend their money and their Medisave funds. We also encourage them and help them to stay healthy at the same time so that the best option is they do not have to spend anything on health care. We also let everyone have a choice of service according to what they can afford.”
“But because the actual quantum of subsidy has increased substantially for the Class C and B2 wards, and because Singaporeans are generally better off and most have Medisave funds, we are in the happy situation today of patients and their families complaining that they are being deprived of beds in the less subsidized wards. Sir, on the other hand, the indigent and those who are genuinely poor are given the same medical treatment, free of charge. And that is the true measure of how well the Government has discharged its duties. Sir, Dr Aline Wong yesterday also cited Britain and the USA as examples of countries with generous health care funding because they held deeply the beliefs about social responsibility towards the needy and the under-privileged. She mentioned that these systems are now facing problems and they are now trying to reform the systems rather than doing away with them completely. And she suggested that we could perhaps learn from them. The British and the Americans started their systems with good intentions. Where the British went wrong was that instead of focusing on those needy and under-privileged who required help, they gave free treatment to everybody, regardless of whether they required subsidizing. That was a big mistake. And the result is a tremendous demand for treatment, leading to long queues and waiting time. In fact, in some parts of Britain, a patient requiring elective surgery may have to wait up to two years before he gets one. In Singapore, anyone requiring elective surgery gets it within a week, two weeks at the very most. The British government has just set out to introduce some drastic reforms, to decentralize control over the hospitals and to allow them some autonomy.”
“If we find that they cannot afford to pay but they are not very comfortable about applying for waivers, we will still proceed to grant them the waivers. That has always been our policy. And this is reflected in the number of waivers and partial remissions that we granted in 1987. For the financial year 1987, 1,444 of those who applied for waivers received the waivers. On the other hand, upon investigations, 22,190 of the other patients were either granted waivers or partial remissions, mainly partial remissions, because we found that they required some assistance. And the total amount waived came to $1.87 million or about 1.3% of our total revenues. So our commitment to a liberal grant of waivers and partial remissions is something that we take very seriously and that is a very important safety net for all Singaporeans, especially those in the lower income group. Sir, the NCMP yesterday claimed that the fee increases over the years have deprived poor Singaporeans of hospital care, and that the Government is shirking its duty to look after the medical needs of the poor. Singaporeans, and the NCMP himself, know that hospital services have been vastly improved over the last 20 years. We have today a hospital service that is the envy of many, including those in the developed countries. And it is available to all Singaporeans, regardless of his social status or his income level. This would not be so if the Government had shirked its duty. Hospital fees have risen because, as I have shown, costs have gone up. In particular, the general salaries of Singaporeans have gone up because of the strong economic growth generated by Government policies.”
“For a married couple, for every 10 years of their life within the age of 20-50, they will on the average expect to be hospitalized a total of 12 days, which means that during that 30 years, they can expect to be hospitalized a total of 36 days, which is about 5 hospitalization episodes. So in terms of hospitalization requirements, if you are hospitalized five times, each time you require anything from 5 months to 10 months of savings. Or if you opt for the B2, you require 8 months to 16 months of Medisave contributions. What about those without Medisave? What do these bill size and the expected hospitalization requirements mean to a person who is self-employed or who does not have Medisave? Sir, a husband and wife team together will need to put aside $4 every month, between the ages of 20 to 49. That is only one-tenth of what the Medisave contribution would have been. And this would have allowed them to go into a C class ward and pay the bill quite easily. Sir, as regards the litmus test as to whether our bills are affordable, which the Member for Cheng San GRC, Mr Heng Cheng Miang, has asked for, if they are not affordable, then we will expect the settlement of Class C bills to be very low with plenty of bad debts or people asking for waivers. Most C class patients have no problem settling their bills. This is understandable based on the figures I have just given. For financial year 87 which ended at the end of March 1988, 92.7% of all patients had settled their bills within six months of the ending of the financial year. 1.44% have been granted waivers. The remaining 5.9% which are outstanding will be investigated by our medical social workers.”
“That means 75% of all C class patients pay $235 or less. And the 90th percentile, 90% of all C class patients face a bill of $414 or less. What about B2 patients? The average bill for a B2 patient is $346, not very high. The 75th percentile comes to $392, whereas 90% of all B2 patients pay $690 or less. The question asked by the Member for Pasir Panjang GRC, Dr Wan Soon Bee, is: are these figures affordable? It is not a subsidy. It is the actual bill size. Are these bill sizes affordable? Sir, undoubtedly, Medisave has made it very much so. It is therefore much easier for them to pay the bill and the reason is this. In today's labour market, a household income of $700 is, I think not uncommon. In fact, most people earn much more than that. But taking $700 per month as being the income for the household, the Medisave contribution comes to $42 a month. The average C class bill of $203 will require only five months of Medisave contributions. The average B2 bill size will only require eight months' worth of Medisave contributions from a person in the low income group. Let us look at the 90th percentile, some of the highest bills that are being faced. For C class bill, $414 which is the 90th percentile will require 10 months of Medisave contributions. Similarly, for the B2 90th percentile bill of $690, the low-income worker earning $700 per month will only require 16 months to accumulate that quantum. In terms of hospitalization, Singaporeans thankfully are quite healthy. So most people do not require hospitalization especially when they are within the age group of 20-50.”
“The C class patient will end up paying $493, that is about 10.6% of the A class bill. And for a very major operation, for example, open heart surgery or multiple digit replantation, the class A patient will be facd with a bill of $13,700. The B2 class patient will be paying $2,200, which is about 16% of the A class bill. And the C class patient will only be paying 8.8% of the A class bill, and this amounts to about $1,100. Sir, the figures show that the subsidies are very significiant. Members must take care that they do not confuse the public when discussing subsidies. There are two aspects to subsidies. One is the available subsidy, the other is the utilized subsidy. We must not confuse the two, thereby confusing the public. Let me give an example. Supposing we have a service where the subsidy today is $10 and there are a thousand people using it a year. It means that the total subsidy that we are providing for this service is $10,000. Supposing tomorrow or sometime in the future we increase the subsidy, we double it to $20. But for various reasons, the public prefer to use alternative treatment and only 100 people use it. The total subsidy now has dropped to $2,000. The question is: has the subsidy to the user dropped or increased? This is the situation facing our hospitals today. The subsidy for C class beds has gone up significantly. Fewer people are using this service. More are opting for the higher class wards which are less subsidized and this has therefore slowed down the growth of the total subsidies required. Let me give you a profile of the C and B2 bills, because sometimes averages may hide what is actually facing the patient. The average bill for a C class patient is $203. What does this represent? For 1988, the 75th percentile for C class bills was $235.”
“Members can therefore be assured that the proper level of care appropriate to the medical needs of each patient will be provided, regardless of the class of wards he is in. Sir, let me go into a detailed discussion of the level of subsidy and as to whether the Members' fears on the affordability of the subsidized C class wards are correct. First, the bill size for C class patients. In 1984, the average bill size for the C class patients came to $160. Four years later, this figure has increased to $203, an increase of $43. The cost to the patient a day in that case has increased from $29 in 1984 to $38 today, an increase of $9 per day to the patient staying in a C class bed. On the other hand, the cost of providing the service to the patient has increased from $151 in 1984 to $195 today. That means the cost has gone up by $44 within these four years, as compared to the $9 a day that a patient is paying. This means that the average subsidy for a C class patient amounts to $850 for each stay of about 5� days. This subsidy that is being provided to him has increased by $180 over the past four years. So of the $180 subsidy that has been increased arising from the increase in running cost, he only pays $43. Sir, this shows that the Government has been very generous and fair. Let us see how a C class bill and a B2 class bill compare with an A class bill for a patient who is receiving the same treatment but enjoying the comfort of being in a single-bedded ward. For a Table 5 operation which involves the removal, for example, of part of a stomach (this is a fairly major operation), the A class patient will end up paying $4,600 (operation plus stay in hospital). The B2 class patient will end up with a bill of only $790, 17% of the A class bill.”
“Modern equipment, sophisticated technology and operations also contribute significantly to these higher costs. Hence, irrespective of whether a hospital is restructured, our hospital fees will have to be increased periodically to take into account these cost increases. However, Members may not be unduly worried that the lower income group will be denied medical care as a result of these cost increases. My Ministry will continue to ensure that as fees are increased in the future, subsidized wards will still remain highly affordable to the poor and the indigent. For the indigent, since they cannot afford to pay even the highly subsidized fees, we will continue to liberally grant them waivers or partial remissions. However, those opting for greater privacy and greater personalized services that are available in the A class and the B1 wards must be prepared to pay the full cost of these services without subsidies. Sir, yesterday the NCMP claimed that those in the subsidized wards would not have access to specialists and consultants. Some of our Members here also fear that and, not being doctors themselves, that is quite understandable. But being a medical doctor himself, the NCMP must surely know that this is not true. He must know that the medical team in each ward is headed by a consultant and he is supported by a team of specialists as well as housemen and medical officers. In fact, the likelihood of the subsidized patient being treated by a specialist has never been higher today. In 1980 we had only 378 specialists in both the University and the Government hospitals. Today, this number has increased to 677, almost doubling of the strength.”
“And while these beds are unoccupied, there is a long queue of patients clamouring to be upgraded from the C class beds to B2 or B1. We receive such requests almost daily. Sir, Singaporeans are supposed to be able to choose which type of ward they wish to be admitted into. Unfortunately, this is not so. Many have chosen to be admitted into the B2 or higher wards. Unfortunately, we do not have enough of them and there are no vacancies, and instead such people are being forced, therefore, to stay in the C class wards. I think if we have additional B2 and B1 beds today, the occupancy of the C class wards will plummet again. Sir, the large number of C class beds is a carry-over from the colonial days and the time, not so long ago, when unemployment was high in Singapore and wages were low. Wages have gone up significantly over the last 15 years, and most Singaporeans can afford and do prefer something more than just basic facilities. They can afford also to not take advantage of the subsidies that are available in the C class wards. Sir, the redeveloped hospitals will be configured to meet the actual demands of the public. When completed in 1994, they will continue to have C class beds, but in much reduced numbers, as pointed out by the Member for Tampines GRC, Dr Aline Wong. We will, however, closely monitor to ensure that no one is denied a C class bed should he require one. Let me move on to hospital fees, the topic of much great concern to all our Members here. I will first address this topic generally, before going into the details later. Hospital care is highly labour intensive, with staff salaries making up over 80% of the total running cost. The cost of running a hospital will therefore continue to rise as wages and salaries are increased.”
“While all the Members have supported the objective, they, as well as many Singaporeans, are understandably fearful as to how this will impact on the availability of subsidized beds and as to whether they will remain affordable. This is especially important for the lower income group. Let me reassure Members that the Government's policy of providing subsidized hospital care for the lower income group will not be affected in any way by the restructuring programme. Heavily subsidized C class beds will still be available in sufficient numbers. I will first deal with the question of subsidized beds before going on to discuss the subsidy level. Dr Aline Wong had anticipated that my answer to her would be that we are cutting down on the number of C class beds because people preferred the B2 or higher class wards. Indeed she is correct. That is my answer. But that is the fact facing us. Increased affluence, particularly over the last 15 years, has also resulted in an increased preference for B2 or higher class wards because these offer a higher level of comfort. Dr Aline Wong and Dr Lee Siew-Choh have attributed this also as being due to the availability of Medisave funds. In fact, I think other MPs have also mentioned that. Sir, Medisave is a factor. I will not deny that. However, the preference for the better class beds, in fact, started way before Medisave was launched in 1984. We had to start closing the unoccupied C class beds from 1980. And since then, the number has been gradually reduced from 4,000 in 1980 to about 2,000 today. Yet the occupancy rate has, in line with our closing, gone down to 65%. That means, as at today, 35% of the beds still remain unoccupied.”
“This will allow specialists from both the private and public sectors to pool and upgrade their expertise and to develop them into centres of medical excellence. An Oncology or Cancer Treatment Centre is scheduled to be opened in SGH in July this year. A National Eye Centre will also be set up within the SGH complex and renovation works for this will commence within the next few months. The new Kandang Kerbau Hospital, as I have informed the House this morning, will specialize also in paediatrics. This way, we can then develop the new KK Hospital into a centre of medical excellence for both women and children. Sir, let me now deal with the subject of restructuring which is the concern of many Members who have spoken. Restructuring has been supported, I think, by all, except one, and that is the NCMP. Let me first reiterate the objective of restructuring. This is to enable the Government hospitals to be more responsive to the needs of the general public and to be able to provide a better level of service to all Singaporeans. Restructuring will provide all our hospitals with the necessary management authority, autonomy and, more importantly, the responsibility to achieve this objective. By subjecting the restructured hospitals to commercial accounting practices and strict financial controls, there will be greater cost consciousness and better cost controls. The end result of restructuring will then be Government hospitals which are more cost effective, efficient and highly responsive to public needs. Singaporeans will therefore be the ultimate beneficiaries of this whole programme.”
“In this way, the funds raised by the Foundation can be channelled to building more of these centres and they are much needed as long as donor kidneys are in short supply. The Acting Minister for Health (Mr Yeo Cheow Tong): Sir, first, I would like to thank the many Members who have spoken yesterday and today on the first cut of my Ministry's budget. For the benefit of new Members, let me first briefly re-state my Ministry's main policy objectives. The aim of my Ministry is to build a healthy nation and to achieve a high standard of health care for all Singaporeans. We will continue to emphasize the prevention of disease and the education of the public on all aspects of health, healthy habits and lifestyles and this is the only way to reduce the cost of health care for Singaporeans, ie, by their remaining healthy. Unfortunately, in spite of all health education and preventive medicine, people will still fall ill and require hospitalization. We must therefore ensure that our hospitals and their professional staff are competent and efficient in restoring back the sick to good health. We must also ensure that the physical condition of all our acute hospitals meet the higher expectations of Singaporeans. Today, because they are our most modern hospitals, the NUH and the Singapore General Hospital are viewed by the general public as being more desirable than the older hospitals such as Toa Payoh Hospital and Tan Tock Seng Hospital. This situation will be corrected when the other three major acute hospitals, namely, Tan Tock Seng, Toa Payoh and Kandang Kerbau Hospitals, are redeveloped by 1994. Planning for the three hospitals is in progress and we hope to commence building works by the middle of next year. Sir, my Ministry will also be setting up several speciality centres.”
“But it is only tackling the symptoms, not the root of the problem. I believe the root of the problem is the lack of donor kidneys. Dialysis treatment only keeps the patient alive while he waits for a donor kidney. Are there no other ways of encouraging more people to be willing donors? I would like to ask why is the opting-in scheme a failure? Is it because of lack of publicity and public education? I suggest that the Ministry could step up its efforts to educate the public to be more willing donors to their beloved ones. After all, one can still live a normal life with only one kidney. Perhaps this could be complemented by amending the Human Organ Transplant Act to ensure that such willing donors would get top priority in the receipt of kidneys should they themselves be in need in later years. The Minister should also consider extending the Human Organ Transplant Act to cover removal of kidneys for all types of death, so long as the kidneys are usable. Currently, kidneys can only be removed from deaths resulting from accidents. Sir, I would also like to appeal for financial assistance for the National Kidney Foundation. Currently, the Foundation runs two satellite dialysis centres. These centres are heavily subsidized. The Foundation has to raise funds for the establishment of the centres. They also need to raise funds to operate the centres. In respect of what they are doing, they are in a way like mini-hospitals - at least in respect of providing dialysis treatment. In other words, they have, by providing these facilities, taken over a small part of health services which ought to be provided by the Government. I am thus suggesting that the Government provide the Foundation with an annual grant to cover part of the centre's operating costs.”
“Sir, earlier in this sitting, the Acting Minister for Health told the House that 23 cadaveric kidneys were transplanted in 1988. Of these, 16 came from the Human Organ Transplant Act while seven were from the Medical (Therapy, Education and Research) Act. Yet, Sir, for 1987, without the enforcement of the Human Organ Transplant Act, the number of available kidneys was 16. Looking at these figures, one can put up a case that without the Human Organ Transplant Act, the number of cadaveric kidneys would have gone down from 16 in 1987 to only seven in 1988. Yet, about 250 new cases of end-stage kidney diseases are diagnosed in Singapore every year. Out of these, only about 50 are accepted for either transplant or dialysis. I believe this is due to the lack of donor kidneys and dialysis treatment facilities more than anything else. With such statistics, how long does a person have to wait before he can get a transplant? In the meanwhile, while waiting for a donor kidney, the affected person has to undergo dialysis treatment. This is not cheap, even at subsidized rates. I understand that the actual cost of treatment is in the region of $1,500 to $2,000 per month and if we consider the number of new cases every year one can see that the cost of caring for these patients is not an insignificant amount. Sir, there too is a personal cost to himself, to his friends, to his beloved ones, to his relatives and also the cost to the State because kidney problems are not only confined to the aged, they can happen to anybody of any age at any time. Yet looking at the statistics of available kidneys from sources other than voluntary donations from living persons, there is still much work to be done. The proposed Medisave withdrawal scheme for dialysis treatment is welcome.”
“What is the expenditure of private health care so that it can be dovetailed into public health care and its subsidies? Where should the subsidy start? In which area should subsidy be emphasized? These are important questions to an important issue. The Acting Minister cannot simply say that the charges are affordable. He must prove to the people that these fees and increases are truly and really affordable. I think only an overall conceptual comprehensive paper can do this. I strongly urge him to consider this. This is important for future planning in the light of our aging population for in the coming years this situation of the aging population will only mean one thing - health expenditure will go up and up. Medisave will not be enough for many of us as we grow older. It is said that a person spends more on health care during the last year of his life than the sum total prior to the last year. If this is true, then with increasing fees and charges, we are just pushing the problem into the future. Surely, Sir, this cannot be the objective of the Ministry of Health. Sir, I have got another cut, may I continue?”
“But what I am saying is that defence of the body is just as important. So why therefore the declining importance paid to health - at least in terms of relatively declining subsidies to the Ministry of Health? For example, the subsidy for Government hospitals has been reduced from 73% in 1982 to 61% in 1985 and now to 56% in 1989. Sir, every time hospital charges are increased, the Minister always says that they are affordable. But, Sir, that is just his opinion. So far, we do not have any findings of any sort that these increasing fees and charges are really affordable. Could such a study be done? In this respect, it may be worthwhile to find out whether there has been an increase in the number of multiple Medisave accounts to pay one single bill, especially if it is by sons and daughters for their aged parents. If so, surely it is an indication of some inability to pay so that all of them must pool together. More significantly, in order to ensure medical health for their parents, filial sons and daughters may be depleting their Medisave accounts which they will, and I say they will definitely, need it in later years. Sir, overall, I must say that I do not disagree with the policy that the subsidy for public health care must be kept to a realistic figure - a figure which must straddle the line between State affordability and personal affordability. My issue is that of the level. Piecemeal ad hoc reductions in the subsidy without any overall objective in the level itself is not the answer. All it does, Sir, is to periodically increase fees and charges. What is needed is a comprehensive conceptual plan on health expenditure. As a nation, how much can we, how much should we subsidize public health care?”