Lily Neo
Singapore
“Thank you, Mr Speaker. May I ask Minister for Health on MOH's capacity in coping with serious cases of COVID-19 in terms of adequacy in respirators and in our ICU beds. Am I correct to say that already half of NCID's ICUs are taken up? What will happen when it reaches its full capacity?”
“But even so, with the right measures of social and medical assistance in place to assist them with their daily living, they can still age gracefully in the comfort of their own homes.”
“Thank you, Mr Chairman. Yes, I will keep it short. Minister earlier said that MSF will proactively reach out to families in HDB rental homes to assist them, to possibly buy their own HDB flats. Many of these families lamented that they cannot afford it. How does the Minister plan to do it?”
“Thank you, Mr Chairman. May I ask the Minister whether there is a possibility of more widespread community spread of COVID-19? And will MOH be able to cope with this? And whether does our Government have more specific measures in place to cope with this scenario?”
“Thank you, Mr Chairman. Earlier in my speech, I asked whether there are assessments by HDB for applicants of Joint Singles Scheme (JSS) to ensure that they are free from mental illnesses and medical conditions before compelling them to stay together.”
“Many of them have lived in rental housing for more than six years and some more than 10 years. Thus, there are signs of entrenchment. What are the schemes in place and the success rate of such schemes, to assist them in looking for better options in their housing needs and to help them get out of their predicaments?”
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“Similarly, we should not allow medical inflation at an excessive rate, beyond what the economy as a whole and Singaporeans can bear. But what we can and should do is to make sure that the medical inflation rate does not diverge too much from the general rate of increase in wages and other factor prices. I think that is a fair proposition. So, while I will try to maintain current hospital charges when the economy is down, you know that I cannot do this forever. When the economy recovers, we must accept that general price levels will go up. And when other workers are enjoying wage increases again, we will also have to let our healthcare workers enjoy their fair increases. In order that hospital budgets can be balanced, you know that we will have to let some hospital charges adjust. But the heavy subsidy that we provide to Class B2 and Class C will remain. In Class C wards, MOH picks up 80% of the cost. In other words, for a $100 Class C bill, we pick up $80 and the patient pays $20. Meanwhile, we will do our best to keep the cost low, by doing more with less, squeeze out productivity and share best practices. That is why I pushed through the publication of hospital bill sizes for common illnesses. It has caused some stir in the hospitals, as it should. Along the way, the right questions are being asked and, hopefully, there will be useful lessons learnt and applied. We have published data for 28 most common medical conditions. In the next monthly update on 1st November 2003, we will increase the data to cover 45 medical conditions. For each priority, I have appointed a champion to drive the work, and I will ask the champions to carefully consider what Dr Lily Neo has suggested and, where practical, we will adopt them.”
“There are many things worth doing, but we need to focus our energy, if we are to be effective, and we have settled on the eight priorities. These are all long-term issues. They are not easy nuts to crack. There are no quick fixes or instant results. We need patience and perseverance. It will be a slow push up the hill, but worth doing. For example, healthy lifestyle, which Dr Lily Neo mentioned a few times. Imagine: if every Singaporean can be as disciplined as Senior Minister Lee - whether it is in his diet or exercise routine - what a dramatic difference that will make to our total healthcare needs. Of course, I am not naive. It is not possible to get 100% of Singaporeans to be like Senior Minister Lee. But, if every five years, we convert another 20% of Singaporeans to join the healthy lifestyle club, we can potentially reduce healthcare need by 10-20%. That means hundreds of millions of dollars saved per year. This is not a trivial sum. I agree with Dr Lily Neo that Singaporeans are worried about rising hospital bills, and this is also one of my priorities. We are getting our hospitals to pay close attention to this and to slow down the medical inflation rate. Medical inflation rate in recent years has exceeded general inflation rate. I hear the concerns and I will do my best to strike a balance and address them. Let me explain this. We cannot over-manipulate the prices of healthcare services. It is not possible for us to artificially induce deflation in medical fees, especially when the rest of the economy is doing well by, say, suppressing or cutting the wages of our healthcare workers. Otherwise, our hospitals will suffer a brain drain, which will be detrimental.”
“Then-Governor Gray Davis had to rush through a Bill in the last few days of his term, shortly before elections, to require employers to insure their employees based on an 80-20 co-funding formula. But that was not sufficient for him to prevent his term from being terminated. And people remain unhappy. In the last few days, supermarket employees - and today I read in the newspapers transport workers - have gone on strike over rising health insurance premiums. In comparison, the Singapore system has not done too badly. Compared to my first day in the Ministry of Health in 1978, we have made significant progress. First, we now have more money set aside for healthcare. Singaporeans now have $28 billion in their Medisave Accounts, and Medifund has built up to $900 million. Second, we have rebuilt all our pre-war hospitals, with the exception of Alexandra Hospital. Even Alexandra Hospital has had a facelift and is no longer the same British Military Hospital that we inherited. Third, we have many more doctors and nurses: 6,000 doctors and 18,000 nurses on the registers, and these are double or triple the numbers 25 years ago. Mdm Deputy Speaker, my job is to build on this very strong foundation which I have inherited and to build on it, so that when it is my turn to pass on the responsibility, my successor will have something even stronger and better. I have, therefore, spent the first few weeks of my appointment to MOH talking and consulting a wide range of stakeholders in healthcare - doctors, nurses, sinsehs, pharmacists, administrators, the public and private sectors, politicians, journalists, patients, etc. My first task is to settle the priorities for my term.”
“Indeed, as part of my preparation when the Prime Minister assigned me the health portfolio, I read up all her comments in Parliament in recent years on healthcare policies. Shortly after I rejoined the Ministry of Health, I also had a working lunch with Dr Lily Neo and her GPC members. I thought we had a good exchange of views and I was struck by how much we agreed than disagreed. To be sure, healthcare policies are complex. At the core of the complexity is the fact that healthcare services are, what economists call, a public good and non-excludable. Unlike other goods and services which can be left to the market to allocate through pricing and consumers' ability to pay, we cannot deny the sick and dying with basic healthcare, just because they cannot afford to pay. So governments all over the world, and Singapore included, subsidise to varying degrees the provision of healthcare services. With subsidy, however, comes distortion of both supply and demand. So the challenge is to subsidise, but with minimum distortions. And this is the healthcare dilemma: how to ensure subsidy goes to the right person, but without it being abused. No government has a perfect solution to this healthcare dilemma. When I first joined the Ministry of Health 25 years ago, I read about the many healthcare problems faced by UK, US, Japan, Germany and many others. As I restarted my reading of healthcare journals, I was struck by how little the problems had changed in these 25 years. Indeed, in some countries, the problems seem to have worsened. For example, in the recent California Governor election, the issue of rising uninsured was a hot item.”
“By continuing to invest heavily on our undergraduate and postgraduate medical education, we ensure that our doctors are competent and we help them to be conversant with new developments in medical sciences. We must encourage and facilitate those who are willing to teach and those who are willing to learn by providing them with the opportunities. We ought to enhance our investments on the Health Manpower Development Programme (HMDP). It is worthwhile to include the extension of the service hub to become a training hub as this will boost our aim of being a medical hub in the region. This will have the effect of promoting collaboration with doctors in the neighbouring countries and of gaining their acceptance of us. The goodwill and mentorship will continue long after the training period is over. Priority Eight on establishing Singapore as the Regional Medical Hub On the last priority of Singapore being the Regional Medical Hub, I have spoken, at length, in this House before. I would not, therefore, repeat myself, except to say that there is a need for both public and private sectors to come together for it to be successful and preferably through integration. Hopefully, there is the will and the tenacity to see to it that we succeed before it is too late. I commend the Minister and his Ministry for the initiative to set the eight priorities for our healthcare needs. I support them and hope to see many positive changes going forward. The Acting Minister for Health (Mr Khaw Boon Wan): Mdm Deputy Speaker, I thank Dr Lily Neo for her strong support and her comments on our health priorities. She has deep knowledge and experience, both as a doctor and as a parliamentarian specialising in healthcare policies. I therefore value her views on this subject.”
“We need immediate action towards assuring people that affordability of hospitalisation presently is ensured with our 3M scheme (Medisave, MediShield and Medifund). Remarkably, many people still do not understand their usage fully and opting for hospital care that they have to pay out from their own pockets substantially. Now with ElderShield and Elderfund added to the list, it may be worthwhile for MOH to rope in the MPs and their grassroots workers to help disseminate the message to their residents and support them with materials to explain the available schemes and how to best use them according to the individual's affordability and on moderating expectations. Priority Seven on safeguarding medical standards The Ministry of Health's seventh priority is on safeguarding medical standards. We must ensure the care of our subsidised patients in the public sector to the extent of having relevant policies enforced to prevent attention being skewed towards looking after paying patients. Public hospital 'A' class beds should be limited to no more than 13%. Our "research culture" was not great and our "clinical research" was never the emphasis. There has to be a complete mindset change and a radical system revamp in the institutions if we are going to make the various aspects of "clinical research" meaningful. Doctors in the public sector have expressed disappointment in the high rejection rates on research projects and the lack of grants for what they proposed. Research activities on the worldwide prevalent diseases should be expanded expeditiously. Research on prevention, early diagnosis and drug therapy to combat coronary heart diseases is an example. In order for Singapore to remain competitive, we need to pay attention to training of our future healthcare providers.”
“Of course, the premise that our Public Primary Healthcare Outpatient Clinics would be developed further to take on a bigger role to ease the SOC overload must be seen to. There is growing evidence that much of the demand in medical care could be generated by the providers themselves. This supply-induced demand is due to the fact that patients usually cannot exercise their sovereignty in getting the appropriate amount and level of medical care. Therefore, a review should be done to remove policy that encourages such practices, especially on the remuneration of personnel that favour such practices. A further effective watchdog body or systems of checks and balances can reduce on such unnecessary spending. This will also safeguard the medical standard. Priority Six to ensure long-term healthcare financing with our 3M (Medisave, MediShield, Medifund) framework On the sixth priority to ensure long-term healthcare financing with our 3M framework, this is the time to enhance our 3M financing with our present and future circumstances. Due to the globalised market and the fluid labour market, especially during an economic downturn, employers' offered insurance may be diminished or cut. The present Medisave system, where we save and pay as we go financing for healthcare, is becoming increasingly inadequate to serve our needs. Risk pooling through a good health insurance expansion, with nationwide coverage to involve the entire population, dependable coverage year after year and adequate benefits with stable premiums together with a combination of co-payment and strict enforcement of uniform fee schedules should have a bigger role. There is also a need to allay the concerns of many, especially the elderly, on the affordability of the hospitalisation bills should they fall sick.”
“Prudent prescriptions to ensure that only what the patients require are given and on the use of generic drugs require more emphasis. While central bulk buying adopted by the two clusters has achieved cost savings, further reduction can be gained through better sourcing of products and more vigilant on other best practices. Capital expense needs reviewing especially in an economic downturn. Better postulation of our present and future needs is necessary to avoid ending up with unjustifiably overbuilt facilities requiring tremendous cost. Newer medical technology can contribute towards efficient usage of hospitals by allowing for more day surgeries and obviating otherwise expensive hospitalisation. Technology acquisition is closely linked with manpower considerations and doctors are a major factor in the demand for and the use of technology. Thus, more specific training of physicians to use high-tech devices should be encouraged. The cost of in-patient care accounts for a greater share of total healthcare expenditure. Therefore, the challenge is to provide continuing care of the many diseases and problems of ageing through primary care. The strategy should be on greater emphasis on step-down care and primary care as it is recognised that they are an effective means of reducing healthcare costs. Last year, as many as 3,083,458 attendances at the Specialist Outpatient Clinics (SOC) were recorded at our public hospitals. This may have stemmed from the ease for people to self diagnose and use specialists as first-line medical care. Perhaps, patients were not discharged as readily from the clinics because of the system.”
“It is, indeed, useful to have some systems in place which can continuously monitor, adopt measures, encourage contributions, recognise new ideas of best practices and study from the experiences of others. The Harvard University School of Public Health had a comparative study on the healthcare systems of several countries, Singapore included. It had referred to Singapore in this way: Two countries opted for competition in health financing: United States and Singapore. These two countries expected that competition would drive down prices while providing incentives to improve efficiency and quality. However, evidence suggests the contrary: the USA and Singapore have experienced the highest growth in healthcare expenditures. Madam, whilst cost containment through competition is the desired intention, we are inadvertently having more ill-effects from having our two clusters. The impression of many is that there are duplication and wastage of resources, such as personnel, administrative costs, specialised services and more high-tech equipment. Even institutions within the same cluster seem unable to cooperate in cost saving measures. Let me cite you an example: Hospital X did not own a certain radiology diagnostic machine and had to refer its patients to Hospital Y within the same cluster. It was ludicrous that Hospital X eventually decided on buying its own machine simply because it was charged so highly by Hospital Y. This is certainly not maximisation of resources, especially when the equipment is expensive and gets outdated very quickly. Is this approach ideal for a small country like Singapore with a limited and small pool of medical personnel and other resources? Drug costs are a big expenditure item. There is a proliferation of more and more expensive drugs.”
“Our National Health Expenditure (NHE) increased from $4.4 billion in 1999 to $4.7 billion in 2000. As a percentage of GDP, NHE formed about 3%. Per capita health expenditure rose about 6% from $1,360 in 1999 to $1,439 in 2000. The NHE proportion was borne two thirds by the people and only one third by the Government. NHE for the year 2002 increased to $5.5 billion or 3.5% of GDP. My point is that, with the increasing NHE over the years but without increased Government's share of NHE, the extra burden on the people was great indeed, especially during an economic downturn. The WHO recently ranked the Singapore health system as sixth in the world, in terms of performance. In other words, we seem to be getting relatively excellent value for money in relation to the health status of our population. However, it did not rank Singapore favourably, in terms of equity in financing. This is based on its criteria of estimating the extent of financial burden in healthcare costs that are borne by individual households relative to total public expenditure. Today, I would like to beseech the Government to address this concern of many Singaporeans and find ways to ameliorate their worry with some expedient actions and with further and better planning to soften the future burden. Finding a sustainable way to fund health services and the challenge of cutting costs are key issues in need of urgent attention. Our public sector accounts for a high percentage of our NHE and it must, therefore, focus on cost discipline through eliminating waste and duplication and implementing best practices. We need champions that see to it that it is their mandate to prioritise on cost savings while maintaining good patient care.”
“Even as of now, a person with an undiagnosed highly contagious infection, like SARS, who seeks treatment in one of our public hospitals is likely to expose the disease to about 50 to 250 people in that one hospital alone. This calls for a concerted effort to revamp our hospital set-up to curb the problem. Communication and dissemination of useful information amongst the medical personnel proved to be such an important tool in combating infectious diseases which was almost non-existent before SARS. Many medical facilities in the private sector were in the frontline as they were preferred to hospitals by the patients. Although they were most vulnerable, they were left to fend for themselves with no support. The level of preparedness to combat any infectious disease can only be maintained with the determination to be vigilant and to ensure that all the various resources are in readiness. Our laboratories here deal with many dangerous microbiological organisms that can be disastrous to our community and country if mishaps happen as in the recent case where a researcher was infected at the National Environment Agency (NEA) laboratory. Urgent measures must, no doubt, be taken quickly to prevent a repeat of such occurrences. Having a 'safety culture' as a priority is the cornerstone for us to succeed as a biomedical hub. Stipulated biological safety standards must be in place and regulated. And, very importantly, all our laboratory personnel should be well-informed, well-trained and always mindful of safety standards. Priority Five on managing healthcare inflation The fifth MOH priority on managing healthcare inflation is indeed welcome and I am confident MOH will do this with tenacity and without jeopardising patient care.”
“The need to stay in tertiary institutions and the ancillary costs will lessen. It is vital we aim to have more patients looked after in their homes, anticipate an increasing demand for homecare services and recognise this as an integral part of our healthcare system. Priority Three on exploiting IT maximally and maintaining secure electronic medical records The third priority is still a relatively new concept here. A good electronic data system with comprehensive, well-organised and useful health database providing accessible and high-quality information will be useful, especially if we can link all medical facilities electronically and avoid the problems of medical records transfer. The resultant easy availability of medical information on the patient will enable better continuity of care, avert unnecessary repeats of medical investigations and so on. Connectivity and the use of IT can also be used as a means to tap up-to-date medical resources. Medical informatics will facilitate and provide an integrated and seamless healthcare system from primary to secondary and tertiary levels or to homecare. Telemedicine and video-conferencing will overcome distance boundaries and will provide efficient and seamless transfer of information towards better patient care. Priority Four on plans to counter disease outbreaks Here, our recent SARS experience gave us much insight and ideas to follow on. That episode exemplified our strength. But it also showed up our inadequacies. Our inadequacies in prevention of infectious disease spread in our public hospitals resulted from our complacency in terms of infrastructure and measures in infectious disease control. Improving upon our inadequacies is crucial towards coping with future eventualities.”
“Adequate allocation of funds today and success of preventive measures will save us millions in the future. The Ministry's priority is to continually identify prevalent diseases that need greater attention and to continuously monitor and study the trends for prevention of such diseases. We should have more detailed epidemiological studies of disease patterns and base our medical research and life sciences studies on them to better plan and cushion our long-term healthcare. Appropriate investment in medical research and life sciences directed at our prevalent needs, like finding the cures for the common diseases and cancers that affect most Singaporeans, can help address long-term healthcare affordability. If gene therapy can be found to treat and prevent heart diseases, diabetes and hypertension, the amount of savings will be enormous. Emphasis on the strategy and health promotion on eldercare with innovations and prediction of future trends is increasingly important because the higher life expectancy is associated with increase in the incidence of chronic diseases. The recent improved surgical procedure by our local doctors on reshaping the heart in order to give patients with chronic heart failure a new lease of life for a third of the price of a heart transplant is a good example of this. On managing any disease through the combined efforts of the Government, community and the individual, I would like to suggest that MOH look at our homecare services that are almost non-existent at present. Community volunteers and home-help for families to care for the dependent elderly in their homes through domiciliary, daycare and rehabilitation services and home adaptations will translate into lower costs and more convenience for a happier people.”
“Perhaps, we may reach them with programmes organised through community centres and grassroots organisations. Madam, it is vital to look at the most prevalent diseases in Singapore and tackle them head on when promoting healthy living. The aim should be preventing people from getting such diseases and preventing those already afflicted with such diseases from disabling complications. A good example here would be diabetes which afflicts about one-tenth of the population between the ages of 18 and 69 and one-third of those between 60 and 69, and carries complications like kidney failure, heart diseases, strokes, blindness, just to name a few. Other examples of prevalent conditions are hypertension and high blood cholesterol. As morbidity and mortality from any disease can be dramatically reduced when the disease is treated in its earlier stages, preventive healthcare should be targeted at the entire population, especially to include the younger people. The young may erroneously assume that they are less vulnerable because of their age and therefore have no need for regular checkups. Our Primary Care Partnership Scheme (PCPS) for those who are 65 years and above and have a per capita income of $700 per month or less, excludes the care for such chronic diseases like diabetes and hypertension and this should be adjusted. Our PCPS beneficiaries are the vulnerable ones that most crucially call for good treatment and follow-up to prevent the complications that eventually require hospitalisation and incur higher healthcare costs. Priority Two on managing diseases holistically instead of episodically and on maximising overall cost-effectiveness Preventive healthcare must be the hallmark of all issues concerning healthcare affordability.”
“Mdm Deputy Speaker, I support and welcome the eight priorities set out last July by the Ministry of Health to embark on. I would, however, like this House to consider the prerequisites necessary for such aspiring targets to be achieved with the best outcome for Singaporeans. Priority One on building a healthy population or promoting healthy lifestyle in an aggressive and comprehensive way I cannot agree more on this first on the list of priorities as it is better to prevent the occurrence of diseases through healthy living than treating end-stage diseases. Madam, healthy lifestyle will prevent many common diseases, for example, healthy living with eating healthily, exercising regularly and not smoking will prevent diabetes, obesity and lung cancer respectively. For better outcome of healthy lifestyle promotion and a wider coverage of the population, there is a need for much creativity, funding and enthusiasm. Since about 1.9 million or 65% of Singaporeans are working, healthy lifestyle promotion on workers would be a key factor in influencing the health of our people and this can be most effectively administered at the workplace. Essential in workplace health promotion includes having good programmes and guidelines as well as getting the support for them from the various companies. Also, providing adequate support to the administrators or health facilitators and expanding the scope of occupational health and safety to include the promotion of workers' health through healthy living and financial assistance in the form of grants would help jumpstart health promotion programmes, particularly for small workplaces. One group of the population that may be left out of reach from health promotion is the housewives and more should be done to target this group.”
“May I ask the Minister whether our NSmen receive adequate medical attention and rest when they report sick? Are there too many NSmen labelled as malingerers when they report sick? Have there been more mishaps occurring when NSmen are feeling unwell? And have there been surveys and studies done to ascertain the correlation between feeling unwell and accidents during training? RAdm Teo Chee Hean: Sir, I am not aware that we have done any correlation studies between feeling unwell and accidents during training. But the basic philosophy which the SAF doctors practise, and this is something which is a requirement for them as doctors, is to treat those who come to see them, first, as patients, then as soldiers. So this is the priority and the attention which they give to those SAF personnel who come to see them.”
“May I ask the Minister on the number of deaths of our National Servicemen in the last three years? Does he have a breakdown on the causes of such deaths? How many of them were due to irregularities, mishaps and sickness? RAdm Teo Chee Hean: Sir, in the last three years, ie, from 2001 until September 2003, the Army has had a total of six training-related deaths, including the three that occurred this year: three this year, two in 2002, and one in 2001. There are various reasons for these. In the last 10 years since 1993, there were a total of 24 training-related deaths in the Army. There were a number of reasons. Some of the men were struck by lightning during exercises in the open; some died because of premature explosions of ordnance in the barrel; others had died during physical training, either during exercising or in field training exercises; and none, until this particular incident, had died for this kind of reason.”
“Sir, I would like to conclude that good health insurance expansion encompasses a national coverage involving the entire population with dependable coverage year after year, and stable premiums and benefits. We should, therefore, explore ways to achieve these objectives. I beseech Prime Minister Goh and Deputy Prime Minister Lee to set on this path of embarking on health insurance expansion.”
“According to this report, this attractive vision of a far-sighted and public-spirited regulatory capacity is hard to envisage in the absence of a strong risk-pooling function, which is a necessary one for a wider range of health service functions that we associate with developed health systems, such as rising health expenditure, demographic change and technical innovation. Sir, the role of preventive care and keeping healthy cannot be over emphasised in any healthcare issues. In our health insurance expansion planning therefore some incentives should be incorporated to rally Singaporeans towards keeping fit and healthy. The other issue in health insurance expansion is to also ensure coverage for Singaporeans when they are in dire need, such as when they are without jobs and in between jobs, in view of our present and future trends of unemployment. The two key features of Japanese healthcare financing are: Firstly, universal coverage that is achieved through a multi-tiered insurance system with varying degrees of subsidisation according to the perceived economic vulnerability on the part of the population insured; and Secondly, on the provider payment side, healthcare financing in Japan is characterised by reimbursement according to a nationally uniform fee schedule. It is the combination of universal coverage with strict enforcement of the uniform fee schedule - preventing balance billing, etc - that has been critical in avoiding some of the problems of cost inflation observed in other countries. The Japanese experience thus indicates that the main risks in healthcare insurance, "incomplete coverage of the population and rising costs", may be manageable.”
“Mr Deputy Speaker, Sir, Japan has achieved the lowest infant mortality rate and the highest life expectancy in the world. Long-term observers of the Japanese healthcare system have concluded that Japan achieved these healthcare outcomes at a comparatively small price: "Japan's healthcare system helps to keep its population healthy at an exceptionally low cost. They rate the Japanese system as excellent in cost control and access, and very good in equality." Universal health insurance coverage has been key in bringing about these results. Japan started its health insurance expansion in 1961. Today, Japan's healthcare system has universal health insurance coverage that covers the entire population. The World Health Organisation defines risk pooling as "the practice of bringing several risks together for insurance purposes in order to balance the consequences of the realisation of each individual." Risk pooling is the health system function, whereby collected health revenues are transferred to purchasing organisations. Pooling ensures that the risk related to financing health interventions is borne by all the members of the pool, and not by each contributor individually. Its main purpose is to share the financial risks associated with health interventions, for which there is uncertain need. Risk pooling is required because of the large uncertainty in the magnitude and timing of an individual's healthcare expenditure needs. It implies the redistributive functions from the healthy to the sick, and from the productive to the unproductive stage of the life cycle. The arguments in favour of risk pooling in healthcare reflect equity and efficiency considerations. The World Health Report 2000 puts emphasis on the role of government in terms of "stewardship" of the health sector.”
“This trend is unlikely to ease soon when the economic growth forecast for this year has been slashed to between 0% and 1%. The granting of HDB loans to downgraders is not permissible presently, although the Minister for National Development said earlier that his Ministry would consider on a case-by-case basis for those in great difficulty. I would like to urge for a change in this HDB policy. Those who want to downgrade are being prudent here and should be helped. Mr Deputy Speaker, Sir, I feel that it is now time to relook and revamp another of our "sacred cows". Sir, I mean our Medisave accounts. In our heavily human resource-dependent economy, our economic health has to go hand in hand with good health of our people. The present Medisave system, where we save and pay as we go, financing for healthcare, is becoming less adequate to serve our needs, especially when our society is fast aging and people are living longer. By retirement age, healthcare costs are expected to be higher. Medisave has a low rate of return within the CPF mechanism and has inadequate real growth to be sufficiently available when needed in old age. We need to make drastic changes here and now for a better tomorrow. Risk pooling in health care finance is a good consideration. Currently, we have individual medical savings accounts (Medisave) with no risk pooling, and a national catastrophic illness insurance scheme (MediShield) which covers prolonged and expensive treatment which does pool risks but minimally. In addition, there is a complex system of co-payments and deductibles, which involves direct out-of-pocket private payments. It is timely to convert savings in the Medisave into more risk pooling insurance schemes with co-payments.”
“It is timely for us to look at the following issues as examples where we should adjust according to our present needs in addition to what had been announced earlier today by the Minister for National Development. Young couples should be able to have the choice of rental flats rather than buying new flats. Less commitment in the early days of joining the workforce means greater flexibility in the ability to adapt to the working environment, which can be very fluid in these times of a globalised economy. They are also less bound by commitments and, therefore, are able to take more risks, should they want to venture out on their own. This augurs well, especially amongst our young, for our strive towards being a more entrepreneurial nation. It has been argued that HDB rental flats are very heavily subsidised, and are meant only for those who are in dire need. Those in difficulty should continue to be subsidised heavily through means testing. Flats catering to the needs of young families should be made available for rental, so that they have that choice of renting HDB flats until such time when they are more sure-footed with their commitments. Presently, there are only about 60,000 rental flats available, and there is a long waiting period for an allocation. It would be good if more HDB flats are built to cater to the rental needs of young couples. Moreover, the choice of starting a family should be encouraged, and this priority for young couples should be assisted. Some Singaporeans may have to downgrade now because they are unable to meet the monthly instalments resulting from a reduction in CPF, pay cuts or uncertainty of job prospects. More than 5,000 families moved to smaller flats in 2002, a 23% jump from 2001.”
“Mr Deputy Speaker, Sir, I would like this House to revisit the policy set out in 1994 on "asset worth" and "asset enhancement" with regard to "encouragement of home ownership for Singaporeans". At that time, the emphasis was on enhancing the assets of Singaporeans, increasing their commitment as Singaporeans and seeking their support for the political, economic and social systems which make owning these assets possible. Today, however, it would seem that Singaporeans will support policies on the basis of security of their jobs and on whether the Government that they have voted for will give them peace of mind concerning their present and future livelihood, not on whether they can own their homes quickly or whether they can upgrade to bigger homes. Today, 92% of Singaporeans already own their HDB flats, and Singapore is tops in the world in terms of home ownership percentage. In the early 1990s, Singapore's growth rates were often more than 9%. This phenomenon has passed and the expected growth rates for Singapore will be much lower in the years to come. It would therefore seem that the 1994 policy needs to be moderated, especially for young couples. Notwithstanding DPM Lee's announcement last week that encouraging home ownership remains a fundamental objective of the Government's Public Housing Policy and a key purpose of the CPF, I feel that retuning this policy will be timely under our present circumstances. I am suggesting that Singaporeans give up this dream of ownership mentioned earlier by the Acting Minister for Manpower, but I am saying that there is no hurry.”
“It is rental flats per se. If you do not need to invest in HDB property, then you can provide more rental flats. It is related.”
“May I ask the Minister whether he will consider moderating our HDB home ownership as an enhancement policy due to our present changed circumstances that Singaporeans are facing?”
“May I ask the Minister whether he would also consider renting flats to those young couples who may not want to commit to buy new flats when they get married due to the trend of unemployment and the prospects of the present job market?”
“May I ask the Minister of State whether the Ministry had investigated every suicide case of our students in the past, so that more precautionary measures can be taken to prevent loss of lives?”
“May I ask the Minister of State whether we have any schemes in place to detect early suicidal cases in students who suffer from a lot of stress in our schools.”
“Could I ask the Minister whether his Ministry could ensure that the CCA does not increase more stress to our students as the present load is already very high?”
“May I ask the Minister of State whether these various schemes are well publicised and targeted at those who may benefit most, and whether he would consider promoting these schemes further to increase their take-up rate so that we can help more SMEs?”
“May I ask the Minister of State whether his Ministry has been stringent in approving applications under the various schemes, such as LETAS, LEFS and MLP? What are the approval rates for such schemes? Is there too much red tape associated with these schemes? Am I correct to say that LETAS application is cumbersome, requiring a lot of information and difficult ones, such as the impact of the project on the company's future operations and business?”
“May I ask the Minister of State whether reducing the quantum for LETAS in fact runs counter to the bigger picture of the need to revive our economy and to increase entrepreneurship? Should there not be priority given to assist local businesses, with concerted efforts by various Ministries, rather than cutting back?”
“Could I have the Minister's clarification again that Tan Tock Seng Hospital's medical staff are not meant to be the contact of the disease under section 21A(1), because it says anybody that has "contact of a disease". This is because, if we follow it closely, then Tan Tock Seng Hospital staff are in the definition. Could I have a clarification?”
“Could I seek clarification on the statement made by Dr Balaji earlier on public hospital doctors who have recovered from SARS taking throat swabs for patients suffering from SARS? May I ask the Minister whether we may have the same disease pattern, as reported in Hong Kong, that they had been resistant cases to previous treatment in Hong Kong suggesting maybe a new mutated virus? Do we have the same problem in Singapore and should we be cautious, rather than presuming that all our recovered healthcare workers are now immune with antibodies to the same virus? Before we go to the Third Reading, could the Minister just clarify on section 21A(1) and (2) on the word "contact" and the other one on "having the care"?”
“Furthermore, how do these persons carry out this requirement if that is against the wish of their care? I hope the Minister could enlighten me on these points.”
“We have to ensure that those who are jailed do not endanger the health of other inmates. Sir, nobody should be deprived of medical care. Therefore, should they fall sick, will they be transferred to Tan Tock Seng Hospital? Is Tan Tock Seng Hospital going to be made secure to treat them? Sir, the successful control of SARS must be coupled with the avoidance of import of new cases. I raised the need to have the rights of implementation of compulsory statutory declaration for travellers during the Second Reading of the Infectious Diseases (Amendment) Bill last month. I had asked whether we could implement a clause on entry declaration for travellers by way of subsidiary legislation as it had not been provided in the Infectious Diseases Act. The case of the British manager who had disappeared, despite being issued with the quarantine order in Indonesia, will be an example of the importance of such a compulsory entry declaration. On the legal sanctions in false declaration of the forms, the penalty must be backed up by law. Of course, the form must be clear and unambiguous. Will the Minister consider introducing this measure? Sir, new section 21A(2) of the Bill is rather vague on the use of the phrase "person having the care". It reads, and I quote: "A person having the care of another person whom he knows or has reason to suspect is a case or carrier or contact of a disease set out in the Fifth Schedule shall not cause or permit that person to expose other persons to the risk of infection by that person's presence or conduct in any such place." May I ask the Minister to clarify if such a person comprises the family members, domestic maids, teachers, childcare personnel and all the medical professionals, such as sinsehs, nurses and doctors?”
“Some of the quarantine cases may need urgent medical attention for other conditions such as gastritis, severe arthritis pain or even delivery of their babies. Which hospital do we advise these patients to go to? Sir, I would like to reiterate that many are fearful of going to Tan Tock Seng Hospital thinking that they may get infected there instead of getting better. We need to allay people's fear of Tan Tock Seng Hospital, and the Ministry of Health needs to step up education in this respect. Indeed, we need to also increase education on various aspects of SARS, reaching out to as many Singaporeans as possible. This is the hallmark of our success in our battle against SARS as many people may still be ignorant about SARS leading to unnecessary behaviour or paranoia. It is important to get knowledge about the disease, such as how it is spread and how to detect its early stages and how to seek early treatment for a better chance of recovery and so on, to everyone. We can reduce people's fear if they know how to protect themselves and their family members more rationally and effectively. The "crisis of fear" that Prime Minister alluded to would be lessened. Sir, in view of the infectivity of SARS, any legal sanction may be ineffective as long as the actual physical movement of the quarantined individual is not rigorously curtailed. It will be poor consolation that we are able to impose a fine or even a jail sentence at some later stage. Will the Minister, therefore, consider tagging all quarantined individuals for better compliance and better monitoring to ensure success? For those who would be jailed, it has been announced that a section of the Selarang Park Drug Rehabilitation Centre is being prepared for this purpose.”
“The successful implementation of Home Quarantine Orders is important to regain the confidence of the people and let them revert to normalcy knowing their chances of getting SARS from the community is low. This will certainly give our economy a big boost and, in time, will also bring back the tourists and foreign businesses. Sir, having said that, I welcome stricter enforcement of Home Quarantine Orders. But I would like to stress that we must ensure that undue hardship should not befall those under quarantine. We need to help them tide through the ill-effects of being quarantined. For example, their daily delivery of food or their need for any urgent errands could be facilitated. We must remember that some families may not have family members or friends to assist them. May I ask the Minister whether there are agencies that can look into these basic needs of these households? Although those under quarantine can claim $70 a day, what considerations are we planning for those who suffer substantial direct losses, such as those from the Pasir Panjang Wholesale Centre who lost their perishable goods? Sir, in spite of the Minister for Health's announcement that financial assistance will be provided so that they can maintain their families and workers, and the announcement by the Deputy Prime Minister yesterday that they will be compensated for the loss of their goods, can we ensure that Home Quarantine Orders do not cause any bankruptcy or loss of livelihood for those quarantined? The people under quarantine must be better equipped with knowledge on how to protect their family members and relatives from infection and on the sort of help (like availability of the free ambulances) they can get if they should fall sick themselves.”
“Mr Speaker, Sir, I stand to speak in support of the Infections Diseases (Amendment No. 2) Bill. Severe Acute Respiratory Syndrome (or SARS) has swept over us like a hurricane leaving a trail of damage, uprooting us and having us still finding our own feet. After decades of bliss without perilous diseases and just when we are finding delight with our medical and technological advancements, our globe is suddenly seized by a new microbe having a field day disrupting our lives. SARS is of grave concern to us as there is no treatment for it right now and there is no vaccine against it. Many people can be affected by just one afflicted person causing a ceaseless chain of reactions if left unabated. The only weapon we can have is to try and contain it. We need to stop the spread of SARS urgently and quickly before it gets out of hand. The failure in this will not only cause loss of many lives and turmoil amongst our people but also serious repercussions on our economic and social structures. This fight against SARS involves the cooperation of the whole community in being civic-minded and courageous. The involvement of the community as stakeholders who are vulnerable cannot be over-emphasised. Sir, although I feel that the majority of Singaporeans are responsible, sensible and law-abiding citizens, this Bill to address the misdemeanor of some black sheep is necessary and very timely. This time, a few black sheep can cost us our battle against SARS. We really have no choice but to have strict enforcement of punishment upon SARS quarantine breakers for the containment of the disease and the protection of the community at large. Mr Speaker, Sir, we have to win this war at all costs for our survival as a nation.”
“Could I seek clarifications, Sir? The Minister for Health earlier mentioned that we have had this epidemiological study group all this while. May I ask him what kind of study results have been obtained so far and could he share that with us? The Minister for Health also said earlier that all the medical staff in our public hospitals are protected with face masks. Could I ask him whether face masks are sufficient? Or should they don space suit outfits as well? Is the conjunctiva of the eyes not an entry route for viruses? Could I also ask him whether Tan Tock Seng Hospital could share their good practices with other hospitals? The Minister for Health also said earlier that anti-viral drugs are being used by our doctors in our public hospitals. Can I ask him whether it is correct to say that there is no medicine that can combat SARS coronavirus? Why then are our doctors using the available anti-viral drugs now that they have many side effects? The Minister also did not answer my earlier question on public directives for better containment and contact tracing of SARS. The Deputy Prime Minister said earlier that those under quarantine can claim $70 a day. But it has also been mentioned that they can claim $70 from the Courage Fund. Does it mean that now they can claim $140 a day?”
“I would like to ask the Minister for Health whether he would consider public measures for the better containment and tracing of SARS cases by giving more public directives, eg, answering questionnaires and temperature taking for public gatherings in confined places. May I ask him what kind of treatment has been given in our public hospitals for SARS patients? Have we had cases where they were less responsive to previous treatment, suggesting maybe a more virulent or mutated virus? May I also ask him how near is Singapore in the development of a quick and reliable testing kit for SARS? Could I also ask the Minister whether it is true that Ward 55 and Ward 68 in NUH had probable and suspect cases of SARS yesterday, with a plan of removing them en bloc to Tan Tock Seng Hospital but was aborted in the evening? Could he clarify this? Mr Loh Meng See (Jalan Besar): Sir, I think one of the concerns of the members of the public is the survivability if the person were to be suspected of SARS. The concern is the number of deaths and mortality rate. One way of addressing it is that many get out of it but, on the other hand, a number have succumbed to it. I wonder if we have learnt from the lessons of those who have passed away. Is there a better way of treating and taking care of these patients so that we can enhance the rate of survival of our patients?”
“Thank you, Mr Tan Soo Khoon, for doing it for all of us.”
“Is the welfare of our medical staff well taken care of? Are our public hospitals coping with the delivery of services to our patients? Are our public hospitals in crisis? May I also ask the Deputy Prime Minister and Minister for Finance whether our Government is prioritising our healthcare urgently and sufficiently, and also through more funding? Are the public hospitals given more funds to fight SARS? And would the Deputy Prime Minister consider waiving hospital charges for patients seeking treatment for SARS?”
“May I ask the Minister for Health whether the outbreak in SGH in the first week of April could have been averted? Could we not have prevented the in-patient in SGH spreading SARS to so many patients, causing a huge chain reaction, especially knowing that the patient had just been discharged from Tan Tock Seng Hospital and that SARS had been around for about two weeks at that time? Why were more stringent or precautionary measures not taken by SGH? May I ask the Minister for Health how widespread is SARS infection now? Is he having difficulty in ringfencing SARS presently? May I ask how are we coping in contact tracing of probable SARS? Why was the first case of SARS from Pasir Panjang Wholesale Centre not quarantined when, in fact, his brother died from SARS? May I ask the Minister for Health whether it is right and prudent that we should follow WHO's guidelines on SARS? The reason I am asking this is because the Ministry of Health has been quoting that it is following WHO's guidelines. Sir, are we not fighting a new entity with no precedent incident? Is Singapore not one of the countries quite affected with about 189 cases today? Should we not set our own guidelines for better containment? Should we not err on the side of caution? May I also ask the Minister for Health whether his Ministry would urgently put up an epidemiological study group to go through quickly the SARS case notes we have so far, in order to map out the disease pattern so that we can control SARS better? May I also ask him whether our healthcare workers in our public hospitals are adequately protected? Are doctors and nurses over-stretched, especially in wards with quarantined personnel? Is the past shortage of junior doctors now becoming critical?”
“Could the Minister comment whether the patients under the unethical medical research suffered any side effects or long-term effects as a result of unacceptable withdrawal of their long-term medication?”
“I just want to seek clarification, Sir. Should we think that we need to implement self-declaration by travellers later on, can we implement the clause of the entry declaration by way of subsidiary legislation? Could I also ask whether our public is getting sufficient advice and guidance presently with regard to SARS?”
“Moreover, we may not be aware of the long-term side-effects of certain vaccines. Even if this order is implemented, we have to be mindful that it is not a blanket order without exception, as it may kill people, such as the frail-elderly, the infants and those with immune deficiencies. Sir, section 29 of the Infectious Diseases Act seems to empower the Director-General or Port Health Office to obtain information to ascertain the health of the persons on board. But there is no provision for the "Entry Declaration" for travellers coming into Singapore. Sir, it was reported in the Straits Times today by Salma Kahlik that the three Singaporean women, who brought SARS here, had been traced to a Hongkong hotel. They were all staying on the same floor as the doctor who has since died. In view of this current outbreak of SARS, and the fact that SARS is highly contagious and potentially deadly, should we not make sure that there is provision in this Bill to provide implementation of urgent measure on the containment of this illness? Sir, it may be prudent that we take steps to ensure that travellers do not enter Singapore without declaring that they are free of such disease and/or not in contact with person who had contracted such disease. May I ask therefore whether we can implement a clause of "Entry Declaration" for travellers by way of subsidiary legislation? Sir, I hope that the Minister of State can address my concerns.”
“Sir, only 10 days ago, on 12th March, the World Health Organisation issued a global alert about the outbreak of SARS. As of today, there are 34 Singaporeans with SARS. Other than the initial three cases, there are an additional 31 patients who had been admitted to hospital. All these have been in close contact with the patients of SARS. My question to the Minister of State is which Ministry is taking on the responsibilities of the urgent situation of SARS now, since the transfer of responsibility from NEA to MOH is scheduled to be effective only from 1st April. We need to have one Ministry taking the lead responsibility and seeing through the whole process. Otherwise, this transitional stage will be detrimental to our well-being. Could the Minister of State enlighten us on what has been done by the Ministry of Health and what role had been played by the National Environment Agency (NEA) with regard to SARS? Sir, clause 13 amends section 32 to transfer the responsibility for the cleansing, disinfection and treatment of infected vessels, vehicles and personal effects to the Director and Health Officers authorised by the Director. May I ask the Minister of State how the Ministry of Health is preparing to take over this responsibility as this will be completely new for MOH? Are there personnel that can assume this role in MOH? Is MOH setting up a new department to take over this role? Sir, clause 20 of this Bill empowers the Minister to order mandatory vaccination of persons in certain cases. May I seek the assurance from the Minister of State that this order will not be taken lightly until it is proven to be absolutely necessary? This is due to the fact that vaccines are not without side-effects themselves. At times, they can do more harm than good in some people.”
“Mr Speaker, Sir, I stand to speak in support of the Infectious Diseases (Amendment) Bill. The amendment in this Bill that enables the for the prevention and control of all communicable diseases, such as prevention and control of outbreaks, notifications, surveillance and investigations, from the National Environment Agency (NEA) to Ministry of Health (MOH) is appropriate, and I welcome it. Sir, the Ministry of Health is most suited to assume this responsibility of prevention and control of all communicable diseases. The Ministry of Health is in a better position to understand the different types of communicable diseases and is able to monitor the diseases better because those affected are usually under its care. Furthermore, the Ministry of Health has the support of personnel and laboratories to better investigate any diseases, is in a better position to inform and notify diseases more effectively, and is able to involve all the doctors in Singapore in the surveillance of any outbreak. This Bill is relevant indeed in view of the new infectious disease named Severe Acute Respiratory Syndrome (SARS) that is threatening us presently. The amendment in new section 2(c) of this Bill enlarges the definition of "infectious disease" to include certain diseases not specified in the First Schedule, but if left uninvestigated or unchecked, would result in an epidemic of that disease. SARS definitely falls into this ambit as it is not listed in the First Schedule, although it is a highly contagious and dangerous disease. Bio-terrorism is also the concern of the day. A good example would be the recent Anthrax scare. Anthrax is another example of a highly dangerous infectious disease that is not in the First Schedule.”
“Sir, there is a saying with regard to growing old gracefully - use it or lose it. Yes, use your brains, spread your experience and wisdom or you stand to lose them. Keep up the physical activity or you may lose your muscle and strength. As we are one of the fastest ageing societies, the best approach for us to adopt is to ensure that all our elderly, especially our retired, are encouraged to be active physically, mentally and socially in order to maintain good health. This will not only prevent many illnesses but will also result in happier people. Prevention of illnesses and keeping the mind active and healthy should be prioritised. Depression which is more prevalent in the elderly can be prevented by getting the elderly more engaged socially and involving them with new hobbies and purposes in life. We need to do more and facilitate better in achieving total holistic care for the well-being of our elderly. And this should be done island-wide, not just through the Ministry but also through voluntary organisations, grassroots organisations and charitable organisations. Of course, the Ministry of Community Development and Sports should facilitate these organisations in setting up care centres that aim to do this. I believe that the Ministry of Community Development and Sports started care centres a few years ago with the above views in mind, and catering not only for the elderly but also for the children. May I ask what progress has been achieved so far and will this project be further expanded?”