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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“We should also streamline the process flow to make it a little easier for the grieving families. I fully agree. We have had 20 years of such experience, but each incident is a case study for us, to learn and to refine our process. Following the SGH's incident last year which Mdm Halimah mentioned, and which Prof. Thio talked about too, we have now made social worker support for the donor family mandatory for every organ donation case. All such family members will receive grief counselling and emotional support. And we have also enhanced the training of the senior doctors who are responsible for giving final authorisation in organ donation cases to further equip them with crisis management skills. Measures have been put in place to ensure that all doctors who take on this task are well-trained and retrained. We have also sought the assistance of the various religious groups to provide volunteers whom we can call upon to help address any religious concerns that may arise during the organ retrieval process. With the inclusion of Muslims under HOTA, MUIS has agreed to provide religious support to advise Muslim families on the position of Islam on organ donation and HOTA, should the need arise. Hospitals will also rope in doctors and nurses who can better communicate in Bahasa Melayu in this effort. Volunteer HOTA ambassadors are welcome to join in such hospital activities, whenever the need arises. During the dialogues with the Muslim community, many expressed the concern that any organ transplantation should not unduly delay the release of the body to the family. We took this feedback to heart. We have tightened operational procedures and coordination between hospitals, the Police and the pathologists. We will cut out any unnecessary delay.”
“Each package will contain four things: (1) a letter informing them that they will soon be included under HOTA unless they opt out; (2) an information booklet on HOTA describing in detail the implications of being included under HOTA; (3) a booklet prepared by MUIS explaining why Muslims can now be included under HOTA and the Islamic position on organ donation; and (4) an opt-out form for those who wish to do so. We have done a similar exercise before, although in a more simplified fashion, when we first introduced HOTA in 1987, and again in 2004 when we amended it to include other organs. Nevertheless, it will still be a massive exercise for us. We estimate that it will take us three months, from February to June to complete it. The actual inclusion of Muslims under HOTA will then commence on 1st August 2008. Dr Fatimah proposed that we lower the age of HOTA inclusion from 21 to 18. I have also received suggestions from the public to raise the maximum age of 60 as the organs of those dying above 60 are often also suitable for transplantation. But these proposals require further study. Let us concentrate on extending HOTA to the Muslims first as that itself is a major milestone and we want to make sure that it is implemented well, achieving results of saving lives without causing undue worries and concerns to the community. Meanwhile, those who are between 18 and 21, and who wish to make an organ pledge can do so under MTERA. Mdm Halimah and Dr Fatimah reminded our hospitals to be extra sensitive when approaching organ donation cases and their families. They said that our hospital staff should be well-trained and have relevant communication skills so as to minimise conflicts with the distressed family members.”
“Organ donation booklets and opt-out forms will continue to be couriered to every Singaporean citizen and PR when they turn 21 years old. We will continue to partner the Society of Transplantation, the NKF, the Malay Kidney Action Association and other entities to reach out to Singaporeans on organ donation and HOTA. We will also intensify efforts to reach out to community centres, grassroots organisations, schools, students, colleges and tertiary institutions. Concepts like brain death, presumed consent and the religious implications require regular explanation and a sustained educational effort. It is time-consuming, it is costly, but it is necessary. The more effective we are in this, in easing the fears and concerns of donors and their families, the more lives we can save. Dr Ahmad Magad suggested that we rope in organ recipients, professionals, grassroots leaders and other persons who strongly believe in HOTA as our HOTA ambassadors to help us explain HOTA and to ensure buy-in. Next month, we will refresh our HOTA website to also be a repository of human stories from people whose lives have been changed after receiving the gift of life, and they will be our online HOTA ambassadors. Meanwhile, we are gearing up to inform the Muslim community about this Bill and its implications. We are preparing 300,000 packages to be individually delivered to all the Muslim citizens and PRs aged 21 to 60. The packages will be comprehensive and easily readable.”
“Mdm Deputy Speaker, let me thank Minister Yaacob Ibrahim and the Members for their strong support of this Bill. The Muslim MPs, in particular, have gone all out to help rally support for this Bill. They have not merely stated their stand clearly in this House. They have conducted many dialogue sessions in the mosques and the community centres to help us reach out to the Muslim community to explain what HOTA is all about, how they can save lives by supporting HOTA and that HOTA is not in conflict with their religion. My Ministry and the many patients with kidney failure are grateful for their support and their tireless efforts, and the efforts to reach out to explain and reassure will continue. As noted by all Members, it is important that we keep up the efforts to improve the public's understanding of organ donation, brain death and presumed consent. These are difficult concepts and I do not think, even with intensified efforts, we can say, "All right, at the end of this year, that's it, we do not have to do it anymore." It is not possible. We have to constantly explain and re-explain, not only because there will be new citizens or new adult Singaporeans who turn 21, but, even for existing people, it requires constant reminders. My Ministry will work closely with MUIS and Muslim leaders on this effort. As Dr Ahmad Magad put it, we need to strengthen the belief of those who say "Yes", address the concerns of those who say "Maybe", and try to convince those who say "No". Furthermore, we will henceforth no longer need to make the distinction between Muslims and non-Muslims on HOTA. All information dissemination regarding organ donation or HOTA will continue and will appear regularly in our local media.”
“Even though this problem affects all races, Malays are a vulnerable group. The main cause for kidney failure is diabetes. Among the races here, Malays have the highest number of diabetes patients, much more as compared to the Chinese. Malays are overly represented in the list of patients awaiting kidney transplants. Before HOTA was introduced, we depended on voluntary organ pledging. But we find that such a scheme is not effective. On average, only five cadaveric kidney transplants were done each year before HOTA began. Now, the average rate of kidney transplants has increased by 10 times. So I am happy that the Fatwa Committee of MUIS, after reviewing the issue, has explained that there is nothing wrong under Islamic law to include Muslims under HOTA. With this explanation, we can now amend HOTA to remove the original exclusion of Malays from HOTA. With that, we can save more lives, not only those who have kidney failure but also patients with heart or liver failure. I am happy that Muslims have voiced their support for this Bill. Some Malay MPs have helped me to reach out to the Muslims to explain to them this proposed Bill and to get their support. I would like to record my thanks to them. They include the Senior Minister of State for Foreign Affairs, Mr Zainul Abidin Rasheed, Dr Mohamad Maliki Osman, Mdm Halimah Yacob, Mr Zainudin Nordin and Dr Fatimah Lateef. I hope the House will support this Bill to enable us to save lives. *Cols. 183-184. (In English): Sir, I beg to move. Question proposed. 4.29 pm”
“HOTA includes regulations on living donor organ transplantation to safeguard the well-being of the donor and ensure that he was not under any form of duress or coercion to donate his organs. HOTA also prohibits any trading in organs and blood as it is deemed unethical. My Ministry currently relies on the Police to investigate such offences as we lack the power to do so. The proposed amendment would allow my Ministry to appoint inspectors and provide them with the appropriate investigative powers, which would enable them to look into complaints and conduct investigations in a timely manner. We also need to be able to disclose donor or recipient-related information for the purpose of administering and enforcing HOTA, as well as for the purpose of referring complaints regarding any errant medical practitioner to the Singapore Medical Council for any disciplinary action. Lifting the Whip Mr Speaker, Sir, as the issues concerning organ removal under the presumed consent framework are ethically and culturally sensitive, I have asked the Whip to be lifted to allow Members to debate and vote on the Bill based on their religious and ethical beliefs. Conclusion Although the implementation of these amendments to HOTA will not fully resolve the problem of organ shortage, it will allow more Muslims to have the same chance as others in obtaining a new lease of life through an organ transplant. My Ministry has estimated that about 30 more patients per year may benefit from the proposed amendments to HOTA. I hope the House will join me in giving them this gift of life. Mr Speaker, Sir, before I end, let me say a few words in Malay. (In Malay): [For vernacular speech, please refer to Appendix A *.] Sir, for a few years, I was concerned about the problem of kidney failure among Malays.”
“" In 2006, MUIS embarked on a series of public education campaigns concerning organ donation and the religious issues surrounding organ donation. While there were some concerns on the practical aspects of transplantation, the Muslim community generally voiced their acceptance of the permissibility of organ donation from a religious perspective, and supported the move to increase the number of Muslim donors. In parallel, the Fatwa Committee launched a review of the Fatwa on organ donation. The review eventually led to a new Fatwa being issued in July 2007, making it permissible for Muslims to be covered under HOTA. With the new Fatwa, we are now in a position to amend HOTA to include Muslims like the rest of the Singaporeans. This is a significant achievement, both for the Muslim community as well as for Singapore. The main objective of this Bill which is now before the House is to bring this about. Technically, the Bill itself is relatively straightforward as it merely removes the current exclusion clauses of HOTA. Accordingly, clauses 2, 3 and 8 of the Bill expand the target population under HOTA to now include Muslims. With the inclusion of Muslims under HOTA, Muslims who do not opt out of HOTA will be accorded the same priority as other Singaporeans who have not opted out of HOTA. Muslims who have already pledged their organs under the Medical (Therapy, Research and Education) Act will also be placed in this group and receive the same priority. This will level the playing field for all Singaporeans who are in need of an organ transplant. Enforcement Powers I am also taking this opportunity to amend HOTA, through clauses 4 to 7 of the Bill, to provide my Ministry with the necessary enforcement powers to investigate any offence under HOTA.”
“According to the 2004 National Health Survey, there was a disproportionately higher number of Malays with diabetes mellitus (11%) compared to, for example, the Chinese population (7%). There is, therefore, a greater burden of kidney failure among Malays. This trend is also evident from the racial breakdown of the national waiting list for kidneys. Malays made up 21% of the total number of patients on the 2007 kidney waiting list, even though they formed about 13% of the resident population. In 2004, MUIS, through the Fatwa Committee, made it easier for Muslims to pledge their organs. But this has not resulted in any significant increase in the number of Muslim pledgers, despite intensive publicity by the Muslim Kidney Action Association and the National Kidney Foundation. Since HOTA was enacted in 1987, there have been about 16,000 Muslim pledgers. In 2007, there were less than 200 pledgers. To date, these pledges have not yielded any organ donations. And this problem of voluntary pledging not producing enough organs for transplant is not unique to the Muslim community or to Singapore. It is observed all over the world - the US, UK, Spain, Europe. It is all the same. Some of you may have read that right now, the UK is going through a major public consultation,finally thinking seriously about enacting a similar legislation as ours of presumed consent, ie, the opting-out system. When HOTA was amended in 2004, several Members asked if MUIS could review its position on HOTA to bring the disadvantaged position of the Muslim community up to par with the rest of Singaporeans. I remember SMS Zainul Abidin Rasheed stressing a point that "The disadvantages of (Muslims) being out of the system are real and the Malay-Muslims as a community cannot afford to let this continue.”
“HOTA does not take away the freedom of Singaporeans to refuse organ donation for any particular reason. One percent of adult Singaporeans have opted out of HOTA. And we respect their decision. Inclusion of Muslims However, HOTA has not been able to bring major benefits to the Muslims, as a deliberate decision was made in 1987 to exclude them from HOTA. This was because the Fatwa then required the consent of two waris (paternal next-of-kin, according to Islamic hierarchy) for organ donation to proceed. Even so, the Majlis Ugama Islam Singapura (MUIS) made it clear that organ donation to save lives was permissible under Muslim law. Muslims who wish to donate their organs can do so by making a pledge under MTERA. Because of the exclusion, Muslim non-pledgers are accorded a lower priority for organ transplant than non-Muslims who have not opted out of HOTA. In similar spirit, Muslims who have pledged their organs under MTERA generally need to wait two years before they are accorded the same priority as those who have not opted out of HOTA, if they made their pledge after the period prescribed in the Act. However, I should clarify that lower priority does not mean that Muslims have not benefited from HOTA. In fact, this morning I was flipping through Berita Harian and the top story was about one Muslim businessman, I think 42 years old with two kids had his life saved. He had liver failure and there was a cadaveric liver which was available. Tissues matched and his life is now saved and he has benefited from HOTA. Unfortunately, there is a rising number of kidney failure patients among the Muslim Malays. New cases of kidney failure among the Malay population rose from 19% in 2000 to 22% in 2006. In Singapore, the primary cause of kidney failure is diabetes mellitus.”
“Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time". In 1987, this House, with the recommendations of a parliamentary Select Committee, moved the Human Organ Transplant Act (HOTA) after two days of debate. The debate in the House was, in turn, preceded by 12 months of public discussion and consultation, involving many stakeholders, religious bodies, professional groups, doctors and patients. The extensive public debate was necessary as we were then breaking new ground over the sensitive and emotional subjects of organ donation, organ transplantation, brain death and the concept of presumed consent. Prior to HOTA, organ donation was done solely through the Medical (Therapy, Education and Research) Act of 1972, or MTERA, which allowed Singaporeans to pledge their organs through an opt-in system. However, globally, the experience with opt-in systems is that they have not been effective in saving many lives through cadaveric organ transplant. Our experience with HOTA provides a good illustration. Prior to HOTA, the number of cadaveric kidney transplantations was only five per year, on average. With the introduction of HOTA, and especially after its amendment in 2004, the rate has gone up 10 times, saving the lives, on average, of 48 kidney patients every year, about one a week. Many other patients with liver or heart failure have also been saved. Many more patients have regained their eyesight through cornea transplants. HOTA saves lives and is an important piece of legislation in our healthcare delivery system. On behalf of the many patients with organ failure, I thank Members for their continuous support of this piece of legislation. Singaporeans, too, support HOTA strongly.”
“As we narrow the differences between Class C and Class B2, Class B2 and Class B1, and if I do not have this filter, I think, more likely, I will begin to attract more and more who can actually well afford Class A or Class B1 to come and save a lot of money in Class C. Because the difference between Class B2 and Class C is four times. And when we narrow the differences, and without means testing in place, more will be drawn into Class C when they could well afford Class B2. The alternative is I do not improve on Class C. Then, of course, this change will not come about, in which case, I also do not need to have means testing. But I genuinely want to up the standard of Class C and Class B2 so that, in tandem with economic growth, we can pass on some of the benefits to the lower-income group in Singapore. AFFORDABILITY OF PUBLIC HOUSING AND DESIGN, BUILD AND SELL SCHEME The following questions stood on the Order Paper - 8. Dr Muhammad Faishal Ibrahim: To ask the Minister for National Development with the rising prices of new and resale HDB flats, what plans does the Government have to ensure that home ownership continues to be affordable for lower income families. 9. Dr Ong Seh Hong: To ask the Minister for National Development whether he can provide the rationale for the shift from providing affordable housing to the Design, Build and Sell Scheme flats in Boon Keng, with some costing as much as $700,000, especially with the income ceiling being fixed at $8,000 a month. 10. Ms Eunice Elizabeth Olsen: To ask the Minister for National Development whether his Ministry will consider raising the income ceiling of $8,000 for the purchase of HDB flats under the Design, Build and Sell Scheme.”
“Sir, on means testing, how much additional revenue we will collect? It really depends on the details which are still being finalised and the eventual impact on the ground. As I said, it is not a scheme for the present. The problem is not really big, meaning that large numbers of high income or upper middle income groups are using Class C. Some do, but not in big numbers. And if they are not big numbers, the impact in terms of additional revenue collected by Government will not be huge. But whatever it is, whatever additional revenue collected will be ploughed back to Ministry of Health to subsidise more patients. So, the end result is year by year, with or without means testing, we will be spending more money to subsidise the low-income group. The additional incremental revenue that means testing will yield will just give me additional money to help the low-income group, which is really the purpose of this exercise. What is the yardstick to determine whether means testing is successful or not? Let us go back to the objective. Our objective is to be able to continue to improve services in Class C and Class B2. If we are able to do so, then I will call that success. You just need to look at, say, Class C or B2 ward today, and 10 years ago and 20 years ago. The other day there was a public event where Mdm Halimah talked about her experience in KK Class C ward in 1981. She described it pretty graphically, and her conclusion is that it is a world apart, between then and now. And I hope, going forward, 10 years from now, the Class C of the future will again be better than the Class C of today.”
“Sir, each year, Medifund applications run into hundreds of thousands of cases. "Applications" does not mean patients, because a patient may apply several times if there are several episodes, several clinic visits, and it will be the same patient and if his financial status is low income and has difficulty. So a patient may chalk up four or five applications. Last year, there was something like 300,000 applications which were approved. As for the average bill size of the successful applicants, it is bound to vary from year to year, because these are for both inpatients as well as outpatients, and for all types of illnesses, all types of clinic procedures. Given such diversity, I am not surprised that it should come down or go up. I do not think we should read any more into it. The key point is that those who need help will be helped. As I said, 98% of the applications were successful.”
“Mr Speaker, Sir, Medifund payouts to help low-income patients have been steadily increasing over the years. In FY2006, it was $40.7 million, 4% higher than the disbursement in the previous financial year. As medical costs increase in tandem with enhancements in standard, the cost burden on all patients, rich or poor, will similarly grow. But we ensure that healthcare services remain highly affordable to the low-income group, through heavy direct subsidies from the Government. As I said just now, Class C and Class B2 subsidies of 80% and 65% of cost remain unchanged. As any patient can apply to Medifund, the number of applications itself does not tell the full story, as not all cases are as deserving. The fact though is that the bulk of the applications, 98%, were approved. The proposal to introduce means-testing in hospitals is intended precisely to ensure that the subsidy for the low-income group will remain protected for them, as we upgrade the services in the Class C and B2 wards.”
“Sir, I certainly agree with Mdm Halimah that a certain amount of supervision and watching over is necessary, and we do. We spend a lot of time monitoring clinical standards and less on charges in the private sector, which is based on willing-buyer-willing-seller. As it is the private sector, we also do not want to interfere too much in the market. But where I felt I should intervene is that patients may not be as well informed. So my job is to collect as much information as is practical and put them into statistical tables which can be interpreted more easily, and push it out to the market place. Then it is really up to the patients to decide. If despite knowing that this particular doctor for a particular type of treatment is always on the high side, patients still flock to the clinic, then I think it is not for me to say, "Why are you not going to other places?" There must be some reason why the clinic remains crowded. I see that as a more important role that I can play. INCREASED MEDICAL COSTS FOR LOW INCOME PATIENTS 7. Ms Eunice Elizabeth Olsen asked the Minister for Health (a) whether low income patients have been paying more in medical costs given that the increase in aid applicants to Medifund is greater than the increase in Medifund payouts and that medical inflation has outstripped the national inflation rate; and (b) whether means testing will result in lower medical costs for low income patients.”
“And that is why when I published the hospital bill sizes, I actually wanted to educate the people to move away from the fee schedule. If I may give an example, it is like going to a restaurant. We can look at the menu and see different items with different prices. But what finally counts to a diner or to a patient is what is the final bill. That final bill depends on what we order. If we order very expensive abalone, the bill is likely to be high. Likewise, in the case of hospitals, what finally counts is the total bill which the patient has to pay, and that will determine whether it is affordable or not. And that is the reason why I collected all those data, averaged out the statistics and published them by treatment and disease conditions, whether it is delivery, lasik, by-pass or something else. That allows for a better and more meaningful comparison of charges between hospitals and clinics. I hope that will help guide our patients. If a doctor says that you need a by-pass, and you can check into our website and you can see a wide range of by-pass bill sizes. I know that, in practice, it is more likely than not that the patient will not check, but the general practitioners (GPs) may check. You may go to a GP with some problems. The GP will be better able to interpret this data. I hope that they will be able to better advise their patients which clinic to consult and which doctor to go to. I think this will be particularly useful especially when we improve this publication to also include qualitative data like complication rate, mortality rate, morbidity rate, and so on.”
“Our healthcare subsidy for Class C, Class B2 and, in fact, also Class B1 is something that has evolved over many years, and is quite appropriate for the income level that the subsidy was targeting at. Members know that I am making some refinements to this scheme by introducing means testing, so that we can further target it. As to the headline subsidy levels, I think it is unwise to vary them. In practice, for those who are really in need of help despite the heavy 80% subsidy, there are other ways of assisting these patients, and Medifund is one of those schemes. In fact, for those who apply to Medifund, because they are distressed by the 80% subsidy, often the bills are just written off, in which case the subsidy is actually 100%. As for SMA, the fee guidelines have been around for a long time. After the Competition Act was enacted, SMA sought legal advice. The legal advice, I understand, that was given to SMA was that the SMA directed fee schedule may be construed as anti-competitive. That was the reason which led to SMA withdrawing the fee schedule. Let me use this opportunity to explain that the SMA's schedule was just a guideline. It was not enforceable. It did not mean that everybody would follow the fees prescribed. In fact, for a long time, many doctors and specialists, if their patients are willing to pay, go beyond the fee schedule. So the fee schedule was more a reference. Whether it is reintroduced or if it is kept, really makes very little difference. It does serve a certain purpose. It does provide the public to have some sense that the likelihood of a clinic consultation would follow this range of prices. To me, a more important point is not the fee schedule.”
“In addition, the recent payment of the Workfare Income Supplement scheme will directly increase the Medisave Accounts of many low-income workers. Fifth, we push our hospitals to reduce cost and cut out wastages wherever possible, and publish their bill sizes so that patients can make appropriate choices of which hospital or clinic to seek services from. Finally, the best approach to cope with rising healthcare cost is ultimately for all to stay healthy. We will get more Singaporeans to adopt a healthy lifestyle and help those with chronic diseases to manage them well so as to avoid future complications of their conditions.”
“Mr Speaker, Sir, healthcare inflation rate was 6.2% over the past one year. This is higher than normal, as it has averaged 2.4% per annum during the preceding five-year period. The main factors driving the recent increase were: (a) the large increase in oil prices resulting in higher import prices for many medical supplies, (b) the increase in wages of healthcare workers, and (c) the GST increase in July 2007. Healthcare inflation covers the price changes of a wide range of healthcare components. Not all increased at similar rates. The components which went up significantly last year were: (a) the fees in public and private hospitals, (b) the specialist outpatient fees at public institutions, and (c) Chinese herbs and Chinese physicians' treatment fees. The prices of these components have actually been fairly stable over the last five years. The only exception was the Traditional Chinese Medicine components which started moving since the second half of 2005 and have moved up by 33% over the last two years. Some healthcare inflation is inevitable as we import most medical consumables and the wages of healthcare workers form a big part of healthcare cost. For basic healthcare services in public institutions, we will ensure that they remain affordable to all Singaporeans. First, we have fully absorbed the impact of GST increase for subsidised patients. Second, we subsidise patients heavily, at 80% for Class C and 65% for Class B2. Third, we are reviewing MediShield to increase its payout for large hospital bills but Singaporeans should do their part by subscribing to an appropriate medical insurance plan. Fourth, the Government will provide Medisave Top-ups whenever the Budget allows, particularly to the elderly and those with low income.”
“Tattooing procedures carry the risk of transmitting infectious diseases, like HIV, Hepatitis B and C. However, if sterilised or disposable needles are used and proper infection control measures are followed, the risk of infection is very small. The Health Promotion Board has put in place health education programmes, mainly through health education pamphlets, for tattooists, barbers, hairdressers and beauticians. These include information on the precautions that should be taken, such as the use of disposable equipment where possible, thorough disinfection and sterilisation of non-disposable skin-piercing equipment, and the practice of good personal hygiene. In the past 30 years, there have been no reports of infectious disease transmission or serious complications from a body tattooing procedure in Singapore. There is no compelling need to regulate the industry. But we will continue to monitor this industry, and leave open the issue of whether to introduce legislation to control it. WRITTEN ANSWER TO QUESTION UNITED NATIONS EDUCATIONAL, SCIENTIFIC AND CULTURAL ORGANISATION (UNESCO) 1. Assoc. Prof. Kalyani K Mehta asked the Minister for Education (a) if he will be able to provide more details about the Singapore National Commission for United Nations Educational, Scientific and Cultural Organisation (UNESCO) which is due to be set up by end of 2007 following Singapore's rejoining of UNESCO; (b) what are the plans to partner with other national institutions; and (c) how cultural and scientific exchanges with other UNESCO members will benefit Singaporeans.”
“Mr Speaker, Sir, I thank Members for supporting this Bill, and I share their concerns on patients' confidentiality, and I share it deeply. When drafting the subsidiary legislation, we will be particularly mindful of ensuring adequate checks and balances. And this is part of the reason why we are taking a cautious incremental approach, beginning with the Cancer Registry, which has an almost 40-year history. I note the call by Dr Lam and Dr Fatimah to expedite the inclusion of other diseases under the Bill. We will learn from the experience of the Cancer Registry before we embark on any such extension. Meanwhile, a Committee has been formed to advise the Ministry on future expansion. I also note the call by Members, including Dr Lam, to ensure hassle-free processes and that fees should be kept reasonable. These are valid concerns and my staff would streamline the notification processes and the use of electronic means of data submission as far as possible. This would help reduce the operating costs. I thank the House for their support. Question put, and agreed to. Bill accordingly read a Second time and committed to a Committee of the whole House. The House immediately resolved itself into a Committee on the Bill. - [Mr Khaw Boon Wan]. Bill considered in Committee; reported without amendment; read a Third time and passed. INCOME TAX (AMENDMENT NO. 2) BILL Order for Second Reading read.”
“Second, the manager or person having the management or control of the healthcare institution would be the one held accountable for notifying the Registry. We have not listed the specific titles as these could vary from one institution to another. Prof. Thio found clause 21 on general exemption to grant too broad a power. I think she described it as giving me the power to issue "get out of jail free" card. That is not the intent. Let me clarify that this exemption power will primarily be used to exempt managers of healthcare institutions from having to notify the Registry of persons diagnosed with or undergoing treatment for a reportable disease, if it will create unnecessary duplication in reporting. This can happen. This is to reduce the overall burden on reporting. Let me assure this House that clause 21 will not be used to exempt anybody from the obligation to respect the confidentiality of identifiable information stored in the Registry. This is not the intention behind this provision. Prof. Thio also commented on judicial review and to what extent is judicial review available under the Bill. My understanding in this aspect of the law is that judicial review is available to any person who can show the court that he should be granted relief. I think Mr Chiam made a similar query as well. As to the definition of "cancer" by Dr Lam, I stand advised by the professionals. And I think the Director of Medical Services will set up an expert committee to advise him, among other things, to look through the current data submission to the Cancer Registry, to see whether we could add or substract, whether we can improve the form and, along the way, I think they would also sort out the question of which cancer to include and which to exclude.”
“Thio asked if officers, under clause 10(2), are bound by the confidentiality requirements of clause 8. Let me clarify here that the Registry officers are bound by clause 8 to protect the confidentiality of identifiable data stored in the Registry. On the other hand, those who received identifiable information under clause 10 to pursue an approved national public health programme will in turn be bound by the conditions imposed under clause 10, to protect the data from unauthorised use and disclosure. Mdm Halimah suggested that we refer all requests for individually-identifiable information for public health research to the National Research Advisory Committee, otherwise she felt that an inordinate amount of power would have been rendered to one person in the Registrar. That is a fair point. But let me clarify that, indeed, all research proposals would have been reviewed and supported by the respective Institutional Review Boards (IRBs) which comprise quite a number of people before they are submitted to the Registrar. And my Ministry has strict operational guidelines for all IRBs and these include guidelines on how informed consent should be obtained. Hence, for each research proposal, several people would have been involved in its approval process. Clause 12(5) is to empower the Registrar to seek a second opinion through the National Research Advisory Committee in the event that he has concerns which were not adequately addressed by the IRBs. I think this is an adequate safeguard. Let me now address the other queries by the Members. Mdm Halimah and Dr Fatimah sought clarifications on clause 2 definitions of the Bill. First, the Bill applies to all healthcare establishments irrespective of whether they are in the public or private sector.”
“But for us to probe into such a scenario, the Registry may need to release identifiable data to the investigators that we set up, to enable them to match the Registry data with, for example, the cancer screening data, so that the experts can identify the problem and then to address it in order to formulate a more effective cancer programme. So far, we have not encountered such a scenario here. But I have read of such development, which cropped up either in Australia or New Zealand, of a particular cancer screening programme. When they finally investigated and got to the bottom of it, they were able to discover that a particular laboratory was doing the testing poorly so that many of the cancer cases were missed. Without the power of such a provision, getting such a conclusion will be almost impossible. So, taking a leaf from the experience of the US, Canada and Australia, we think it is appropriate now to include such a provision in our legislation. Let me assure the House that such disclosure would only be allowed if the Ministry is fully satisfied that a programme cannot be effectively carried out with anonymised data. There will be rigorous scrutiny of every such request before release of data. Stringent requirements will also be put in place for maintaining confidentiality and limiting the use of data for the specified purpose. Certainly, the release of the individualised data is not meant to be public, that so and so has "cancer X". It is only to release to the investigators that the Ministry of Health appointed, for example. The Director of Medical Services can also request for appropriate ethical review to assist him in evaluating complex requests for such data. Prof.”
“The function of a Registry is limited to collection, analysis and reporting of routine statistics. Registry data may however, from time to time, show worrying trends that are beyond the scope of the registry to investigate. The purpose of setting up the Registry is really for us to be aware when a worrying trend develops. And once you identify a problem, you need to get to the bottom of it - why is there a worrying trend? Consider this scenario. Supposing we introduce a new national mass screening programme for a particular cancer, "cancer X". After several years, the expectation must be that if the screening is effective and it is well done, then we should expect the incidence rate to go down and with it, survival rate to improve. But supposing that having done so, we found from the Registry data that that is not the case, and we continue to see a rising trend and a significant number of very severe "cancer X" cases; in other words, patients presenting themselves at stage four, very advanced stage of severity. What is wrong? Then, you must ask the questions: What is the reason? Is it because the screening is poorly done? Is it generally poorly done or only certain screening centres are particularly bad? Why is that so? What is wrong? Or is it because, while we intended it to be a mass screening, significant segments of a population are not coming forward to be screened? Is it a particular racial group or a particular age group? I think these are critical questions that, as Minister for Health, my job is to try to understand them, so that we can take corrective action.”
“I would suggest Mr Chiam read up the BAC report. Because, while I note what Mr Chiam has said about traditional medical views on sharing of individualised information, developments in recent years have updated many of those views. Second, we studied similar legislation in the US, Canada and Australia for reference when crafting the provisions on patient confidentiality. They have much more experience in protecting patient confidentiality and their disease registry legislation has similar provisions on release of identifiable information under certain conditions. Let me assure this House that the data that the Registry collects will be treated with the strictest confidence. First, any unauthorised disclosure of identifiable data would be a criminal offence. Second, we will only collect information that is absolutely essential for healthcare policy making. Third, we will spell out clearly in subsidiary legislation the type of information to be collected. Fourth, any disclosure of information will be in anonymised form. This will be the default position. However, if it is established that disclosure of individually-identifiable information cannot be avoided, then there should be prior consent by patient. We have, however, made a provision in the Bill for power to disclose identifiable information without prior consent in the event that there is such a need to support certain public health programmes. Understandably, these provisions drew the attention of Members, including Mdm Halimah and Mr Sam Tan. This is not a local innovation. And by the way, even the word "anonymised" is not a local innovation. Australia, United States and Canada have similar provisions in their registry legislation and for good reasons.”
“Although there has been an overall improvement in cancer survival in Singapore over the years, the five-year age standardised survival rate for stomach cancer remains very low, at only 25%. In other words, only one-quarter survives more than five years. There is obviously room for improvement and we will put some research priority on stomach cancer to improve early detection and its treatment. While the benefits of a disease registry are more easily explained, the key concern, which all Members have rightly focused their comments upon, pertains to privacy and patient confidentiality. How do we protect privacy and patient confidentiality while ensuring that their data can be put to good use? How do we retain the trust of the patients and the public that we and the doctors will not abuse their trust? My Ministry shares these concerns. Indeed, it is precisely because of these concerns that this Bill is formulated. And when drafting the Bill, we strive to balance the potential benefits to society with the rights of the individual to privacy and confidentiality of information. First, we drew upon the excellent works and the recommendations of the Bioethics Advisory Committee (BAC) chaired by Prof. Lim Pin. Earlier this year, Members will remember that the BAC published its report titled, "Personal Information in Biomedical Research", after an extensive public consultation among doctors, members of the public, experts in ethics, international scientists, and so on. Among other things, the BAC concluded that it is "ethically proper for medical information to be disclosed by physicians to national disease registries without patients' consent, provided that adequate privacy and other ethical safeguards are in place and patients are appropriately informed".”
“Mr Speaker, Sir, I thank the Members who have spoken in support of this Bill. I particularly want to thank Prof. Thio for a very clear explanation of the various clauses and various obligations and objectives that we set up under this Bill. Mr Sam Tan wanted a clearer explanation of the benefits that patients can expect out of our setting up a National Registry of Diseases. In a way, Dr Lam, in his speech, has clarified, from a doctor's point of view, what are those public health objectives. Let me illustrate in my own way using the example of, say, lung cancer. As I said just now, the Singapore Cancer Registry is now almost 40 years old. And if you look at our earlier set of data, they show clearly that Singapore ranked very high in age adjusted mortality due to lung cancer among men, and we were among the highest among the developing countries at that time. Research on data drawn not only from our own Cancer Registry but from many other global cancer registries proved strong correlation between smoking and lung cancer. So like others, we then embarked on an aggressive anti-smoking campaign. As a result, our smoking prevalence in males dropped from 37% in 1984 to 22% in 2004, now among the lowest in the world. In turn, these efforts have reduced lung cancer rates in males from 65 per hundred thousand population in 1978 to now less than 45 per hundred thousand population. The benefits in terms of lives saved and the miseries reduced are immense. The Cancer Registry also helps us to prioritise our research focus, again with a view to benefit patients. Let me give another example - stomach cancer, which is now topical. It is currently the fifth most common cancer among Singaporean males. Among females, it is ranked number seven.”
“Clause 17(2) is noteworthy as it clarifies that a person who makes a notification to the Registry or who makes available to the Registry any document or information for the purposes of complying with the Bill will not incur liability for breach of confidence or of professional ethics. Implementation plan Reportable diseases To facilitate the smooth implementation of this Bill and to allow healthcare institutions to ease into this new reporting framework, only cancer will be listed as a reportable disease for now. The other three national-level disease registries maintained by the NRD for stroke, heart and renal disease will be reviewed for possible inclusion over the next two years. Listing of additional reportable diseases will depend on epidemiological and public health needs. Feedback and consultation Extensive public consultations were held with doctors, healthcare administrators, ethicists and regulatory bodies, and researchers. There was general support for the Bill, and points of concerns have been addressed in the draft Bill. Conclusion The National Registry of Diseases Bill, and the Registry that it will create, will play a vital role in our public health efforts. It provides for the compilation of important information on non-communi cable diseases that will guide policymaking on national healthcare and the formulation of public health programmes. It will provide greater clarity on the type of health information which can be collected at national level and spells out the purpose for, and the form in which it may be put to use. I ask all Members of this House to support this Bill. Sir, I beg to move. Question proposed. 3.37 pm”
“Clause 6, in Part III of the Bill, makes the notification of reportable diseases mandatory for managers of all healthcare institutions. The burden is placed on the manager as he has the management and control of the institution. Very limited data will be required to make a notification. Clause 7 empowers registry officers or agents to follow up on the notification to extract patient data from the relevant medical records. The kind of information that can be obtained will be predetermined, and will be listed clearly in subsidiary legislation. Part IV addresses the issues of confidentiality and disclosure of Registry information. It imposes stringent obligations on registry officers and all other persons who request and receive Registry data. Unauthorised disclosure of identifiable personal information stored in the Registry is punishable with a jail term or a fine, or both. Clause 9 allows the Registrar to release anonymised information to any person on request, and to charge a fee and set conditions that have to be met. Clause 10 provides for the release of identifiable personal information for the conduct of national public health programmes, while clause 12 provides for the release of identifiable data for the purposes of public health research but only if the requisite patient consent has been obtained. Clause 11 allows patients to authorise their doctors to retrieve their Registry data if this is necessary for their proper treatment. Clause 13 in Part V of the Bill provides for the appointment of investigation officers. Clauses 14 and 15 clothe these officers with enforcement powers that will allow them to investigate offences committed under this Bill. Part VI deals with a host of miscellaneous matters.”
“Identifiable patient information may be disclosed under the Bill for the purposes of national public health programmes. Such disclosure will need the approval of the Director of Medical Services (DMS). In deciding whether to give his approval, the Director of Medical Services will, amongst other things, consider the aims and objectives of the proposed programme, and whether it has any public health benefits to Singapore. He must be satisfied that the programme cannot be carried out using anonymised data. In addition, the Director of Medical Services must also be convinced that adequate measures will be put in place to protect the individually-identifiable information from unauthorised disclosure. The Bill permits identifiable patient information to be disclosed for the purposes of medical treatment or for public health research. This will only take place if the person to whom the identifiable information relates has given the requisite consent. NRD data will not be released for other purposes, for instance, to employers or insurance companies. Main features of Bill Let me now run through the main features of the Bill. Clause 2 of the Bill defines reportable diseases as those listed in the Schedule. Cancer will be the first reportable disease. Part II of the Bill establishes the National Registry of Diseases and sets out its functions. These include the collection of information on reportable diseases, establishment of registers, compilation and publication of statistics, and the provision of information for supporting health services and national public health policies. Clause 3 sets out the various categories of officers that may be appointed to run the Registry.”
“This includes batch reporting by linkages with hospital information systems, online reporting through the Internet, or submission of simple paper forms. As we are dealing with chronic diseases, instantaneous real-time reporting is not required and a reasonable grace period will be provided. Three: Patient privacy and data security In addition to administrative safeguards, such as clearly defined operating procedures with strict access controls to the Registry, encryption of data and regular audits, which are already in place, the Bill imposes a very strict obligation on all officers and agents of the Registry to protect confidential data. Similarly, those persons who request for and receive Registry data are bound to observe conditions of confidentiality set by the Registry. Any person, including a registry officer or agent, who discloses individually-identifiable information from the Registry in breach of the Bill faces imprisonment of up to 12 months, or a fine of up to $10,000, or both. Four: Purposes of disclosure The Bill clearly lays down the rules as to whom, and for what purpose, and in what form, the information can be released. In addition to its primary use by MOH for healthcare policy planning, we anticipate that the public, doctors, academics and researchers will want to know some key statistics about the chronic diseases. The Registry Office will therefore publish reports of analysed data in simplified form on a regular basis. Such reports will be made publicly-available. The Registrar of the National Registry of Diseases is also empowered to release de-identified data for research of significant public health importance that has undergone rigorous scientific, ethical and regulatory scrutiny.”
“Cancer will be the first reportable disease to be listed in the Schedule as the current cancer registry is well established with clearly defined work processes. MOH will add further diseases to the Schedule only if the collection of such information is essential to support national policies. Communicable diseases will not be covered under this Bill, as there are already provisions under the Infectious Diseases Act to obtain information on such diseases for the purpose of disease prevention and control. Two: Basic data requirements Collection of detailed information for every case of a disease will be tedious and expensive. We will therefore only collect data that is essential for public health planning. This will vary for different reportable diseases and the type of information collected will be set out clearly in subsidiary legislation. Any change to the list of information that can be collected will require Ministerial approval and will be published in the Government Gazette. While it may be tempting to try and collect as much information as possible to anticipate future policy needs, this is neither feasible nor desirable. Excess data reporting imposes a heavy burden on healthcare institutions. Neither is it efficient nor cost-effective for the Ministry. We also need to respect the privileged access that this Bill provides to patients' medical records. We are sensitive to the fact that healthcare policy questions may change over time, but, instead of collecting a lot of information in anticipation, we will review and make some changes to the data collected by the Registry from time to time. To make compliance as painless as possible, the Registry will work with healthcare institutions to facilitate convenient reporting.”
“The breakthrough came from the United States where a regulation was enacted in 1939, requiring reporting of all cancer cases diagnosed in New York State. Since then, the US has made cancer reporting mandatory in most of its states. Similar laws have been passed over the last 50 years in Canada, Australia, New Zealand, Denmark, Norway, Finland and Germany, just to name a few. We have studied their legislation and drawn on relevant features when drafting our own Bill. The National Registry of Diseases Bill makes it mandatory for healthcare institutions to submit relevant epidemiological data to the National Registry of Diseases for public policy and planning purposes. The Bill also commits MOH to responsible stewardship in the storage and disclosure of registry data by ensuring that patient confidentiality is observed by all persons who maintain and use the data. The Registry is already subject to stringent governance standards in securing the information collected and protecting patient confidentiality. The Bill articulates these practices and provides for powers of enforcement. Objectives The Bill aims to achieve four objectives: One: Comprehensive coverage The Bill makes it mandatory for the manager of a healthcare institution to notify the Registry when a person is diagnosed with or undergoes treatment for a reportable disease listed in the Schedule to the Bill. The types of cases that have to be reported will be further specified in subsidiary legislation. The Bill also empowers the Registry to collect information about notified cases from the relevant medical records. The kind of information that may be obtained will be set out clearly in subsidiary legislation. Patient consent is not required.”
“Disease Registries In 1968, we set up our first disease registry, which was the Singapore Cancer Registry. So this was almost 40 years ago. This was followed by the Heart Registry in 1988 and the Renal Registry in 1993. Currently, the Stroke Registry is being piloted in some public hospitals. These four registries make up our National Registry of Diseases. A good national registry must meet two criteria. First, it must be comprehensive, ie, it should cover all cases or almost all cases in the country. If a Registry misses out a significant segment of the population, this may result in under or over reporting of disease burden. Second, the registry must be well maintained with close tracking of how the disease progresses over time. This requires the submission of individualised information, so that new data can be matched with existing data in the registry, thus avoiding any double-counting. Our current disease registries suffer a major limitation because it is based on voluntary reporting. While public hospitals have been forthcoming in reporting, many private hospitals have largely not taken part. As a result, our registries are incomplete. A major concern of the healthcare providers is the lack of clarity on the legal basis for the disclosure of individualised information to disease registries, whether they will be breaching medical confidentiality. Legislation Formal attempts at registering diseases date back to 1728, the year of London's first General Census of Cancer. This was followed by attempts in the Netherlands, Spain, Portugal, Sweden, Hungary, among other countries. Most of these attempts failed due to incompleteness of data, as the reporting was voluntary.”
“Sir, I beg to move, "That the Bill be now read a Second time." Introduction Rational healthcare policies are underpinned by accurate and timely information. For example, should we promote regular breast screening among Singaporean women? If so, for which age groups and at what frequency? Settling such policies requires robust analysis of cost-effectiveness and survival data, without which our decisions will be merely arbitrary or based on data drawn from other countries which may or may not apply to Singaporeans. Good information is especially critical when we have to deal with diseases such as cancer, heart disease, stroke and kidney failure that are major causes of death and morbidity among Singaporeans. There are many ways to collect such information. We do so through periodic surveys but such data can only provide a snapshot of the prevailing situation at a particular point in time. We need to supplement this with continuous time-series data which tracks the incidence and the outcomes of the disease in the population. A well established method for gathering such information is through setting up a national disease registry. With time-series data collected by the registry, we can answer many critical health policy questions, for example: (i) What is the number of new cases of a disease every year - is it rising or falling? Do we need to adjust the type of health services to meet this changing trend? (ii) Is the disease affecting a particular segment of the population more than the others - how can we better target our prevention and treatment programmes? (iii) How do people suffering from the chronic disease fare? How long do they survive and how do we compare with other countries? (iv) Have prevention and treatment programmes made a difference?”
“I thank the Member, Dr Fatimah, for her support of the Bill and I certainly agree with her that the Ministry, together with the Singapore Red Cross and IPOS, would raise public awareness and educate the public, especially the companies, corporations and NGOs, not to abuse the law. This morning, while coming to work, three ambulances from three different nursing homes overtook me. I gave way of course. But I paid particular attention to the logos they used. None of the them flouted the Geneva Conventions as they used different but acceptable symbols to do with health, like the traditional serpent. One of them used a red cross, but a stylised cross and in a different colour. So, I think they are permissible symbols. Certainly we will work with IPOS, through their website as well as through their Trademarks Office, to publicise this more. But I thought I should make a clarification that our SAF medical troops are entitled under the Geneva Conventions to use the Red Cross logo. That is precisely why the Geneva Conventions were formulated for them. So, they are not flouting the law in any way. Question put, and agreed to. Bill accordingly read a Second time and committed to a Committee of the whole House. The House immediately resolved itself into a Committee on the Bill. - [Mr Khaw Boon Wan]. Bill considered in Committee; reported without amendment; read a Third time and passed. NATIONAL REGISTRY OF DISEASES BILL Order for Second Reading read. 3.19 pm”
“While we want to encourage our people to be more creative, we would never allow them to break the law and apply "artistic licence", so called the wrong way, by using these logos for commercial purposes. We should protect these emblems as a symbol of assistance, disaster response and service to vulnerable people. Sir, yesterday there were two members of the public who approached me and asked whether the tone and the shade of the red on the cross would make any difference, and I told them certainly it would. It would again be useful for the Ministry to clarify that publicly. The appointment of public officers as inspectors to investigate offences in relation to the misuse of the emblems is indeed practical and necessary as it underlies our true intentions of safeguarding and protecting the emblems from being misused. Finally, Sir, would it be possible for the Ministry and perhaps the Intellectual Property Office of Singapore, or IPOS, to assist with the provision of a toll-free number that will allow members of the public to call and inform if they notice any improper use of the emblems. On that note, Sir, I reiterate my support for the Bill.”
“I wish to highlight, Sir, that there are many and a variety of organisations and products currently using, in whole or part, some of the emblems in discussion. These may include private ambulance companies, non-Governmental organisations, pharmaceutical companies on the best of healthcare responders to mass casualty and disaster events, and even on T-shirts. No doubt the 12-month grace period is given, but I would like to ask that the Ministry come up with a public awareness and education programme, which I hear they are going to work with the Red Cross Association, on a wide scale to enhance and increase the spread of information to ensure compliance. Perhaps we can also consider writing in to the companies and organisations which are affected informing them of this decision. It could also be publicised on relevant websites as indicated. Sir, many medical units still have their men carry the Red Cross logo on their arms and armbands and also on their uniforms, essentially to depict that it is a medical response team, or even on the medical response vehicles. It appears to be a universal medical or medical response sign. Thus, for this enforcement to be effected and effective, we need that awareness creation, adequate explanation and formal information to be given out adequately. The essence of it all is that the new legislation will prevent any misuse on the use of such symbols. In fact, it is important to have symbols that are easily recognisable; yet, at the same time, acceptable to all people of different faiths and beliefs. It is also only through common acceptance that we can promote better understanding of one another.”
“Let me now take this House through the amendments. First, the use of any of these emblems, including colourable imitations, will not be allowed in Singapore from now onwards unless approval is given by the Ministry of Health. Organisations and businesses, which currently use trademark symbols similar to these distinctive emblems for their products or services, will be given a grace period of up to a year to take the necessary measures to comply with the Act. Second, the maximum penalty for misuse of any of the emblems will be increased from $1,000 to $10,000. Third, the amended Act will allow for the appointment of public officers as Inspectors to investigate offences in relation to the misuse of the emblems. These amendments are necessary to ensure that the distinctive emblems are readily recognised and respected in Singapore as trusted symbols of protection and humanitarian aid. My Ministry will work with the Singapore Red Cross Society to educate the general public, businesses and other organisations on the importance of respecting these distinctive emblems. Sir, I beg to move. Question proposed. Dr Fatimah Lateef (Marine Parade): Sir, I rise in support of the amendment Bill. The Red Cross, Red Crescent, Red Lion and Sun and the Red Crystal represent international humanitarian movement emblems with millions of volunteers worldwide whose stated mission is to protect the human race without any discrimination based on nationality, race or religious beliefs. The existence of these movements is aimed at promoting mutual understanding, friendship, cooperation and lasting peace among people the world over. Thus, efforts by the Government to protect all these emblems from being misused are indeed welcome.”
“Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time." In times of armed conflict, the Geneva Conventions of 1949 lay down basic humanitarian rules to be observed by all parties. One such rule is to recognise certain universal symbols which confer protection on authorised emergency relief agencies. These include military medical services and the international relief organisations. Under the Geneva Conventions, the Red Cross and the Swiss flag, which is the Red Cross with colours reversed, were the original protected symbols. But while the original intention of the Red Cross was to be a universally-recognised neutral emblem, several Islamic countries had objected to its usage. As a result, Red Cross societies were not recognised in these states. In order to enable emergency relief efforts in these states, the Red Crescent and the Red Lion and Sun emblems were created and added to the Geneva Conventions. But these new emblems were themselves viewed by others as possessing religious connotations. Given these difficulties, the Geneva Conventions introduced another emblem, the Red Crystal. It was designed to be easily recognised and devoid of religious connotations, such that it can be accepted by all countries, regardless of religious orientation. A new protocol, the Third Additional Protocol (APIII) to the Geneva Conventions, was introduced in 2005 to recognise the Red Crystal as an additional universal symbol. Singapore subscribes to the Geneva Conventions and we have signed the APIII. To date, 87 countries have signed the APIII and 19 have ratified it. To play our part as an international citizen, my Ministry therefore proposes that Singapore's Geneva Conventions Act be amended and ratified to extend legal protection to all these emblems.”
“These are licensing conditions for which there is the backing of the demerit points system, especially the revocation of licence, if there is any breach. Indeed, one such gaming centre has had its licence revoked because of a breach of these licensing conditions. The other point about patrolling, the Police has many things to do. While in so far that they patrol shopping centres to prevent crimes, they may also ascertain whether any of the conditions has been breached. I think the solution really must be a holistic one, in particular with regard to students being there either in uniform or before 6.30 pm, I think the other stakeholders have a role to play, which is the schools and parents. So I say this is the best way to move forward.”
“Hence, the Police carefully assesses each application to set up a computer gaming establishment looking at the suitability of its location, amongst other criteria, before deciding whether or not to grant a licence. Sir, the Police does not allow computer gaming establishments to be set up in HDB residential zones where most schools are located. This is because such locations offer high accessibility to youths. Computer gaming establishments are only allowed to be set up at shopping, recreational or commercial centres. This includes HDB town centres, which are part commercial and part residential. Sir, in addition, licensees of computer gaming centres are required to keep out persons below 16 years of age before 6.30 pm on a school day. Further, the licensee has to ensure that students wearing school uniforms are not admitted into the establishment at any time, and is also not allowed to provide a change of clothes to students. A breach of any of these licensing conditions is an offence under the Public Entertainments and Meetings Act. Errant licensees face a penalty of up to $10,000. There is also a demerit points system to help regulate the licensees. Repeat offenders may have their licences suspended or revoked. Ms Ellen Lee (Sembawang): Sir, I would like to ask the Senior Minister of State how frequent does the Police patrol these establishments to make sure that all the rules and regulations are being complied with, and would the Police be just relying on voluntary compliance of these rules rather than seeking some mandatory compliance, because I think it is known that there has been flouting of these rules and patronising of these establishments by students under 16 years of age. Assoc. Prof. Ho Peng Kee: Sir, it is not a matter of voluntary compliance.”
“Certainly, we will be most happy to work with any groups to help resolve the problem. But let me reiterate that not all babies born with special needs are not insurable. As I have explained very clearly just now, let us say, an autistic child, why should an autistic child not be insurable by MediShield? I asked CPF yesterday and they confirmed the policy. They will not cover conditions related to a congenital condition. Insurance will not cover treatment related to a congenital condition. But if you pay the insurance, you can cover for treatments for all the other conditions that may crop up - cough and cold, whatever that may crop up - like any other normal child. So my advice remains: please immediately go and insure your child now and do not wait when he actually falls sick, then you may find the insurance company is not willing to take your case. CYBER/GAMING CAFES (Control over excessive proliferation) 7. Ms Ellen Lee asked the Deputy Prime Minister and Minister for Home Affairs (a) whether there is control over the excessive proliferation of cyber/gaming cafes, especially in the heartlands and within close proximity to schools; and (b) whether there are measures to control children and young persons, particularly students under 16 years of age, from patronising them. The Senior Minister of State for Home Affairs (Assoc. Prof. Ho Peng Kee) (for the Deputy Prime Minister and Minister for Home Affairs): Mr Speaker, Sir, Police is aware of the potential problems of easy access by youths to cyber gaming. While computer gaming does not in itself lead to delinquency, ease of accessibility may encourage truancy and affect attitudes of students towards their academic work, which may eventually lead to youth delinquency and crime.”
“I did not quite catch the last few words, but let me try to guess. When I explored this scheme about how to insure financial protection against pregnancy that leads to babies born with congenital difficulties, I was looking at MediShield. But I also asked them to study how to load it onto all pregnancies so that as soon as you discover you are pregnant, buy an insurance policy which would then cover all these eventualities. It is the same old thing. The premium is hefty, and to make it compulsory, it becomes very difficult for us to justify. It was because of those series of enquiries and discussions I had with the private insurers, which led to products which I have just named a while ago, which are offered by NTUC i-Maternity, and so on. Even then, the insurers were careful in not saying that the insurance would then cover all medical treatments. It just says that if the baby is unfortunately born with certain conditions, here is the cash amount which you can claim, and how you spend the money is left to the parents. I will continue to look at the other countries on how they take care of problems like this through the insurance route, but because of our very small market, unfortunately, the situation is what I have just described. Mr Speaker: Ms Phua, last question.”
“Sir, I am sympathetic to those parents - a small minority of parents - with children born with such congenital difficulties. About three years ago, I had in fact asked our actuaries and consultants to take a look at how much would this additional burden be because if it is quite inexpensive to load onto the rest of the population, I could try to make a case to let us share this burden. I was hoping that the increase in the premiums on Basic MediShield, if we take on this additional liability, was not too much. Unfortunately, it was a lot. The MediShield premium for a young Singaporean below 30 years of age today, I think, is only $30 a year which is very inexpensive. But if we were to load this liability on - I rely on my memory now - the consultants' recommendation would be something like a seven-fold increase, so from $30 per year to something like more than $200 per year, and even then, it is to limit the payout to just the first year of birth, in other words, before the child hits one year old. That is the difficulty we are faced with. And to load such hefty increase of premiums onto the rest of the population I think it is hard to justify. So we have to look for other means, which is the families themselves, and of course the society. Where they require additional medical treatment, then Medifund can come in, and we can be more helpful by making use of Medifund as a tool. Of course, NGOs, VWOs on specific causes, if they want to chip in, I think that is certainly welcomed. So I am afraid to load it onto the rest of the population with such hefty increase of premiums, I would find it very difficult to explain and justify.”
“We therefore encourage all parents, including those who have children with special needs, to cover them under MediShield as soon as possible, before they develop any other illnesses that could disqualify them in future.”
“Sir, Basic MediShield and the enhanced rider plans offered by private insurers are all self-funded. In other words, the premiums collected from policyholders must more than cover the anticipated payouts claimed by patients. For the plans to be sustainable, premiums are determined on an actuarially-sound basis. Persons with congenital illnesses can join MediShield to obtain coverage for medical treatment that is not related to their congenital condition. However, it will be unusual for insurers to cover pre-existing illnesses or to cover treatment related to known congenital conditions. To do so will be to load the burden on the rest of the policyholders who may not support a manifold increase in premiums to take on this additional liability. More importantly, if MediShield were to cover pre-existing illnesses, it will encourage potential policyholders to delay subscription until they are sick. This will defeat the whole principle of insurance which is based on the sharing of burden among policyholders with similar risk profile. Nevertheless, some private insurers do offer cash benefit products which pay lump sum amounts if a baby is diagnosed with specific congenital anomalies. They include the Prudential PruSmart Lady's Maternity Rider, HSBC Lady FirstCare, and NTUC i-Maternity. Subscription to these products must of course be made prior to the discovery of any known congenital anomaly. As for children attending special schools or with special needs, the basis of coverage is the same as the basis for other children, that is, they should be healthy at the point of entry and have no pre-existing illnesses.”
“Yes, deductible will be part of the review. My own view is that the deductible for the Basic MediShield for class B2/C, which is $1,500 and $1,000 respectively, is probably about the right level. But I have some views on the deductible for the enhanced MediShield, which I purposely set it a bit high at $3,000 because I was not sure then. But looking at the data the last few months, it suggests that maybe there is some scope to reduce that deductible perhaps by about $500. But we will settle the details early next year. MEDISHIELD (Coverage for special needs children) 6. Ms Denise Phua Lay Peng asked the Minister for Health (a) whether MediShield is self-funded by the Central Provident Fund; and (b) how much will it cost to enable families to cover special needs children (i) born with congenital or pre-existing illnesses and (ii) attending special schools, to allow them to enjoy the same health insurance coverage as normal children.”
“Mr Speaker, Sir, we reformed the MediShield in July 2005, which is almost two years ago. Mdm Halimah Yacob asked about the average payout per claim before and after the reform. For basic MediShield which covers class B2/C hospitalisation, the average payout has increased from $837 per claim to $1,274, an increase of more than 50%. More importantly, the reform has enabled us to return MediShield to its original objective of covering large hospital bills. Basic MediShield now covers about 60% of class B2/C bills above $10,000, up from about 40% pre-reform. The average payout for such large bills has risen to $9,800 per claim from $7,300 pre-reform. My objective is to reduce the burden on patients with large bills further, from 40% to about 20%, if it is possible. This will require an increase in premium but we will see if the required increase can remain affordable. The actuarial computations are ongoing and I hope to finalise the details by early next year so that we can bring about the next round of improvements to MediShield during 2008. Mdm Halimah Yacob: May I ask the Minister whether there will also be a review of the amount of deductible, because the amount of deductible was increased at the last review? There is some feedback that the amount of deductible seems to be high. Will that also be reviewed by the Minister?”