Tan Sze Wee
Singapore
“Sir, the Baby Bonus Scheme, which was first introduced in April 2001 and further enhanced in August 2004, supports the parents' decision to have more children by helping to lighten the financial cost of raising children. The Baby Bonus Scheme is a laudable one.”
“Mr Chairman, Sir, we know the importance of growing our human capital and to make education more affordable for those from the lower-income families. To make education accessible and affordable for all, the fees for educational courses should not and cannot be priced beyond the reach of the average student.”
“Sir, I would like to have the opportunity to ask the Minister again to provide the answer to my cut, which is what is the level of subsidy that is provided for medical students, and also when the Graduate Medical School starts operating next year, will the same level of subsidy be provided to the students of the Graduate Medical School as…”
“I would like to thank the Senior Parliamentary Secretary for the clarification regarding not handling dead birds per se. But I have a clarification.”
“Sir, before I start, I would like to declare my interest as the CEO of a diagnostic company developing rapid tests for Avian flu. My question relates to the recent world-wide fears about the emergence of bird flu in the region.”
“The redevelopment of SGH's Pathology Department is especially far more pressing now with an H5 Avian flu pandemic, and probably a human flu pandemic, looming over the horizon.”
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“Sir, I would like to thank the Minister for the answer. I understand that the programme is targeted at nurses as we are having a shortage of nurses. I think this is a very good programme. Although the percentage is quite small, the Ministry should look into the reasons why they absconded, because every single person that we invest in for our healthcare needs is a contribution to our society. Perhaps this is something that we should look at.”
“The question is, there should be concerted efforts between MCYS, MOH and the Ministry of Education to look into this rising trend because a lot of these gay teens are not even concerned about protecting themselves using condoms and anecdotal reports of them having multiple sexual partners and having it with older men.”
“I thank the Parliamentary Secretary for the answer. I am actually concerned about the rising trends although I do not think we have actively collected data on this. The reason why it has prompted me to ask the question is from a recent report in the newspapers where based on the Action for Aids finding, that out of 113 youths, who were below 20 years old, they were tested for HIV, 90 were boys and half of them were gays and the remaining were girls. Although the percentage of HIV-infected individuals below the age of 19 is still very small, between 0.5% and 1.5%, I find it quite disturbing that ---”
“Sir, I thank the Minister for considering this question and also the very brief answer to the fact that this actually amounts to micro-managing it, which I think is the case. However, from the total bill cost point of view of a patient, drug component is an important aspect of it. Perhaps, instead of allowing the vendor prices or even the prices at which the hospital buys be disclosed, why not consider, for example, in order to facilitate the care to the private sector, if it is possible for participating doctors, GPs or even specialists to be able to partake in a scheme that the Ministry is actually enjoying in terms of the prices that they are getting, so that, perhaps, when the means test comes into place, such savings can be passed on to the public as well?”
“Because gambling is a hidden addiction, the health and social problems arising from pathological gambling will not be immediately known. It would take about two to three years after the introduction of the casino before the full impact of the problems be known. By then, the social and health costs to our society may outweigh the economic benefits. Is one family worth sacrificing for the projected boost to the economy? How many more broken families or the untimely deaths of the innocent little ones before we realise the consequences? Every Singaporean counts and every Singaporean that gets into trouble is a Singaporean family affected. Projected economic gains are not worth pursuing at the cost of lives affected by the influx of other social ills the integrated resorts with casino are expected to bring. With that, Sir, my stand is a firm "no" to the proposed integrated resorts with casino in Singapore.”
“A lesser well-known fact is that there is a correlation between problem gambling and domestic violence. In a study of 286 women admitted to the Emergency Department of a Nebraska Hospital, it was reported that a woman whose partner was a gambler had 10 times risk to be afflicted with violence than a woman whose partner is not a gambler. Furthermore, in 2003, the National Coalition Against Legalised Gambling in the United States reported that with the opening of casinos in South Dakota, child abuse and domestic assaults rose by 42% and 80% respectively. This was directly attributed to the increase in casino gambling. Opportunities to gamble will similarly increase if a casino is introduced in Singapore. Research from other countries has clearly shown that the increase in accessibility not only increases the number of regular gamblers, but also the number of problem gamblers although it may not be directly proportional. It means that the more the opportunities, the more the problems. There is clear evidence in Australia, Canada and New Zealand that problem gambling has increased as a result of the introduction of casinos in these countries. For example, Australia is currently facing a tough situation where tackling problem gambling has become a priority for the Howard government, after legislation was passed allowing the establishment of casinos and "pokie" machines in various key states. The Federal Government is now asking Australian banks to test restrictions and have limits to amounts withdrawn on ATMs at gaming venues, in a bid to help problem gamblers. Yet, I believe that these steps are a small and insignificant attempt at giving a plaster "cover" situation and will not solve the issue of problem gambling.”
“The result is that, instead of cutting their losses and walking away, gamblers get deeper and deeper into debt, guided by a delusion that a big win will recoup all losses and solve all their problems. Compulsive or pathological gamblers will tend to lose control of the amounts they risk and cannot stop gambling even when they continue to lose. Money may be important but they lose sight of their losses as they often say they are looking for "action", an emotional state similar to a drug addict when they are "high"on drugs, and this keeps them going on irrationally, and they are hooked on gambling. They always use gambling as a means to escape from problems of daily life, and from feelings of depression or anxiety. Eventually, compulsive gamblers may engage in vice activities, such as fraud, theft, and other crimes to provide more money to continue gambling, also to alleviate a desperate financial situation resulting from gambling losses. This is clearly evident from the recent reports that we read of commercial fraud in China banks, where employees siphon off money to perhaps gamble in Macau. Closer to home, we have our own incidents of professionals, senior company executives in blue-chip companies and banks, stealing funds to support gambling debts incurred in Australian casinos. Sadly, this thrill from the "high" of gambling action may have what induced Mr Simon Lee back to his gambling tables at Genting before his poor family's untimely death. The health costs of problem gambling are large at both individual and societal levels. Personal costs include displays of stress related disorders, problems with personal relationships, irritability, depression, anxiety and suicidal tendencies.”
“With the various gambling opportunities available now, it was found that 1% of the population in Britain had severe gambling problem, and the rate was twice as high in adolescents, particularly as a result of access to the slot machine gambling. In the United States, the prevalence of problematic gambling has increased and it is estimated that up to 3% of the population has pathological gambling habits. The MCYS released this report on 14th April which estimated that 2.1% or 55,000 of the Singapore population were classified as "probable pathological gamblers" in Singapore. There is also a 2% being labelled as "probable problem gamblers" as well. This is the current base line rate that we have in Singapore, even before we introduce the IR with a casino in Singapore. We must understand that, from the baseline, every 1% increase will amount to about 20,000 population adults. However, it is not just one single person, as brought up by Mdm Halimah before me. It may be up to eight to 15 people who are collaterally involved if a person is a gambler. My own personal experience with this has been that you cannot ring-wall a person because when he goes down due to gambling, the whole social network, ie, the friends and families, will want to rescue him, but everyone gets dragged down together with it. In comparison, Macau has a prevalence rate of 1.8% and Hong Kong 1.95% of pathological gambling. Pathological gambling has been characterised by unrealistic optimism on the gambler's part to which all bets are made in unrealistic manner so that you want to recoup your loss. We know that they would try to even bet against the house. Unfortunately, as pointed out by Mr Chia Teck Leng's case in his article, we all know that the house always wins.”
“Sir, the Government has stated strongly that the proposed Integrated Resort (IR), which includes a casino, is part of the overall set of initiatives that aim to promote tourism and to improve the conducive environment of businesses in Singapore. [Mr Deputy Speaker (Mr S Iswaran) in the Chair] 5.30 pm At the heart of the matter is the need to reinvent Singapore so that it will become an exciting metropolis for both foreigners and locals to stay. This issue has definitely brought about much heated debate from various Members of the House, to which I hope all our views will be taken seriously as we go ahead for the building of the IR with the casino in Singapore. However, I would like to share some of the findings, as a medical doctor, on the health and social issues of gambling. I would like to share an article from the British Medical Journal. In 6th November 2004 editorial, titled "Betting your life on it: Problem gambling has clear health related consequences" by Prof. Mark Griffiths of the Gambling Studies at the International Gaming Research Unit, Nottingham Trent University, UK. The United Kingdom relaxed its Gaming Act of 1968 to allow increased opportunities and access to gambling, as mentioned before by various speakers. Las Vegas style casinos have been introduced in many areas of UK, such as Edinburgh, Glasgow, Liverpool, Blackpool and London, in fact. The deregulation of gambling was also coupled with the advent of many new media to allow people to gamble freely, which includes even the Internet, interactive TV and also mobile phone gambling.”
“Mr Speaker, Sir, I thank the Minister for his reply. I refer to the reply that was given to me for the written answer where out of the patients who had VRE in SGH, a significant proportion - in fact, more than 50% - were in B2 and C Class wards. I would like to suggest that perhaps the Minister consider, in the proposed new northern general hospital, that the wards as well as the bed sizes are so designed that it takes into account the fact that infectious diseases can be spread much more easily when patients are confined in the same space.”
“I would like to ask, on the grounds of privacy and confidentiality, perhaps the Minister may want to consider gazetting VRE as one of the diseases under the Infectious Diseases Act.”
“Sir, the Minister has suggested that there are probably no grounds to consider VRE being gazetted as a disease under the Infectious Diseases Act. But I would like to clarify that it was reported in the papers that SGH had given the names of the patients tested positive for VRE to all hospitals. I agree that there are many good reasons for SGH to do so. However, I would like to know if consent from these patients has been expressly sought. If not, the privacy and confidentiality rights of these patients perhaps could have inadvertently been violated in the process. This is because VRE at present is not a disease on any Schedule of the Infectious Diseases Act and SGH may not be empowered ---”
“The exceptions being that of immunisation, whereby it is treated as a public good with positive externalities as well as certain disease screening, such as pap smear and mammography. However, from the years 2000 and 2004, it is largely perceived that the polyclinic went on a marketing spree to market its services. Because there is no means test currently in practice in the polyclinics, the capacity to abuse through a "buffet mentality" or "moral hazard" remains pretty large. The other issue with block funding of polyclinics is the disproportionate distribution of market share between the two clusters. One cluster has almost two-thirds of the polyclinic cluster while on the other hand, it only has 40% market share on the hospital, ie, secondary and tertiary, level. So, it is not 50-50 down the line vertically integrated. Going forward, is this mal-distribution sustainable? With the advent of block funding, what is there to prevent one cluster from dumping subsidised patients on another cluster by getting polyclinics to refer its patients to the other cluster? Infectious Diseases As brought up by Mdm Halimah Yacob yesterday as well, it was mentioned that during the SARS outbreak in 2003, Singapore did not have enough infectious disease specialists and public health specialists. Can the Minister inform the House how many doctors have been recruited for the Basic Specialty Training (BST) and the Advanced Specialty (AST) for the disciplines of infectious disease and public health respectively?”
“Sir, let me first declare my interest, although very little as a part-time GP on weekends when I do not travel. On the anecdotal feedback from my medical colleagues that the two cluster polyclinics have very different objectives and modus operandi, one is rather conservative while the other is quite aggressive, and hence the growth rates for the two polyclinic clusters are quite different. This has also been compounded by the introduction of night polyclinics back in 2001 which led to further growth. If these growth rates are sustained in the future, will block funding be able to sustain these growth rates? If not, what can we do about it? Will the Minister kindly furnish us with the following information: (1) The year-on-year growth in workload and year-on-year growth rate of the polyclinic workloads of each of the two clusters from 2000 to 2004 inclusive; (2) Give us the possible explanations to account for the differences in growth rates between the two clusters, should the rates be quite different; (3) Given that the rates obtained in (1) above, does the Minister expect these growth rates to continue to vary very significantly in the next five years; and (4) Reassure us that the proposed block funding mechanism will be able to continue funding these rates of increase, as given in (1) above of the two clusters' polyclinics in, say, the next five years and, if not, are there any plans to fund the polyclinics along these rates of historical expansion or to curtail demand for polyclinic services. In developed countries all over the world, it is established wisdom and common practice to "de-market" subsidised primary healthcare.”
“Having read through the relevant sections of the Medical Registration Act (MRA) on Temporary Registration, which is section 23, and given the nature that these doctors are purely here to give service with skills that are already commonly available amongst Singaporean doctors, I am uncertain how they can qualify for temporary registration on such a prolonged basis. Temporary registration is for doctors to "engage themselves exclusively in teaching, research and postgraduate studies in medicine". These doctors are here in our polyclinics to give a service primarily. Therefore, would it be better to amend the MRA to create a special class of conditional registration instead? 12.45 pm In addition, in a reply to my learned colleague, Dr Lily Neo in 2002, Dr Balaji, SMS for Health, said that there would be many more doctors entering the workforce in 2007. Can MOH confirm now that we will no longer need such temporary registered doctors working in our polyclinics from 2007 onwards? Preventive Healthcare”
“This is relating to health manpower. Can the Minister inform the House what is the exact number of doctors working in the polyclinics of each cluster in each financial year from 2001 to 2004, particularly those doctors who are registered under Temporary Registration with the Singapore Medical Council (SMC). The reason why I ask this is that I understand that the temporary registered doctors in polyclinics are not Singaporeans. Singaporeans are either provisional, conditional or fully registered with SMC. Can the Minister provide the nationalities of these temporary registered doctors in the polyclinics? Also, can we request for this data from the cluster hospitals as well? The second question is, what are the average salaries of our doctors, say, for a first year medical officer after his housemanship who has graduated from either NUS, or Singaporeans who are trained overseas, either UK, Australia or approved universities, versus the temporary registered doctors who are working and employed in the same service. Third, with the onset of block funding, should there be a difference between those under temporary registration and the other two categories? Would the clusters be, therefore, more inclined to hire more doctors under temporary registration versus locally-trained or overseas-trained Singaporean doctors? Fourth, can the Minister assure the House that, with block funding and possibly increased use of such foreign doctors under temporary registration, quality care to our Singaporeans will not be compromised in the public sector? Finally, I understand that these doctors are registered under the temporary SMC registration.”
“After all, under our present healthcare system, the outlets available to the TCM practitioners are more limited than the western doctors. Can the Minister state categorically that we have unconsciously trained excessive western-trained family doctors and TCM practitioners? I would also like to know whether the Minister is of the view that the Government should directly or indirectly control the number of training places for TCM practitioners, as it did for the western-trained doctors, thereby providing some form of security for basic job opportunity for the newly graduated Chinese physicians. Chinese Massage Therapist Certification”
“Sir, I would like to ask the Minister for Health whether he could enlighten this House as to how many students are currently studying in each year of the six-year part-time training course in the two TCM colleges. Whenever we mention primary healthcare service, we would inevitably think of the western-trained family doctors. This is an incomplete perception. In fact, from the patient's point of view, there is a variety of primary healthcare services available, including western-trained doctors, retail pharmacists, natural cure practitioners and Chinese physicians. At the moment, there are two privately-run TCM colleges recognised by the Government. I understand that the two colleges are actively training a considerable number of Chinese physicians. In recent years, there is an upward trend in both enrolment and number of graduates. Since we do not have any TCM hospital, the number of outlets available to the fresh graduates is limited. Generally speaking, they can only play the role of the primary healthcare providers after graduation. In the field of western medicine, our only NUS Medical School trains more than 200 western doctors each year. About half of them will eventually become family doctors. The second medical school will start its enrolment soon to train even more western doctors. In other words, there will be some 100-200 western-trained doctors becoming family doctors. In the situation of an over-supply of western doctors, we may face the following problems: First, the crisis of “suppliers inducing demand�? as mentioned in the MOH's 1993 White Paper; and Second, the TCM practitioners will be first to face the impact. As the Chinese saying goes, “Too many monks with too little porridge to go round�?.”
“Just a point of clarification and some additional questions. I am actually heartened to hear that the Ministry has acknowledged that in the landscape that we are competing globally, the expenditure for R&D has to increase to compete in the next phase of our economic growth. In fact, I am looking forward to the R&D report coming out in June. The new thing I am going to be interested in looking at is the involvement of local enterprises in the whole R&D landscape of Singapore as well. I would like to just ask the Minister for clarification with regard to two points in my questions that I brought up in the COS. One is the point I brought up on the SEEDS grant for start-ups for biomedical companies, of which $600,000 under SEEDS is actually quite limited. You basically only have the money to buy the equipment, and that is it. You cannot even start anything with $600,000. That ceiling was the feedback that I received from Bio-Singapore, the trade association, that we cannot use a one-rule-fits-all. We may have to review that for biomedical companies because it is a very high capital industry. The second point is that, for the funds under the BMRC which is administered through A*STAR, can I seek a clarification whether private local companies are able to apply through BMRC for research work, which can be done in their own premises and through contract researchers in public research institutes as well? That is how the model is being played out all over the world, in my company as well. For example, we are part of a NIH programme which is from US and Australia, where we participate and apply for funding from the Australian Government through my Australian subsidiary as well. The main point is that you must understand the BMRC's funding fulfils a certain ---”
“Sir, I have outlined in my speech in the debate on the Budget Statement that I find Singapore still has a long way to go in developing R&D capabilities. In the United States, about US$57 billion is spent annually on medical and health research. This represents about 0.6% of the US GDP. In comparison, Singapore's expenditure on health R&D was 0.2% of GDP in the years 2000-2001. In the United States, both local and foreign companies, private and public alike, could apply for the biomedical research funding through the United States National Institute of Health. There are two known research grant bodies in Singapore, that is, the Biomedical Research Council through A*STAR, and the National Medical Research Council through the Ministry of Health. They provide grants for biomedical and clinical research conducted within public research institutes in Singapore. Presently, it may appear that private local companies do not qualify for grants from either one of these bodies for research work conducted in Singapore, which also results in IPs that reside in Singapore as well. Why is this so? In this light, if we intend to create a world-class biomedical hub in Singapore, we would need to increase the funding grants available for biomedical research, that is less restrained by regulations that hamper the research process. Broadly speaking, Singapore still lags behind Sweden, Finland, Japan and Switzerland in the expenditure allocated to healthcare R&D. I would like to ask the Minister for Trade and Industry for the breakdown for the R&D expenditure for FY 2003 and 2004 in both the private and public sectors and, in particular, the expenditure on the biomedical industry.”
“The next level of funding, which is the Growth Financing Programme, is not within reach of the local bio-tech firms because their products are likely in the R&D phase, and not approved for market sale yet. Hollowing out of Manufacturing”
“Sir, SEEDS, or the Start-up Enterprise Development Scheme under EDB and SPRING Singapore, is an equity financing scheme which provides matching funding for start-ups with a third party investor. Under this scheme, EDB and SPRING will match every dollar raised by a start-up from a third party investor up to a maximum of $300,000. The third party investor must put in at least $75,000 as a requirement. Since SEEDS started, I would like to ask the Minister on the number of companies that has successfully secured funding under the SEEDS programme, both under EDB and SPRING, for technology and non-technology companies in the period since it started to 2004, and the total funds raised. Could the Minister also provide information on whether these companies have managed to become profitable or managed to secure additional funding after the initial seed funding period is over? Sir, the reason why I asked this is that the President in his message mentioned that "the Government will exploit promising technologies like bio-technology to enhance our industry clusters or develop new growth areas", and this was illustrated by a newspaper article as well. Speaking from experience as a "bio-entrepreneur" of sorts, and has faced funding difficulty as a start-up, and on behalf of the local private bio-tech community, the current SEEDS' limit of $600,000 is not really sufficient for bio-tech start-ups. The current ceiling, perhaps, requires review. This is because $600,000 would only be enough to (1) set up the research facility, and (2) purchase the laboratory equipment. This hardly covers much needed working capital to start the research work. It costs up to US$800 million and 10 years to take a drug from the laboratory to the marketplace.”
“This will ensure that there will be a minimal standard of professionalism among these real estate agents. Furthermore, it will allow the industry to police their own practitioners, and to set guidelines in place for proper registration of all practitioners; thereby freeing the Government from the task of micro-managing the practitioners in the industry. I would like to urge the HDB to explore putting such measures in place, to reduce further incidences of the cash-back transactions from occurring. The implementation of the above suggestions would serve to protect the buyers of 3- and 4-room flat establishments, who are often the ones most vulnerable to such offers of fast cash-back, to the detriment of their own CPF savings. With that, Sir, I support the motion.”
“With such a limitation, buyers and sellers cannot use this ResaleNet without a CEHA agent's account, as only those agents holding a CEHA certificate can submit transactions via the ResaleNet. From the feedback that I have received, I understand that most of the cash-back transactions are carried out by non-CEHA agents submitting the transaction application manually. Therefore, it may be difficult for both HDB as well as the real estate agencies to police the practices by these errant agents. I would like to suggest that the Ministry of National Development, through the HDB, make it compulsory for all agents (those with CEHA and non-CEHA certified ones) to submit all HDB resale flat transactions through the ResaleNet. Even though all transactions are made through this online portal, I would propose to HDB that CEHA-certified agents be given the advantage of paying a lower transaction fee as well as obtain an earlier appointment date with HDB officers, compared to non-CEHA certified agents. By encouraging the use of information technology, this will expedite the HDB's move towards a paperless system. It would also ensure the information is easily monitored and that all agents' transactions would be accounted for. Another solution put forth, from the estate practitioner's point of view, is to ensure some level of accountability among all individual practising property agents. I would like to suggest that the Ministry of National Development, through the HDB, consider only allowing estate agents who are members of a recognised organisation, be it the Singapore Institute of Surveyors' and Valuers (SISV) or the Institute of Estate Agents (IEA), to broker HDB resale flat transactions.”
“Patenting indicators Once again, the Economic Survey on Singapore's patenting activities shows that such services continued to grow in 2003. The number of patent applications increased 6.9% from 936 in 2002, to 1,001 in 2003. The number of patent awards rose 2.0% from 451 in 2002 to 460 in 2003. R&D expenditure per patent application decreased marginally from $3.6 million per patent application in 2002 to $3.4 million per patent application in 2003. Hence, I hope that the Ministry of Law will, through the Intellectual Property Office of Singapore (IPOS), look into the matter of educating the public on intellectual patenting rights and raise awareness on research developments in the biomedical industry. After all, the biomedical industry is a nascent field, with the vision to develop Singapore into a regional biomedical hub within the next few years, and needs the concerted effort and support of both the private and public sectors to make it viable. HDB ResaleNet - a single avenue for submission of HDB flat transactions Mr Speaker, Sir, the budget has been lauded as one with opportunities for all. With this, I would like to address an area concerning the provision of affordable housing, which is one of the issues highlighted by Dr Wang Kai Yuen before me from the survey that he has gathered from the public. It has been suggested by some estate agents that the "cashback" transactions, which took place recently, arose because there are different avenues for the submission of resale flat transactions. From my understanding, HDB has a ResaleNet system in place, where only agents holding a Common Examination for Housing Agents (CEHA) certification, and who brokered the resale flat transactions, have access to.”
“In Singapore, we have the Biomedical Research Council under A*STAR, as well as the National Medical Research Council through Ministry of Health, which provides grants for biomedical and clinical research. Presently, it may appear that private local companies do not qualify for grants from the Biomedical Research Council. Why is this so? In this light, if we intend to create a world-class biomedical hub in Singapore, we will need to increase the funding grants available for biomedical research that is less restrained by regulations that hamper research processes. Intellectual property (IP) and public education The Patents Act came into effect in Singapore in 1995. With the Patents Act in place, an independent patenting system was established, where local patents could be filed directly in Singapore for patent protection. Sir, the importance of intellectual property rights (IPR) and trademark patenting education for the public cannot be over-emphasised. As we head towards a knowledge-based economy, intellectual property rights and trademark patenting will act as the impetus to the creation and innovation of new products in various industries ranging from the arts to the mass media, design, scientific innovations and information technology. With reference to the biomedical industry, there are long lead times as well as high capital costs involved in the commercialisation of new biomedical products. Most hon. Members would know that it takes up to US$800 million and 10 years for a new drug to gain US Food and Drug Administration (FDA) approval. After the drug is approved, it is still considered an expensive item, as the company has to recover their cost of investment and risk incurred during the research and development process.”
“Figures taken from the Singapore Economic Survey Report show that expenditure on R&D totalled S$3.4 billion in 2003. As a percentage of GDP, total R&D expenditure in Singapore is maintained at 2.1%. In comparison, Sweden's total R&D expenditure as a percentage of GDP was 4.3% in 2001; Finland, 3.5% in 2002; Japan, 3.1% in 2002; and Switzerland, 2.6% in 2000 - all higher than Singapore. While we spend around 0.2% of GDP for healthcare research, both in biomedical and clinical research, Canada spends 0.32 to 0.4%; Japan, 0.46%; France, 0.57%; the United States, 0.6% to 0.71%; the United Kingdom, 0.80%; and Denmark, 1.1%. Switzerland spends 0.86% of GDP without even counting its pharmaceutical industry spending. I would like to pose to the Minister for Trade and Industry whether his Ministry could release the breakdown of the figures for healthcare research in Singapore, both in the public and private sectors. Moreover, Singapore has benefited substantially from global investments in health research and development. Between 1960 and 2003, the mean life expectancy at birth in Singapore increased by 15 years, from about 63 to 78 years, giving us one of the highest lifespans in the world. These gains have derived largely from reduced death rates from cardiovascular diseases, together with an almost complete eradication of deaths from infectious diseases, such as polio, tetanus, smallpox, measles, mumps and rubella, as well as reductions in morbidity and mortality from respiratory diseases, cancer and other causes. In the United States, local and foreign companies, private and public alike, can apply for biomedical research funding through the United States National Institute of Health (NIH).”
“If we want to truly retain more doctors in clinical disciplines that are important, such as endocrinology, geriatrics and renal medicine, then it is important that they do not feel they are pressurised to continually balance the books for their clinical department, against seemingly insurmountable odds stacked against them by the current financing system. I am not asking for more subsidies at the governmental level from the Ministry, but merely a recalibration of the Specialist Outpatient Clinic subsidy rates and revenue caps to be discipline-specific, to better reflect market and clinical reality. Funding for biomedical research I would now like to move on to the level of funding that is available in Singapore for biomedical research, both in the public as well as private research entities. I have to declare my interest as a Managing Director of an Australian Stock Exchange-listed biomedical company. In the United States, around US$57 billion is spent annually on both biomedical as well as health research. This represents about 0.6% of GDP back in 2002. In comparison, Singapore's spending on health R&D was 0.2% of GDP in 2000 and 2001. In the US, public sources of funds account for 39% of that spent, and private sources account for 61%. The direct and indirect costs of illnesses are worth around US$3 trillion per year or about 32% of US GDP. Direct costs account for 44% of the total and indirect for 56%, according to the NIH in 2000. The rate of return on publicly funded research, ie, in terms of direct and indirect cost savings, is in the order of 24% to 40% per annum (NIH, 2000). About one-third of improvements in mortality and morbidity can be attributable to medical advances.”
“However, with published rates, the GPs now have something to rate the prices by, so that they may know that they are being charged vastly different prices from that enjoyed by the clusters. I hope the Minister can consider this suggestion favourably so that there is more transparency in the system. Specialist Outpatient Clinic (SOC) financing Another issue is the Specialist Outpatient Clinic (SOC) financing. At present, I understand that the clusters are financed at the SOC level on a per-episode flat rate regardless of discipline. On top of this, there is also a revenue cap that also disregards the type of clinical specialty. This does not reflect market reality. We know that certain disciplines use many drugs and investigations consume a lot of resources. These disciplines are typically the medical disciplines that often have elderly patients on many drugs, for example, renal medicine, which relates to patients with kidney diseases; geriatrics, which relates to elderly patients; as well as endocrinology, which relates to patients who are diabetic. The current system leads to chronic under-funding for these disciplines. On the other hand, Specialist Outpatient Clinic surgery services, which typically use less medicines, are also reimbursed on the same rate. The result is that, at the financial statement level, some disciplines are perpetually losing money while others are always making money. I would like to suggest to the Minister that this one-size-fits-all rate needs recalibration and variation. Some disciplines should enjoy a higher rate while others have a lower rate. One may argue that this is a moot point with block funding in place. I think not.”
“Mr Speaker, Sir, I would like to begin by expressing my support for the Budget Statement that was announced by the Prime Minister and Minister for Finance. The theme for this year's Budget, "Creating Opportunity, Building Community" speaks of more good things to come, both for the individual and the community. As a healthcare practitioner, I would like to focus on the areas that relate to health reforms, as discussed in the Budget, before moving on to other pertinent issues which relate to the biomedical industry and also affordable housing for the public. Harnessing market forces The Minister for Health has done a wonderful job using market forces in getting a better deal for patients and taxpayers. His master stroke in publishing hospital bills is a case in point. In many cases, hospital bill sizes have come down. I would like to propose to the Minister that we expand this idea further to drug prices. We know that the clusters enjoy good drug prices due to economies of scale and sheer purchasing power. Some time ago, it was mooted that the clusters pass on their preferential drug prices to general practitioners, by selling their low-priced drugs to them, so that general practitioners can pass on these drugs at lower costs to their patients. This has not come about. I would like to suggest to the Minister for Health a simpler task instead. The clusters can publish on the Internet the prices offered to them by vendors for certain expensive drugs that are used in the outpatient setting. The GPs will realise that they still have to give maybe a 20% to 30% premium to the drug supplier, because they are only small buyers.”
“Sir, I am glad to hear that, on average, Singaporeans do have an average of about $10,000 in their Medisave account. However, with the increase in deductibles, the amount that is going to be drawn out of Medisave to pay for deductibles would increase over time. Currently now, until over time when savings are increased, it is still a limited pool. I just want to ask a point of clarification.Is there any way in which the Ministry would look into, for example, what happens if, let us say, Medisave runs out? Will that mean there will be more out-of-pocket payments for hospitalisation bills?”
“Through exposure to tough situations, responding to the crises of the moment and responding by venturing overseas in rebuilding efforts, Singapore youths are in a unique position to contribute; to make a difference in the lives of our Asian neighbours. I hope many youths will stand up and be counted, to volunteer for the YEP efforts in the coming months. Many Singaporeans demand the best of their leaders. Role models are often icons who influence an entire generation, just look at the recent examples of stars, such as Christopher Reeves, Anita Mui and Jacky Chan. In Singapore, we have our Stephanie Sun, Kit Chan and the recently selected Singapore Idol, Taufik Batisah. I would also like to suggest that our youths be given more role models to emulate. Hence, I would like to propose that the Members of Parliament and Nominated Members alike be given the opportunity to visit schools and give talks to the students on various topics, such as entrepreneurship, leadership or governance, to show the youths that we too can 'walk the talk' and inspire the youths to go for their achievements. Finally, Mr Speaker, Sir, the Tiger Cup final, held last Sunday, demonstrates triumphantly how a small country with limited resources, but with determination and focus, can reach the goal if we choose to aim for it. The current team is young, averaging 22 years of age, and they are the product of the national youth soccer programme that was started in year 2000. It shows how, with the right training, enablement and go-getting spirit, youths can be motivated to reach their highest goals of success. This 'go-getting spirit' is, no less, what we expect of our nation, and what we can hope to achieve. With that, Sir, I support the motion.”
“However, these youths, I saw, were putting in efforts and fund-raising out of their own initiative, proving that the spirit of volunteerism is alive and well in Singapore. We would do well to harness this spirit of volunteerism, of contribution out of compassion and not compunction. I strongly believe that volunteerism begins at home, and more youths should be encouraged to opt for their own voluntary service to the community rather than participating to chalk up points for their Community Involvement Projects (CIPs). One true volunteerism - if the CIP were removed from the school curriculum, would the students still volunteer of their own accord? The philosopher Goethe wisely commented: "Talent is nurtured in solitude, character is formed in the stormy billows of the world." Perhaps, the Singapore youth need to realise that nothing is handed over to you on a silver platter and there is no substitute for hard work and resilience. I find that the Youth Expedition Project is an excellent programme to nurture resilience in youth. The YEP serves a noble purpose - to expand the vision of young Singaporeans through exposure to overseas community service expeditions - in order that they might learn from the overseas communities and inculcate a spirit of volunteerism. Yet, none of the overseas community service efforts thus far have managed to impact the psyches of our youth as much as the recent tsunamis, whereby lives of thousands in Southeast Asia have been changed irrevocably. It is a commendable effort then, when I hear that the YEP is being reshaped into a rebuilding project.”
“The Government, through the Ministry of Community Development, Youth and Sports (MCYS) as well as the National Youth Council (NYC), has created opportunities and platforms to empower our youth. Through initiatives, such as the 'Youth: Creating Our Future' consultation exercise last August, and at forums, such as the National Youth Forum, conducted in November last year, youths are encouraged to speak up and make a difference. I applaud the Government for creating opportunities to engage the youth in nation building and in creating a common future for Singapore. The challenge now is to see these ideas formalising into specific action plans and making them a reality. More youths must 'walk the talk' and put forward their thoughts into concrete action. As pointed out by Eunice before me, let us not forget to strive for a more compassionate society that does not forget the less fortunate. In the wake of the earthquake and the tsunamis, I was heartened to see many Singaporeans self-mobilising and assisting in various ways and means, those affected by the tragedy. Many Singaporeans donated money, volunteered their time at relief organisations after school and work, many also gave generously of their personal items, such as clothes, tents, shoes and even toys to the needy victims. Around the New Year, I chanced not upon one, but several youth groups from various community organisations, schools and youth organisations, volunteering their efforts on weekends to raise funds for the Asian tsunami victims. There were youth groups stationed at MRT stations either performing classical music, singing or even miming, in order to raise funds to meet the urgent need, thereby putting a new twist to the phrase "Singing for your supper".”
“This would be a further distortion of the market. I believe the solution lies in the society and in the individual consumer realising that a price exists for the production of these vital services to take place. I hope the Government can come up with strategies and plans to raise awareness that the General Practitioner is not just the place you go for minor episodic treatments, such as the flu. The General Practitioner is also the person you go to for health education, counselling and preventive medicine. These come at a price, which should be borne by the individual. Only when the patient sees that the General Practitioners are more than mere paracetamol dispensers, will the General Practitioners be given a larger role as envisaged. Somehow, I hope that the Ministry of Health can be impressed to understand that these aspects of primary healthcare are part of a market economy pricing that does exist. As Singapore unveils its vision and looks set to metamorphose into an exciting, attractive and modern metropolis, I am aware that the contributions of youth matter too. Youth brings with it a feeling of invincibility. Yes, we were all young once, but youth may with each passing day fade. To the extent that the youth of Singapore realise their good fortune - that their forefathers paid the price to labour and contribute to the success of this nation; to build this nation from the Third World to the First, is to drive home the point that Singapore's success does not come cheap, and that youths are wont to be reminded of that fact. This nation was built upon the blood, sweat and tears of the preceding generation. Our generation is reaping the fruits of labour of the previous one. Opportunities for youth abound and there is no greater time to be born than in this.”
“The patient would not blame the doctor because he certainly does not expect the doctor to subsidise him. But this gets more complicated in the presence of subsidies whereby the better choice can be made available through subsidies. I hope the House can understand the angst that goes on in the minds of public sector specialists, because a medical means test, such as the MSP, behoves them to play God. They would rather have a financial means test and keep the social bond of trust between doctor and patient. I read with much hope that the Ministry of Health would like to employ market forces to enhance more efficiency as well as enlarge the General Practitioner's role in healthcare. I work too sometimes, when I do not travel, as a part-time GP and would like to encourage the Minister to proceed forward in this direction. The heart of a market economy is the price mechanism. There are many things that the Government and the General Practitioners see eye to eye, and this was pointed out before me by Dr Warren Lee about the importance of health education, preventive medicine and workplace health promotion. This is largely carried out for free, or at minimal charge in the public sector, which takes up about 20% of the primary healthcare sector. Unfortunately, in the remaining 80% of the General Practitioner market, with no subsidies from the Government, the price mechanism does not work because patients are unwilling to pay for additional services or medicines beyond the customary vaccinations. This is a pity because the General Practitioner can do a lot more, but the public seems unwilling to pay for these services in the private sector. I am not asking that the Ministry of Health gives out subsidies to GPs who provide 80% of the primary healthcare.”
“The uncoated stents have a one in three chance of restenosis, or narrowing again within a year after insertion. The new drug coated stents that were introduced last year were able to reduce this restenosis rate to 1 in 20 chance. However, this new technology comes with a price and it is currently 3 to 4 times more expensive than uncoated stents. Some of my medical colleagues find this responsibility of deciding which patients could qualify for the coated stents too onerous. It is an all-or-nothing choice. Basically, you cannot choose B2 and pay 100% of your drug-coated stent together. In other words, the drug-coated stent is not an a la carte option, but part and parcel of the whole subsidised package. This creates some internal psychological pressure on the attending cardiologist. Because we all know that drug-coated stents are better than uncoated ones. When it comes to choice, of course, you would choose the better ones. However, because subsidies are limited, we cannot offer subsidised drug-coated stents for everyone, we have to resort to a means test. Rather than having a financial means test, we put in place through the MSP, a sort of medical means test. This runs counter to the nature of the doctor-patient relationship and is the source of unhappiness amongst some doctors. To compromise in quality and to risk an imputation of failure, it is true even in the absence of subsidies, although it is simpler, because the implicit understand ing is that the doctor will give the best treatment that the patient can afford. If a patient cannot afford a drug-coated stent in the private hospital, the attending cardiologist will just give the patient the best he or she can afford, maybe an uncoated stent.”
“In addition to the means test, the Health Minister has put strengthening the 3M framework and managing medical inflation as key areas that he will tackle. These are laudable objectives. However, there is a limit to how much more quality and efficiency we can extract from the system before cost rises and affordability decreases. At the end of the day, it is back to the trade-offs between affordability, accessibility and quality. Often, it is quality that suffers. Comparing the patient workloads of our nurses and doctors in the public sector, they are at the top end in terms of productivity in comparison to doctors in developed countries. How many more patients can we continue to pile on one doctor or one nurse? So quality would have to suffer after a while. We cannot always get cheaper and better. It is not positive economics. More doctors are being asked to manage costs and bear the responsibility of increased costs. This is correct in part, because doctors are responsible for some of the costs. Yet there is a limit to how much a doctor can do before he is actually asked to play God. In fact, some day, I sincerely hope the Ministry can step in to help by saying that there are only so much subsidies and we really cannot afford fantastic quality without increasing costs. Take the recent Medical Service Package (MSP) for cardiology as an example. Doctors in public sector are asked to decide which subsidised patients can receive drug-coated stents and which cannot. For the information of some of the Members of the House, a heart stent is used for heart patients with diseases to open up narrowed heart vessels. This process, called stenting, keeps the heart vessels open for some time.”
“Let me now move on to health issues. The Health Minister had mentioned that in the coming year, introducing means test for inpatients would be a priority. I strongly support this. Subsidies must go to areas of greatest need. However, without a means test, this would be impossible because those who actually do not need subsidies will still try and obtain them, such is human nature. We should instead moderate such excesses with the means test, and to declare: we want universal access to healthcare through subsidies to the poor, not universal access to subsidies for rich and poor alike through healthcare. An eminent health economist, Victor R Fuchs of Stanford University and President of the American Economic Association, said that universal access cannot be achieved unless two criteria are met: subsidisation and compulsion. Subsidisation is to make sure those who cannot pay are subsidised to receive healthcare, and compulsion is to make sure the "free-loaders" do not avail themselves to subsidies that they can afford to pay themselves. The implementation of a means test is really an implicit line drawn between those who need compulsion and those who should receive subsidisation. The real issue is then: how do we draw this arbitrary line? This is where, for a start, I believe the Ministry of Health should start with a light hand. As we get more experienced, we can better titrate and apply the test not just to inpatients, but perhaps to outpatients as well. While outpatient bills are small, its impact is even greater than that in inpatient care. I would like to move on to the universal equation of healthcare policy in Singapore, which is the equilibrium of quality, affordability and accessibility.”
“Mr Speaker, Sir, I rise in support of the Motion of Thanks for the President's Address and thank the Members of Parliament for the opportunity to contribute as a Nominated Member. Sir, I concur with the President's statement that Singapore is a land of opportunities, where everyone can play a part in making a difference, and talents of all forms can be nurtured. Sir, I stand by the Government's mission, namely, that Singapore must continue to provide an open door policy and attract the relevant talented and skilled foreign manpower to contribute to the workforce. As I have had the recent experience of starting my own biotechnology company, let me just share some of my own personal experiences of the start-up process in this aspect. Sourcing of skilled human resource is one of the most important steps in commercialising a biotechnology company (or its product). In my company, I found that, as biotechnology commercialisation is a nascent industry here in Singapore, we had to outsource for skilled human resource from overseas, who had the expertise to contribute in this field. Perhaps the training and development of Singapore workers in biotechnology research and development should also be an important consideration in the future. Many of my staff are foreigners, comprising Australians, Britons and even an Austrian German. Every day, when I step in to work, I feel like my office is a miniature United Nations. Hence, I support the Government's stand to build a globally competitive workforce, by including foreign talents in the workplace. We should consider granting permanent residency to those who share our values and want to call Singapore home, as long as they can contribute, and share in our nation's values and work towards a common good.”