Lim Hng Kiang
Singapore
“The company has made commitments to recycle the ash, and as for renewable energy, the gasification project is not an energy project, it is not a generation company (genco). It is to produce hydrogen and carbon monoxide or, essentially, carbon. Because as feedstock to the petrochemical sector, you need more C and more H2.”
“The Government will continue to recover the IIA awarded if the company fails any conditions or breaches the legislative amendments. I would like to highlight that there are no errant cases in the last five years for IIA and the current amendments are, therefore, not reactionary in nature, but are being made for legislative clarity.”
“In addition, the IIA scheme will be extended till 31 December 2022. Clauses 10 to 13 give legislative effect to this change. The remaining legislative changes arising from our periodic review of the income tax system are either administrative or technical in nature.”
“Data on household and individual savings rates by income groups are not available. However, data on the aggregate level of household financial assets can be obtained from the Household Sector balance sheet compiled by the Department of Statistics.”
“The aggregate level of financial assets owned by Singapore’s household sector6 in each of the past five years is provided in Table 1 below. Data on the amount of financial assets owned by households and individuals in the different income percentiles is not available.”
“The Second Review of the Comprehensive Economic Cooperation Agreement (Second CECA Review) is ongoing. The review is taking some time as both countries have our respective interests to work through, such as in the area of labour mobility. Our agencies regularly engage Indian counterparts to work through issues collaboratively.”
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Every one of 2,677 lines we hold for Lim Hng Kiang, in date order, each linked to its source. Free to read, in full, without an account. Page 27 of 54.
“Let me congratulate the Member for displaying a tremendous knowledge of the system. First of all, although Singapore may be the first country to adopt this system as a whole, because we are a small country, it is therefore easy for us to implement. But in many countries, this system is implemented by a group of banks or within a state. He is partially right that we are the first country to adopt this system nationally. But this technology and practice is fairly widespread between groups of banks or within states. As I mentioned in my speech, countries like the UK or US are already progressing to make this a national system. I agree with him that security is of paramount importance to the Cheque Truncation System. I can assure Members here that much effort has been put in to ensure that the infrastructure is fully trusted and secured. The cheque images that are captured at the point of deposit are sealed and encrypted before they are transmitted, and therefore they are tamper-proof. The presenting bank will also take the responsibility to ensure that the scanned cheque images are of sufficiently good quality for the paying bank to rely on for cheque verification. The whole idea of this system is that we are handling more than 80-90 million cheques and we need very good technology for the images for verification and automation. But, at the same time, we must make sure that the customers have confidence in the system and, to do so, the system that the banks have put together has to comply with international standards of security and of encryption. The signature matching is done by matching the images and the specimen signature. Human intervention is avoided unless there is a controversy.”
“The Attorney-General's Chambers have advised that it is not appropriate to release patient information to the public. As these questions pertain to specific information in a patient's personal and confidential medical records, it would not be appropriate to provide detailed replies to all the questions as we do not have the consent of the patient or the next-of-kin. The following reply provides general information about the necessity of performing dental extractions for patients who are scheduled to undergo liver transplants. In any event, Ms Raja was a patient of the National University Hospital, not the Ministry of Health. The NUH is a restructured hospital and is independently managed. MOH does not have access to NUH records except as a regulator. Prior to liver transplantation, it is good clinical practice to treat or remove infected teeth, as these may become potential sources of infection in the patient after the transplant procedure. However, this is not an essential medical requirement, and, as was the case for Ms Raja, would not delay transplantation should a suitable liver become available before the affected teeth are treated. It is a standard practice for the dental extraction to be carried out under local anaesthesia. $388 MILLION COMPENSATION TO SINGTEL 11. Mr Steve Chia Kiah Hong asked the Acting Minister for Information, Communications and the Arts why his Ministry did not carry out a simple check with the Inland Revenue Authority of Singapore regarding the tax of S$388 million before paying out the compensation to SingTel and who is going to be responsible for the loss to the Government.”
“The Government provides 50% subsidy for adult patients and 75% subsidy for child and elderly patients who seek medical treatments at polyclinics. In dollar terms, an adult would receive $10 subsidy per attendance for acute illness and $36 subsidy per attendance for chronic illness. For child and elderly patients, the Government's subsidy is higher, at $15.50 per attendance for acute illness and $54 per attendance for chronic illness. General practitioners (GPs) contracted under the Primary Care Partnership Scheme (PCPS) are subsidised on the same basis as elderly attendance at the polyclinics to cover their operating costs, rental and GST. GPs are paid $18.50 for each elderly patient that they see. PCPS covers common outpatient medical services and dental services. It does not cover chronic conditions such as hypertension. This is because proper management of chronic conditions requires a multi-disciplinary team of healthcare professionals to achieve good treatment outcomes. Polyclinics are in a better position to provide such comprehensive care. MISS RAJA'S DENTAL TREATMENT 10. Mr Steve Chia Kiah Hong asked the Minister for Health (a) whether the removal of Miss Raja's decayed tooth was necessary before she could go for a liver transplant operation; (b) if so, could the decayed tooth be extracted under anaesthesia; (c) how and when was the information that the decayed tooth could be extracted under anaesthesia communicated to her and her family; and (d) as her condition was already critical and she had finally decided to go for the extraction, why was she made to wait for another two days for it.”
“Steam autoclaving is recommended by the Ministry's Advisory Committee on Infection Control as a method for sterilisation of all heat-stable surgical instruments. Dry heat using a hot-air oven is only recommended for materials that might be damaged by moist heat. Examples of such materials include powder and fine instruments used for microsurgery. Dry heat sterilisation process is more difficult to control and monitor because of the following: (i) the long duration of time taken to reach recommended temperatures to achieve optimum sterilisation (time taken may vary from 1/2 hour to 1 hour depending on the make of the hot air oven); (ii) uneven distribution of heat, and therefore proper sterility cannot be assured unless other monitoring devices, such as biological indicators, are used to show that sterility has been achieved. The Ministry's primary concern is patient safety and infection control. Health care institutions should use the recommended method to sterilise reusable heat stable instruments. Alternatively, they could use sterile disposable instruments. SUBSIDY AT POLYCLINICS 7. Dr Ong Seh Hong asked the Minister for Health what is the Government's subsidy per attendance at polyclinics for (i) acute illnesses and (ii) chronic illnesses. 8. Dr Ong Seh Hong asked the Minister for Health what is the amount of his Ministry's payment to general practitioners under the Primary Healthcare Partnership Scheme as compared to the subsidy given to the polyclinics. 9. Dr Ong Seh Hong asked the Minister for Health whether the Primary Healthcare Partnership Scheme covers chronic illnesses such as hypertension, and if not, why not.”
“For trucks carrying sand, marine clay and incineration ash, due to the nature of these materials, the fine and soft materials leak continuously from the gap between the tailgate and the body of the trucks carrying them. As a result, it contaminates the roads, dirties the cars, generates dust and pollutes the air. Sir, all the above problems are partly due to the inadequate design of the waste transportation vehicles, and partly due to the negligence of the drivers. What are the measures taken by the Ministry to ensure that all waste carrying vehicles have adequate designs? Is there any action to deter people from committing such irresponsible acts?”
“Sir, our time-frame is to put up the consultation paper sometime at the end of the year and then, depending on how the public response progresses, we hope to come to Parliament probably early next year. ESTIMATES OF EXPENDITURE FOR THE FINANCIAL YEAR 1ST APRIL, 2002 TO 31ST MARCH, 2003 (Paper Cmd. 3 of 2002) Order read for consideration in Committee of Supply (7th Allotted Day). [Mr Speaker in the Chair] Head L (cont.) - Resumption of Debate on Question [21st May, 2002], "That the total sum to be allocated for Head L for the Main Estimates be reduced by $100." - [Dr Teo Ho Pin]. Question again proposed. 12.38 pm Assoc. Prof. Low Seow Chay (Chua Chu Kang): Sir, it is not uncommon to see refuse vehicles carrying wastes leak sullage water on the roads. They cause nuisance to road users and residents. It also pollutes the environment. Some popular spots I notice of the leak of sullage water from garbage trucks are the uphill road in Hillview Estate, the junction where vehicles turn from Chua Chu Kang Drive into Chua Chu Kang Avenue 3, and the junction, turning from Toh Tuck Road into Commonwealth Avenue West. Under the sun, the sullage water emits a strong and unbearable pungent smell that affects the people living near the contaminated roads, and also the roadusers. Such dirty and smelly sullage water from the garbage trucks is unhygienic and could be a health hazard. Sullage water must not leak from garbage trucks. I would like to ask the Minister whether his Ministry has any rules to prevent leakage of sullage water from garbage trucks. Last month, large amounts of construction debris dropped from an overloaded lorry, causing two out of three lanes of the PIE unusable. Luckily, it happened during an off-peak period; otherwise, it would have caused serious traffic jams.”
“I agree with the hon. Member that there are many issues involved, and that is why we are taking a more cautious approach before expanding the scope of organ transplants. As I mentioned earlier, before we allow a living unrelated transplant, we require that the donor's motive must be purely altruistic, and that the donor must be reviewed by an independent psychiatrist, and not just a medical report that he is medically fit. So, we do have these safeguards in place for living unrelated donor. We are also concerned about emotional coercion and that there could be a risk of financial inducements leading to organ trading. We could put in a clause - as we have in HOTA - to say that organ trading is illegal, but then we have to enforce it. There are many issues involved and, as I have said, we are putting up some proposals. We will do a fairly comprehensive public consultation, and we will then come back to the House later with our final proposals.”
“Mr Speaker, Sir, as I have explained, today our two Acts, MTERA and the HOTA, cover only cadaveric organ transplants. All other transplants, particularly for related organ transplants, we have regulated these through professional guidelines under the Private Hospitals and Medical Clinics Act. Last year, we said that we were prepared to look at unrelated living organ transplants. As I also said in my reply, we are looking at the Human Organ Transplant Act, and we will be conducting consultations sometime towards the end of the year to gauge public reaction to our proposals to expand the Act. Right now, the main thing we want to expand the Act is, first, to cover from accidental death to non-accidental death. The second thing we want to put forward to the public to consider is to expand the scope of HOTA, to expand from just kidney to also include liver, and maybe even cornea. This is something that we want to propose and gauge public response. And, third, to be able to move from cadaveric transplants to living transplants. All these are being considered, and the best way forward, because the Ministry does not want to be too far ahead of community reactions to such changes, we will put these proposals up for consultation. We will then make the necessary legislative amendments after that.”
“They would only be allowed under exceptional circumstances if they meet the following conditions: (i) the medical condition must be urgent; (ii) all options for organ donation by a living relative of the patient have been explored and found to be not possible; (iii) the donor's motive must be purely altruistic, as established through a review by an independent psychiatrist and a medical social worker, and stated by the donor in a statutory declaration; and (iv) the risks and the possible outcomes of the operation must be fully explained to, and accepted by, the donor and the recipient. Another, and better, option to increase the availability of organs for transplantation is to raise the number of cadaveric organs. To achieve this aim, my Ministry is considering amending the Human Organ Transplant Act, such as including non-accidental deaths under the Act.”
“Mr Speaker, Sir, the current laws governing organ donation are the Medical (Therapy, Education and Research) Act (MTERA) and the Human Organ Transplant Act (HOTA). MTERA provides for an opt-in system for organ donations, whereas HOTA provides for a presumed consent system covering only kidneys from accidental deaths. Both laws are narrowly defined and refer only to cadaveric donations. My Ministry regulates living donor organ transplantation through professional guidelines. The existing guidelines allow living donors who are related. Last year, MOH announced that it was prepared to consider living unrelated organ transplants. We have examined the regulations and practices of other countries that allow living unrelated organ donations and have worked out a set of ethical guidelines. There are legitimate concerns about allowing living unrelated organ transplants. Firstly, there are risks to the donor from the procedure, particularly for organs such as the liver, where the risk of death or medical complications is significant. Secondly, there is a danger that healthy individuals may be offered financial inducements to donate their organs, thus creating the potential for organ trading. MOH is therefore very careful in allowing living unrelated organ transplants.”
“I shall reply to one clarification. All junior doctors work under supervision. So when we bring junior doctors from neighbouring country, the senior doctors also continue to supervise them.”
“I just want to supplement what MOS Balaji has said about case-mix because it is a very important point that Dr Tan Cheng Bock raised. As MOS Balaji said, if the doctors do their job professionally and, say, your appendicitis case, the patient needs to stay in the hospital for 10 days, what happens is that the Ministry will subvent the average of four days under case-mix and the additional six days will be subvented on a per diem basis. So as long as doctors do their job correctly and, say, this patient, in fact, needs to stay 10 days, we will give the patient the subsidy for the average of four days, the statistical method under case-mix, and the additional six days on a per diem basis. So we are not pushing people to be prematurely discharged.”
“Sir, even though we do not recognise or we stop recognising some of these institutions since 1993, they are still allowed to come in under temporary registration. So we are not forgoing these sources. Even if I make a decision, or we get a decision to recognise these institutions, it would be another 5-6 years before people decide that, now that it is recognised, they send their children there and then they come back after graduation. So what I am talking about is a temporary shortage. We have increased the medical intake. When we start taking the 230-250 doctors from our local NUS and we continue to recruit between 50-80 doctors overseas, we will have a complement of about 320-350 doctors, and that is enough for our needs. So there is no need to change the rules of the game. The current shortage is temporary, transitional shortage, and within 2-3 years we should get over the worse of this shortage.”
“Sir, as I mentioned in my response, we are currently facing a shortage because our population expanded since 1993, and our medical intake only expanded since 1996. So, for these 6-9 years, we have a mismatch. But, starting from this year, we will be getting a higher intake of graduates from our medical school, and we are also bringing in more foreign doctors. So that would relieve the situation. I expect the doctor situation to improve over the next five years. But that is not a guarantee. We still have to continuously adjust our working conditions, adjust our remuneration structure, to make sure that our public hospitals are competitive, and that we are able to attract our fair share of doctors. The service levels are not so adversely affected. As I mentioned last year, we engaged a group of operational research consultants to look at the queuing system and the waiting times. We are now finalising the study. If we introduce some of the proposals that the consultants put up, I am confident that we can improve the level of service in our public hospitals.”
“The CEO and the departmental heads, in managing the specialists under them, must make sure that allowing these specialists to look after private patients through the faculty practice, that they do not compromise the level of service to the subsidised patients. The Ministry of Health signs a 3-year contract with our restructured hospitals. We set down very strict conditions of service standards, etc, etc. They have to undertake to meet these service standards. If the CEO and the departmental heads allow their specialists to undertake faculty practice and fail to deliver on these service standards to the subsidised patients, then under the service contract that we have with them they will pay a very heavy price.”
“I regret making that decision because, in the end, the baby continued to be in intensive care and KK Hospital now runs up a total bill of more than $300,000. These are very expensive cases. When a baby is born prematurely, it requires a lot of resources to keep the baby alive. I had a long discussion with my Minister of State, Dr Balaji, and I said, "Is there any way you can tell whether there is brain damage?" Being a neurosurgeon, he said, "There is no way you can tell. It is only after one or two years that you will know whether the whole period of premature birth has resulted in brain damage." So it is a very sad situation, but unfortunately we do have these types of cases of neo-natal babies, premature babies. If the family is unfortunate to have such a case, I sympathise with them. If they want to keep the baby alive, the hospitals want to help, but they must find the resources. And that is the reason why I have decided to include neo-natal coverage within MediShield. It may not be the best decision because, in the end, somebody has to pay for the cost. What we are doing is then sharing the cost among all of us, Singaporeans, and not just on the families that are unfortunate enough to have such a baby. So anyway, from next year onwards, we hope to incorporate neo-natal coverage within MediShield. On the extension of the specialists in the faculty practice, let me again assure Dr Michael Lim that it is not the MOH's policy to ask our specialists in our restructured hospitals to set up clinics in a private hospital or to undertake faculty practice. We leave that decision to the CEO and to the departmental heads.”
“First, on the primary care sector. In the White Paper, the Government is committed to serving 25% of the market. This means the Government undertakes that in the primary care, through our polyclinics, we will service the bottom 25% of the population. Today, we are around there. We think that with the investment that we have put into our polyclinics, we should provide night services. This means, of course, stretching the doctors further and the CEOs in charge of the polyclinics have to go out there and recruit doctors. My Ministry has given them the mission that they should service the bottom 25% of Singaporeans and if that service includes night clinics, then they must provide the night clinics, and if they do not have enough doctors, they jolly well go out there and recruit the doctors and they have the budget to do so. So that is not a problem of resources. The second question is on the deposit. This is a special case of a neo-natal admission. So when KK Hospital receives or evaluates a premature baby, KK Hospital has to make an assessment to take over the baby and to look after the baby for the next few months, and in fact, in one case, they looked after the baby for the next one year. It is going to cost a lot of money, and therefore, the family should pay a deposit commensurate with the severity of the case. It is not to say that all private patients coming to restructured hospitals have to pay a deposit of $20,000 or $60,000. It depends on what case he is coming in for. 5.30 pm I know neo-natal cases are very emotional examples. We had one appeal, probably the same case. KK Hospital admitted the baby, even though they were very reluctant to do so. Because the appeal came to me, we asked KK Hospital to admit.”
“If healthcare cost goes up 6-8%, our economy grows by 4-6%, we maintain our national health expenditure at around 3-4% of GDP, and that is the best solution for affordability of healthcare. If you do not generate the growth, healthcare cost will still go up because Singaporeans will still want good healthcare. Then, we will be in a fix, trying to find the money to pay for healthcare cost. Having maintained the growth and we contain healthcare cost to between 6-8%, then we are still ahead in the game. What we need to do, recognising that healthcare cost will go up, is to prepare for the situation in 10-20 years from now when a higher percentage of our population is aged and we have to spend more on healthcare. This is what the tax changes are all about. What we do in Health is to prepare for that day. This means we introduce ElderShield, we expand MediShield, we build up ElderCare Fund. In case Members need to be reminded, we launched ElderCare Fund less than two years ago, and because of the budget surpluses that we were able to generate, we are able to set aside $1 billion already in ElderCare Fund. We build up all these endowment funds during this period where we are enjoying good growth and these endowment funds will serve us well when we are in a period of lower growth because of a maturing economy.”
“But for the immediate future, we still need to depend on between 20-25% foreigners to fill up the nursing positions in our hospitals. Mr Chairman, I believe I have covered most of the items. Let me just say that for the point on PCPS, I have answered this previously in Parliament, so there is no need to go through it again. Mr Low Thia Khiang also raised about the MOs being overworked. We are reviewing the situation. Today, there is some disparity in the hospitals and also between departments in the hospitals, where some MOs, who are posted to some departments, because of the shortage of junior MOs there, they end up having more than a fair share of their night duties. We have asked the hospitals to review this and rationalise the situation. We are keeping a close watch on this. Let me just end by saying that healthcare cost will continue to go up. I cannot stand here and tell you that we can control healthcare cost to the extent that it will not go up. As Dr Ong Seh Hong summarised, there are so many reasons why healthcare cost goes up, many of these are beyond our control. The more sensible approach is to recognise that if you want a level of healthcare equivalent to what is available in the developed countries, then we must accept the fact that healthcare cost will go up. It will go up by between 4%, 6% or even 8% every year. So far, we have been very fortunate because our economy also grows by 6%, 8% and even 10% in the first seven years in the 1990s. Our national healthcare expenditure is able to maintain at 3% of GDP. If we undertake all the changes put up by DPM Lee in his tax review and we generate the 4-6% growth, that will be the best bet for us to keep up with healthcare costs.”
“On nurses, the situation has also improved a little. We have a 3.3% increase in nurses compared to 2000. Our nurses to population ratio is now 1:300. In the public sector, we have vacancies of about 6.6%. This is a slight improvement from last year's shortfall of 7.5%. We have taken steps to address this shortfall. First, we have increased the total nursing student intake in Nanyang Polytechnic and the ITE by more than 100 places. We have looked at salary reviews, increased the salaries of nurses by an average of 13% in the year 2000, and 6% last year. We have worked out a clinical career path for nurses. Our intention is that we will facilitate around 25% of our nurses in taking up degree courses. Whether the degree course is done locally or overseas is something we have to work with the Ministry of Education. But we have worked out a career path and our intention is that 25% of our nurses should have the opportunity to progress to degree courses. Dr Michael Lim suggests that maybe we can set up overseas training facilities. We have the resources here. Our problem is not training facilities. Our problem is attracting Singaporeans to take up nursing as a career. There is an article in the Today paper. It is a three-part series on nursing. The most striking feature of that article is that some of the students, who take up the courses, drop out when they realise quite early in the course that it is a very, very demanding career. If you do not have the commitment, then many of them do not make it. It is a very challenging and a very demanding career. Our job is to make it attractive and make sure that enough Singaporeans are attracted to nursing to serve Singaporeans.”
“They practise within an institutional framework under close supervision. It is not our intention to diminish the reputation of Singapore as a healthcare centre. But we do need them as a way of building up our supply. Singapore has a very small population and it cannot just depend on Singaporeans to be doctors. At the steady stage, if we can train between 230-250 Singaporeans in our university and we supplement it by an annual recruitment of between 50-80 doctors trained overseas, both Singaporeans and Malaysians, as well as other nationalities, I think it will provide for a fairly robust system. So we are not having a group of doctors that are overly represented by foreign doctors. On the medical intake quotas, there are three sound reasons why there is a quota. First, we still believe that we need to have a finger on the supply of doctors. Second, we have a limited talent pool. We cannot have all our brightest students going to be doctors. And third, the cost of training doctors is very expensive. There are still reasons for us to have a quota. With regard to the one-third quota on female students, unfortunately, the data still shows that more female doctors work part-time than male doctors. You can either look at it as a container being half-full or half-empty, but that is a fact of life. I have said earlier that we are reviewing this quota. In fact, the Economic Review Committee's Services Sub-committee, chaired by Mr Khaw Boon Wan, is studying the medical manpower requirements, including the quota on female medical students, in the light of the overall medical services review to promote the healthcare services industry. I would urge Members to be a little bit more patient and give Mr Khaw Boon Wan a bit more time to complete his study.”
“Compared to December 2000, in December 2001, we had a nett increase of 345 doctors, or 6.2%. Our doctor to population ratio has improved from 1:720 to 1:700 now. If you ask me, the overall doctor situation is all right. If we look around, do we have a shortage of private-sector GPs? I think the answer is no. Many of our private-sector GPs have to compete and are struggling. So there is really no shortage of doctors. We do have a shortage of specialists. Not enough doctors are becoming specialists, and we do have a shortfall of specialists in a few areas, eg, cardiac surgery, radiology and geriatrics. But, by and large, the total number of doctors is sufficient. We do have a shortage of doctors in the public sector. By our norms, we have a shortfall of about 12%. This means that our doctors in the public sector are heavily worked. Instead of working eight or nine hours per day, they have to work 10, 11 or 12 hours. This is obviously not sustainable and we have taken action to try and recruit more and improve the manpower situation. 5.15 pm On a national basis, NUS has increased its intake for medicine starting in 1996 and, therefore, we should start seeing more doctors graduating from this year. The Singapore Medical Council has also exercised greater flexibility in approving temporary registration of foreign-trained doctors. That allows us to bring in a few more foreign-trained doctors. Dr Lily Neo is not very happy with this and she feels that we are bringing in doctors from neighbouring or immediate countries and that would diminish our reputation and lower the standards of care here. Let me assure her that when SMC allows these doctors in on temporary registration, it means that these doctors are strictly supervised. They are not allowed to practise on their own.”
“Dr Michael Lim also queried why the polyclinics have gone into night clinics. The reason why I have allowed the polyclinics to go into night clinics is because I consider that as providing better services for Singaporeans. Unfortunately, it also means a little bit more competition for the private clinics in the area. But all of us should be able to take competition in our stride. We have restructured our public-sector hospitals and polyclinics so that they are more efficient, productive and responsive. I think this is one of the areas contributing to our lower NHE. If we had continued running our polyclinics and hospitals like the old Government departments without subjecting them to competition and without subjecting them to productivity pressures and efficiency pressures, the costs would have been higher. The idea is not for these institutions to maximise profits but, really, to bring costs down and offer a better service to Singaporeans. Last year, we went one step forward to position the public sector, both the Singapore Healthcare Services and the National Healthcare Group, the two clusters, as "Not-for-Profit" entities explicitly. We designate them as not-for-profit organisations so that our two clusters will preserve their sense of public service and have a different organisation culture from the private hospitals. But that does not mean that they do not make surpluses. They must be efficient and, with the private patients, they must charge what the market can bear, and they should make surpluses. They should not be embarrassed by it. But, having made the surpluses, these are not-for-profit organisations, and they will then use these surpluses for research, better services and training of their staff. Let me now turn to the doctor situation.”
“We face several of such cases every year. They deliver the babies, the babies are premature, complications, so the bills mount. One way is to tell the private hospital that since they have accepted the patient, it is their moral responsibility to look after the patient. If they have accepted the patient, if there are complications, they carry on looking after the patient and, if there is a bad debt, it is part of their operating costs. We should not have a situation where the private hospitals encounter such cases and then encourage the patients to go to the public hospitals. Then the public hospitals become the hospital of last resort. The other approach is to cover this under MediShield, and this is what we intend to do. So when we make the changes next year, we will allow MediShield to cover such neo-natal cases. Dr Michael Lim also asked about the role of public healthcare institutions. Let me assure Dr Michael Lim and all Members here that, today, more than 90% of the beds in the public-sector hospitals are subsidised beds. That is our primary role and remains our primary role. However, we do run a small percentage of beds for A-class patients where we treat them as private patients, whether it is Singaporean or foreign patients. In NUH, for example, foreign patients account for less than 5% of the patient-load. When we allow the hospitals to run the Faculty Practice Plan, less than 1% of the specialist manpower in the public sector is involved. When we allow them to do so, the hospitals have to do so strictly at arm's length, and all their services are priced at market rates. So it is proper accounting. There is no cross-subsidy. Hence, it is not true that we are using public resources to compete with the private sector.”
“When Mr Zainul Abidin raised the example of one of his MPS cases, where one of his constituents decided to send the parent to an A-class ward despite our financial counselling, then there is very little we can do to help. If I may just reinforce this point. As I have said here before, we have universal accessibility to our healthcare system. As long as a patient chooses B2 and C-class wards - I used to give the example, unlike lawyers, when Mr Chiam raised this question - we do not collect deposits when a patient chooses a B2 or C-class ward. So when Dr Michael Lim raised the example of KK Hospital wanting a deposit of $20,000 or $60,000, this refers to private patients. Our rules are straightforward. If you are a subsidised B2 or C-class patient, you are guaranteed access to our healthcare system. There is no deposit. We treat you first and settle the bill later on. We have done so in all cases. We use Medifund for the deserving cases. However, if you choose to come in for B1 and A-class, that means you have self-selected, you have decided for yourself that you are above the median and you can pay for the healthcare costs. Therefore, we will treat you just like in a private hospital. We will evaluate what kind of condition you are coming in for and we will ask you for the relevant and appropriate deposit. I think that is fair. When you go to a private hospital, you have also decided for yourself that you do not need subsidies and you can pay for your medical bills. We are very happy that you are able to go and can afford private healthcare. But, when you want to switch from a private hospital to a public hospital, we will deem you as a private patient and, therefore, we require you to put up a deposit. The example that Dr Michael Lim raised is a neo-natal case.”
“For this group, in fact the Government becomes the insurer, but they will receive half of what they will get from ElderShield. To run this transition scheme will cost the Government $300 million. Just to introduce ElderShield, we have to go to the Government and seek a total of $660 million to ease the scheme in. After this transition, when the scheme is on a sure footing, then it will be on its own. Mr Yeo Guat Kwang asked why we have not promoted the scheme more rigorously. For pragmatic reasons, if I do a major promotion last year, most Singaporeans would have forgotten by now. So we target to go out and promote this scheme more aggressively between June and September when the scheme will be launched. We are enlisting the help of all the Mayors to help us work the ground and launch the scheme from June to September. Finally, for the low-income group, Medifund is a very important safety net. As Mr Gan Kim Yong said, it is very effective. 97% of Medifund applicants are successful in their applications. We continue to review the Medifund eligibility criteria regularly. Each hospital has a Medifund Committee and it has the flexibility to deviate from the Medifund criteria and approve deserving cases under exceptional circumstances. That is the reason why we have such a high approval rate. But it is still within the interest income that we are earning from the capital sum of $800 million in the Medifund. On public education, I agree with both Mr Yeo Guat Kwang and Mr Zainul Abidin that we have to do more and get Singaporeans, particularly our elderly Singaporeans, to understand the system and to navigate the system. A key component of this is counselling at the point of service, in the hospitals.”
“The intention is that after they have run this scheme for one or two years, we will encourage the private sector to have top-up to this scheme. So this is a basic scheme. In one or two years, when the private insurers running the scheme have more experience, I see no reason why they cannot offer enhancements, eg, higher payouts, longer payout periods and different types of coverage. So this is just the basic coverage. To make this scheme work, we need to ease it in. For somebody who is 40 years old today, it is not a problem. You pay the premiums, at the age of 65 you are covered for the rest of your life. For somebody who is 65 now, to pay the premium to be covered for the rest of your life, the premiums will be very high. So we need to find a way to ease it in. And the way we have done so is to allow people to pay premiums over a 10-year period, from 59 years old to 69 years old. So we have a cut-off at 70. Anybody who is younger than that will have a 10-year payout, and the Government will, in fact, contribute almost a third of the premiums to help make the premiums affordable. This subsidy will amount to $360 million. So we have persuaded the Government to give us $360 million to help pay almost one-third of the premiums of the senior citizens. Then, there are two groups - those above 70 and those with pre-existing disabilities. They are not covered. For these, we have the IDAPE scheme in which the Government really becomes the insurer. If they are above 70 or are already disabled, the Government will, in fact, pay them $100 or $150 for up to 60 months. So the Government undertakes to be the insurer, because it is not fair to load them onto the actuarial system. If we load them onto ElderShield, then the rest of Singaporeans will pay.”
“If we lower the ADLs to 1 or 2 ADLs, then the payout ratio will be much higher. Then we have to collect from fewer people to pay out to more people, in which case, the premiums will be higher. As a start, we have decided to stick at 3 ADLs, which is the industry norm, and that means a payout ratio of about 1:12. 5.00 pm The next feature is the level of payout. We have decided on $300. Why? Because if you are a low-income person and you are disabled and you have to go to a nursing home, through our means testing, you will qualify for 75% subsidy. The Government will pay 75% subsidy if you are the bottom 10%. If you are the bottom 30%, the Government will pay 50% subsidy. The nursing homes today charge around $1,000-$1,200. So, your share will be about $250 or $500. Therefore, a $300 payout will go quite a long way to help you pay for your share of a nursing home. That is why we decided on $300. We decided on cash rather than claims for service, so that it gives you flexibility. As Dr Lily Neo said, if the patient also has chronic illnesses but stays at home, he could use the $300 for outpatient services, for home medical or home nursing. But in the more severe case when you have to end up in a nursing home, then the $300 is a significant percentage of the co-sharing of your component of nursing home fees. The other feature is the payout period. We decided on five years or 60-month payout because our survey shows that the average length of stay for nursing home patients is normally between two and five years. So a 60-month payout is sufficient. But let me just say that we are launching ElderShield and we want to make it as simple as possible to get it started. We have got two private insurers to provide the service.”
“If we have a number of such private schemes and they each take 5-10% of the market share, the danger is that the private sector will then cherry-pick the good risks and leave the bad risks to MediShield, and that will make MediShield untenable. So we have to review the guidelines governing the use of Medisave for approved insurance scheme. We will consult the industry players. Our intent is to give private insurers greater flexibility to offer more products as long as key safeguards, such as deductibles and co-payments remain to deter the "buffet syndrome". But we must also make sure that each player carries a fair share of the good risks and the bad risks. Sir, as I said, we are targeting to do this study and for the major reform of the MediShield, it will take us about a year and we will be in a position to come to this House with the new scheme before 2004. The next area is ElderShield. We introduced the concept of ElderShield and we got the private sector to tender for it and we are in the position now to implement it in September this year. Dr Lily Neo and Mdm Halimah raised several questions about ElderShield. Let me just go through some of the key principles in the ElderShield. First, we decided that it should be an actuarial insurance, rather than a social insurance. If it is an actuarial insurance, then it means that the pre-existing disabilities cannot be covered. That is the industry practice. Second, we have to decide on the payout ratio. The current industry norm is 3 Activities of Daily Living (ADLs). If we lower it to 1 or 2 ADLs, then the payout ratio will be higher. Today, at 3 ADLs, the payout ratio is 1:12. So that is the whole idea of insurance. We collect from 12 persons and we pay out to one person. So the premium is low.”
“Under this scheme, currently what happens is that Singaporeans pay a higher premium as they grow older. So it becomes less affordable as one grows older. With pre-funding, what we can do is to get Singaporeans to pre-fund, or collect a higher premium, when they are younger and then when they reach 65, they will be covered for the rest of their life. This is a major change and it means quite a major restructuring of the MediShield, and we target to do this in 2004. Mr Gan Kim Yong said that we need to raise the premiums if we want to do such a major change. Indeed, we have to. Today, MediShield plays a fairly limited role because it is a catastrophic insurance scheme. We collect about $90 million in premiums every year. If we look at the national health expenditure (NHE) of about $4.2 billion, $90 million is between 1-2% of the national health expenditure. So MediShield is only playing a piffling role in our overall structure. If we want MediShield to undertake, say, 10% of our NHE, something like $400-over million, then we need a four-time increase in the premiums to make it really effective. So I am giving Members early warning. When I come next to the House with a major restructuring of the MediShield, and if we want MediShield to play a major role and be the foundation for the portable medical benefits scheme, then we need a fairly quantum leap in the coverage. Mr Yeo Guat Kwang also suggested that we accredit more insurance schemes as Medisave-approved schemes. To-date, besides MediShield, we have four other Medisave-approved catastrophic illnesses insurance schemes, namely, IncomeShield, HealthShield Plus, SupremeHealth and MaxHealth, of which the last two were just introduced last year. Let me just sound this word of caution.”
“The third area is to reset the Medisave withdrawal limits and the MediShield claimable limits based on the Diagnosis Related Group (DRG). Today, the limits are based on the number of days a patient is hospitalised, the so-called "per-diem" basis, and the complexity of the surgical procedures, a set of tables. They may not truly reflect the level of resources needed to treat the different medical conditions. We are therefore revising the Medisave withdrawal limits and the MediShield claimable limits for inpatient care and day surgery based on the Diagnosis Related Group, so that they will be better commensurate with the medical conditions of the patients. The intention is to enable patients with more severe medical conditions to withdraw more Medisave and claim more from MediShield to pay for their medical bills as compared to today. These changes are scheduled for the first quarter of 2003. The fourth area is really to expand MediShield so that it can better cater to the needs for old age. This is what several Members have advocated, for example, Mr Yeo Guat Kwang. We are looking into this. And there are two stages that we will proceed. The first is to enhance the features of MediShield in the first quarter of 2003. In that first phase, we will increase the claimable limits, we will lower the deductibles and the co-payment, and expand the coverage to additional outpatient treatments and neo-natal care, so that MediShield can play a bigger role in our personal healthcare financing. The second phase is to expand MediShield to provide lifetime coverage, instead of just stopping its coverage at the age of 80. To do so, we will have to introduce some form of pre-funding of MediShield. We will do so in 2004.”
“We will gradually do so, but I would urge that we do so cautiously. The first thing we can do is to allow Medisave for ambulatory care. Because of the rapid advances in medical technology, some of the medical treatments, which are traditionally done in an inpatient setting, can now be done in an outpatient setting. But because Medisave and MediShield currently only cover primarily hospitalisation expenses, we inadvertently discourage the right setting of care. In other words, there is little incentive for the patients and the providers to seek or provide treatments at the outpatient settings since they are unable to access Medisave and MediShield. I have therefore decided to extend the use of Medisave and MediShield to several outpatient treatments, which are in lieu of inpatient treatments. This will reduce the need for inpatient hospitalisation and will save costs. The changes for Medisave extension will take effect in October 2002. My Ministry will put out a press release on this. Similarly, to facilitate patients who need to use step-down care facilities, MOH will also revise the Medisave withdrawal limits for step-down care on 1st July 2002. We will raise the Medisave annual withdrawal limit for community hospitals from $3,000 to $3,500, and the daily withdrawal limit for hospices from $125 to $160. Singaporeans who need community hospital, or hospice care, would therefore be able to use more Medisave and, in turn, less out-of-pocket cash. But here, I would like to caution Members that these changes should not and do not signal that we are liberalising Medisave and MediShield for general outpatient care. We must proceed cautiously because an overly liberal use of Medisave would necessitate higher Medisave contribution rates. We therefore need to strike a balance.”
“Mr Yeo Guat Kwang pointed out that we need to watch out for this group - the self-employed, the low income, the non-working population - as they are outside the CPF network. I agree with him because if they are not covered by MediShield and they are struck by catastrophic illnesses, then they will have problems paying for their share of the healthcare costs. So, in this regard, my Ministry will extend the opt-out, or the auto-coverage mechanism, to non-working spouses, so that they will have the opportunity to join the MediShield. We will introduce a new MediShield opt-out point for non-working spouses when couples register for their marriage. This will take effect in 2003. The thinking is that when a couple registers for marriage and if one of the couple is a non-working spouse and is not covered, then we will send a little polite note to the couple and say, "Congratulations! One of the spouse is not covered, you are now automatically in, unless you sign an opt-out form." And we hope that the spouse who is covered will not sign the opt-out form for the non-working spouse. I do not think it will happen. Some of my more enthusiastic staff say, "What about children? Why do we not send similar letters every time we get the registration in the birth certificate?" I told my staff, "Let us take this one step at a time. If we do this too much, then we will be accused of being too intrusive." In any case, when the children grow up, when they work and get their CPF account, they will be covered by MediShield. So I think we have some time. Meanwhile, we will mount more public education programmes to get people to sign on their entire family under MediShield. The next thing we can do is, of course, to extend the use of Medisave and MediShield.”
“If we expand it to half, or two-thirds of the national health expenditure, then we are talking about increasing the budget to 2% of the GDP. Every percent of the GDP, as Members now realise, is equivalent to nearly 2% of GST. So we cannot say do not raise GST, but increase the healthcare expenditure. Some where, the budget must balance. With the budget that we have, there are still quite a number of things that we can do to improve the healthcare financing system. Let me just name some of these. First, is universal coverage. A few Members raised this, especially Mr Gan Kim Yong and Mr Yeo Guat Kwang. We have decided that our healthcare system lays emphasis on personal responsibility. It is not the national health system in the UK and it is not the private insurance system of the US. But our system puts a great store on personal responsibility, and that is the reason why our schemes insist on opt-out. By and large, a person is in, but we give him a choice to opt-out. So he is personally responsible for that decision. It is not a mandatory national social insurance scheme. We try to achieve universal coverage through an opt-out scheme. But an opt-out scheme means that some segments of our population may not be covered, for example, MediShield. MediShield today applies only primarily to Singaporeans with CPF accounts. As a result, about 74% of our resident population is covered by MediShield and 26% are not covered. This is largely the non-working spouses and children, who are not covered. If we look at the working population, our coverage rate is not too bad, at 90%. But there is still a small segment who are not covered - some of the self-employed and low income people. So, how do we increase the coverage?”
“One approach is that whenever we introduce new programmes in our polyclinics and in our hospitals, and if it is appropriate, then we introduce means testing selectively. For example, when we introduce the Primary Care Partnership Scheme where we allow our senior citizens to see their private GP clinics and still claim subsidies from the Government, then I think that should be means tested. Whenever we introduce new programmes and it is appropriate, then we will incorporate means testing. Dr Ong raised a point about means testing in the step-down sector, particularly in the community hospitals. Let me reassure him that we will phase in the target subsidy rates gradually and we will work with the community hospital to moderate the impact on the patients' bills. We will also give the community hospitals additional funding so that they would not need to increase their fees and charges substantially. We will work with the other community hospitals and other step-down care operators to ease means testing in. But this is a transition. In the end, we have to decide on the fundamentals. Mdm Halimah asked whether we should just subsidise the lower half, or should we also subsidise the upper half of the population, in terms of income. If today, we are spending one-third of the overall national health expenditure, then it is inevitable that our subsidy is targeted at the lower half. Once we start subsidising beyond the median into the upper half, then Government's share of expenditure must increase substantially, beyond one-third to more than half to two-thirds. 4.45 pm Today, the budget for health is $1.6 billion, 1% of the GDP, and that constitutes one-third of the national health expenditure.”
“The third prong is, as many Members have raised, how to reinforce the financing system through allowing better use of the Medisave, through expanding the scope of MediShield and when we introduce ElderShield, to make sure that ElderShield works. Sir, I will cover these points in turn. First, on means testing. Both Mdm Halimah and Dr Ong Seh Hong raised this. The idea of means testing is not new. This was mooted way back in the 1993 White Paper. It is a mechanism that will allow us to target subsidies at the lower income group. As Dr Ong himself has said, philosophically, I think most of us would not disagree that Government subsidies should be targeted and given to Singaporeans who are the most deserving. Today, we have some form of self-selection. Singaporeans who are better off would opt for B1 or A class and therefore do not avail themselves of the subsidies. Singaporeans who are better off would not go to the polyclinics and therefore do not compete for the subsidies in our polyclinics. As long as this self-selection takes place, then I think we can postpone the date of means testing. As long as the demand is within what our subsidised healthcare system can supply and there are no serious accessibility problems, such as long queues and waiting times, then there is no need to implement means testing in our hospitals and our polyclinics. But if the subsidies keep expanding and we need to target, then I am afraid, at some point in time, means testing would have to be introduced. So it is inevitable that, at some point in the future, we may have to introduce means testing. So how do we gradually ease this in?”
“In fact, 97% of the applications for Medifund assistance are approved. Our safety nets do work. [Mr Deputy Speaker (Mr Chew Heng Ching) in the Chair] 4.40 pm But going forward, when our population gets more aged - today, it is 7% of our population above 65, in 20-30 years, this will more than double to 16-17% of the population - we have to strengthen our healthcare financing system to deal with the aging population. When the population gets more aged, we will find that the component borne by the employers will come down, because the working population will be a smaller proportion. And, therefore, the employer's share will reduce. The Government's share will have to increase, because we have to look after a greater proportion of the aged population. The MediShield and the Medisave will have to take on a heavier burden because the individual has to pay for his healthcare expenses as he grows older. Going forward, there are three main things we have to do. First, for the employers, I support the Ministry of Manpower and NTUC's move to make employers' medical benefits more portable, so that even when an employee changes jobs, he is covered. Better still, make employers' medical benefits portable beyond retirement, so that it covers post-retirement period. Second, for the Government, we would bear our fair share of the healthcare cost. But if we want to keep to our share at between a third to half, then Members must realise that we cannot subsidise the entire spectrum of the population. We must target our subsidies to the most deserving, and that means, at some point in time, we would have to introduce means testing, so that whatever subsidies the Government is prepared to fork out, those subsidies are targeted at the low income, at the most deserving.”
“The cash component is also affordable to the majority of Singaporeans. If we look at the Household Expenditure Survey, each household spends, on the average, 3.3% of its household expenditure, or about $120 per month, on healthcare. I know that the last time I compared healthcare cost with hairdo, some segment of the population took offence. I promised my wife that I will not compare healthcare with hairdo anymore. Let me just compare healthcare cost to other forms of household expenditure. $120 per month, which is the same expenditure as a household spends on telephone or mobile phone, SMS, fax and Internet. So, is that affordable? In fact, the average household spends more on his annual vacation. The average household spends $162 per month on vacations, which is 26% more than healthcare. I would say that, on the average, we have kept healthcare cost down, and it is affordable. The cash component is affordable by Singaporeans, by and large. As for the low income household Singaporeans, I have told Members before that if they have any MPS cases about Singaporeans having difficulty in paying their hospital bills, send the case to the Medical Social Worker of the hospital concerned. We have a team of very competent, effective Medical Social Workers in the hospitals, and they will deal with the case. I have made this offer to Members before, ie, if they have any cases that have been rejected and they still feel that the cases have merits, send the appeals either to MOS or myself. I am happy to report that in the last three years, both MOS and I have received very few cases of such appeals. So it shows that our system works and that low income families, who face financial difficulties in the hospitals, are adequately dealt with.”
“Sir, first, I would like to thank the Members for raising the various issues on healthcare. Let me, first, address Members' concerns on healthcare cost, the affordability of healthcare, because that receives the most number of cuts. Let me just give Members the background. To make sure that healthcare is affordable in Singapore, the first thing we must try to do is to keep the overall National Healthcare Expenditure (NHE) down. Today, our National Healthcare Expenditure is about 3% of our GDP. It is low when we compare it with other OECD countries. They spend, on the average, between 8-10% of their GDP. In the US, healthcare expenditure is creeping up to 14% of GDP. For us, 3% of GDP is very low, compared to the 8% or 10% of the OECD countries. Therefore, as a country, it is very affordable. So we are already ahead in the game. As long as we keep our NHE down, we are ahead of the game. The next question is, having kept the NHE down, who should pay for it, especially with healthcare cost increasing every year? Should it be the individuals? Should it be the Government? Should it be the employers? Or should it be the insurance companies? In very round numbers, about one-third of our NHE is borne by the Government, one-third by the employers through the employer-provided medical benefit schemes, and one-third by the individual through his Medisave and through his out-of-pocket cash payments. So the question many Members have asked is: is the individual's share at one-third of the healthcare affordable? Our response is that if every Singaporean saves diligently, through his Medisave and if he is covered by MediShield, then he is able to afford B2 charges. That is how we have calculated the level of savings for Medisave.”
“The answer is "No". To be able to evaluate the efficacy claims, if you want to do so scientifically, then you must have the whole process of evidence-based medicine, you must have proper trials. Unfortunately, for some of these products, whether it is supplements, or natural products, or herbs, they do not have this kind of records. So there is no way we can evaluate such items for efficacy claims. That is why we state very clearly that for such products, our primary objective is safety. And, where the rules for safety are not tight enough, I can assure the House that we will tighten them. But there is no way we can evaluate, or justify to the public, the evaluation of efficacy claims. ESTIMATES OF EXPENDITURE FOR THE FINANCIAL YEAR 1ST APRIL, 2002 TO 31ST MARCH, 2003 (Paper Cmd. 3 of 2002) Order read for consideration in Committee of Supply [5th Allotted Day]. [Mr Speaker in the Chair] Head T (cont.) - Resumption of Debate on Question [18th May, 2002], "That the total sum to be allocated for Head T of the Main Estimates be reduced by $100." - [Dr Teo Ho Pin]. Question again proposed. 1.05 pm”
“HSA is still in the process of investigating and the 2-year jail deterrent is under the Act, for the violation of the Poisons Act. If the consequences are more serious, HSA will consult AG's Chambers to see under what other Act we can pursue the importer, which will carry a heavier penalty.”
“They take about a few days to a week for the test results to come in. So I have examined the report and the procedures. I do not think HSA was laggard in their reaction. I think what they put out was commensurate with the test results, and when they found this banned item, then I think they make it very clear, not only to withdraw the product, but also to warn the public.”
“Mr Speaker, Sir, in fact, this is the current regime. We try to use the private laboratories. This importer came with the declaration from a private laboratory. We accepted the report of the private laboratory. Now, we are saying that maybe not all private laboratories can be trusted, and therefore, we ought to have a shorter list of accredited laboratories. This is one of the things that we are thinking of doing. As to the time difference, according to the report given to me, when HSA first received the report of adverse drug reaction, they went out to the market and picked up samples from different batches to test. They found nicotinamide, which is a B3 vitamin. This is not banned, but the dosage that was found in this Slim 10 was beyond safe levels. It is not a banned item, but it is above the safe dosage. HSA told the importer to withdraw the item and the product was withdrawn from retail. HSA also sent out an advisory to all the doctors to say that they have received these adverse drug reactions and asked for other confirmation from the doctors. It is after HSA sent out this advisory that other doctors also sent in reports and HSA then suspected that what is adulterated is beyond B3. From the kind of reports that they get from the doctors, they came to the conclusion that excessive dosage of Vitamin B3 could not have caused some of these reactions. These reactions were not just hyper-thyroidism but also, in some cases, hepatitis. So they investigated further, and this is where they found traces of fenfluramine, and this is where they put up the press release and took action. HSA took action according to the investigations, because when you bring in these products and send them to the laboratories for testing, the test results do not come in immediately.”
“But I agree with Mr Leong that we must have in place a regime that deters and which can ferret out those who are unscrupulous. As far as deterrence is concerned, our present Act allows for a two-year jail sentence for those who bring in items which are adulterated.”
“Mr Speaker, Sir, I agree with the sentiments of some of the Members here that even though our procedures are stricter than in UK or US and about the same as Australia, because of the widespread use of Chinese proprietary medicine in Singapore, we ought to re-look at the procedures and see how we can tighten this up. We are, in fact, doing this review. On the other hand, I do not want to give the House the wrong impression that whatever we come up, it is going to ensure 100% safety. I think we can improve, but it is the nature of such products. I have many meetings with Health Ministers from the region. When I meet the Health Minister from Taiwan or Hong Kong and we discuss the problems we face, this is quite a widespread problem in Taiwan and Hong Kong, where they bring in Chinese proprietary medicine. So, we are all grappling with this. Specifically, with regard to Mr Leong Horn Kee's suggestion, we will take this up. We do conduct random testing. HSA does not have the resources to test every batch and everything that comes in. But HSA will do random testing, and we indeed do that as part of our post-marketing surveillance mechanism. Mr Leong also suggests that we do batch testing. We will review that but it means we are going to slow down and, in fact, it will affect the trade and it will raise costs. For the bulk of the Chinese medicine that comes in, the herbs and grasses are fairly innocuous. They have been used for hundreds of years and they are reasonably safe. But if an importer wants to adulterate such stuff, then it is very hard for us to prevent them from doing so. We must have a regime that does not penalise the bona fide importer. We cannot treat every importer as a possible crook.”
“It is very difficult for us to say that a food product cannot be adulterated. If somebody puts adulterants into food products and thinks he can get away with it, unless you go round checking every item and every consignment, there is no way we can prevent that from happening.”
“Since 1994 and then in 1999, we have put in place a system which tries to address the unique characteristics of Chinese proprietary medicine and, at the same time, put in some safeguards. One of the safeguards, as explained earlier, is when somebody wants to bring in a product, HSA tests the product and makes sure that it is qualified under Chinese medicine, and not Western medicine disguising as Chinese medicine. Having allowed the importer to bring it in, we make sure that for each consignment, the importer declares that whatever he brings in has the minimum safety standards of not having poisons or heavy metals in it. What happens in some of these cases is that the quality control in the manufacturing of these products in China is not tight and sometimes, it gets adulterated. The laboratories that test these products are not stringent enough, so it gets through the net. We are reviewing the system. One of the things that we may consider is to only accredit qualified laboratories to make sure that the testing is done by certified laboratories, and not just laboratories from different parts of China. This is one of the measures that we are considering. Our objective is to ensure safety but if it is prescription-only medicine, we have a higher level of safety because there are more checks, the doctor is in charge of prescribing it, we ensure that the pharmaceutical companies which manufacture them have good manufacturing certificates, so there are more stringent checks. When it comes to traditional medicine, I am afraid that the regulatory regime is quite different, as practised everywhere else. There are a lot of grey areas, whether it is medical devices, health supplements or food products, they are now coming in with different claims.”
“Mr Speaker, Sir, even for Western medicine, the synthetic pharmaceuticals which are manufactured by the big pharmaceutical companies with very stringent quality control, which have certificates for good manufacturing practice and a series of clinical tests and approved by the home regulatory body, whether it is FDA in the US, etc, even for such drugs, you cannot test for the full range of adverse drug reactions. Sometimes, even after such a stringent process, you do come across unexpected adverse drug reactions. Even for synthetic pharmaceuticals, you get products being withdrawn because some of these after-effects were not encountered during the clinical trials. What I am saying is that even at this end of the spectrum, where we have such a strict regime, together with the western countries, we also have unexpected drug reactions, and through this Adverse Drug Reaction Monitoring System, we have to pull products out. When you look at Chinese medicine at the other end of the spectrum, generally, we do not face this problem because these are low concentrations which have been used for a long time, through historical and traditional use, the adverse reaction is minimal. When we come to the middle area, this is where the problem arises. As I explained just now, we cannot adopt wholesale the Western medicine approach of regulating it, in line with what other countries do. In the US, for example, when they come to traditional medicine or complementary medicine, the approach is that you take it at your own risk. FDA does not regulate. If you take traditional medicine or Chinese medicine, it is entirely at your own risk. In Singapore, we realise we cannot adopt that hands-off approach because traditional medicine or Chinese medicine has a wide following in Singapore.”
“The whole issue of medical devices is currently not regulated, and we intend to regulate medical devices when we put up legislation towards the end of this year or next year. So, medical devices and devices which claim to have health benefits, these we intend to put under regulation. As for the rest, slimming oil, body wrap, these cannot be regulated. If you want to wrap plastic or elastic around your waist and claim that you will be slim, there is no way we can tell you not to do so. In helping CASE to look after the products, I am sure we can work together. But as I have said, health products cover a wide range and when it relates to pharmaceutical products, the so-called Western medicine, because these are synthetic, and chemicals, they pose higher risks. The HSA's stand is to regulate this stringently. At the other end of the spectrum, when it is Chinese medicine, because these are herbs and plants, and these are traditional medicine which have been in use for hundreds of years and proven to be reasonably safe, we have to take a different approach. Unfortunately, the problem now is that many people bring in Chinese medicine but actually they adulterate it with Western medicine, and they come in under the guise of pure Chinese medicine. This is the middle area that we have to review and make sure that even though we cannot regulate the efficacy, we must regulate for safety, and that is the intention that we set out.”
“Therefore, we put the responsibility on the importer, the wholesaler, to make sure that whatever they bring in they must declare that the product they bring in does not have the items in the Poisons Act, do not have heavy metals, and the ingredients of the product are clearly labelled. Dr Teo Ho Pin (Holland-Bukit Panjang): Sir, may I ask the Minister whether the Ministry has any plans to control other slimming treatments, such as the use of equipment for slimming, the use of slimming oil and body wraps, and also whether the Ministry will help CASE to investigate into all those complaints on slimming treatment?”