Khaw Boon Wan
Singapore
“Motor vehicle dealerships and showrooms have been closed since the start of the circuit breaker. As COE bidding is done mostly by the motor vehicle dealers on behalf of prospective owners, the Land Transport Authority (LTA) suspended COE bidding for the months of April and May.”
“Though stressed by the financial pain, they press on with the immediate priority of fighting the virus and supporting essential services. Post-pandemic, we will see how public transport evolves. Will demand for public transport services simply return to the pre-pandemic level?”
“Under our rail financing framework, the Government fully pays for the cost of building new rail lines. In other words, we do not recover the cost of building the Cross Island Line (CRL) from commuters through fares. The CRL project is being implemented and the final costs will depend on tender bids.”
“There are around 5,000 private bus operators with a combined fleet of 13,500 private buses. As we do not track the number of private bus trips and passengers, we do not have data on their carbon emissions.”
“There are nursing rooms at 50% of our bus interchanges. We will provide nursing rooms at all new bus interchanges and integrated transport hubs. For the MRT network, we will provide nursing rooms at all new interchange stations. We will also explore providing such facilities when MRT stations undergo upgrading.”
“Over the last three years, Singapore carriers have reported a total of 20 incidents of food allergies on board their flights. None required the use of epinephrine or emergency flight diversions.”
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“So, I think we are making progress. Like Dr Neo, I would like to hope that we can move faster but critically is we also need the support from society at large, in particular, society's attitude towards the mentally ill. It is easy for us to talk about destigmatisation but it is real. I have been trying to help some VWOs because I was inspired by the Yellow Ribbon project for ex-convicts. With the help of the Ministry of the Home Affairs, I think they have achieved a lot in the last few years in changing attitude and getting employers to recruit some ex-convicts, and I have visited some of those shops, restaurants run by ex-convicts and I was very warmed by what I saw. A few years ago, a few of us wanted to help the ex-mentally ill in similar fashion; but it is an uphill task. Still we have to push it otherwise we will never make progress. I am not so sure what is psychiatric referral in the community – meaning that they can refer directly?”
“As I have said, I think our system is far from perfect but I would like to believe that it is much less imperfect now than three years ago, and much, much better than 10 years ago. We are making progress and, honestly, very few countries have reached perfection in treating the mentally ill. It is a real challenge. I discuss and compare notes with my counterparts from other countries, and all tear their hair out over this issue because it is not an easy problem. It requires strong co-operation all round. Acute cases are always easier to handle. If you come in with a heart attack or whatever, a few days' stay in a good hospital with high technology, you get treated. But much of the life-long chronic diseases require support and often behavourial changes, both of the patient as well as the family. It is really a marathon, and we judge ourselves and encourage each other on by hoping that this year is better than last year, and next year will be better than this year. So, I think there will always be progress and we will push in this direction. For the last few years, I have paid some attention to this area because I worry a lot about this particular topic. Members may be aware that I formed an inter-agency committee – an Inter-Ministerial Committee chaired by my Permanent Secretary – and they have been at work with the professionals from the Ministry of Education, Ministry of Home Affairs and all related Ministries. It is an ongoing committee. They had put up recommendations a couple of years ago and we were able to get the support of the Ministry of Finance for an injection of new money. And this year when they reviewed it, they asked for more resources to plug certain areas of gaps, and the Finance Ministry was, again, very supportive.”
“Let us all work together to support the mentally ill, to help them get to terms with their illness, comply with the prescribed treatment and achieve early recovery, so that they can have a fresh start in life.”
“Those with higher risk of relapses are followed up by Community Mental Health Teams led by IMH psychiatrists. They keep in close contact with the patients by telephone and also through regular home visits. Case managers will monitor and alert the doctors if patients default on their follow-up. And if necessary, trained social workers and Community Psychiatry Nurses will make home visits to assess the need for re-admission. For the lower risk cases, IMH runs several outpatient clinics across the island, and has several partnerships with trained GPs who are able to provide follow-up care nearer the patients' homes. Patients are closely tracked to make sure they go for regular treatment and they remain well. Fourth, IMH runs a 24-hour Emergency Service and attends to patients who require immediate treatment. In addition, there is a crisis hotline and the IMH Mobile Crisis Team can make home visits, if necessary. Finally, under the Mental Disorders and Treatment Act, the Police are empowered to bring mentally ill persons to IMH for assessment, if they are found or believed to be acting in a manner that is dangerous to themselves or to others. Our community-based approach is not perfect. I think it is far from perfect, and we will continue to enhance it in the light of experience. In particular, we need the support and cooperation of family members and the community at large. We will further strengthen the community support network. We are devoting more resources to train community partners to support the patients. Every year, more than 600 individuals are trained to increase their awareness of mental health issues and to facilitate early identification of at-risk individuals.”
“Sir, how and where to treat a mentally ill patient is a decision for the attending psychiatrist to make. There is a wide range of mental illnesses and many are treatable with prospects of a full recovery. Advances in medical science have led to the general conclusion that prolonged institutionalisation is the wrong approach for the vast majority of mentally ill patients. Instead, good community-based care can result in a better health outcome for the patient, besides rendering a higher quality of life and helping in reintegrating the patient back into society. Community-based care for the mentally ill is a key recommendation of the World Health Organization and all developed countries, including cities, are moving in this direction. In Singapore, there are about 25,000 patients with serious mental illness, principally schizophrenia. 10% of them are institutionalised at the Institute of Mental Health (IMH) and psychiatric homes. The rest continue their treatment in the community, often in partnership with the IMH. While the policy of community-based care is appropriate, successful implementation requires proper planning. First, IMH has to carefully select the patients for discharge. They must (a) have responded positively to treatment; (b) have adequate family and/or social support; and (c) be assessed to pose minimal danger to themselves or to others. Second, IMH will educate the patients and their families on the need to comply with medication and regular follow-up. This is to avoid future relapses. Third, IMH will formulate an appropriate post-discharge support plan for the patients. Patients are categorised by the level of care, supervision and outpatient treatment that they need.”
“Yes, Alexandra Hospital is a ready resource with about 350 beds. That is why a couple of years ago, I decided that even as we open Khoo Teck Puat Hospital, we will keep Alexandra Hospital until a larger and newer hospital in Jurong comes about. So we have resources at Alexandra Hospital to tide us over. But long term, that is a very expensive piece of real estate, and I am sure the Government has other plans for that place. PSYCHIATRIC PATIENTS 2. Dr Lily Neo asked the Minister for Health (a) whether the Ministry will review the policy of favouring psychiatric patients remaining in the community as much as possible; and (b) whether such a policy is suited to our densely populated city state where there is insufficient psychiatric community support.”
“They are quite different. I think what is more important is to make sure that we utilise our resources as best as we can. The average occupancy rate is about 85%, which is all right. On whether the downturn will mean more default in payments, we anticipate some of this. I said so in last month's debate too. We are pumping in some money to the hospitals in anticipation of an increase in bad debt provisions.”
“Sir, with the downturn and its possible impact on hospitalisation, I have been looking at the admission figures and they remain quite stable. There has been an increase. It has been increasing every year. But the main driver is still the ageing of the population and the sharp increase in the total population here. Whether there is a direct result of the downturn – it is not noticeable to us yet. I think part of the reason is because in the hospital sector, we are the dominant player. We have 80% market share. What our doctors in polyclinics have told me is that they experience this surge much more than in hospitals, because their market share is only 20%. During a downturn, people tend to move to the cheaper sector. While both are affected – acute hospitals and clinics – the clinics, because of their sheer small size, face it more. Overall, I will be happier if I had started the construction of Khoo Teck Puat Hospital two years earlier. I cannot change history, so we have been coping with interim solutions. The additions in the last three years were deliberate and in anticipation of this. It does not mean that this year's addition is less than last year. That is because we added in the easier beds a couple of years ago in anticipation of this. We will cope; we will have to cope. The relief will come early next year when the Khoo Teck Puat Hospital opens. I just drove past the hospital site, they have reached level 10 now. I think they will be topping out quite soon. So we are not affected by delays in the construction. On whether we need to use private hospital beds, we will see if it is necessary and also if it is practical. Subsidised beds are in open wards. In for-profit private hospitals, they are all single room/double room.”
“The seniors will inevitably end up seeing many sub-specialists and being referred from one clinic to the other, whereas many of them could have been better treated in the step-down care sector. W e have discussed the growth of step-down care previously too. The growth has been in two directions, both quantitatively as well as qualitatively – capabilities as well as numbers. Part and parcel of that is manpower – training the appropriate level of care. So we have a lot of things to do. Mdm Halimah Yacob (Jurong): Sir, I would like to ask the Minister whether the number of 134 additional beds for 2009 is sufficient, bearing in mind that we are in the midst of a very severe economic downturn and there will be more people moving to the subsidised wards. Would the Minister be able to comment on the comment made recently by the CEO of a public hospital who said that one way of addressing the shortage of beds was purchasing beds from the private hospitals? Is that one of the things that the Ministry is considering? Third, I want to ask the Minister whether the hospitals are seeing an increase in the number of patients who find difficulty in paying their bills, and how do the hospitals address that point.”
“Sir, the short answer is "yes". I discussed a little bit of that at last month's Budget debate. And that is why there has been support from the Ministry of Finance for a very substantial increase in the Budget this year. Looking forward, we know that we will also need to increase it further. In the case of Singapore, the population growth – particularly the non- Singaporean population growth – has been substantial. The organic growth itself is manageable, but the increase in the foreign residents here is substantial, eg, in the last decade, we added a million. For a small population, that is a very sharp increase. M ore importantly, as Dr Neo has pointed out, it is the ageing of the population which will raise the demand. I have been watching age-specific admission rates, and we all know that for the elderly, the admission hospitalisation rates are much higher than the younger population. For the population of residents already here, it is quite arithmetical. We can just churn out projection figures. And that is why we built Khoo Teck Puat Hospital – although, in hindsight, I would be happier if I had started the process maybe two years before we did. We are now planning Jurong General Hospital, and I am carefully studying whether there may be a need for a future hospital in the north eastern sector, which is currently served by Changi Hospital. As Dr Neo pointed out, it is not just acute hospitals. The step-down care sector will grow even faster. And if we do not ensure proper development of step-down care facilities, patients will flock to acute hospitals. It is very costly for them and I am not very sure whether it is good quality of care, because the hospitals are highly sub-specialised.”
“From 2002 to 2008, there were 4,583 applications for ElderShield claims. 85%, or 3,912 claims, were successful, giving a rejection rate of 15%. During the same period, there were 9,144 applications for IDAPE claims. 84%, or 8,563 claims, were successful, giving a rejection rate of 16%. Using 2008 figures as an illustration, the number of successful claims was 732 for ElderShield and 618 for IDAPE. ElderShield and IDAPE cover severe disabilities as measured by the patient’s inability to perform three or more of the six Activities of Daily Living. The main reason for rejection was because the applicants could not meet the claim criteria. PERFORMANCE AT PSLE AND O-LEVELS 3. Mr Siew Kum Hong asked the Minister for Education whether there are any gaps in performance between students from different socio-economic status families at PSLE and O-levels and, if so, whether the gaps have increased over the past 10 years.”
“Co-funding for Assisted Reproductive Technology such as IVF was introduced in August 2008. From September to December 2008, 335 couples have benefited from it. They accounted for 65% of the total fresh IVF cycles conducted in the restructured hospitals. Seventy percent of them enjoyed the maximum co-funding of $3,000 per IVF cycle. As the scheme is still new, the vast majority of them were on their first IVF cycle. ELDERSHIELD AND INTERIM DISABILITY ASSISTANCE PROGRAMME 2. Assoc. Prof. Kalyani K Mehta asked the Minister for Health from 2002 to February 2009 (a) how many patients’ applications are approved annually for ElderShield and Interim Disability Assistance Programme for the Elderly (IDAPE); (b) what is the rejection rate; and (c) what are the main reasons for rejection.”
“HPB has also brought together several NGOs to collaborate and implement such programmes. Next month, a public education campaign on Optimism for Mental Resilience will be rolled out. This aims to reach every Singaporean, with the message that "bad times don’t last forever", and motivate everyone to take charge by adopting a positive attitude so that they will emerge stronger from this crisis. DESTITUTE PERSONS 45. Dr Lim Wee Kiak asked the Minister for Community Development, Youth and Sports (a) how many destitute persons were detained by the Ministry over the past three years; (b) how many of these were of unsound mind and were referred to a mental institution for treatment; (c) what liaison is there between MCYS and MOH before a destitute with a history of mental illness is discharged from a hospital; (d) how are destitute persons being helped to support themselves financially before being released from detention; and (e) which agency handles cases of destitutes with unsound mind who are living alone in HDB estates and posing a problem to their neighbours.”
“With greater awareness and reduced stigmatisation of mental illness, we have served a steadily increasing number of patients seeking psychiatric help. Last year, there were 17,000 new attendances at public psychiatric clinics, an increase of 900 compared with 2007. This increase was consistent with the trend seen in the past 10 years. Promoting an emotionally resilient society is one of our priorities, whether in good time or bad. The Health Promotion Board has an active nationwide workplace mental health education programme, called "Treasure Your Mind". With the current economic downturn, HPB has updated it. For working adults, there are workshops to equip them with the skills to manage day to day stresses with a practical and positive frame of mind. They will also be taught to understand and recognise depression and anxiety, in order to seek help early. Specific courses for supervisors and union leaders provide knowledge on how to render support to other employees or refer them for appropriate help. HPB will work with SNEF, NTUC, and MOM to reach out to vulnerable employees and their families. In addition, we have set up an employers-led alliance that brings together like-minded employers from various sectors to champion workplace mental wellbeing. This is led by Mr Hsieh Fu Hua, CEO of Singapore Exchange (SGX). They have identified a set of good practices to promote employee mental well-being and will encourage other employers to adopt them. For the community, talks, seminars and forums will be conducted at community clubs, CDCs, public libraries and other public venues, to address the psycho-emotional impact of the economic crisis on the individual, the family and the community.”
“There are three voluntary welfare organisations (VWOs) which run dialysis centres. They serve more than 2,500 patients every year. Out of these, about 50 to 70 patients would develop complications requiring more intensive care during dialysis. The VWOs do not turn such patients away. Instead, they are referred to public hospitals for dialysis, until their conditions stabilise. With Government subsidy and generous donations from the public, no patient should have to cut down on dialysis because of financial difficulties. The VWOs report that all their patients are dialysed at the medically recommended frequency. PSYCHOLOGICAL RESILIENCE DURING DOWNTURN 44. Dr Lam Pin Min asked the Minister for Health (a) if there is a surge in the number of patients seeking psychiatric/psychological help in hospitals in the recent months; and (b) whether the Health Promotion Board will introduce appropriate mental health programmes to build the psychological resilience of Singaporeans during this economic downturn.”
“Besides putting in place an outreach programme to help reduce the percentage of children not attending pre-school, MOE has been providing Focused Language Assistance in Reading, or FLAiR, to selected second year kindergarten (K2) children since 2007. Under the FLAiR project, trained personnel, called Pro-FLAiRs, provide focused assistance to K2 children who have difficulties with English, as identified by their kindergarten teachers. The Pro-FLAiRs will help the children in speaking, reading and other uses of English daily through dedicated time on a one-to-one basis or in small groups. Feedback from kindergartens and parents has shown that the children have benefited from the intervention. As FLAiR is relatively new, MOE will continue to look into ways to further improve the programme. SECOND MEDICAL SCHOOL 41. Dr Fatimah Lateef asked the Minister for Education in view of the overwhelming and increasing number of high quality and eligible applicants to the medical school every year, whether there are plans to start a second medical school in Singapore (excluding Duke-NUS Medical School which is a graduate medical school programme).”
“Around 45% of the children in the LSP are able to pass their schools’ English Language examinations and read at a level that commensurate with their age by the end of Primary One. Another 20% are able to do by the end of Primary Two. The remaining pupils had made considerable improvements in their reading skills although the reading gap had not been totally eliminated. Although the LSP does not extend beyond Primary Two, these students would continue to be monitored and supported by their teachers through school-based supplementary and remedial lessons. For better results, we believe that we should be working upstream. Data from MOE has also shown that children from lower income households who do not attend pre-school are more likely to experience difficulties. Since 2006, MOE has been focusing its efforts and resources on helping children to attend pre-school, especially those from lower-income families to help them level up opportunities early in life. Preliminary joint efforts by MOE, MCYS and Grassroots Organisations in the outreach programme to reduce the percentage of children not attending pre-school are bearing results. With the measures and efforts in place, we have reduced the percentage of those entering Primary One without any pre-school education from more than 4% to about 2.5%. This year, we are continuing with our efforts to reach out to children who are not enrolled in pre-school. We have sent the list of these children to the Grassroot Advisers and we urge grassroots leaders to conduct the outreach early to provide the necessary assistance to the children and their families.”
“Consumers have an important role to play to safeguard their own vision: Do not buy contact lenses from unlicensed vendors over the internet or elsewhere. Those who wish to use contact lenses should undergo proper eye examination and contact lens fitting by qualified optometrists or CLP opticians. We will carry out regular public education efforts on this subject. READING ABILITIES OF PRIMARY ONE STUDENTS 40. Dr Ong Seh Hong asked the Minister for Education (a) over the last five years, what is the number of Primary One students who have reading difficulties when they start school; (b) what is being done to help them catch up with the rest of the class; and (c) which are the vulnerable groups and whether efforts to encourage preschool education have been successful. Dr Ng Eng Hen: Over the last five years, around 12% to14% of the children who entered Primary One had very weak oral English and literacy skills. Their knowledge of the English alphabet was incomplete and they were not able to recognise simple English words. They were also not able to understand very simple oral instructions in English. These pupils are identified in January each year and provided with additional support through the Learning Support Programme (LSP). The LSP is a specialised early intervention programme. The aim is to teach these children basic language and literacy skills as well as word attack strategies so that they can read and access learning in the regular classes as soon as possible. The LSP is implemented by Learning Support Co-ordinators (LSCs) who are qualified teachers specially trained by MOE in reading intervention. The LSP was reviewed and enhanced in 2005. The enhanced LSP is currently implemented in all primary schools at Primary One and Two.”
“Eye infections caused by coloured contact lenses are not that common. Over the past three years, there were about six cases a year of eye infections seen at our public hospitals, due to the use of cosmetic contact lenses, of which coloured contact lenses form a sub-set. This is probably because the usage of such lenses is low. We control the sale of contact lenses to protect consumer interest, as ill-fitted contacts can cause complications including conjunctivitis, allergic reactions, corneal abrasions and corneal ulcers, which may lead to deterioration of vision. Under the Optometrists and Opticians Act, only registered optometrists and contact lens practice (CLP) opticians can prescribe, dispense or sell contact lenses. In addition, importers and distributors of contact lenses, including those who operate online, are required under the Health Products (Medical Devices) Regulations to maintain distribution and complaint records. If they are aware of any adverse events associated with the use of the contact lenses that they had imported or supplied in Singapore, they are required by law to inform the Health Sciences Authority. We do not allow companies to sell contact lenses on-line directly to consumers. Companies can supply contact lenses only to qualified persons. Over the past three years, there have been three cases of successful prosecution on those practising optometry or selling contact lenses illegally. The Ministry is currently investigating several cases relating to the sale of contact lenses on the Internet. We maintain close surveillance of the situation and will take relevant enforcement and public health action when needed. The enforcement against Internet sale of contact lenses is particularly challenging as the owners of the websites are often elusive.”
“About 2,600 means-tested elderly Singaporeans, who were not eligible for ElderShield coverage when it was launched in 2002, are currently on the Interim Disability Assistance Programme for the Elderly (IDAPE). We now have 74 doctors acting as medical assessors for the IDAPE scheme and are open to accept more. Those who are interested can approach MOH for information on how to join the scheme. SALE OF COSMETIC CONTACT LENSES (Control measures) 36. Dr Lim Wee Kiak asked the Minister for Health (a) how many cases of eye infection caused by the use of coloured contact lenses were treated at Government clinics/hospitals over the past three years; (b) whether there is any control on the sale of cosmetic contact lenses; (c) what is the Ministry doing to prevent the sale of cosmetic contact lenses which are also sold on the Internet; and (d) how many people have been booked for selling these lenses or practising optometry without a proper licence over the past three years.”
“We have significantly increased the budget allocation to Medifund and we have also advised the Medifund committees to render assistance in a flexible and compassionate manner. The jobless, the retrenched and the needy elderly will all be helped. The quantum of assistance to the patients will depend on the financial situation of each case. It is common for Medifund to pay the outstanding hospital bill in full, on behalf of the patient. LOAN TO MICRON TECHNOLOGIES 20. Mr Inderjit Singh asked the Minister for Trade and Industry (a) what are the terms of the $300 million loan provided by the Government to Micron Technologies; (b) what are the risks of this loan and are there terms and conditions which benefit Singapore; (c) whether this loan was disbursed through any of the banks in Singapore or was it a direct loan from the Government; and (d) whether the Government is now prepared to give direct loans to companies instead of sharing risks with banks.”
“If the House supports this Bill, my Ministry will continue with its efforts to increase the awareness among Singaporeans of these amendments and their implications. Sir, today, many Singaporeans continue to suffer as a result of the shortage of organs for transplant. We must try all reasonable means to maximise our yield of cadaveric donors and to promote altruistic living donor organ transplants. Our proposed amendments will not eliminate the shortage of organs, but they will help to save more lives and reduce suffering. I hope this House will join me in this mission. Sir, I beg to move. Question proposed. 5.40 pm”
“We have thus removed the term "compensation" and instead used the words "defraying" and "reimbursing" to refer to the payment to cover the costs or expenses that a donor incurs as a result of his donation. Hospital transplant ethics committees will continue to screen living donor transplants to weed out organ trading. In addition, clause 5 of the Bill allows us to make subsidiary legislation, if necessary, to regulate and administer reimbursement and the payment process, as an added safeguard against organ trading. Applicability of the law on payment to foreign donors Second, some suggested that foreign donors should not be paid, as what is a reasonable quantum in Singapore may end up inducing the poor in the region to sell their organs. We appreciate the underlying concerns and we certainly do not intend Singapore to become a regional organ trading hub. But we cannot address these concerns by enacting a law that unfairly discriminates against organ donors based on their nationality. The principle underlying this amendment is one of fairness to donors. We achieve this by allowing donors to be comprehensively reimbursed for costs, expenses and lost earnings that they incur. It would be patently unfair if a donor in Singapore who is a citizen can be reimbursed, but a donor in Singapore who happens to be of a different nationality cannot. Instead, we will continue to rely on the hospital transplant ethics committees, and our law, to prevent organ trading. Lifting the Whip Mr Deputy Speaker, Sir, as with past amendments to HOTA, I have asked that the Whip be lifted to allow Members to debate and vote on the Bill based on their religious and ethical beliefs.”
“Increase penalty for syndicated organ trading Finally, clause 3 of the Bill increases the penalty for syndicated organ trading. The current penalty in HOTA for organ trading does not distinguish between the buyer, the seller and the middleman. In syndicated organ trading, both the buyer and the seller are exploited by the middleman, who often creams off a significant portion of the transacted amount. We all sympathise with the plight of patients suffering from organ failure, as well as those who may be driven by desperation to sell their organs in order to make ends meet. Within the existing framework that criminalises organ trading, we propose a specific, aggravated offence for middlemen and syndicates who engage in organ trading, with an increased maximum penalty of a fine not exceeding $100,000 or imprisonment not exceeding 10 years, or both. This is a ten-fold increase from the current maximum penalty and will serve as a greater deterrence for these middlemen and syndicates and protect the vulnerable from being exploited. Public consultation These proposed amendments were extensively discussed over several months last year, among the public, the medical and the professional organisations. A formal public consultation based on the text of a draft Bill was further organised during the last few months of the year. We received strong support for all the proposed amendments. There were two concerns with regard to payment for living organ donors. Use of the term "compensation" First, there was concern over the use of the term "compensation". We use that term in the original draft Bill. Some Singaporeans felt that it might be misconstrued as the legalisation of organ trading.”
“Allow payment for living donors Currently, HOTA prohibits all forms of payment to organ donors, including the reimbursement for the costs and expenses that they incur. For example, any reimbursement of lost income or medical expenses incurred by the donor is illegal. This position is really outdated and is unfair to the donors. It is not in line with accepted ethical practice in other countries. Many countries have already updated their legislations to provide for such reimbursements. For instance, US law permits reasonable payments associated with the medical costs, and other expenses of travel, housing, and lost wages incurred by the donor due to the donation. In UK, payments to defray or reimburse any expenses or loss of earnings incurred by a living organ donor so far as reasonably and directly attributable to his donation are allowed. Clauses 3 and 5 of the Bill will amend the Act to permit the comprehensive reimbursement of costs and expenses – such as for short- or long-term medical care or insurance protection – and loss of earnings, which may be reasonably incurred by living organ donors as a result of their donation. This amendment does not condone organ trading or legalise it. It seeks merely to allow some patients who wish to defray or reimburse the costs or expenses which their donors may incur, to ensure that these donors do not suffer financially as a result of their altruistic acts. This is based on the ethical principles of equity and fairness, which demand that we protect not just the welfare of the recipients, but also that of the donors. Our proposed amendment does not mandate, but merely allows, some reasonable payments to be made to the donors, insofar as they do not constitute an inducement to the donor.”
“Allow paired matching Second, clause 3 of the Bill will allow "paired matching". This is a way of matching living donors with compatible recipients across two or more medically incompatible donor-recipient pairs. The recipients essentially exchange donors so that each recipient can receive a medically suitable organ. Currently, HOTA does not explicitly allow this. We have had patients with relatives who were willing to donate their organs, but who were found to be medically incompatible. These patients thus had to be placed on the cadaveric organ waiting list for a suitable donor. With "paired matching", arrangements could be made for the relative of a patient to donate his organ to another medically compatible patient in return for that patient's relative to donate an organ to the first patient. This way, more patients can be matched with a suitable living organ donor. Such "pair-matched donations" already take place overseas, such as in the US and UK. The Johns Hopkins Hospital was particularly successful, having transplanted over 50 patients involving more than 20 exchanges since its paired kidney exchange programme started in 2001. It also performed the world's first three-way swap, that means three pairs, bringing six willing donors and recipients together for simultaneous operations in 2003. Recently, two lives were saved in Hong Kong's first paired exchange liver transplant where the wife of a patient and the sister-in-law of another patient cross-donated part of their livers. With our small population, the number of donor-recipient pairs that can be successfully matched may not be large, but such exchanges should be allowed wherever possible. To facilitate matching, we will set up a living donor registry.”
“Finally, we propose to raise the penalties on middlemen and syndicates that engage in organ trading. This will help to deter organ trading. Let me now go into the details of the amendments. Remove upper age limit Currently, organs from deceased persons who were over 60 years of age at the time of death are not removed for transplant under HOTA even though their organs may be medically suitable for transplant. The limit of 60 years was set many years ago as a proxy indicator of a person's health in relation to his suitability as a donor. In practice, however, whether an organ can be used for transplant depends on the organ's condition, not the age of the donor. Clause 2 of the Bill will remove the age limit of 60 years for cadaveric organ donation under HOTA. As it is with all transplants today, before any organ is removed, a transplant doctor will assess the organ's condition to ensure that it is suitable for transplantation. We estimate that the removal of the age limit could increase the number of cadaveric organ donors by 10 to 12 each year – about one a month. This would potentially save and benefit 70 more patients a year. If the Bill is passed, we will carry out intensive public education to inform persons over 60 of how they will be affected. They will be given time to decide whether or not to opt-out of HOTA. The Bill clarifies in clause 6 that those who have already opted out of HOTA before this amendment will continue to be excluded even when they turn 60, unless they have withdrawn their objections. In parallel, we will also remove the upper age limit of 60 years for patients to be placed on the transplant waiting list. This will allow more elderly patients to benefit from organ transplant, which I think is a fair arrangement.”
“Mr Deputy Speaker, Sir, I beg to move, "That the Bill be now read a Second time." This is the third time I am coming to the House to seek Members' support to amend the Human Organ Transplant Act (HOTA). I am grateful to Members for your strong support for the previous amendments. As a result, we have been able to save the lives of more patients with organ failure who would otherwise die prematurely or live in misery. Prior to the first round of amendments in 2004, there were, on average, 13 cadaveric kidney transplants in Singapore under HOTA each year. This is about one a month. Now, we are doing an average of 41 such transplants a year, more than three times as many. This is almost one every week. The two rounds of amendments have helped save many more lives. I am now ready to seek Members' support for the third round of HOTA amendments. There remains a shortage of organs. Last year, 26 patients died while waiting for an organ; currently, more than 560 patients remain waiting. We must continue to try to raise both cadaveric as well as living donor transplant rates. And we intend to do this by making the following changes to the Act. Proposed amendments First, we propose to remove the upper age limit for cadaveric organ donation under HOTA. This will increase the number of cadaveric donors. Second, we propose to allow paired matching for the exchange of organs between living donor-recipient pairs. This will facilitate living donor transplants. Third, we propose to remove the prohibition of payment to reimburse or defray the costs or expenses of living organ donors. This will better protect their welfare and ensure that they do not suffer from additional losses because of their altruistic acts.”
“Ms Phua raised an interesting question, which I have been reflecting as well as to whether is it better that community hospitals come directly under the Ministry of Health. In fact, when it started, it was under the Ministry of Health. As a young officer, I was involved in planning the first community hospital, the Ang Mo Kio Community Hospital. But, subsequently, the Ministry felt that it was worth trying out to see if charities could run community hospitals. That was how the change came about. I do not think it is critical, one way or the other, that we must be the provider or we must not be the provider. But we know we will always be the financier for the lower income group because that is our job to make sure that the low income can afford essential services, whether in acute hospitals or in community hospitals. Whether the provider must necessarily be the Government, I think one can debate on such an issue. The key point is that they must be competent, are able to do the job and do bring additional value to the table. I believe they do. SALE OF STRUCTURED PRODUCTS (Update on investigations by MAS) 9. Mr Siew Kum Hong asked the Senior Minister (a) if he will provide an update on the MAS investigations into alleged mis-selling of structured products by financial institutions (FIs); and (b) since January 2009 (i) how many new complaints of mis-selling have been filed against FIs and in respect of what products; (ii) how many settlement offers by FIs have been accepted and rejected; and (iii) how many complaints have been filed with the Financial Industry Disputes Resolution Centre and how many of these complaints have been resolved.”
“As I have said, Sir, I am studying this anomaly at the margin to make sure that patients do not lose out when they move from acute hospitals to community hospitals. Otherwise it would not work because if it does not save you money, then why should you go to community hospitals. I am studying this problem and I will fix the anomaly. I am quite confident I can do that. As to how many of the community hospitals patients are subsidised, if I recall correctly, I think about half.”
“The number of admissions to community hospitals has been increasing steadily. We are also getting acute hospitals to collaborate closely with community hospitals to make the transfers hassle free. Tan Tock Seng Hospital and Ren Ci community hospital formalised such a collaboration recently and we encourage other hospitals to do the same.”
“By design, community hospitals (CHs) cost less to run than acute hospitals. They are less capital, manpower and skills intensive. This does not compromise care because the patients admitted there do not require the intensive treatment offered by acute hospitals. The cost of running the community hospital is about one third the cost of running an acute hospital. The Ministry of Health subsidises many patients for their community hospital care. Our subsidy extends up to middle income Singaporeans, say, with a monthly income of $5,200 per month for a family of four. Patients can use Medisave to help pay their bills and MediShield also covers the hospitalisation in community hospital for those who subscribe to it. For patients who still have financial difficulty paying the bills, Medifund provides the safety net. In addition, the community hospitals run by charities raise funds, as part of their social mission, to help provide financial assistance to patients in need. Last year, my Ministry increased the subvention to community hospitals to help them and their patients cope with the economic slowdown and we will do more as we discussed in last month's Budget debate. I have explained before why means-testing in community hospitals and acute hospitals is not identical although both share the same objective of wanting to help the low income group. I have feedback that some patients get missed out at the margin. I am studying this problem and I am confident that I can fix this anomaly. Patients who no longer need acute hospital care and can benefit from community hospital care will save money if they transfer to a community hospital. We set up the Agency for Integrated Care to strengthen discharge planning and facilitate transfers.”
“Lack of motivation is the obstacle because, often, after a person has been screened, the follow-up is the big difficulty. Follow up requires even greater motivation. If he is not willing to change and disrupt his lifestyle, his health will just go downhill. It is inevitable.”
“I flipped through a few articles in the journal, they all screamed out that their healthcare system is on the verge of collapsing. On and off, we read of such stories. Just last week, there was a pregnant woman who subsequently died, and this is in Tokyo, because the ambulance had to negotiate with every hospital, "Please take this patient, urgent, dying." They said, "Sorry, full house." Or at least they gave the excuse that it was full house. After several hospitals, by the time one kind-hearted hospital took her in, it was too late, she died. And this is in Tokyo, Japan. It is not a third-world country or rural town. It is first-world and second richest country in the world. I flipped through the journal and one article was written by my Japanese counterpart, and I saw his first paragraph. He blamed all the problems of the healthcare system in Japan on pandering to political populist measures, which then just collapsed the whole system. Let us not fall into that trap. We are not in that hole. My job is to make sure that we do not walk into that hole, and please do not lead Singaporeans into that hole. On long-term care, what else can we do? We have done a lot. If it is not enough, we will do more. We will certainly do more prevention, more screening. But let me just say a word of caution, which is that at the end of the day – what is the Cantonese expression – we cannot drag the cow to the water unless it is willing to, and it must cooperate. All smokers know that smoking causes lung cancer. They still smoke. It is not as if they do not know. What can I do? So, it is motivation. We organise health screening. We subsidise screening so that it is affordable. Money is not an obstacle.”
“Sir, on affordability, all my speeches yesterday and today were directed at it. That is what motivated me and that is what motivated my Ministry – how to make sure that healthcare remains affordable and of a high standard. Frankly speaking, it is easy to keep healthcare cost affordable if the standard is not an issue. Many third-world countries achieve that – absolutely free healthcare or very cheap healthcare. But what kind of healthcare? Mr Low mentioned JB when I discussed my trip there. Was it two weeks ago, a Singaporean had an accident in the northern part of JB? He was "semi-treated" in a hospital there, but he was dissatisfied. He called an ambulance and, I think, he was sent to Changi General Hospital or SGH. He was quoted by the newspapers to have said that it was a blessing for Singaporeans to have such a high standard of healthcare, and yet affordable. So, to keep healthcare cost affordable is the easiest thing in the world. But to also keep it of a high standard and yet affordable, very few countries have done so. I like to believe that, while we are not perfect, we have done a fairly good job. Just a while ago, I was sharing with the Finance Minister. There is this monthly journal that the Japanese publish called Japan Echo, which has serious articles on contemporary issues in Japan. The latest issue which we just received this morning, the front page headline is about how to create a sustainable healthcare system in Japan. I was sharing with the Finance Minister that I felt very sorry for Japan because, for a long time, they had one of the best healthcare systems in the world, and they could be truly proud of that.”
“But instead of accusing each other of dumping, I think let us focus on how to make sure that the patients get the best of care, and that requires cooperation from everybody all round. I am quite sure IMH's psychiatrists will be looking at how best, when they discharge patients to the community, to maintain contact with the patients, perhaps, through the GPs. I know they started a programme working with the GPs, so that there is shared treatment. If a specialist is needed, he is always there for consultation, but the day-to-day treatment is done by the GPs. I know this because one of my former classmates is a very good GP outside, and one day he told me about this programme. He said that it is very good for his patients who have some mental illness, and now he is able to handle them with confidence. And the patients prefer that too, again because of the stigma associated with IMH. They rather go to a GP if they can, rather than go to IMH and to report to their friends or families that they went to IMH. 1.30 pm”
“I am not a doctor, so my knowledge is that of a layman, and I would not be able to discuss seriously some of the queries that Dr Neo has raised. How many are undiagnosed? I would not know. I do not know whether there are such surveys. Probably there are. Globally, my journal readings suggest to me that this is one of their big problems as well. Even the definition of what is mentally ill, there is no consensus: you can be strict or loose. I remember reading an article in New Zealand when I was there for a meeting, where the front page headline screamed out to say "Half of New Zealanders are mentally ill", following a survey that they have done. So I think this is a difficult problem. But whether our professional policy is to discharge mentally ill patients "as much as possible", whether that is correctly worded, I do not know. I have to check with our professionals. I do not think that is the policy. The policy is to make sure that the patients get the best care, and they have to decide whether that best care is rendered in the institution or in a community. And to be fair to them, talking to them, the impression I get is they are not just dumping the patients out of IMH. They are a bunch of very nice, passionate people. I met some of them recently when I opened a community outpatient facility that they started in Queenstown Polyclinic: a nice bunch of people, very passionate about their patients and wanting to do the best for their patients. So it is not a case of the psychiatric doctors just dumping the patients out of the hospital and leaving it to the community to sort itself out. More correctly is the other way round: that we have seen many families who dumped their mental patients into IMH and on our laps, and we have to look after them for life.”
“So, no, I am not saying that if you are poor, I will put you in an ambulance, send you across the Causeway to Johor nursing home. That is not what I said and please do not twist my words. But what I am saying is for those in the middle-income group, you have choices, you are paying out of your own pocket, you decide. Do you want to have a seafood meal in Singapore or you want to have a family reunion in JB? It is up to you, this is your own choice. Do you want to fill your car tank in Singapore or you want to drive across and have a haircut? That is up to you. You are spending your own money. And I am just sharing with Singaporeans that there are alternatives of that kind. But for low-income Singaporeans, we look after and heavily subsidise them. There is no need for them to walk across, because they enjoy a heavy subsidy here. They have to pay unsubsidised rate in JB. It will be more expensive than what they can receive in Singapore. So that is the way we do our systems and I hope to get the Member's support for it as well.”
“A simple and robust answer is "no". Everybody can afford healthcare in Singapore, whether acute or long-term care. I think this is our pride, our healthcare system, as quoted by Mr Low himself just now, is the best in Asia and the sixth in the world. And I think we have reasons to be proud of our healthcare system. Our doctors, nurses, work very hard. We have thought through carefully about how to bring about this very good outcome – that even if you are unemployed, or low-income group, you can afford a standard of healthcare which is comparable to the US. You look at the 40-50 million American citizens there who just cannot afford to even buy medical insurance because their insurance rate for a family of four runs into five-digit US dollars per year. Mr Baey, who is familiar with US, nodded his head. This is just for premium, let alone talking about hospital bills. You step into an emergency department in an American hospital, it is triple-digit US dollars. But in Singapore, we make sure that healthcare of good standard is available to all – rich or poor. If you are rich, we will subsidise a little bit less. But if you are poor and if you need to write off your whole bill, we do. That is what the 3M system is all about. Yesterday I spent some time discussing with Members to think about long-term care. It is not a big problem today because we are still a relatively young society. But we will not be. I am already 57 and there are many in my generation. And very soon this Silver tsunami will come but we have 10, 15 years to prepare for this. So Minister Lim Boon Heng is absolutely correct. We have 3Ms which render this very good system that we have today, for acute care; let us make sure that we have an equivalent for long-term care.”
“Whether means testing has caused a behavioural change, it may be a bit too early to conclude. But as I shared with Members yesterday, less than 10% were means tested out, which suggests to me that most Singaporeans, by and large, chose the right class of ward. So the middle-income, they go Class A, Class B1. It is only a small percentage who actually can afford Class A, Class B1, even private hospitals, but they chose subsidised ward. We do not begrudge them, we still subsidise them, except what we are asking is maybe we will subsidise them less than those who come from a lower income group than they. So far, I consider the implementation quite smooth, suggesting that there is general support by Singaporeans for this policy. Some patients, because of company benefits, end up in private GP clinics or private hospitals, but may then require subsidised care in the public hospitals, we treat and accept them and there is an avenue for downgrading. But if they do not ask for it, we will just treat them as private patients. If they express difficulties, then we would assess and downgrade them. The example of that obstetric patient who was going to deliver the second baby in KK Hospital, which I mentioned yesterday, was one of those cases. I think she paid for private sector healthcare all the time, but she wanted to reduce costs. When she came in, we treated her as a subsidised patient, and she was able to save about $2,000, according to the newspapers.”
“I note Mdm Cynthia Phua's observation, and I think we discussed this yesterday too, that clearly we need to do more. But it is not just more resources thrown in, but to also find a way how to integrate and coordinate better. VWOs have a lot of passion to help but they may not have sufficient clinical knowledge. Our professionals know what to do but may not be able to have the same social outreach as the VWOs. So it is to get them to really work together. And like all things, we have to pilot and experiment. And this is certainly what we want to do. But let me also make an appeal to the family members: you have a major role to play as well, because talking to some of these patients and the professionals who have to manage these cases, sometimes there is just no family support and the poor fellow is just left in the lurch. The incident of the attack on our colleague, Mr Seng Han Thong, involves many issues. One of my big concerns arising from that incident was that we have been trying very hard over the years to de-stigmatise the mentally ill, and I was very worried that the case will push our efforts back several years. Then after that there was the incident involving Ms Denise Phua. And I worry that the society will group all mentally ill together as one group. No doubt there are such patients out there who need help but mental illness is a wide range of illnesses and many are reversible if we give them a chance, if we give them jobs, if we are able to accept them in the community. If you institutionalise them, which is the traditional way of doing things in the last century, lock them up in the mental asylum, they do not improve, they just go downhill, just like in the movie "One Flew Over The Cuckoo's Nest". That does not solve the problem.”
“I am sympathetic but, if you want to cover more conditions, then the insurance premium has to go up a few dollars. I doubt this is a time to talk about raising MediShield premiums. So the next time when we need to revise MediShield – presuming that is after the economy has fully recovered – we will put a file record for whoever is the Minister for Health, to take a look at mental illness. In the case of private insurers who are riding on the basic MediShield, many of them already provide this coverage. But this is more for the middle-income group. For the lower-income group, they will not be able to afford. Meanwhile, the way we do this is through subsidising IMH and the psychiatric departments in general hospitals heavily. We subsidise mental illness much more than the traditional %, 65% for class C, B2 wards. In fact, often, the subsidy goes beyond 90%. If you look at the usage of Medifund, a big chunk goes to mental illness, where the bills are completely written off. This means a subsidy of 100%. Sometimes, quite unfortunately, the patients are just dumped onto our laps. We have to treat and house them. So this is how we handle mental illness. But, long term, I agree that risk pooling offers a way out, and at the next round of MediShield reform, we will bear this point in mind. Medisave for dementia – I thought Dr Fatimah gave a very good prescription yesterday: step-by-step. So I am taking her prescription. So we do the biggest group first which is depression and schizophrenia.”
“Unfortunately, they have dragged in lawyers now, so I think that will take quite some time. But, patients who feel that they have been overcharged – maybe Mr Chiam's patient with the $3,500 root canal treatment – can complain to Singapore Medical Council (SMC) or in the case of dental, the Singapore Dental Council (SDC). SMC will review them, to see if there is gross overcharging. In fact, we have cases like that which the Committee had looked at in the past. My advice to patients is this: get a second opinion. And the best second opinion is from the public hospitals. If you are not sure if it is too expensive, just ask the restructured hospitals and you will know their rates. Hence, with or without fee guidelines, in fact by getting a second opinion, you get a more precise advice on whether you are being overcharged or not. Related to this point is the earlier advice that the Senior Parliamentary Secretary gave: have a family physician. The fee schedule covers tens of thousands of fee items, and the layman may not understand the details – what is it and how much does it cost. And the one to give you that guidance, really, is a family physician whom you trust and have known for years. Go to him and he will be the best one to advise you that, "you have this medical condition, you need a specialist, better go to that group of specialists. This group, I think, they tend to be on the high side, don't go". That is the best way to handle this issue of overcharging. MediShield on mental illness – we will be moving on Medisave for outpatient mental illness. As for MediShield on mental illness, I have some sympathy. Mdm Halimah has been advocating this for a few years.”
“Mdm Halimah, I am sorry that I missed out a couple of your cuts. First, the implants – the problem is that there is a wide range of implants. It is just like drugs, medication. We, typically, set our subsidy based on generics. So we are looking for the generic equivalent of implants – which we call standard implants – versus more fanciful ones. If you set your subsidy rate too high, who will want to go for the lower cost, even though the lower cost may be good enough? It is a problem, and hence we have to, typically, set our subsidised rates, which from a patient's point of view, more on the low side. But for knee transplant, the example that Mdm Halimah mentioned, I have actually done quite a few things over the last few months. We have adjusted MediShield implants reimbursement rates. In fact, it is now quite substantial. Say the example of knee replacement, most of the hospital bills will now be picked up by MediShield. And yesterday, the Medisave liberalisation rules that we talked about for surgical patients will further benefit patients with that kind of operations. But, certainly, we review implant rates periodically because of inflation, and if the original cap is really too low, we will raise it in due course. It may not be immediate. But, we look at those data quite often. The bottomline is this – patients, rich or poor, can afford the essential treatment that they need. But we, certainly, cannot set subsidised rates too high as to encourage the use of fanciful stuff, which may not be necessary. The second point is about SMA and the Competition Commission's arguments – quite intellectual arguments – on whether having fee guidelines is anti-competitive. I leave it to them to sort it out.”
“The global consensus, actually, is that the law should be slow. Do not be too fast. You may be drawing a line in a rush, and that line may be drawn in a wrong place. Then, as we all know, when you want to move the line after it has been drawn, it is typically very difficult.”
“I am not too familiar with the technicalities of the research on stem cell. I believe there is a lot of work on stem cell in general. Are our scientists doing cybrid research – I stand corrected – but I doubt they do. I think part of the reason the Bioethics Advisory Committee wanted to study this subject is because the researchers want clarity. Can they or can they not? They are, by nature, very conservative people. And I think, because of the uncertainty, they stay out. So the Member's point that we should emphasise more on adult stem cell and not do cybrid research, does not even arise because, as far as I know, I do not think there is anybody doing cybrid research at the moment. Meanwhile, I think we let BAC conduct their public consultation first. I attended one of the sessions and I was educated along the way, but not sufficiently to be able to do a meaningful dialogue with him today. I walked away from the session with the impression that there are strong views and similarly cogent views on both sides of the camp. So it is not as straightforward as, say, we should not clone a human being and grow it into an adult. The law against human cloning was straightforward. But for research on human-animal combinations, there are other issues involved. There are possible upsides, which the researchers are looking for, that will benefit mankind. That is why they want it to be discussed much more, and not put a clear-cut prohibition, which may then miss out on possible upsides that will eventually benefit mankind. That is as far as my understanding goes. The last point is about keeping pace. Yes and no, because it is such an evolving field. Understanding of this subject and the implications of it is not obvious or intuitive.”
“I think we should allow that. In any case, how can we prevent it? We cannot prevent it. But in fact, by keeping the borders "open", it puts some competitive pressure on our local providers which eventually will be good for our own consumers. Because if they price themselves too high, the patients will start going across the Causeway and they lose customers.”
“I went by the Tuas Second Link, then from west to east to Pasir Gudang, ended up with a nice seafood and cheap lunch near Pasir Gudang and came back through the new CIQ Checkpoint to our Causeway. At the Iskandar Malaysia region, I also took a look at the site where I heard they have investment from a medical school from England which is coming to set up. I also went to take a look at the Legoland theme park where the land is being prepared. Sorry, for digressing. But many Singaporeans, including many residents in my constituency, go to Johor very regularly, top up their car tanks, which many do, and also to have a nice seafood meal at much cheaper prices. I think these are natural activities, and that is part and parcel of globalisation. In fact, this is not even globalisation; this is regionalisation, and there is nothing wrong with that. Consumers are free to choose. I know many go over to the pharmacies there to get cheaper drugs. It is not our fault. The pharmaceutical companies have a way of setting prices: Third World, they set lower prices; First World, like Singapore, they set higher prices. By allowing the flexibility of consumers walking over the Causeway, they benefit. I do not think we should constrain them from doing so. Our cost will always be higher because our wages are different. Nurses are paid very differently here compared to Johor and ditto for doctors; likewise construction cost. I just want to point out to Singaporeans that there are options like these. In fact, it is already happening. This free flow of patients across borders, so much so that there is a term called "medical tourism". Singaporeans go to Bangkok, I know, for lasik, and vice versa. Americans come here. Russians come here. Singaporeans go to Penang and Malacca.”
“Sir, I thank Ms Sylvia Lim for seeking the clarifications. No, I did not misunderstand her point about "gross versus net income". What I said was that we must be consistent. If you want to look at gross income, then you must be consistent in setting threshold criteria based on gross income. But if you prefer to look at net income, then your threshold criteria for means testing should also be based on net income. At the end of the day, we are talking about targeting subsidy and who do you want to subsidise. In the case of the nursing home, the current rule is we will subsidise the bottom 50% of Singaporeans. You can argue about whether it should be 50%, 60%, or whatever. But that was the policy - we will subsidise 50%. So that will include all the low income plus part of the middle income as well. Having decided that it is the 50th percentile, if you decide to look at the gross income, then, of course, you set the threshold based on the gross income data. Or if you want to look at the net income, you can do so too, in which case, then the threshold criteria will have to be lowered to suit the net income. For practical reasons, we use gross income because it is harder to get the net income data comprehensively, as there are all sorts of complications. On the other hand, we have more readily available CPF data on gross income. On the nursing home in Johor, I mentioned it in passing because I made a trip there. Actually my main purpose was to look at the hospital because Members have asked me to consider the possibility of Medisave to be used for hospitals there. I used the opportunity to look at the Iskandar Malaysia region; I have not been to that part of Johor for many years and wanted to see how the development is shaping up there. It was a very pleasant trip.”
“I thank Mrs Teo for the clarification because this was a query which I forgot to reply yesterday. Not that I forgot, but I was not sure of my data, so I did not respond immediately. I heard she quoted a rather high health inflation rate of 7.4% which, relying on memory, I thought that was high. I checked and yes, I was not wrong. She talked about 2007 health inflation figure and asked me about the 2008 data. She thought 2007 was 7.4%. Actually, it was 4.1%, and not 7.4%. 7.4% could be for a particular month in a year, maybe, I do not know. And she asked about the 2008 figure. The 2008 figure was high, and it is not just in healthcare. We all know the reasons for the high inflation rate last year when oil prices went up sky high. Health inflation was high at 5.6% but it is, in fact, below CPI, which was 6.5%. So we did better from that point of view. If you take a longer period, 2005 to 2008, for example, health inflation averaged 2.8% per annum. and CPI was 2.5%. So we were just 0.3% higher than CPI. However, the point is taken, globally everyone tried very hard to control healthcare cost. But still in every country, the health inflation exceeds the general CPI, and it is quite a challenge trying to control healthcare cost. I think our data suggest that we have been doing a relatively good job.”