MAIN AND DEVELOPMENT ESTIMATES OF SINGAPORE FOR THE FINANCIAL YEAR 1ST APRIL, 1991 TO 31ST MARCH, 1992

Order read for consideration in Committee of Supply [6th Allotted Day].

[Mr Speaker in the Chair]

Head J (cont.) -

Resumption of Debate on Question [19th March, 1991],

"That the sum to be allocated for Head J be reduced by $10 in respect of Code JD 1500 of the Main Estimates." - [Mr Abdullah Tarmugi].

Question again proposed.

The Chairman: Dr Lee is not here. Mr Chay Wai Chuen.

Mr Chay Wai Chuen (Brickworks GRC): Sir, I have another cut under item (5), Code JD 9908103 of the Development Estimates. May I be permitted to take it together?

The Chairman: No.

Mr Chay Wai Chuen: Sir, yesterday, the Chairman of the GPC made allusion to the Rent and Utilities Assistance Scheme. I would like to ask the Minister how the Rent and Utilities Assistance Scheme has been operating, what is the present position of this scheme, and how the Ministry determines who are entitled to partake of this scheme.

Mr Peh Chin Hua (Jalan Besar GRC): ( In Mandarin): Mr Chairman, Sir, here I would like to urge the Ministry of Community Development to consider helping those poorer families in paying the arrears in service and conservancy charges owing to the town councils. As the Chairman of Jalan Besar Town Council, I notice that in the past one year, residents owe the Town Council as much as $280,000 in arrears of service and conservancy charges. The Town Council sent several reminders to them. Yet, as many as 525 families failed to pay up even after receiving the lawyer's letters. Even after judgment was entered at the Small Claims Tribunal, 145 families were unable to pay up the arrears, of which 129 families were from the 3-room or smaller flats, accounting for 0.5% of the flats under the Town Council. The amount owed amounted to approximately $50,000.

Although the $50,000 in bad debts is not a large amount, the town councils are actually charging only minimal amounts for service and conservancy charges from the residents. We have to work very prudently to save on our expenses. In a year, we are in deficit for more than one million dollars. So if we do not have the subsidy of more than one million dollars from the Government annually, the town council will surely encounter great financial crisis. Therefore, if we want the town council to play the role of a charitable or welfare organisation by being responsible for these bad debts, then surely it will make the town council's burden even heavier.

So I suggest the Ministry of Community Development investigate into the plight of these poor families who cannot afford to pay their conservancy charges, and help those who are genuinely having financial problem by paying the arrears owing to the town council on their behalf or encourage some charitable or welfare organisations to offer them some financial aids. However, upon investigation, if MCD discovers that certain families have the means but refuse to pay up, they should inform the town council and we will take very stern legal action against these families. By so doing, we can avoid having the majority of our residents bearing these large sums of bad debts, as it will not be fair.

The Minister of State for Community Development (Dr Seet Ai Mee): Sir, I will address the enquiry of the Chairman of the GPC on Community Development on the Women's Welfare Unit. Last year, I informed the House that my Ministry was setting up a Women's Welfare Unit. It was set up on 1st April, 1990 and serves as a point of contact for women in need of assistance, whether it be with marital problems, single parenting or unwanted pregnancies. Officers of the Unit assist distressed women who call at the Ministry for assistance to think through their problems and decide on possible courses of action. They provide information and referral services and for those who qualify and are in need of financial assistance, financial assistance is given.

The most common problems faced by unmarried and single mothers are financial difficulties, child care, child management and assistance for their schooling children. MCD's officers work with these mothers and help them sort out their needs. They are then referred for further counselling and help to agencies such as Canossaville which runs a "Help Every Lone Parent (HELP)" Family Service. Muslim women are referred to PERTAPIS and Young Women Muslim Association. There are a large number of voluntary social service centres and other organisations which provide financial assistance and child care.

Divorced women seek legal advice on maintenance, custody of children, property matters and housing. My officers make a first attempt at reconciliation and where professional counselling is required, the women are referred to one of the VWOs' counselling centres. Examples are the Counselling and Care Centre, 800 Counselling Care and PERTAPIS. We refer those who need legal advice to the Legal Aid Bureau, Subordinate Court or Shariah Court and for free legal counselling to Legal Aid, Singapore Association of Women's Lawyers, the Singapore Council of Women's Organisations, the Muneeswaran Temple Legal Service and JAMIYAH.

Rape victims who seek assistance from the Unit are advised firstly to make a police report. Rape is a criminal offence and the Police would take action to prosecute the rapist. They are also advised to undergo a medical examination and discuss their problem with the Medical Social Worker in the hospital. To help them cope with the trauma, they are then referred to counselling agencies, such as Samaritans of Singapore (SOS), Counselling and Care Centre, 800 Counselling Centres and AWARE's new Helpline which was inaugurated a fortnight ago on 8th March. They are also referred to the appropriate agency for free legal advice and some rape victims are also referred to the Pregnancy Crisis Service run by the Family Life Society.

For the Member's information, between April and December 1990, 105 women called at the Unit to seek assistance. These were mainly for marital problems. 41 of the women whom the Unit felt could be better helped by other agencies were referred accordingly. 848 women called the Unit for information on legal matters. They were also assisted and referred to the relevant organisations for legal advice.

Currently, the Women's Welfare Unit in my Ministry is compiling a directory of services for women which highlights various programmes and services provided by the Government, community and voluntary welfare organisations. This will be published soon and made available to all organisations concerned with the welfare and concerns of women. In addition, Sir, public educational pamphlets on current social issues affecting women such as violence at home, assistance for single parents and services for unwed mothers are being prepared for distribution to the public. 12.45 pm

Mr Chairman, Sir, Encik Abdullah has asked about the Skills Training Scheme for low-income families. My Ministry is working on various measures to help low-income families. However, I would like to say that the Government can only create the conditions and opportunities for families with low income and low skills to upgrade themselves. It is really up to the individuals themselves to take advantage of the opportunities that Government has created. Our effort to help low-income families upgrade themselves so far has had limited success mainly because those who need help do not want to help themselves.

Let me give a few examples. In August last year, MCD liaised with the Vocational and Industrial Training Board (VITB) to offer training places to children of low-income families below 20 years of age with at least Primary 6 education. VITB wrote to 31 persons and invited them to attend a briefing on its training opportunities. Only one person responded and even he declined subsequent training offers. On another occasion, VITB offered training placement to two persons. Both declined, one citing distance of training place from his home, the other claimed that he had found employment.

In another instance, my Ministry worked with a private contract cleaning company to conduct a two-week housekeeping operatives course in November. The course was specially designed and conducted by a consultant firm engaged by the company. There were 15 trainees, of which seven were referred by the Ministry. These trainees were carefully selected by our officers through personal interviews. The rest were the company's employees. The company placed the seven MCD trainees on its payroll and agreed to pay $420 per month as starting pay, with increments after completion of training. Transport was also provided from pick-up points. All the seven MCD trainees failed to turn up for training on the second day. Our officers made follow-up home visits to their homes and managed to persuade one of them to resume training. The rest of the trainees gave various excuses such as low pay and distance from training site as reasons for dropping out. The trainee who resumed training, a 17-year old girl, had to be constantly coaxed and counselled to remain in the programme. At one stage, she refused to continue as her mother was not keen on her getting gainful employment, although the mother herself was unemployed. Our officers had to counsel the mother as well. Under our officers' close supervision, the girl has now completed her training and is drawing an income of $750 per month. Despite this good wage, she is still wanting to quit work. Our officers are still counselling her.

In a situation of full employment in Singapore, there is no lack of jobs for Sin-gaporeans. Singaporeans who remain unemployed do so because of two main reasons. One is a lack of basic education. That can be corrected. VITB runs Basic Education Through Skills Training (BEST) classes which provide basic education for this purpose. The other reason is a lack of will. This is more difficult. We can provide all the opportunities but if the will is not there to take up the opportunities given, there is little that we can do. There is a well-known saying which goes: "We can bring a horse to water, but we cannot make it drink." Although we must be realistic and practical, we are also cautiously optimistic.

We will give the Skills Training Scheme another try. We will set up a centralised training centre to provide motivational counselling and an orientation programme on job training to potential trainees who come from low-income families. We are working with the Counselling and Care Centre, a voluntary welfare organisation, to conduct the first motivational counselling class. We would also like to encourage corporations, voluntary welfare organisations and others in coming to help in providing opportunities to help the poor help themselves.

Mr Chairman, Sir, Encik Abdullah, Mr Chay and Mr Peh have raised the issue of the Rent and Utilities Assistance Scheme (RUAS). The RUAS is another example of the national shared value of Regard and Community Support for the Individual. There are groups and individuals in the community who want to help others in hardship. The Government will encourage and help them to do so. There are many community and voluntary organisations in Singapore set up with the objective of helping families in hardship. My Ministry felt that it would be advantageous to involve them from the very start in the Rent and Utilities Assistance Scheme. We met with the HDB and the Singapore Council of Social Service (SCSS), which is the umbrella body for many voluntary welfare organisations in Singapore, and we worked out the implementation of the Scheme. SCSS obtained the support of 15 of their member organisations to operate the Scheme under their guidance. SCSS receives referrals from the HDB and, with the help of the VWOs, investigates each case to determine the assistance needed. Each case is then means-tested. The VWOs then follow up on the families. They assist, counsel and help them get back on their feet. They help the families to build up the inner strength to cope with social difficulties.

The Rent and Utilities Assistance Scheme is different from the Public Assistance (PA) scheme administered by Government. Very strict criteria are used to determine eligibility for Public Assistance. Under the PA scheme, Government provides financial handouts to destitutes and destitute families with no resources of their own, or no support and assistance from family and friends. The majority of PA recipients are single persons. The Rent and Utilities Assistance Scheme, however, is meant to help lower-income families who, although having an income, are unable, through special circumstances as an illness, or disability, to keep up with their rent and utilities payments. The scheme is meant to help them temporarily until such time as they can get back on their feet. The financial assistance is given for a period of three to six months, in the first instance, and is then reviewed. Financial assistance to pay rent and utilities is only one aspect of the help that they need. They also require much counselling and guidance.

Our Ministry obtained funding from the 25th Anniversary Charity Fund to operate the RUAS scheme. An initial sum of $1 million has been given and the Singapore Council of Social Service implemented the scheme in October last year. As at 1st March this year, 144 families were referred by HDB. 68 were approved for assistance, 32 were rejected as they had the means to pay. Eight families declined assistance, as they preferred to seek assistance on their own or from relatives. The applications of the remaining 36 families are being processed. The RUAS is not a scheme to give hand-outs to the indolent and those who do not want to work.

In Singapore, an able-bodied person has no difficulty getting a job. He can walk into one any time. The Rent and Utilities Assistance Scheme is intended as temporary assistance to allow our voluntary welfare organisations to work with those temporary needy families to help them to again stand on their own feet.

The Chairman: Dr Seet, we are running out of time on this amendment.

Dr Seet Ai Mee: The Member for Jalan Besar GRC spoke about his Town Council's difficulty in getting low-income families to pay conservancy charges. May I suggest that for those who do qualify for the Rent and Utilities Assistance Scheme, he refers them to the Singapore Council of Social Service and takes advantage of the scheme available. But I would also like to make a point here that in these cases of Town Council arrears, there are many who are not in hardship. There are very few genuinely hardship cases, most can pay. From our experience in the Ministry, we have discovered that a high percentage will not pay and just hold on until they are chased to pay.

Mrs Yu-Foo Yee Shoon (Yuhua): Mr Chairman, Sir, following the 1984 recommendations of the National Task Force on Female Participation in the Labour Force, the Government took various steps to increase the number of child care centres in Singapore. These resulted in a sharp increase of child care centres by over 400%, from 48 centres in 1984 to 221 centres in 1990. It is projected that 350 centres will be needed by 1995.

Statistics show that nearly all our children attend kindergarten, child care pre-school, nursery classes before starting formal schooling. Consequently, about 4,500 trained kindergarten and child care personnel will be required to work in existing and new kindergartens and child care centres by 1995. Based on past experience, around 15% to 20% of the teaching force would either resign or retire each year. Hence, we need to train a few hundred persons each year to fill the vacancies.

Sir, there is currently very little formal training on early childhood education available in Singapore. Only three organisations, the Institute of Education, NTUC Child Care Services and Kinderland Educare Services provide pre-service and in-service child care training. Due to a lack of trainers, a Master's Programme in early childhood education will be conducted by NTUC and a USA college, with the assistance of MCD in Singapore. However, such a programme is only ad hoc and to solve the urgent need for trainers. Presently, the Institute of Education conducts the bulk of the training at the basic, intermediate and advanced levels. When the National Institute of Education becomes part of the Nanyang Technological University, the Early Childhood Department will merge with another department. Therefore, I would like to know what arrangements would be made for the training of kindergarten, nursery, pre-school and child care staff in the new context.

Sir, formal education in Singapore has always assumed great importance. Likewise, we should not treat early childhood education as any less important. From a national perspective, we need a long-term training strategy in order to have quality early childhood services for our children.

I agree with the Ministry of Education that kindergarten, nursery, child care and pre-school education should be run by the private sector. In fact, most of them are run privately. However, owing to their lack of resources and expertise, they are unable to undertake the training of teachers on a sufficiently large scale. I would like to stress that the training provided in the private sector by Kinderland and NTUC Child Care Services can only supplement the efforts of the Government. Because of a lack of coordination and centralisation in these training programmes, uneven quality of early childhood services may result.

It is time the Government played a pioneering role in providing proper training facilities for kindergarten and child care personnel. An environment for greater training opportunities and professionalism is needed because it would solve the problem of having to go overseas for a higher level of early childhood education, which can be unaffordable to most people. It would attract and encourage school leavers to choose a career in early childhood care. It would solve the problem of the training of existing staff. Finally, a well-trained teacher would be able to educate a child to his fullest, and early moulding is crucial to the development of a child.

In conclusion, Sir, as we know, almost all developed countries and countries in Asia, like Japan and Taiwan, have extensive train ing for all levels of early childhood education. Being a modern country, we should accord our early childhood training the needed emphasis. I would like to suggest that the advanced Early Childhood Education be conducted at the National Institute of Education at two levels. Firstly, to prov ide a programme leading to an undergraduate and post-graduate degree and, secondly, to introduce some extramural courses for a more elementary training. Our polytechnics can also consider providing a diploma course in early childhood education. This has been done in Hong Kong. Having said all this, I would like to ask the Minister if there are any long-term plans on early childhood training in Singapore?

Dr Seet Ai Mee: Mr Chairman, Sir, it would have been better if the Member for Yuhua had raised her questions in the debate on the Education budget as IE, the polytechnics and university are all under Education.

I would like to assure the Member for Yuhua that Government has not left the training of child care personnel to private organisations. Since the Government embarked on the development programme for child care centres in 1985, the Institute of Education has been providing for the training of child care centre personnel. 1.00 pm

In 1985, the IE, together with our Ministry, developed and implemented a three-tier child care training programme and, since then, the IE has been conducting child care courses regularly. Between 1985 and 1990, 79% of the trainees received their training at the Institute of Education, ie, 1,906 trainees, 275 or 11.4% were trained by Kinderland and the remaining 229 or 9.6% were trained by NTUC. Those private organisations which are providing training have to assure the Ministry of acceptable standards of training and the Ministry has an Accreditation Committee which makes recommendations to the Ministry on the applications made by various organisations for accreditation as training agencies.

However, I do agree with the Member for Yuhua that we should look beyond IE and the private training organisations for child care training. In the longer term, when large numbers of children are in child care centres and there is greater need for child care teachers, and most child care teachers are trained at basic, intermediate and ad vanced levels, we will need to provide higher level training at diploma level for child care teachers who want to upgrade themselves. This will provide for career development opportunities. However, it will not be cost effective to develop a Masters programme at University level in the next 5-10 years. It is unlikely that there will be a demand for such a programme. It may be not only more cost effective, but also a mind broadening and life enriching experience to send persons who are interested in tertiary level training to do so in reputable institutions overseas.

I shall, nevertheless, bear in mind the views of the Member for Yuhua in the planning for higher level training for child care personnel and bring it up at the Committee I shall be chairing under the Ministry of Education to look into the provision of training for pre-school teachers and care givers. I made mention of this to the House in answer to Dr Beng's question at the debate on the Ministry of Education's budget.

Mr Abdullah Tarmugi (Siglap): Sir, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

The Chairman: I would like to remind Members that the guillotine time for this Head is 1.35 pm and we are behind schedule. Amendment No. (4), Mr Chay, three minutes.

Mr Chay Wai Chuen: Sir, I beg to move,

That the sum to be allocated for Head J be reduced by $10 in respect of Code JD 2510 of the Main Estimates.

Sir, this is on social transfers. The figure shown for the year under review is $3.75 million, which is a decrease of about 24.7% over last year. I gather that the Minister has raised the rates for public assistance. Can the Minister explain the reasons for the decrease?

Dr Seet Ai Mee: Sir, the reduction in provision for social transfer from $4.976 million in FY 90 to $3.746 million in FY 91 is mainly because of a lower provision for Public Assistance (PA) allowance. The actual reduction under PA for FY 91 is $1.35 million. Currently, about 900 aged residents staying in voluntary Homes for the Aged are receiving public assistance. The bulk of the allowance goes towards meeting part of the operating costs of the Homes. This allowance will be withdrawn when the voluntary Homes for the Aged receive funding under the new Government financial assistance scheme to avoid double subsidy. Hence, the reduction of overall provision of Public Assistance allowance for FY 91.

We have set aside $2.86 million to provide for the care of the 900 destitute aged in the Homes. This is a little more than double the reduction of $1.35 million in the Public Assistance provision. This amount is included in the sum of $8.89 million under Grants and Subventions to Voluntary Organisations for Services to the Aged. What surprises me is that the Member for Brickworks GRC picks out the $1.28 million decrease in social transfers and fails to see the $12.103 million increase in Subventions to local organisations, ie, from an actual expenditure of $16.8 million to the budgeted amount of $28.9 million, an increase of $12.1 million or a 71.9% increase.

Mr Chay Wai Chuen: Sir, may I be permitted to reply? The category on subventions may include social transfers. All social transfers are part of subventions, but not all subventions are part of social transfers. Therefore, the category on social transfers should be correctly reflected to indicate correct work load and performance indicators.

Dr Seet Ai Mee: Sir, subventions are reflected very clearly in the budget book. If the Member had very clearly looked into them, he would have noted the large increase in subventions for the Homes for the Aged.

Mr Chay Wai Chuen: I thank the Minister for her reply and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

The Chairman: Amendment No. (5), Mr Chay.

Mr Chay Wai Chuen: Sir, as the Minister has answered my query on this subject, I do not wish to move this amendment.

The Chairman: All right. Amendment No. (6), Dr Lee Siew-Choh. We have only five minutes for this amendment.

Dr Lee Siew-Choh (Non-Constituency Member): Sir, I beg to move,

That the sum to be allocated for Head J be reduced by $10 in respect of Code JE 1500 of the Main Estimates.

Sir, this is on the subject of Feedback Services. The Feedback Unit has been in operation for quite some time. It holds regular feedback forums with invited representatives from professional bodies and associations as well as PAP grassroots organisations. Perhaps some people may have asked on their own to attend such forums to air their views. But, in general, such feedback forums are formal affairs and the man-in-the-street is not represented. He may not even know that such a unit exists. From time to time, the MP in charge of feedback services may, as part of his speech, give the House a short summary on some of the views he has gathered. But, ultimately, what has resulted from the feedback? That is what I like to know.

According to Mr Chandra Das, the Head of the Unit, feedback is not simply a one-way feedback from the people to the Government, but a two-way process. The unit also explains and helps to clarify Government policies to those attending the forums. It is therefore more a Government PR exercise than a gathering of feedback on people's reactions to Government. It is all cosmetic. The basic principle and premise behind any major Government proposal remains unchanged whatever the feedback. In order that feedback forums be more representative of people's views, I suggest that the feedback forums be open to wider sections of the people. They should not be closed door or semi-closed door affairs. May I suggest that:

(1) Participants need not be those who are specially invited to attend;

(2) Views given by those who attend the forums should, without exception, be available to all people who are interested and would like to read them;

(3) Government's response to the views gathered in the forums should also be published;

(4) Since the Government now sponsors open participatory democracy, uncensored summarised proceedings, especially of views expressed by participants, should also be publicised over TV.

Would the Minister consider these suggestions, Sir?

The Minister for Community Development (Mr Wong Kan Seng): Obviously, Sir, Dr Lee has not been following the subject of Feedback Unit and the reports in the newspapers. All the things that he has suggested have actually be done. It is not just getting views from the grassroots organisations. Anyone can write to the Feedback Unit. Anyone can walk into the Feedback Unit, phone up the Feedback Unit or fax messages to the Feedback Unit. There is no restriction. Let me say again that there is no restriction on anyone wanting to give their views to the Feedback Unit.

All the views that have been collected during the feedback sessions are summarised and, at times, they are also publicised. One example, I think he must have forgotten this, is the session on the Environment Ministry officials meeting the hawkers. It was widely publicised. The session on weekend car scheme was widely publicised. And the views expressed by the people attending these sessions had been summarised and submitted to the Ministries concerned. In fact, the Minister for Communications himself participated in the session, and many of the views which were put forward were accepted by the Ministry when it considered the weekend car scheme and announced it in the papers. So I do not know what precisely Dr Lee is griping about. If he thinks that his views have not been publicised or have not been heard, do so in this House. If he thinks that there are people who wish to take up issues with the Feedback Unit and have not been able to do so, let me know about it. I will look into it.

Dr Lee Siew-Choh: Sir, on a couple of occasions, I did ask Mr Chandra Das whether we could get the summarised proceedings of such feedback forums, but I was told I would not be able to get them.

Mr Wong Kan Seng: If other Members of Parliament do not routinely get a copy of these views, why should Dr Lee get one?

Dr Lee Siew-Choh: That is the point, Sir. What I want is that these proceedings should be publicised and be avilable to everybody, whoever wants it.

Mr Wong Kan Seng: Whenever a session is held and when there is a need to widely publicise it, it is always done.

The Chairman: Do you wish to withdraw your amendment?

Dr Lee Siew-Choh: I half withdraw, Sir.

The Chairman: You either withdraw the amendment or I have to put it to a vote.

Dr Lee Siew-Choh: I withdraw, Sir.

Amendment, by leave, withdrawn.

Mr Chay Wai Chuen: Sir, I beg to move,

That the sum to be allocated for Head J be reduced by $10 in respect of Code JF 3100 of the Main Estimates.

Sir, the topic is on the upgrading of community centres (CCs). Many community centres built in the late 70s and early 80s were not so architecturally aesthetic and attractive compared to many of the so-called new generation CCs. Community centres' management committees and the People's Association are facing difficulties in trying to attract more people to participate in the activities of these CCs. These older CCs face competition from the new generation CCs in terms of comfort and facilities.

Presently, the PA through the Ministry of Finance gives dollar-for-dollar grants for extension building funds. There is no such dollar-for-dollar funding for upgrading, renovations, fixtures, etc. Yet, the upgrading of facilities is important to answer to the needs of modern Singaporeans. I sincerely hope that the Minister can respond positively on this.

The Minister for Labour (Mr Lee Yock Suan): Sir, I am responding in my capacity as the Deputy Chairman of the People's Association. 1.15 pm

There are 75 modern community centres in Singapore. The vast majority were built in the 80s. In other words, they are 10 years old or newer. The majority are still relatively new and I think adequate for their purpose although, as the Member has said, expectations are rising. I think it may not be so important to make the buildings aesthetically attractive so long as there are good activities which will attract residents to come and take part. As I have mentioned last year, the key factors really are what activities should go on in the community centres and who are the people who are attracted to come and organise activities for like-minded participants. That is one area where I feel we should all put in further efforts to make the community centres focal points of activities within the regions where they are located.

Some of the centres which were built in the 1970s do not have the finishes and equipment normally found in modern community centres. I therefore agree that some may need to be renovated and furnished to bring them up to date. So the questions are: to what extent should we do it and who should bear the cost? My officers in the PA are studying this issue and discussing with the Ministry of Finance.

For the construction and expansion of modern community centres, the formula for cost sharing is set and already familiar to Members. There is no change. For major repairs and renovations of old community centres, a cost-sharing formula has to be settled with the Ministry of Finance.

Mr Chay Wai Chuen: I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Encik Abbas Abu Amin (Pasir Panjang GRC): Sir, I beg to move,

That the sum to be allocated for Head J be reduced by $10 in respect of Code JG 3100 of the Main Estimates.

Sir, the report of the Advisory Council on Sports and Recreation (ACSR) was made public in early 1989. Yesterday, the Minister briefed the House on the implementation of those programmes.

Sir, one of the three major themes of the ACSR's report states, "Nation building through international champions". What I would like to know, Sir, is this: Are there special programmes being coordinated between the Singapore Sports Council, the Ministry of Education and the National Sports Associations for the training of Youth Development Programme for selected sports already identified by this ACSR.

During the last budget session, the Minister of State, Dr Seet Ai Mee, mentioned the formation of a special committee to look into the Sports Excellence Programme. Could we know what has been achieved through this special committee?

Mrs Yu-Foo Yee Shoon: ( In Mandarin): Sir, I would like to support my Parliamentary colleague, Encik Abbas' concern for the development of sports in Singapore. As a developing country, we have been trying very hard in the past to create more work so that our people would have a job and a house to live, but with the raising of our standard of living and our educational level, our people's demand for sports facilities has been enhanced. In order to popularise sports activities, I must say the Singapore Sports Council has done a lot. As we all know, we have many public swimming pools now. Almost every housing estate has its own swimming pool. Compared to some of our neighbouring countries, we have done well.

However, the more important thing is that we are talking a lot about national consciousness. I believe that sports activities play also a very important part in building up our national consciousness. When we send our competitors abroad to compete in international competitions, they do more than competing in skills, sports and physical fitness but, more importantly, they represent our whole nation, irrespective of their racial, cultural and religious backgrounds. So when our team competes with others, we will very naturally identify ourselves with them. Our patriotism is developed naturally. For this reason, I hope that while we are promoting sports activities, we should not neglect this point, that is, how to develop some strong national teams, in other words, to professionalise our sports activities. Take, for example, our soccer team. Previously, at the football matches, many workers, many young people follow them enthusiastically.

The Chairman: Madam Yu-Foo, we are running out of time.

Mrs Yu-Foo Yee Shoon: ( In Mandarin): I will just have a few more sentences to say. I believe Singapore now has the means to support a professional team. I would like to ask the Minister what plan he has to build up a strong professional team.

Encik Ibrahim Othman (Bedok GRC): Sir, since time is running short, I just wish to ask the Minister what kind of support the Ministry can provide to our National Sports Association and constituency sports clubs in the area of: (a) administration, (b) technical expertise, (c) facilities, and (d) finance.

Dr Seet Ai Mee: Sir, in answer to Encik Abbas' query about the Sports Excellence Committee, the final report of the Committee has been prepared and is awaiting Mr Chiam's comments before it is confirmed and released. So until Mr Chiam's comments are received, we will not be able to show you a copy of the Report.

I would like to take all three questions from Encik Abbas, Mrs Yu-Foo and Encik Ibrahim together. All three have referred to the situation of sports excellence. Let me assure Encik Abbas that there are currently eight schemes in schools with the Sports Council and these schemes for improving sports excellence in schools and among our young are on-going and we are thinking of introducing new schemes wherever possible.

Let me also address Mrs Yu-Foo's question on professionalism in sports. Yesterday, the Straits Times highlighted the fame and earnings top footballers can achieve. The choice of whether or not to develop one's potential and excellence fully in sports is clearly a personal one, and I am sure a very difficult one for sports persons. The question is not whether NSAs or SSCs or SNOC would do the job. The question which every young person has to ask is: Where is my future going to be? In sports as a profession or in a normal profession or vocation? My guess is that most Sin-gaporeans would opt for the latter. Allow me to quote Quah Kim Song from yesterday's Straits Times Life Section. He said:

'If you can excel in your studies, then concentrate on them. Academic qualifications are more permanent. You can fall back on them. In football, the most you can last is up to 35 years of age.' This is from one of our top football stars of the last decade. You may argue that it is a chicken and egg problem. We need to create professionalism in order to generate spectator and commercial interests. But, the question we ask is whether the Government should pump resources to develop professionalism. I do not think it is the Government's role to do this. We should leave it to the market to decide.

Encik Ibrahim has asked about constituency sports clubs. Constituency sports clubs are meant not to establish excellence in sports, but they are part of our sports-for-all programme at the constituency level. Therefore, constituency sports clubs play very limited roles in developing sports excellence. They just build the base of the pyramid so that as the pyramid gets bigger, we will have a higher apex and therefore larger numbers of young people who are excellent in sports.

Finally, he asked about the National Sports Associations and the assistance from Government. I would like to assure him that NSAs get a lot of assistance in the development of sports excellence from the Government and from the Singapore Sports Council. Besides the Singapore Sports Council, other establishments, such as the Singapore National Olympic Council, Ministry of Education, MINDEF, commercial firms and the mass media have a part to play in promoting sports excellence, and we should give them the opportunity to do so.

Encik Abbas Abu Amin: I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

Encik Ibrahim Othman: ( In Malay): Sir, I beg to move,

That the sum to be allocated for Head J be reduced by $10 in respect of Code JH 3100 of the Main Estimates.

Firstly, I would like to applaud the Muslim Religious Council's decision to proceed with haj pilgrimage administration this year. Although the decision was made rather late, there is still time to make the necessary preparations for this year's season.

In view of the recent crisis in the Gulf, I would like to know what security measures are being taken by MUIS to ensure the welfare and safety of our pilgrims. Secondly, can we send more welfare officers to Makkah to look after the safety of our pilgrims. Could the Minister also elaborate on the other preparations made for this year's haj pilgrimage for the benefit of our pilgrims over there?

Next, I would like to deal with the 'madrasahs' or Islamic schools. We know the madrasahs play an important role in the Islamic education of our children. In line with the rapid development in the country, the madrasahs are also offering secular subjects like English, Science and Mathematics, beside religious subjects. This is to enable madrasah students to find a job after completing school. I would like to find out from the Hon. Minister what long term plans MUIS has to upgrade the madrasahs to a standard equal to ordinary schools. In my view, MUIS could provide assistance to the Islamic schools in the following areas: firstly, getting qualified people as teachers, secondly, professional training for teachers to upgrade their performance, thirdly, streamlining a curriculum of equal standard to that of secular schools for all madrasahs, and, fourthly, financial assistance to provide more conducive study facilities. I hope with MUIS assistance we would be able to enhance the standard of education in the madrasahs.

Encik Wan Hussin bin Hj Zoohri (Aljunied GRC): Sir, without going into details, I would just like to ask the Minister that in the light of the increased volume of financial transactions in MUIS, whether it is not timely for the Minister to consider seriously the appointment of a qualified accountant. So far, MUIS has only relied on a financial officer of an Executive Officer's status.

Encik Abbas Abu Amin: ( In Malay): I would just like to ask, in addition to the queries raised by Mr Ibrahim Othman, what is the progress of Phase III of the Mosque Building Programme.

The Minister-in-charge of Muslim Affairs (Dr Ahmad Mattar): ( In Malay): Mr Chairman, in response to Encik Wan Hussin's question whether MUIS would engage a full-time accountant, the answer is no. For the moment, MUIS does not require the services of an accountant. However, MUIS has recently recruited an officer with accounting and financial knowledge to beef up its Finance Section.

Next, on this year's pilgrimage, Mr Chairman, in particular the safety of our pilgrims. With regard to the safety of pilgrims, the Saudi authorities have publicly stated that they will beef up security in Makkah, Madinah and other holy places during the pilgrimage season this year. They have assured pilgrims that they should not be worried about the security situation in the Holy Land.

On its part, MUIS will continue to provide medical and welfare services fo Singapore pilgrims. MUIS proposes to send a team of 4 doctors and 12 nursing officers to accompany the pilgrims. The travel agents appointed to bring pilgrims on the pilgrimage are required to provide their own Welfare Officers to look after their pilgrims. Nevertheless, MUIS will also send 6 Welfare Officers to assist in the overall supervision.

As for religious education in the madrasahs, a common syllabus for the primary level has been completed. It will be fully implemented with effect from 1st January next year. The syllabus for secondary level is being prepared now. A common syllabus has also been drawn up for the part-time madrasahs and this was implemented on 1st January this year in all part-time madrasahs. Over the years, MUIS has organised various training courses and workshops to upgrade the teaching skills of madrasah teachers. For example, this year MUIS will hold workshops on the teaching of English and Mathematics. To make certain that teachers put into practice what they have been taught, MUIS will soon be conducting classroom supervision of the teachers to maintain a high standard of teaching. 1.30 pm

Mr Chairman, I will now reply to the points raised on the Mosque Building Programme. Based on current collection, MUIS' projection, made in 1989, shows that it would take up till 1992 to pay the construction of the remaining mosques under Phase II of the Mosque Building Programme. In January last year, MUIS launched a campaign to encourage Muslim employees, pensioners and the self-employed to increase their monthly contributions to the Mosque Building Fund. However, the response to this appeal was very disappointing. The amount of contributions to the Mosque Building Fund increased to only about $3.8 million or 9.9% over the previous year's collection of about $3.5 million.

Mr Chairman, if the cost of land and construction for each mosque is about $7 million, MUIS will require $42 million to build the new Masjid Alkaff Kampong Melayu and the five mosques in Bishan, Serangoon, Choa Chu Kang, Pasir Ris and Bukit Panjang New Towns to be built under Phase III. Since appeals to Muslims to voluntarily increase their monthly contributions to the mosque Building Fund have not drawn positive response, we may have to consider increasing the minimum monthly contribution stipulated in the Administration of Muslim Law Act. This matter is being closely studied right now. And since there is a shortfall in the Mosque Building Fund, MUIS may have to build the mosques under Phase III one at a time.

Encik Ibrahim Othman: I thank the Minister for his explanation and beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The sum of $136,086,970 for Head J ordered to stand part of the Main Estimates.

The sum of $68,528,000 for Head J ordered to stand part of the Development Estimates.

Head P -

The Chairman: Head P - Ministry of Health - Amendment No. (1). Dr Hong Hai.

Dr Hong Hai (Bedok GRC): Sir, I beg to move,

That the total sum to be allocated for Head P of the Main Estimates be reduced by $100.

Sir, I would like to begin by congratulating the Health Minister and his very competent staff in the Ministry of Health (MOH) for having achieved, over the years, so much in health care with so little money. According to MOH's statistics, the Singapore Government spends only about 1% of the country's GDP on health, compared to an average of about 6% in Europe, USA and Japan. The country as a whole spends less than 3% of GDP on health, compared to 6 to 11% in these other countries.

Yet we enjoy an average life expectancy of 74.2 years, comparable to that in other countries. Our infant mortality rate at about 6.6 per one thousand live-births is also among the lowest in the world.

How has the Health Ministry worked such magic? Or is there a catch somewhere?

First, I would like to dispel a myth, which is that we need to spend so little because we are very efficient. It could be that we are more cost efficient than some other countries. But the correct comparison should be with other Ministries in Singapore. If all other Ministries in Singapore - Communications, National Development, Education, etc - were just as efficient as the Ministry of Health, and I think they are, then the small 1% of GDP that we are spending on health can only mean that health is not being accorded the same relative priority in Singapore as in other countries.

Sir, leaving aside the subject of statistics, let us ask a more fundamental question. Are we satisfied with the state of health care for Singaporeans? Is it commensurate with the excellence we have achieved in communications, in education, and in housing?

Although the standard of health care is generally satisfactory in Singapore, I would like to suggest some areas that need more attention and more money.

First, hospitals. Some of our public hospitals are not in a good state of repair. These include Tan Tock Seng Hospital, Alexandra Hospital, and Woodbridge Hospital. I am glad to know that these hospitals will be rebuilt over a period of some years. But this should have been done years ago. I hope the current programmes could be accelerated and perhaps be more ambitious.

Tan Tock Seng Hospital is the national centre for neurosurgery. The condition of the wards in this hospital does not do us proud. I understand that in one of the buildings some time ago, a ceiling fan fell from lack of maintenance and repair.

My GPC visited Woodbridge Hospital recently. We were impressed with the dedication and efficiency of the staff. But we sympathised with the meagre resources available to them. Woodbridge is the largest hospital in Singapore. It has more beds than Singapore General Hospital. It belongs to the 1940s and 50s, not the 90s. Yes, a new hospital is being planned. But why have we left the present hospital to decay? I saw corroded grilles - grilles to hold in psychiatric patients - that could have been pushed down with a child's hand. The wards were crowded. The floors were stark cement most of the way. We are not talking about the beautiful granite and marble that we lavished on our MRT stations. Modest ceramic tiles would have sufficed. Our mentally ill patients deserve better.

Secondly, primary health care. I understand that this is receiving more attention now. And it should. To use a car analogy, better that we maintain a car regularly than spend enormous amounts on repair later. Our hospitals are basically repair shops for broken down bodies. My GPC would like to see more effort on educating Singaporeans particularly those in the lower income category and the elderly - to live healthier lifestyles, go for regular medical check-ups. Perhaps the Ministry could consider providing mobile check-up vans to HDB estates, regularly promote and campaign for regular check-ups by making them convenient and affordable.

Thirdly, hospital charges. The restructured hospitals have continued to post higher hospital fees. There are three contributing factors, as I understand it. Firstly, the quality of service has become better. Secondly, higher pay to doctors and specialists has been awarded in order to retain their services with the Government. And thirdly, lower subsidies, in percentage terms. There is some evidence that reduced subsidies is a significant contributing factor to recent increases in hospital charges. For example, at SGH, patients paid $94.1 million in 1989 against a total running cost of $190.5 million, that is, they bore about 49.4% of the running cost in 1989. In 1990, they paid $132.1 million against a cost of $213.6 million or 61.8% of the cost, from less than half to about 62%. I would ask the Minister to consider restoring the subsidies to more bearable levels.

The Chairman: Dr Hong Hai, you are running out of time.

Dr Hong Hai: Sir, can I combine my next cut with this one?

The Chairman: No.

Dr Hong Hai: Fourthly, the elderly. The population of our elderly will double in the next twenty years. We must prepare to accommodate them with greater health care needs.

Sir, I am only advocating that we allocate a fairer priority to health care than we have seen in the past. The reason for this is clear. By international standards, too little of our national resources go to health. As a country becomes more affluent, health care becomes an increasing priority compared to housing, communications and public infrastructure.

Sir, I shall be handing out some statistics to the Clerk after the speech, which Members can study at their leisure. But it would be amply clear from these statistics that the nation spends comparatively less on health care than other countries in that the Government subsidises too small a proportion of the total cost of health care compared to, say, housing or communications.

Speaking of housing, I would like to support the principle behind the $5 billion programme to upgrade HDB flats with more toilets and better common areas. But let us not forget that while it is nice to have an extra toilet and better plumbing, it is perhaps more important that when we use the toilet, our own body's plumbing system be functioning satisfactorily.

Sir, on that sanitary note, I beg to move.

The Chairman: I would like to inform Members that I have allocated 135 minutes for discussion of this amendment. And it appears that there will be at least a dozen speeches to be made by Backbenchers.

Dr S. Vasoo (Tiong Bahru GRC): Sir, what is the Ministry's direction on health care? Is its emphasis on preventive health care or on curative health care? I am not sure what is actually the emphasis. With the restructuring of hospitals and efforts in terms of curative medicine, a lot of resources are spent in this direction. I think the Ministry should internally debate this issue and find a balance in the direction it sets with regard to the whole issue of preventive health care.

1.45 pm

Sir, the Minister has in his 1989 debate indicated, and I quote:

'My Ministry places strong emphasis on preventive and primary health care. We are reorganising and further upgrading the primary health service to meet the challenges of the next two decades.'

However, the efforts over the last few years do not point to this direction. There is less emphasis on preventive health, that is, primary health care. It appears that primary health care has received less attention in our health policy and planning.

There are some reasons to support my claim. In the last decade, financial allocation to this sector has been between 10% and 15% of the total health expenditure. For FY 91/92, only $90 million out of $720 million is set aside for primary health care. This accounts for only 12 1/2% of the total health expenditure. At the same time, the number of polyclinics has not grown in proportion to our population's health needs. There are only 18 polyclinics today and many other polyclinics have been run down because of population changes. The number of polyclinics planned does not actually meet the needs of primary health care of our population. The programmes related to preventive health care, such as health screening and diagnosis, have not been significantly stepped up.

Sir, we should not just embark on the course to promote corrective and institutional health care, that is, just building and restructuring hospitals. Medical care should be de-institutionalised. Medical services should be taking an outreach perspective in terms of reaching out to the community where preventive steps in health care can be undertaken. In this respect, I would like to know what steps are being taken by the Ministry to emphasise more on preventive health care?

Dr Tan Cheng Bock (Ayer Rajah): Mr Speaker, Sir, as we restructure our hospitals, we are going to see a shift in emphasis in hospital health care. This is because the philosophy of hospital care has changed. Restructuring has made such hospitals treat each other as competitors. And in such circumstances, there is a tendency for each hospital to emphasise the glamorous and exciting areas of medical and surgical sub-specialties, like transplant surgery, neurosurgery, IVF programmes, plastic and reconstructive surgery. There is yet another tendency, and this is to invest in expensive high-tech equipment, such as Magnetic Resonance Imaging (MRI), which costs $8 million.

Mr Speaker, Sir, high-tech equipment and sub-specialties are two means which should give these hospitals a boost to their image. But such practices substantially increase the total cost of running a hospital and benefit only a small percentage of hospital patients. The bulk of hospital patients are those seeking treatment for common illnesses, acute and non-acute. But because of this shift in emphasis to the high-tech equipment and sub-specialties, the base cost for treatment for these types of common illnesses must invariably increase.

There is now a very perceptible fear of going to hospitals. Twenty years ago when I started practice, patients feared to go to hospital because they were afraid of surgery and there was also a genuine fear of hospitalisation. But now the fear to go to hospital is because they worry that they may not be able to afford the new hospital charges. Let me state clearly. The high-tech and sub-specialties do have a place in medical care provided the public is well informed of their merits. There are many who want it and can pay for it. Our restructured hospitals fill this need. These hospitals serve what I would call the high-end needs of the medical market place. However, the bulk of the patients would rather have good basic care at affordable prices. But when they go to the restructured hospital, they are worried about the add-on costs which can be quite substantial, in addition to their basic charges advertised, that is the ward charges. There is therefore that uncertainty.

Mr Speaker, Sir, to alleviate this fear, I propose that the Ministry of Health re-look at the concept of hospital care delivery system in Singapore. At the moment, the Ministry of Health's plan is to restructure most, if not all, hospitals into high-end care hospitals with emphasis on sub-specialties or disease centre hospitals, like Skin Centre, Eye Centre, Cardiac Centre and Kidney Centre. These are impressive set-ups but cannot be cheap. At the low-end care are the community hospitals, the polyclinics and the private clinics.

Thus, we can see that there is a gap in our hospital care delivery system. This gap can be filled by middle-level care type of general hospitals. These hospitals which will link the high-end care hospitals and the community-level care are important. We should have this linkage. These hospitals can then serve the bulk of patients having common hospital illnesses. And these types of hospitals in fact should be the cornerstone of any good hospital care system. For example, patients with chest pains can be treated in such hospitals with limited intensive care unit facilities. The majority of such cases can go home within two weeks. The minority or small percentage who needs specialty treatment, such as pace-makers, can be referred to the high-end hospitals. The same applies to the basic surgical, medical, gynaecological cases. It is this level of care that a section of the people are now looking for, an affordable general hospital. As this middle-level type of hospital care does not involve expensive modality of treatment, the whole set-up will be more cost effective for Singaporeans. And we as the Government must ensure that this basic choice is available.

My observation is that at the rate and manner our present hospitals are being restructured, we may end up over-providing high-end hospital care. I therefore would like to suggest that there should be a rethink on this exercise. Further, I would like to propose to the Ministry of Health that any new hospital to be built, be it in Jurong or Simei, or any more hospital in the pipeline for restructuring, be it Tan Tock Seng Hospital or Alexandra Hospital, must be middle-level care general hospitals. Moreover, these hospitals must be organised to complement the already restructured high-end hospitals.

At the end of all this, there should be a three-tier level of health care:

(1) a high-end, high-tech sub-specialty hospital care;

(2) a middle-level general hospital care; and

(3) a community-level of care comprising community hospitals, polyclinics, private practice clinics.

Mr Speaker, Sir, one or two of these middle-level general hospitals should be linked to a restructured high-end hospital, and each middle-level general hospital be linked to the community health care institutions by the community hospitals and polyclinics. The general hospital and the community and allied health facilities could then reach out into homes and residential communities of the community health care team concept that I proposed some time ago in this House.

Finally, Mr Speaker, let me make it clear that these general hospitals are not to compete, but to complement the restructured hospitals and, above all, to offer our citizens another choice of hospital care.

Mr Yeo Toon Chia (Ang Mo Kio): Sir, as the number of our aged increases, not only will our health and medical facilities and services be stretched but the problem of adequate residential and nursing care will have to be seriously looked into. It is not uncommon for the residents to seek our help time and again to assist them to find residential care for a frail and aged sick family member. This is an almost impossible task as many voluntary homes take in only those who are ambulant while commercial homes are beyond the means of the average family.

The setting up the Geriatric Department in Tan Tock Seng Hospital, 2 1/2 years ago, is a step in the right direction. However, I feel that this service is not adequate and should be extended to all Government hospitals as soon as possible. And in introducing geriatric medicine to all Government hospitals, beds should also be provided for both geriatric assessment and convalescent care.

Mr Chairman, the objective of my proposing the setting up of a Geriatric Unit in every Government hospital is to cope with our increasing demand for geriatric medicine in our aging population and also to provide a place where the frail and the aged sick can be hospitalised for a period of time and, at the same time, to have an opportunity to be rehabilitated. During their stay in the hospital, the patient will also be able to learn how to rehabilitate himself and, at the same time, his family members must be educated and trained to look after the patient, with the aim to nurse him back to recovery. I believe that a good number of illnesses associated with the elderly sick stand a good chance of recovery if the patient is hospitalised early enough and has an opportunity to undergo a period of rehabilitation in the hospital.

Mr Chairman, the aged are an integral part of our society. The problem must be the concern and responsibility of every one - the family, the community, the Government and the aged themselves. In order that the Geriatric Unit in every Government hospital serves its purpose and not as a dumping ground for the aged, I would like to suggest that the Ministry look into the setting up of a coordinating committee to screen all the applications who seek admission to the geriatric ward in all Government hospitals and only on recommendations by the committee or doctor-in-charge of the unit should the applicant be admitted.

Mr Chairman, the Government has a responsibility of looking after and caring for all its citizens. Government must not be seen as only grooming our young but also show care, concern and compassion for the old and elderly sick who have contributed much to our present progress and prosperity. They have little or insufficient savings because of their low or even no CPF contribution during their years of employment. Is it not time for the Government to be more responsible to look after these elderly sick?

Finally, Mr Chairman, we must be seen to be sharing in the task of looking after our frail and aged sick and not to push this problem to voluntary and commercial homes. I hope the Minister will look into these needs and the problems of our increasing aging population with some urgency? 2.00 pm

Dr Arthur Beng Kian Lam (Fengshan): Mr Speaker, Sir, first, I would like to declare pecuniary interest as I am a medical practitioner.

Sir, the rising cost of health care has been a cause for concern. The patient has been blamed for this, the doctors have been blamed for this, and so has the Government. In the defence of his Ministry, the Minister for Health has stated that:

'The Government policy has always been that the low income group who uses B2 and C will be heavily subsidised and therefore the bills in these wards would be highly affordable.'

The Minister has also said:

'I think it is important for us to realise, and for us to give the right message to Singaporeans that, depend ing on your income level, you should be using the class of ward that is most appropriate to your level of affordability. B2 and Class C will always be affordable.'

Sir, one cannot argue against the Minister that one should choose an affordable class for admission. However, here a problem arises for the patient as medical bills often cannot be pre-determined. Let me give an example to elaborate. A patient is admitted for investigation for prolonged fever - not an uncommon occurrence. He may be admitted as a B1 case, as he or the family may feel that they can afford a one week or 10-day stay with no problem. In the course of his stay, blood tests, X-rays and other specialised tests may be conducted. After about 10 days, he is diagnosed to have cancer and surgery is indicated. Furthermore, after surgery, he is required to have further treatment with anti-cancer drugs (chemotherapy) or irradiation. Suddenly he is confronted with an unexpectedly large bill because of (1) expensive but required investigations; (2) unexpected surgery; (3) costly anti-cancer treatment; (4) prolonged hospital stay (a stay longer than expected).

The point that I am trying to make here, Sir, is that the question of "affordability" is sometimes difficult to assess, as often neither the patient nor the doctor can accurately budget for a case. The process of diagnosis, the response to treatment, and the difficulty in predicting complications all make for difficult budgeting. Thus, affordability is easier to say than to assess. What can the Ministry do to help? Firstly, the Ministry can help by updating the patient or family regularly, eg, at weekly intervals or more frequently when costly services are provided. For the patient in the intensive care unit where it may cost up to $1,000 a day, a daily updating may even be warranted because of the high costs involved. Following a major surgery or procedure perhaps, the patient can be informed of the cost incurred on the fourth or fifth post-operative day. I would like to stress that the patient or family should be regularly updated regarding the cost he has incurred, and not be asked to pay whilst still undergoing treatment. If this is not done, the hefty bill that the patient receives at the time of discharge or after discharge may well shock the patient to death.

Secondly, the Ministry should allow the patient to downgrade himself at any time during an admission when he feels he has exceeded his own budget. This is important also because often there is a cap or ceiling to what the employer or insurance company will pay. When the ceiling is exceeded, at the patient's request, downgrading in ward status should be allowed. I realise that automatic permission to downgrade may be unacceptable to the Ministry as the restructured hospitals have to be profitably run and also to prevent abuse. But surely the hardship cases - and the Ministry has the means to check on this - should be allowed to downgrade.

Sir, Singaporeans are not irrational beings. In last year's budget debate, the Minister mentioned a survey which asked the patient: "Who influenced you in the choice of wards?" The reply: "Own choice - 55%; Family and friends - 20%". The most important factors at the time of admission are thus the patient's and family's choice, making up a total of 75%. They have made an assessment of affordability at the time of admission. Should the illness be more costly in the course of admission, they should (1) be informed of this through regular billings; and (2) they should be allowed to downgrade.

Sir, may I now turn to hospital services and here I would also like to focus on expensive equipment?

The Chairman: Dr Beng, could you please wait for the other Members to finish their speeches first?

Dr Arthur Beng Kian Lam: Yes, Sir.

Dr Wong Kwei Cheong (Cairnhill): Sir, I have three issues for the Minister to consider. Firstly, the best way of reducing expenditure on health care is through a programme of preventive health care and health education. The Government should continuously educate the people on good dietary habits, regular exercises and other activities that help to improve their health. May I ask the Minister what budget his Ministry has allocated for this preventive health care and health education programme and if he can reveal to us some features of the programme and how his Ministry would carry this out? May I suggest that the Government should have more publicity on television and through the mass media on our health care programmes for children, mothers and old people so that they know what services are available to our people and what services are free or at low fees.

The Government should also give full support and recognition to charitable organisations that provide free medical services. The Lions, for example, conduct free medical check ups once a year at the Pek Kio Community Centre in Cairnhill Constituency and this service is very well appreciated by the local residents.

Secondly, I would like to join our GPC Chairman, Dr Hong Hai, in requesting the Minister to work harder and try to get his budget increase to more than 1% of GDP for purposes of health. I do not have the exact figure. Perhaps the Minister can enlighten me. But I understand that even our neighbour, Malaysia, spends about 2.5% of GDP on health. According to the statistics just circulated by Dr Hong Hai, Japan and Britain spend about 4.8% and 5.3% respectively. Surely, the Government needs healthy Singaporeans to run the next lap together and certainly Singaporeans deserve more than 1% of GDP to look after their health.

Thirdly, do we have enough medical personnel to support our hospitals? Can the Minister inform us of the shortfall in nurses, physiotherapists, occupational therapists and doctors in the Government hospitals, including the restructured hospitals? What measures have the Ministry undertaken to address this shortfall problem? If Singapore is to develop into a medical centre of excellence, then we must have enough trained medical personnel, not only for Government hospitals but also for our private hospitals. For example, the doctor to population ratio in Singapore is about 1:791. In comparison, the ratios for West Germany, the United Kingdom and Japan are 1:400, 1:700 and 1:667 respectively. May I ask the Minister what plans the Ministry has to improve the doctor to population ratio so as to provide better medical services to Singaporeans and help Singapore to develop into a medical centre of excellence?

Dr Hong Hai: Sir, Government has in recent years taken a bold step of restructuring nearly all the public hospitals. As I understand it, the restructuring provides each hospital with a certain amount of autonomy in determining its quality of service and its emphasis on specific areas of excellence. As each hospital works towards establishing a reputation for itself, the question arises: does each hospital have a sufficient patient load to justify the number of areas in which it seeks excellence? How do we ensure that expensive equipment is not duplicated in several hospitals and that scarce expertise is not competed for by all these hospitals?

I would like to suggest to the Minister that a long-term strategic plan for restructured hospitals be made up so as to avoid inefficient allocation of scarce resources. I would appreciate the Minister's comments on this.

Dr Lee Siew-Choh: Sir, much of what I had intended to say has already been ably said by Dr Hong Hai. I fully agree with what he has said. So I reserve some time for my next amendment.

Dr Arthur Beng Kian Lam: Sir, the by-words of today are privatisation, market forces and deregulation. While this may work in most sectors of the economy, this may not apply in totality to medicine or the health care industry.

Sir, in a small nation state like Singapore, we cannot afford expensive duplication in the purchase of expensive equipment either in the public or private sector. There must be cooperation instead of wastage, as all "new" equipment is dated, and will be superseded by "newer" second or third generation equipment in cycles that run approximately 3-5 years. Besides cost, there is also a danger of creating an unnecessary demand for services should there be an over-supply situation. This will result in a lowering of professional standards.

The problem should be addressed now, as we are beginning to see a race on the installation of multi-million dollar machines for diagnosis and treatment of various diseases by the various restructured hospitals and private hospitals. The Ministry of Health should now take on a regulatory role which oversees the installation of the equipment and audits the usage of these equipment. The personnel using these equipment must be properly trained. Perhaps a committee comprising members from the Ministry of Health, Medical Council, Singapore Medical Association and the Academy of Medicine should be formed, and the installation of all equipment in excess of $500,000 should first have the approval of this committee.

Mr Choo Wee Khiang (Marine Parade GRC): Sir, a hospital is not only labour intensive but also capital intensive. I was told that it costs about $400,000 per bed in the acute hospital, taking into account the cost of land, building, equipment and all the support facilities.

I am glad to note that the Government is launching a major hospital redevelopment programme to improve the standard of hospital services for all Singaporeans. However, I am concerned that this may further increase the burden of the patients on the rising health care costs, if they are required to pay for the cost of such developments.

In my view, public hospitals are basic physical infrastructures that should be provided by the Government just like roads, MRT, schools and the universities. These are necessary investments for our future and therefore should be fully funded by the Government.

Training of doctors, nurses as well as research and development are also important if we are to continue to improve and upgrade the standard of our medical services. This is in the interest of our nation. We should not leave it to individual hospitals to decide. The Government should take the lead to ensure that there will be sufficient doctors and nurses to meet the needs of its people for years to come.

Sir, I would therefore like the Minister to clarify the basis of the costing of hospital services and whether the patients, in particular, the Class B2 and Class C patients, would be asked to bear the cost of capital development, training and R&D. Also, I would like to ask the Minister whether he has decided to allow Dr Tan Cheng Bock and company to run Alexandra Hospital. 2.15 pm

The Minister for Health (Mr Yeo Cheow Tong): Sir, first, I would like to thank Dr Hong Hai, Chairman of the GPC on Health and my other parliamentary colleagues for their comments and suggestions.

They have touched on a very wide range of topics. Generally, the comments and the questions show that on many of the fundamentals there is a convergence of views. For example, many feel strongly that we should encourage and help Singaporeans to take full responsibility for their own good health. They want Singaporeans to be provided quality health services. That the Government also agrees. They expect these health services to be cost effective, which we also agree. By being cost effective, we can then keep the health care cost, or we can at least help to restrain the health care cost, from going up too rapidly. They also want the health services to remain affordable to all Singaporeans, which my Ministry also agrees.

Sir, my Ministry's policies are directed at helping every Singaporean to take full responsibility for his or her own health. With escalating health care costs the world over, the old saying that prevention is better than cure is never truer. My Ministry is also committed to helping those who fall ill to recover as quickly as possible. This we do at three levels: the primary health level, which is the first line of medical care, the secondary and the tertiary care levels. Dr Tan Cheng Bock has touched on those areas and I will elaborate afterwards.

Sir, I will first address the points and questions on expenditures on health care and hospital services, before asking Dr Aline Wong to reply to the other points.

Sir, Dr Hong Hai and several other Members have correctly pointed out that our national health expenditures are low and, in certain cases, extremely low, compared to that of the developed countries. We as a nation spend about 3% of our GDP on health care. In UK, about 7%, Germany and Canada, about 9%, and the USA tops the bill at over 12%. So in comparison with USA, our budget is extremely low. The question is: which is the most appropriate level of expenditure? Are we underspending? Or are the others overspending?

Sir, there are several reasons as to why we spend less. It is important for us to realise and remember that. Firstly, the figures are not totally comparable. Different countries compile their health expenditures differently. For example, some include expenditures which are really welfare expenditures. Others include environmental and industrial health and other expenditures. So we are not really comparing apples to apples. Secondly, Singapore has a relatively young population. Our median age is only 29 years, and the proportion of the elderly, ie, those people who are over the age of 60, is only 8%. Thirdly, our fee-for-service has helped to curb excessive demand for health care. In Singapore, fortunately, pre-paid medical insurance still plays only a very minor role. Fourthly, it is cultural. I think Singaporeans, by and large, especially elderly Singaporeans, would prefer, if they can, not to be hospitalised. It is only with great reluctance. This is reflected in our admission rate. In Singapore, our admission rate into hospitals is 124 per one thousand population. In the USA, it is 170 per one thousand population.

Sir, the last factor, which is a very important one, is that hospital costs comprise the major component of health care expenditures. For example, in my Ministry, they make up almost 80% of our expenditures. The Government has focused on this area over the years and has ensured that our costs are as low as possible by ensuring that our hospitals are operated efficiently without frills, avoiding proliferation of expensive equipment, and ensuring that the treatment procedures are appropriate and not excessive. The Government provides 80% of hospital services. The inexpensive Government hospital services therefore also act as a brake against what the private sector can charge. So that has also helped to keep the private sector charges lower than what they could have been otherwise.

Sir, when you look at the developed countries, there are several factors there that account for why they spend so much. Firstly, there is a very strong practice of defensive medicine. In the West, litigation is fairly common. So doctors over-investigate. If you go in with a sprained ankle, you are likely to get the whole body scanned in case you fell and damaged other parts of your body. Also, there is an unnecessary hospitalisation for observation as well as a propensity to keep patients in hospitals longer to ensure that they are pretty well before being discharged. There is also a proliferation of medical technologies.

The health care cost, the whole world over, is increasing by between 10% and 15% a year. Unfortunately, for the developed countries, their economic growth rates have been averaging 2% to 4%. The inevitable result is that with every passing year the health care costs eat into the budget that is available, and therefore health care costs as a percentage of GDP or GNP in the developed countries have been increasing steadily year by year. In Singapore, our high economic growth rate has meant that although our health care costs have been increasing at about 10%11%, the share of the GDP can be main- tained at between 2 1/2% and 3%. That is something that we must ensure. Keep our high economic growth at the present level to at least 6% in the future.

Sir, many Members have asked about the expenditures. Let me give you some figures. For financial year 1980, we spent $260 million, which is 1% of GDP. This year our expenditure is $954 million, including the expenditures of the restructured hospitals, so that we are comparing apples with apples. This is equivalent to 1.4% of our GDP. If you take away the restructured hospitals, Singapore General Hospital, Toa Payoh Hospital, Kandang Kerbau Hospital, our expenditure is $722 million, which is equivalent to 1.1% of our GDP. So in terms of the GDP percentage, although we have tried our best, it is still creeping up - 1.4% today.

Sir, whilst the amount of money that is being spent, in absolute terms as well as in terms of percentage of GDP, is important, I think what is even more important is that we must look at how the money has been spent. What kind of values are we actually getting for the money. Dr Hong Hai has quoted some figures, so I would not repeat them. Infant mortality rate and life expectancy - these are two key indicators and we are on par with developed countries.

Sir, in terms of the quality of medical services, I have met or have received reports from many prominent visiting specialists, from the US and from the UK, who have been here on short term assignments or passing through while being here on conferences. Their assessment is that our medical services here are very comprehensive and of a quality that is comparable to that of their home countries. Despite the fact that the percentage of GDP that is being spent on health care by the Ministry has only gone up very little over the years, we have been able to achieve a much higher level of service. Let me give you some other data. It is very important. How much time does the doctor have for the patients? In 1985, just five years ago, in one year we had one doctor to 1,800 patient days. Last year, the ratio had dropped to one doctor to 980 patient days. That means the doctor is able to double his time with every patient. In terms of nurses per in-patient day, in 1985, 450 in-patient days to one nurse; 1990, 410. So in the nursing ratio we have also managed to improve and therefore enable them to give a better service.

Another service is the specialist outpatient clinics. In 1985, each doctor saw about 1,900 patients a year. Last year, the ratio went down to one doctor to 1,000 attendances. So again in that area, we have managed to allocate more resources to each patient. This is well reflected in the waiting time. In Singapore, for an elective surgery, the average waiting time is about one to five weeks, average 12 days. In many of the developed countries, the waiting time is two months to as long as two years in the UK. So in terms of value, I do not think anyone can deny the fact that we have a very good health service even though only 3% of the GDP is being spent on it. We can and should be proud of what we have. But we should not celebrate prematurely and start spending more, just because we appear to be able to afford it. The factors influencing the low expenditures may change. In fact, one factor will definitely change, and that is our population profile. The elderly will double in 20 years and double again in another 20 years. So that one factor will definitely change, and they will create more demand for health services. We therefore have to find more inexpensive ways for treatment as well as to discourage over-usage and over-treatment. We must therefore use this period to build up our savings at both the national and individual levels. Otherwise, when the elderly increases, there will be no money in the kitty to help look after them. So the challenge is not that we should spend more of our GDP on health care, but how to ensure that the percentage of GDP on health care does not creep up too fast.

Sir, the Government does place a very high priority on health care. Dr Hong Hai asked whether in comparison to other Ministries, our share is too low. I think the answer to that is that every Ministry must be gauged by the Finance Ministry in terms of what are the requirements and that the funds are given to ensure that those programmes can be carried out properly. In that respect, I must say that the Finance Ministry has been quite fair to the Ministry of Health and they have been giving us the funds that are needed to ensure that our health services remain good.

In terms of affordability and subsidies, which several Members have brought up, Sir, we all know that hospital services are very expensive. I shall not repeat the reasons. Those who want to know can refer to the Hansard. They are well-documented. What we need to realise is the funds available on the part of the Government are never unlimited. Ministries are all competing for funds. So there is a finite amount available for each Ministry. Within the Ministry there are many programmes. We have just heard Dr Vasoo saying, "Why are we spending so much money on acute care? We should be spending more on preventive and primary health care instead." Therefore, acute care now ends up with less. So at every point down the line, an apportionment must be carried out. The answer is to make sure that the apportionment is done in such a way that every programme can be optimised.

2.30 pm

Affordability. Are our health care costs affordable? Are the subsidies adequate? Should we be giving more subsidies? Let us look at the B2 bills. I am going to quote from SGH which has the highest B2 bills. The average cost for a B2 patient is $1,850. We subsidise each patient to the tune of $1,350. The average bill is therefore about $500. So patient pays $500, Government subsidises SGH $1,350. Is that bill affordable?

When we look at the 40th percentile family income, we find that you require 6.1 months of Medisave contributions to pay the bill. For the 20th percentile, which is $900 per month, the answer is for that family member going in, they have to use up 9.3 months of their Medisave contributions. We have to look in terms of the frequency of hospitalisation. The average person would expect to be hospitalised about once every eight to 10 years. For a family of five, they are only using up about 45 months of Medisave and they are able to save on the remaining 45 months. The C Class average cost is quite similar to the B2, but the average subsidy is much bigger, and the result is the bill size for the C Class patient at SGH is about $250. This is equivalent to 3.1 months of Medisave contributions for the 40th percentile family income and to 4.6 months' contributions for the 20th percentile. So therefore B2 and C Class remain highly affordable. Even for the lowest income earners, their Medisave is more than adequate.

The question which Dr Hong Hai has raised is: Should we also make A and B1 more affordable by giving them subsidies? Sir, the policy, as I have stated here in the House many times, is that our aim is to ensure that we recover at least recurrent cost from the A and B1 patients. In SGH, they have managed to recover the recurrent cost, but not capital cost. In Toa Payoh Hospital and the other Government hospitals, each A Class patient still gets $200 subsidy per hospitalisation. So they are still getting subsidies.

For the B1 patients, although they are not supposed to be getting any subsidies on the recurrent expenditure, SGH still has to give the B1 patients $250 subsidy per hospitalisation. At Toa Payoh Hospital and the other Government hospitals, the subsidy is even higher - $500 per hospitalisation. So it is not that we are not giving subsidies. Despite the policy of trying to recover recurrent cost, we are still giving substantial subsidies to the A and B1. We will try to gradually reduce these subsidies so that in this way we will be able to free up more of the future subsidies for the B2 and C Class patients who are the ones who truly need these subsidies.

The principle must be that we let each patient choose the ward that he wants to get into.

Dr Hong Hai: Sir, on a point of clarification. The point on subsidy, if I may clarify, is that the level of subsidy has fallen from previous years. The point I wanted to make was whether it is necessary to reduce the level of subsidies. I do not deny that subsidies still exist. The question was: Is it necessary to reduce them?

Mr Yeo Cheow Tong: Sir, the subsidies have reduced somewhat. But as I have said, our policy is to move towards totalreduction of subsidies.

Dr Hong Hai: Why?

Mr Yeo Cheow Tong: Because for those who can afford to choose Class A and B1, they choose so knowing that the subsidies will not be there. At the present moment, they are still getting subsidies. But in the future, we must try to ensure that the lower income groups are the ones who enjoy the bulk of the subsidies, because they are the ones who require these subsidies. For a person who is in the middle-income group or high-income group, if he chooses to be subsidised, he can still be so subsidised by opting for Class B2 or C, because we do not have a means test. So we are not preventing those who can afford the luxury, those who can afford the comfort of the A Class wards, from actually getting the subsidies. They can go in to the more basic wards and they will be given the subsidies.

Sir, the demand for the A and B1 wards is already high. Evidence shows it. We did a survey and we found that in the Class C wards, 10.5% of the Class C patients were actually held in the Class C wards while waiting for vacancies to be available in the A and B1 wards. For Class B2, about one in five. 21% of Class B2 patients were actually waiting for a transfer to A and B1.

I do not think it is wise for us to subsidise higher class wards. It will only encourage some patients to spend beyond their means and, at the same time, it will reduce the available subsidies for the lower income groups. I think that would be something which we should avoid.

Dr Tan Cheng Bock talked about the three levels of care that we should have: the first level, which is the community hospitals together with the polyclinics, the intermediate level and the tertiary level.

Sir, we classify them as the primary level, secondary level and tertiary level. So it is just a difference of terms, but we mean the same thing. He thinks that we should have the intermediate level because, with the restructuring programme, all the hospitals have now been upgraded to the high-end hospitals. Sir, that is not true, because of the restructured hospitals, two of them (Toa Payoh and Kandang Kerbau Hospitals) still retain basically the same charges as they did before restructuring. And when we computed the subventions, we took that into consideration. So their fee structure has remained very much the same. It is the same Toa Payoh Hospital with perhaps a new coat of paint, some new wallpaper, some areas which have been enlarged, because the hospital management has managed to use its discretion and independence to change the layout. Similarly with Kandang Kerbau Hospital. It is the same Kandang Kerbau Hospital. More attractive paint work but basically the same Kandang Kerbau Hospital.

These hospitals (Toa Payoh, Alexandra, Tan Tock Seng Hospitals) are actually secondary level hospitals. They have departments of general medicine, general surgery, obstetrics and gynaecology, paediatrics, orthopaedics, and of course anaesthesia, so that simple operations can be carried out.

What he is talking about is already existing. Of course, we have also the tertiary hospitals which are really a combination of secondary and tertiary care. SGH also has general medicine and general surgery which are secondary level of care. And they also have the tertiary level like cardiology, neurosurgery. So Tan Tock Seng Hospital, SGH and NUH are combinations of secondary and tertiary care.

Sir, I agree with him that most patients really do not require tertiary care. So our hospitals (Toa Payoh, Kandang Kerbau, Tan Tock Seng Hospitals and AH) see mainly patients with less complex illnesses. But for patients who go to SGH with less complicated illnesses, it does not mean that they must pay for the expensive treatments which are being given to other people. For example, if a patient goes to SGH and only requires a simple, plain x-ray, he is not charged the price of a CAT scan. He is charged the price of a plain x-ray which varies from $5 to $25. So the cost of investigation does not depend on the hospital. The cost of investigation depends on what is actually being provided to the patient, and that should remain the same, whether it is in a secondary hospital or in a tertiary hospital.

Our practice is that those patients who are admitted into a secondary care area, if upon observation and further diagnoses they are found to require tertiary services, they are then transferred to those departments with tertiary care. So if a patient goes to Toa Payoh Hospital and finds that he requires a pace-maker, he is then sent to SGH for the pace-maker to be put in. So what he is saying is actually already existing.

Dr Tan Cheng Bock: Sir, can I just seek a point of clarification from the Minister? Can I get an assurance from the Minister that the present hospitals (TTSH, Toa Payoh and Alexandra Hospitals) will continue to remain as secondary hospitals and that any future upgrading, any future restructuring, will be just to restructure the hospital at middle-level care?

Mr Yeo Cheow Tong: Sir, what I can assure him is that these hospitals will continue to have secondary care services. But as the hospitals evolve, and as the patient load builds up, there may have to be certain adjustments. For example, if certain specialties now have enough patient load where they outgrow one hospital, then the question is: should we just enlarge the hospital with a tertiary department, or should we allow another department to be set up elsewhere, because there is enough patient load to justify another department being opened up elsewhere? It is like, for example, O&G. When we started developing and we had more births, KK Hospital was not the only one with O&G facility. We were prepared to expand to other hospitals. Similarly with orthopaedics. Because there are plenty of orthopaedic cases, therefore, we now have orthopaedics in most of the other hospitals. So it is a question of patient load. But we will ensure that we do not have unnecessary duplication of tertiary development where those are not warranted.

Dr Tan Cheng Bock: How do you prevent this?

Mr Yeo Cheow Tong: Sir, the restructured hospitals are still coordinated through the Health Corporation of Singapore. There is still a top level that endorses all the programmes and we are represented on that body, so we will ensure that this is closely monitored. This is an assurance which I can give to the Member.

The Chairman: Order. We will take the suspension now.

Thereupon Mr Speaker left the Chair of the Committee and took the Chair of the House.

Mr Speaker: I suspend the Sitting and will take the Chair again at 3.10 pm.

Sitting accordingly suspended at 2.45 pm until 3.10 pm. Sitting resumed at 3.10 pm

[Mr Speaker in the Chair]

Debate in Committee of Supply resumed.

[Mr Speaker in the Chair]

Head P - (cont.)

Mr Yeo Cheow Tong: Sir, I now move on to the points made by Dr Arthur Beng. He asked that we update families of long stay patients with weekly bills and to allow such patients to downgrade. Sir, the answer is yes to both the requests. I will take this opportunity to remind the management of MOH and the restructured hospitals that they should be keeping their patients informed on a weekly basis and that for those who require downgrading, to request the medical social workers to look into their cases sympathetically.

Dr Arthur Beng Kian Lam: Mr Speaker, Sir, just a point of clarification. When I asked for updating it is not only with reference to those on long-stay, because we would not know whether a patient is on long-stay or not, but they should be updated frequently right from the beginning.

Mr Yeo Cheow Tong: Sir, most patients stay only four to five days. There is no need to update those on short stay. For those who are staying longer, more than two weeks, for example, then they should be given frequent updating.

Sir, Dr Arthur Beng has also asked that we control and coordinate the purchase of expensive equipment. I would like to assure Members that before the Ministry of Health, as well as the restructed hospitals under the Ministry, purchases expensive equipment, we thoroughly evaluate the need and usefulness of such equipment. Let me give an example, CAT scanners. They were already available in the early 1970s, but it was not until 1983 that MOH approved the purchase of a full body CAT scanner, the first in Singapore, by SGH. Similarly, with the machines called Magnetic Resonance Imaging (MRI). These are very expensive imaging systems and are useful for very specific diagnosis. These MRI machines can give better results and are more effective than either standard X-rays or CAT scans. These machines were introduced more than 10 years ago. Most American Hospitals and even the smaller hospitals have at least one.

In Singapore, the first MRI machine was brought in five years ago by a private company. MOH has only approved the purchase of the first MRI by SGH and that was only recently. I understand the machine will be arriving shortly. So we do evaluate very carefully. We will continue to do that, but we do not have any mechanism to control the purchase of such equipment by the private sector. The private sector will have to carefully evaluate its own business plan and carry out its own feasibility studies. But as a precaution, we will not allow the use of Medisave for machines which are new in Singapore until we are satisfied of its proven value.

This year, we will also set up a new unit in the Ministry called the Hospital Accreditation and Medical Audit Unit. The job of the Unit is to undertake the accreditation and auditing of hospitals. We will monitor and audit the professional standards of each hospital and the practising doctors. This will include utilisation reviews of expensive investigations and procedures. We will also consider making compulsory for all tissues and organs removed during surgery to be submitted for histological report. This way, we will then ensure that the operations are not being carried out unnecessarily. I think this would be adequate safeguard to make sure that machines that they buy are not being used unnecessarily as well.

Sir, Dr Hong Hai and Prof. Maurice Choo in his budget debate had suggested and I quote Prof. Maurice Choo, "that the Ministry reach out to affect not just Government and restructured medical services, but also academic and private medical centres." They have stressed the need for the Ministry of Health to coordinate the overall developments in the health sector. These are indeed sensible thoughts. Many countries today are facing huge problems and we have to guard against such problems. It is not wise for us to take for granted what we have.

Sir, in Singapore, health care has undergone significant changes since the National Health Plan was first launched in 1983. For example, over the last eight years, we have Medisave and MediShield. The population has also changed and there is now a tremendous demand for medical services that are similar in quality and in range to that available in the developed countries. We have restructured our hospitals and, as pointed out by Dr Arthur Beng and also Dr Tan Cheng Bock, with the many new equipment, tests and procedures coming on line very rapidly, the chances of these being introduced in Singapore are also very great. The increased health care costs have come about because of this demand for not just better services but also better facilities.

Sir, it is timely that we now take stock of our position in order to better position ourselves for the 1990s and the 21st century. I would therefore be setting up a Review Committee on national health policies to be chaired by my Minister of State, Dr Aline Wong. The Committee will review and make recommendations on four broad areas. These are:

Firstly, policy directions. It will review progress in the implementation of the National Health Plan and the priority areas for action, including changes due to changed circumstances.

Secondly, the Committee will look into the area on health care financing which is a very key issue. It will look into Medisave, rate of usage, accumulation of Medisave, whether the Medisave contribution rate is adequate and Medisave for the self-employed. It will also look into the subvention policy. Is it adequate? What are our recovery rates and how do we ensure that the basic health care remains highly affordable.

Thirdly, the restructuring programme. It will look into the achievements to-date and what are the areas for improvements. It willalso review whether and when should the restructuring programme be extended to remaining MOH hospitals like the Alexandra Hospital and the other hospitals and other MOH institutions.

Fourthly, the Committee will look into medical matters and policies. For example, as pointed out by Dr Hong Hai and Dr Tan Cheng Bock, with the restructuring programme, tremendous competition is bound to arise, how do we coordinate development? The Committee will look into the role of the Ministry of Health as the national health authority. It will also look into the need to develop further sub-specialties and the need to develop other centres similar to the National Skin Centre and the Singapore National Eye Centre which will allow us to pool and develop our limited resources and also to ensure that we avoid wasteful duplications that would otherwise develop.

Sir, the other members of the Committee have not been finalised yet and I will announce them after consulting with the Prime Minister and with Dr Aline Wong. The review is expected to take between 9-12 months and I will keep the House informed of its findings when their report is ready.

Sir, Mr Choo Wee Khiang had asked about the costings. I wish to inform him that for Class B2 and Class C patients, the costs of the infrastructure, namely, equipment, building and land, are fully subvented by the Government. So they will not have to bear it. For Class B1, it will have this cost subvented as well, but for Class A, we expect to recover at least a portion of such costs. The subventions will take into consideration this policy.

Mr Choo Wee Khiang: Sir, the Minister has not answered my question on whether he will allow Dr Tan Cheng Bock to run the Alexandra Hospital.

Mr Yeo Cheow Tong: Sir, as I said in my last budget debate, if Dr Tan Cheng Bock is interested, we look forward to receiving his proposal. Check the Hansard, please.

Dr Tan Cheng Bock: Sir, I accepted the proposal to run the hospital. If the Minister remembers, I had lunch with him to discuss this proposal. Actually, I am waiting for him to give me the details.

Mr Yeo Cheow Tong: Sir, he must check the Hansard to ensure that he understood what I said. I said that if Dr Tan Cheng Bock is interested, we will be very happy to receive his proposal and I will get my officers to look into it.

Dr Tan Cheng Bock: Sir, I have submitted the proposal through the National University Hospital. I am going along with the National University Hospital on this project.

Mr Yeo Cheow Tong: Sir, I am sorry my Ministry has not received such a proposal from him.

Dr Tan Cheng Bock: Sir, he will receive it in due course.

Dr Arthur Beng Kian Lam: Sir, can I make some clarifications on affordability? The Minister gave us some average cost figures. Referring to B2, he said that the average cost was $1,850 and that the subsidy was $1,350, giving us an average bill of $500. May I point out to the Minister that this average cost will not be reflective. At least he should give us the median cost. Then the cost in relation to the types of disciplines. For example, in a surgical discipline, in operations, if you take an average cost of a person's overnight stay for observation versus that of a person who stays for about two weeks it is, of course, not comparable. But I do not expect the Minister to give all these figures now. It would be unfair of me. But I hope at some future date when we have more time, he could give us some breakdown of how he arrived at this average bill of $500 which I am sure many of us at our Meet-the-People sessions know that it is higher than that.

Mr Yeo Cheow Tong: Sir, these are figures which can be confirmed. If the Member wants more details, he can either write to me, in which case we will be very happy to give them to him, or he can file a Question.

Dr Arthur Beng Kian Lam: Sir, for average cost like this, as I consulted my statistician colleague, Dr Ho Tat Kin, one would have to have a very average illness. What is an average illness?

Mr Yeo Cheow Tong: Sir, unfortunately, he is not a statistician. Anyway, if he requires more information, my statistician would be very happy to give him some pointers.

Sir, I will now ask my Minister of State to reply to the other points.

The Chairman: May I remind Members that we are running out of time on this amendment. Dr Aline Wong.

The Minister of State for Health (Dr Aline K. Wong): Sir, I would like to address the question on primary health care and preventive health care services. As Dr Hong Hai, Dr Vasoo and Dr Wong Kwei Cheong have pointed out, and I agree completely with them, these services should constitute one of the main thrusts of the work of the Ministry, because primary health care and preventive health care are not only the first line of defence against illness, they are also very effective strategies in fighting the rising health care costs.

Let me deal with the question of primary health care and preventive health care by outlining to Members of the House very briefly the whole range of services and programmes that we have in order to impress upon the Members of this House that in fact my Ministry has continued to place a very great emphasis on these two areas of services.

What is preventive health care? It constitutes health education, it constitutes immunisation services and also health screening programmes. We have throughout these years placed a great deal of emphasis on health education. We really want to achieve through health education programmes a change in Singaporeans' perception of depending on doctors to deal with the problems of their illness, and to depend on doctors to provide for medical care, to one which is an attitude where each individual realises that his health is in his own hands, and therefore he should be responsible for his own health. So our health education messages have always stressed healthy lifestyles, such as eating nutritious food, exercising regularly, controlling stress and no smoking.

For the information of Dr Vasoo, last year, we carried out a four-month programme on prevention and early detection of cancer. This year we will be conducting a smoking control programme and a campaign to encourage our people to be physically active and to adopt good dietary habits.

The other prong of preventive health services is immunisation. I am happy to report that we have achieved a very high successful rate of immunisation, particularly of infants against common childhood infectious diseases. In fact, we have eradicated diphtheria and polio, and the number of children coming down with measles has dropped to less than 200 per year. Immunisation programmes are given free and we have been able to cover more than 90% of the babies born here.

We have also introduced health screening programmes. Health screening, as you all realise, will help to detect illnesses and abnormalities early so that early treatment can be given and in the course of it, health care costs, especially to the patient, would be brought down. We have introduced screening of new born babies for congenital abnormalities and also for pre-school children for developmental delays. All the school children in our schools receive a full medical examination in Primary 1, Primary 6 and Secondary 4 levels. For adults, we have also introduced coronary risk screening as well as general health screening. We have special programmes for women and for the elderly. The health screening services for the elderly are provided free.

Polyclinics. Polyclinics provide outpatient treatment for illnesses. We realise that some of the polyclinics are getting run down. But I think Dr Vasoo has to view these older polyclinics against the fact that they have been there for a number of years and that they used to serve the rural population areas. Now, with the shifts in population, the older polyclinics have to be closed down. We have a plan to gradually close down the older ones so that eventually we have a network of 16 polyclinics. As you have seen, some of them are brand new with excellent facilities. These 16 polyclinics will be quite evenly distributed throughout the island. They will be easily accessible to the population and, as I said, they have a full range of primary health services. 3.30 pm

I do not agree with Dr Vasoo that the rate of growth of these polyclinics has not kept up with the rate of growth of the population. We must remember that the services provided by the polyclinics are actually complementary to the services provided by the general practitioners in the private sector. In fact, the general practitioners cater to about 70% of the population, whereas our OPDs cater to 30%. So between the two sectors, we have to strike a fine balance. We aim to be accessible and we provide very cheap and sometimes even free services to the lower income groups.

Again, I do not entirely agree with Dr Vasoo's point of view that we have not been devoting more resources to our primary health care programme. He quoted the figure that over the last 10 years between 10% and 14% of the MOH recurrent budget has been devoted to primary health care. But if he looks at the figures more carefully, he will see that our expenditure has actually increased tremendously since 1986. In 1986, we spent $40 million on the primary health division, which represented about 11% of the whole Ministry's recurrent budget. But in 1991 this budget has increased to $73 million or 14% of our budget. In other words, it is not spread out evenly throughout the 10 years. In the last five years, we really concentrated on developing our primary health care services.

For health promotion, I would like to take this opportunity to clarify one point raised by Prof. Maurice Choo during his speech at the debate on the Budget statement. He quoted some figures on the amount of money we spent on training and health education. He quoted a per capita expenditure of $2.60 in 1990 and this increased only to $2.73 for this financial year 1991. I would like to clarify a bit. Actually the figure that he quoted for 1990 has been revised because now we know how much we have spent. It is revised upwards to $2.81. For 1991, we are now providing for more, $3.65. So the total amount is $9.9 million for financial year 1991. Nobody can say that this amount on health education alone is a small amount.

You also have to look at the nataure of health education. Yes, you can spend lots and lots of money on it, but the idea is that you have to keep it up constantly. It is not just spending on big campaigns every year or every other year, but you must maintain the momentum and the message must be put across to the population. For primary health and preventive health care, our message must be that prevention is better than cure. Dr Hong Hai has put it more graphically. He used the analogy of the car and the plumbing system. It is better to maintain existing parts than have spare parts ready. The idea is that prevention is better than cure. So the message is this: we must take our health in our own hands and be responsible for it.

Let me turn to health care services for the elderly and Mr Yeo Toon Chia's concern. Mr Yeo is very concerned about the provision of residential care and nursing care for the elderly. I too share his concern. The figures stare us in the face. The proportion of the elderly population is increasing. Although at the moment the proportion of the elderly in Singapore is still relatively small as compared to many developed countries: the proportion of the population over 60 is just about 8%, this percentage will increase to about 11% by the year 2000 and by the year 2030 it will increase to 26%.

Mr Yeo's plea is for more residential care facilities for the aged. I think he has a point there. Our senior citizens have done their bit, contributing to the economy, taking care of the families and when they reach a ripe old age, there should be enough facilities to take care of their needs. But I would like to clarify one point. The health facilities for the elderly should not just stop at residential care or institutional care. In fact, we should aim at providing a full range of facilities for the elderly. What I think Mr Yeo meant by emphasising geriatric units was probably a bit too narrowly focused. He probably thought that it is only by providing geriatric wards in hospitals that you can take care of the health needs of the elderly. It is not true. Geriatric units in hospitals are highly specialised wards. The management of geriatric patients actually requires a team of specialists. So in hospitals the geriatric ward might be a small specialised ward, but where a multi-disciplinary approach is needed in the treatment of the patients. This does not mean that the elderly sick patients are not taken care of in the other general wards. They may be in the medical wards, they may be in the surgical wards. So, depending on their condition, they need not be taken care of in a geriatric unit in a hospital.

For geriatric medicine, we have started a new department of Geriatric Medicine in Tan Tock Seng Hospital with 70 beds. We would also be having another such unit in the Eastern General Hospital with about 100 geriatric beds. So when you look at the figures, they may seem a bit small. But my point is that the geriatric patients need not be managed only in geriatric wards.

Taking care of the health care needs of the elderly requires a full range of services. My Ministry has in fact put in place the essential elements of all these care facilities. For example, home nursing. Home nursing care has been an on-going programme since 1976 when the Home Nursing Foundation was established. My Ministry contributes heavily towards the services provided by this Foundation. We provide the doctors, we provide 38 nurses and a clerk. We also provide the premises within our Senior Citizens' Health Care Centres in the polyclinics for the Home Nursing Foundation. So, home nursing care has reached out to thousands of patients each year. A couple of years back, I had noted that the number of home visits by our nurses from the Home Nursing Foundation had been declining, and I had raised some questions on this matter during one of the debates. This time it was brought up again by Prof. Maurice Choo. The number of home nursing visits to the elderly peaked in 1985 with about 46,700 home visits. This number of visits has gradually declined to about 29,000 last year.

But behind this figure is the fact that the number of patients taken care of by the home nursing service has actually gone up, which means that the number of visits per patient has gone down. This has been made possible, I was told by my Ministry officials, because now, certain new methods of changing dressing for the patients have been adopted. For example, we are using a new type of surgical dressing material which needs only to be changed once every three to four days instead of every day. We are using a new type of urinary catheter which is changed every third week instead of weekly. But the point is - I ask, and I make sure that this is the case - that whoever calls for home nursing care is not turned away. In fact, the very next day a nurse will go and visit him. In other words, we are meeting the demand that is there in the population. So that is the important point when you look at this set of figures.

We will continue to work with the Home Nursing Foundation to strengthen this very important health service for the elderly. The public also knows about the rehabilitation, health screening and health education services available in the Senior Citizens' Health Care Centres.

I have touched on the geriatric departments already. Let me just inform the House that we are also trying very hard to train doctors in geriatric medicine. Since 1983, we have sent seven doctors and 10 nurses overseas. We have also introduced post-basic training in geriatric nursing for the nurses. So, Mr Yeo's concern about geriatric medicine and geriatric wards has been addressed in this way. What he may also be concerned about is the problem of the chronic sick. A lot of the elderly are also chronic sick patients. Right now, there is a Chronic Sick Unit with 117 beds at the Woodbridge Hospital. In the new Woodbridge Hospital, there will be about 200 such beds.

As for residential care for the elderly sick, my Ministry and the Ministry of Community Development are working very closely together to follow up on the recommendations of the Advisory Council on the Agedand the Family. We are forming a policy committee. We will be deliberating on and implementing the various programmes to cater to the residential needs of the elderly sick.

Mr Choo Wee Khiang: Sir, point of clarification. When the Minister of State mentioned that prevention is better than cure, I would like to know how the Ministry will incorporate mental health care into our prevention and primary health care system. I would also like to know whether the Ministry is going to have any campaign on mental health care.

Dr Aline Wong: Sir, mental health care constitutes another distinct area of the work of the MOH. On the other hand, in our public health education programmes and in our publicity on healthy life-styles, we emphasise that people should have regular recreation, exercise regularly and control stress. So in that way, through public education, we hope the population will come to an awareness of the importance of mental good health. In that way, we will prevent mental ill health.

Dr Lee Siew-Choh: Sir, this amendment is not intended to question the Singapore Medical Council on its stand on the dispute between the NTUC and the Singapore Medical Association on the much publicised NTUC Discount Scheme.

As the Minister may have known, Sir, the Singapore Medical Council's statement on the dispute has surprised a good number of medical practitioners as well as members of the general public, and has raised, of course, not a few eye-brows. This is because hitherto the Singapore Medical Council, being a disciplinary body, receives complaints in writing accompanied by affidavits before it decides to act, and has never, I believe, issued any press statement and acted in this particular manner. On this occasion --- 3.45 pm

Mr Ng Kah Ting (Punggol): On a point of order, Sir. Can the Non-Constituency MP declare his interest on this matter?

Dr Lee Siew-Choh: Well, I am only a GP. But I have nothing to do with the Medical Council.

The Chairman: You may continue with your speech, Dr Lee.

Dr Lee Siew-Choh: In fact, I am speaking as a member of the public, as a concerned member of the public, and as an MP.

The Chairman: You may proceed with your speech, Dr Lee.

Dr Lee Siew-Choh: On this occasion, Sir, as the dispute, which had attracted editorials and commentaries in the press, was still in progress, it would appear that in issuing the statement to the press the Singapore Medical Council had acted all on its own and, if I may say so, Sir, somewhat officiously on the matter.

As the matter is still controversial among many medical practitioners, I hope the Minister will be able to clarify the situation so that any suspicion that the Singapore Medical Council may have acted under pressure from any quarter may be dispelled. I would ask the Minister briefly:

(i) Was any written complaint (I say "written complaint") about the dispute made to the Singapore Medical Council before it deliberated on the matter and issued the press statement? If not, why did it issue the press statement?

(ii) Before it issued the statement to the press, did the Singapore Medical Council first write to the Singapore Medical Association, Singapore College of General Practitioners or Association of Medical Practitioners, Singapore, to inform them of its views on the matter? And if not, why not? And if the Council did write, did the Association know of the matter before the press statement was issued?

(iii) Before issuing the press statement, or even afterwards, has the Singapore Medical Council communicated its views by letters personally to all the medical practitioners in Singapore? If not, why not?

(iv) Does the Council consider general practitioners and medical specialists as members of the same profession? If so, why did the Council separate the specialists from the general practitioners in its statement?

(v) In issuing the press statement, has the Singapore Medical Council created a precedent for the Singapore Medical Council to act in a similar fashion concerning disputes in the medical profession in future? Or will this press statement be what may be called a "one-off" incident not to be repeated in future?

I trust the Minister will be able to clear the air.

Mr Goh Chee Wee (Boon Lay): Sir, I disagree completely with the views expressed by Dr Lee Siew-Choh.

We have this NTUC scheme which enables the union members to get discounts or concessions when they visit the participating clinics. The Singapore Medical Association says that the scheme is unethical. NTUC says that it is not. NTUC has made it clear that the scheme is open to all the private practitioners in Singapore. It is a voluntary scheme. Any doctor who is interested to join in the scheme is welcomed to do so. So there is therefore no question of unfair advantages enjoyed by a few selected doctors. It is open to everybody, to all the general practitioners.

As we know, NTUC represents a considerable number of lower income workers, including the daily-rated workers, production operators, older workers, etc. The scheme will benefit in particular this group of people and their families. So I do not see what is so unethical about the scheme. We also know that doctors do offer concessionary rates to their corporate clients. They quote and charge their corporate clients rates which are lower than what they will normally charge a walk-in patient. So if such a practice is considered acceptable, I do not see why offering concessions to union members should be considered objectionable.

There is now this controversy as to whether the scheme is ethical or unethical. Someone must make a ruling. The Singapore Medical Council, being a watchdog body for the profession, must make a ruling on this. It is not only right for the Singapore Medical Council to comment and make a ruling on this, but it is expected of them to do so.

I disagree with the views expressed by Dr Lee. And in fact I want to ask Dr Lee whether he supports the NTUC scheme or not. He has not stated his stand whether he is supportive of the scheme which helps the workers, the poor, and he tries to impress on others all the time that he likes to help the poor.

Dr Lee Siew-Choh: Sir, what I have said does not touch on the contents of the statement. I query only the procedure. But since I have been asked what my stand is on the position, let me say that I do not disagree with what the Singapore Medical Council has said. But after examining the NTUC scheme, I find that it is not totally intended to help the low income group. The arguments are very simple, Sir. A general practitioner normally charges less than $20 per patient. So a 10% discount would amount to, at the very most, only $2. Although $2 could mean a lot to the poor, the lower income group, nevertheless, it is not a big sum. But if the intention was to help the low income group, I thought a much better course would be to ask for a discount from the specialists who charge much more, or from the hospitals which charge by the hundreds and thousands. That would certainly help. Therefore, I think this is not really intended to help the low income group as such. I suspect the whole scheme has been brought up to attract more membership for the NTUC. It is a political gimmick and, therefore, I think this should not be supported.

But, unfortunately, Sir, the Singapore Medical Council's statement separates the specialists from the general practitioners. It is something which I just cannot understand and that is why I asked why they have separated them. That's all. I did not query the position that it is not unethical. I do not believe it is unethical. But I queried the intention, the motivation behind the scheme. And as I have said, Sir, I believe the scheme was mooted in order to attract new membership for NTUC.

Mr Goh Chee Wee: Dr Lee has said that the scheme is not unethical. I think his complaint is that the quantum of concessions and discounts given is too small. So can I invite Dr Lee to join the NTUC scheme and offer more than the 10% discount to our union members?

Dr Lee Siew-Choh: Sir, in my case, we work on an old system. I am not the doctor that controls everything in the dispensary in which I work. We have a pharmacy side by side. So it is difficult for a doctor to make all decisions. Whether or not I take part really is of no consequence. The main thing, Sir, as I have said, is that the scheme is not supportable because it is politically motivated.

The Chairman: Mr Yeo, would you like to say something?

Mr Yeo Cheow Tong: Sir, I am surprised that Dr Lee brought all his questions here. Being a doctor, I would expect him to know what are the functions of the Singapore Medical Council (SMC) and to realise that the SMC is an independent body that in no way reports to the Minister for Health. On those detailed questions of his, I would invite him to write direct to SMC for the necessary answers. But, Sir, since he has brought up this issue with all those questions, I think it is important for me to clarify to the public the role of the SMC.

Sir, the SMC is an independent body whose job is to register medical practitioners and to determine and regulate the professional conduct and ethics of medical practitioners. He is right that when a complaint is made, a statutory declaration is normally required. But that refers to a case when a member of the public lodges a complaint against an individual doctor against his medical conduct.

Sir, when the NTUC scheme was announced to the press, I am sure Members would remember that doctors in private sector were also airing their views in the papers. The SMC had also received approaches from the Association of Medical Practitioners seeking its views and guidance. If they did that, then it is very much within the capability of the SMC to reply to them and to set the controversy to rest with a public statement. I do not see anything wrong with that.

Dr Lee Siew-Choh: Sir, I have the Singapore Medical Council's Annual Report 1989 in front of me, and I quote you one section. It says here, the last paragraph:

'In addition to the above duties [which our Minister just enumerated], the Medical Council deliberates on any matter or issues that may have bearing or impact on the conduct and practice of medical practitioners in Singapore.' Good. Arising from these deliberations now, this is what I query:

'The Council may recommend to the Minister [it writes to the Minister] for Health various courses of action or advise practitioners on its views on these issues.' How do you advise medical practitioners? By writing a press statement? Or by writing to them in letters under cover, or by writing to the Association itself? Which would be the proper course to take, not to issue a press statement. The Minister also says that it is an independent body. Yes, it is supposed to be an independent body. I say "supposed to be", because there are quite a number of members who are nominated by the Minister. The Minister may tell us how many members are nominated by him.

Mr Yeo Cheow Tong: Sir, firstly, he has not quoted anything that says that the SMC cannot issue a press statement. I think it is within the prerogative of the SMC to choose whichever avenue it wishes in terms of communicating with the members. Secondly, just because a person of integrity is nominated, it does not mean that he does not function as an individual.

Dr Lee Siew-Choh: I am not saying, Sir, that it cannot issue a press statement. I merely ask whether this is going to be the precedent for more of such press statements. Or is it going to be once and for all and no more after this? Because, as I have said, it has never been done before.

Mr Yeo Cheow Tong: Sir, as I have pointed out earlier on, he should direct these detailed questions to the SMC, not to this House.

Dr Lee Siew-Choh: If the Minister is here, why should I ask the SMC? 4.00 pm

Dr Hong Hai: I would like to thank the Minister and Minister of State for their very comprehensive answers. Since the budget allocated to Health is already so meagre, I do not think we can afford a $100 cut. In the light of that, I withdraw my amendment.

Amendment, by leave, withdrawn.

Encik Abbas Abu Amin: Sir, I beg to move,

That the sum to be allocated for Head P be reduced by $10 in respect of Code PA 1500 of the Main Estimates.

Sir, the statistics available tend to suggest that there is an increase in the utilisation of health services. I would like to enquire on the profile of those who have made use of their Medisave accounts and whether the Ministry intends to strengthen efforts on Medisave audit to prevent any abuse of the system.

Sir, can I touch on my second question on MediShield as well?

The Chairman: All right.

Encik Abbas Abu Amin: The MediShield Scheme was introduced in July 1990. I would like to know the number of members who have benefited from such a scheme. It was reported recently that members between 50 and 60 years of age form 20% of all those members who have opted out of the MediShield Scheme. What further plans does the Ministry intend to take to ensure that the public, especially the older members, is fully aware of the importance of this low-cost medical insurance plan to help to overcome the cost of prolonged hospitalisation and medical expenses?

Dr Lee Siew-Choh: Sir, many people have been disillusioned with the MediShield Scheme. They all realise that the benefits from the scheme are minimal. And it is no surprise that as many as 200,000 people, most of whom belong to the low-income old age groups, have decided to opt out. If so many people opt out of a scheme, supposedly designed to benefit them, then there must be something very, very wrong with it. Many people would say that the scheme is a dismal failure. The Minister of State for Health has expressed disappointment at the reception given to the scheme by those aged people. But what does she expect? Of course, disappointment. But I believe she should express her disappointment at the Ministry instead for pushing through a MediShield Scheme which imposes so many conditions that effectively negates the whole idea of assistance to those who are afflicted with serious and prolonged illnesses.

The main complaints against the MediShield Scheme are in brief:

(1) The premiums for those in the low-income groups are not truly low-cost. They should be lowered for the low-income groups.

(2) The maximum "claimable amounts" are comparatively low. They amount to a mere fraction of the hospital charges. The maximum claimable amount therefore should be raised.

(3) There is a "deductible" amount which the patient has to pay before claims can be made. And that may well mean that the sick cannot make any claims at all. The "deductible" item therefore should be scrapped.

(4) The scheme does not cover people beyond age 65, just when they most need such coverage. The cover should be extended to age 70 and even 75.

(5) The list of diseases covered by the scheme is too limited. It should be extended to cover even those with pre-exist-ing catastrophic illnesses, maybe at a revised higher premium.

The concept of MediShield is very good. I fully agree with it and already earlier on, I had supported it, until the details came out. Unfortunately, it is being operated too much like a commercial business undertaking, and not as a scheme really intended to help the aged and the low-income groups stricken with chronic illnesses.

The PAP Government must get rid of its misconception about the so-called welfare system. Helping the aged and those stricken with catastrophic illnesses is a Government responsibility, and it should be undertaken gladly and honourably by the Government, especially when it also claims to be a caring Government.

With hospitals restructured and hospital charges going up all the time, it is only fair that Government should ensure that all the unfortunate sick people who need assistance from Government be given such assistance. After all, according to what the Minister has just revealed, the number of people who seek admission and the number of days that they are in the hospital is very low and very short.

Mr Peh Chin Hua: ( In Mandarin): Mr Chairman, Sir, I would like to talk about the problems of Chinese physicians and Chinese medicine. We all know that Chinese medicine has got a history which stretched back to a few thousand years. It is an accumulation of experience in the curing of diseases over the 5,000 years of Chinese civilisation. Before Western medicine was introduced to China, Chinese medicine was already there and it has proved to be effective in the curing of diseases. But I feel that the Ministry of Health should exercise more control over Chinese physicians and Chinese medicine and I suggest the following ways of doing it:

(1) To regulate the practice of Chinese physicians to weed out the unqualified ones;

(2) To set up a National Council for Chinese Medicine;

(3) To establish a Department of Chinese Medicine at the National University of Singapore; and

(4) To enhance the control of traditional Chinese herbs.

In January 1989, the Coroner's Court conducted an inquiry into the death of a boy who suffered high fever and consulted a Western doctor and a Chinese physician within three days. Being ignorant, he took an overdose of paracetamol prescribed by both the Western doctor and the Chinese physician, resulting in the damage to his liver and kidney, and eventually he died. The fact is that there are people who have just a few months of informal training in Chinese medicine, beginning to practise as Chinese physicians and prescribing Western medicines at random to their patients resulting in the health and life of the ignorant patients being endangered.

Last year, in November, I received a complaint by a resident that a so-called Chinese physician whom he consulted gave him an injection like a Western practitioner. As a result, his illness became worse and he had to go to a government hospital for help.

For this reason, I feel that the Ministry of Health should consider regulating the practice of Chinese physicians so that those who are unqualified could be weeded out. Secondly, I feel that we should consider the setting up of a National Council for Chinese Medicine to deal with the registration and control of Chinese physicians and Chinese medicine. The Council shall comprise not only officers from the Ministry of Health, but also some people who are knowledgeable in the field of Chinese medicine. The qualifications of the Chinese physicians should be examined and evaluated. Those who are found to have attained a certain degree of proficiency should be accorded professional status, and the medical certificates issued by them should be recognized. Thirdly, I feel that the Ministry of Health should also consider setting up, in conjunction with the Ministry of Education, a Department of Chinese Medicine at the NUS and also to invite highly-qualified Chinese physicians from other countries to lecture and to raise the standard of Chinese medicine in Singapore. This will provide a better prospect for the Chinese physicians here. Fourthly, I understand that since three years ago, the Ministry of Health has started registration and control on the import of Western medicine. I feel that traditional Chinese herbs should also be similarly controlled, so that those sub-standard Chinese herbs would not be allowed to be sold in our market to maintain the good quality of Chinese medicine and the health of our people can be safeguarded.

Mr Yeo Cheow Tong: Sir, Mr Abbas has asked about Medisave, whether we are auditing and what are we auditing. The CPF Board carries out the financial audits while my Ministry carries out the medical audits.

In 1989, we carried out a total of 9,500 financial and medical audits. Last year, 1990, this number increased to 12,100 which made up 4.4% of total Medisave claims. In both years, we found that there was no attempt at deliberate abuse of the system. Most of the audits showed that there were no errors and most of the errors that were found were due to administrative errors. For example, certain parts of the form were not filled in completely, or the relevant documents were not submitted with the form for the record. The doctors also had a few cases of wrong coding of operation. What we found was that there were as many cases of wrong coding, which allowed a lower reimbursement of Medisave, as there were for those with a higher reimbursement of Medisave. Upon investigation, we found that again it was an error in interpretation and there was no attempt at abuse of the system.

He also asked for a profile of the Medisave accounts. The balances in the Medisave have increased quite significantly since 1984 when Medisave was started, for example, for those accounts with balances above $5,000. In 1985, when we started there were 240,000 accounts with balances above $5,000. By the end of last year, that number had more than doubled to 540,000. Similarly, the average balance had gone up. In 1985, the average balance was $2,500. Today, the average balance is $3,700.

Sir, on MediShield, Mr Abbas has asked what are we doing to ensure that the participation rates are improved. MediShield has a 88% participation rate. First, we must remember that this is a voluntary scheme. It is not a compulsory scheme. I think nowhere else in the world, would you be able to find in a voluntary scheme a participation rate of 88%. So we should not be dismayed that 12% have opted out. We must also remember that a large number of workers are actually covered by company medical coverage, or some of them will also have their own medical insurance although this number of coverage is small.

On the question of what we are doing to ensure that the participation rate remains high, the CPF Board will be enhancing its communication programme. It will be carrying out a survey amongst those who have opted out to find out their reasons why they are actually opting out. They will also have a direct mail programme where they will send letters to members who have opted out to encourage them to rejoin the scheme. The CPF Board will continue to publicise the benefits of MediShield and to encourage future members to participate.

Dr Lee has asked his usual questions, or made his usual statements as he did last year that the MediShield programme is a dismal failure and that it is not attractive enough. Firstly, he claims that the premiums are not low cost. The premiums are very cheap for a person aged up to 30, he only pays $1 a month. For those aged 41 to 50, they pay $3 a month and all these are deductible through Medisave. The payments by Medishield are also very attractive. For those people who go to C Class wards after an initial expenditure of $500, they can start claiming from MediShi eld and MediShield will pay 80% of whatever they incur. For B2 patients, they pay $1,000.

4.15 pm

In comparison to a scheme run by private sector companies, we found that the premiums which have been set by MediShield are between half and one-third of those in the private sector. It is very inexpensive compared to the private sector.

The Member talks about life-time payments as being too low. The life-time payment for MediShield is $50,000. For a Class C patient or Class B2 patient, I think even in 10 lifetimes, their bills will not go up to $50,000. So it is more than adequate to cover the disease conditions of those patients who go into B2 and Class C wards.

He said that the deductible is too high. Sir, this is a catastrophic illness insurance meant to cover serious illnesses. The quantum has been computed such that it averages 15 days of stay. So any patient who suffers a serious illness and who stays more than 15 days, straightaway they can start claiming.

Sir, the number of people who have been paid from MediShield so far shows that it is working. So far, in the short six months from July to December last year that the MediShield has been operating, a total of 2,000 members have already received payment. Of those members who have received payment who are aged 50 and above, they comprise 44% of the number of claims. So I think it is of great benefit to those in the older age groups and that is why although some have opted out, there is still a large number in that age group who have stayed in. He has also asked that pre-existing conditions should also be covered. Obviously, he does not understand the meaning of "insurance". "Insurance" means you insure against future risks. If you also insure against existing risks, then the word "risks" is no longer there. I think he should realise first and foremost that this is an insurance system to insure against future risks.

He has also said that it is Government's responsibility to provide health care. Yes, I agree with him, and we do provide good health care, as I have stated earlier this afternoon. And that the B2 and Class C patients, not only have access to the full system, but they pay extremely low rates, rates which are very heavily subsidised by the Government.

Sir, Mr Peh brought up three main points: that my Ministry should control the practice of traditional Chinese medicine by registering all Chinese physicians; that we register all Chinese herbs and medicines; and that the NUS establish a Faculty of Chinese Medicine. Currently, there are no requirements for Chinese physicians to be registered since the Government is not involved in their training in any way. My Ministry will continue this present practice of not registering them.

Mr Peh has also expressed concern that there are some people who call themselves Chinese physicians only after a few months of training. He has also highlighted the dangers of Chinese physicians mixing Western medicine such as Aspirin and Paracetamol in their traditional medicines. Mr Peh is certainly correct to point out these problems. Chinese physicians are not allowed to prescribe or use scheduled drugs. They are also not allowed to mix scheduled drugs such as antibiotics and steroids with their traditional medicines. We will not hesitate to take legal action against Chinese physicians who are found doing this.

Sir, over the past two years, a total of 42 Chinese medicine shops were caught and prosecuted for illegally selling scheduled drugs. The fines imposed on them by the courts ranged up to $35,000. However, there is nothing to prevent them from buying over the counter drugs such as Aspirins and cough mixtures and selling them in a pre-packaged form to their unsuspecting patients. So I will urge patients to be cautious.

Mr Peh has also asked for traditional Chinese medicines and herbs to be registered. My Ministry has been randomly sampling imported processed and manufactured Chinese medicines to ensure that they do not contain arson, mercury and other heavy metals or poisonous substances. Those items found to be dangerous are banned. I must stress that we are only randomly sampling and even then for the presence of heavy metals and poisonous substances. We do not have the capability to check and analyze every brand or type of Chinese medicine that is put on sale here. For a drug to be registered, it would have to comply with accepted standards of manufacture and quality control. The manufacturer is also required to analyze each and every batch produced for its exact composition and to be audited periodically by our local authority.

With regard to herbs, I am not too sure how a herb can be registered, since it is a plant item whose quality varies very, very widely. My Minstry therefore does not intend to register Chinese herbs and medicines. We will continue to study what is being done in other countries and to learn from their experience.

Sir, with regard to the Faculty of Chinese Medicine, I am sorry that it is not within the purview of my Ministry. Mr Peh may wish to pursue this further with the Minister for Education.

Dr Lee Siew-Choh: A clarification for the Minister, Sir. If a patient were to stay more than 15 days, then the deductible would be covered. But he has also said that the average stay of every patient is four or five days. So how does the deductible come in at all?

Mr Yeo Cheow Tong: Sir, he should look at the name of the scheme. It is a Catastrophic Illness Insurance Scheme. It is not a scheme to cover the average medical case. It covers only those cases that belong to serious disease groups or who require long hospitalisation. This is the group which will be incurring heavy expenses and this scheme is meant to alleviate their burden.

Mr Chiam See Tong (Potong Pasir): Sir, I am surprised to hear from the Minister that he is not taking any action to register Chinese physicians. One would think that after the problem has been aired in this House he would look into this question. By not registering Chinese physicians, there is a loophole for Singapore citizens to practise medicine without proper qualifications. And when that is done, it is definitely a danger to the public, as Mr Peh has rightly pointed out. He has read in the papers that a few Singaporeans have in fact suffered from treatments given by unqualified Chinese physicians. I would have thought that the Minister would at least say that he would look into this very important issue.

Mr Yeo Cheow Tong: Sir, Chinese physicians have been existing in Singapore for many, many years. They have gone through many, many different types of training, from apprenticeship with friends, with parents, to training in other countries for which we have no information about the content of the training or the sort of training that they have received. It is not possible for the Government to step into an area where there is no control and no standards. So this situation will have to remain. And I think Singaporeans will have to be very careful in terms of choosing which Chinese physician to go to.

Mr Chiam See Tong: Sir, it is true that Chinese medicine has been practised for thousands of years and, as has been mentioned by Mr Peh, for at least four thousand years. But that does not mean that there will be no quacks and unqualified persons claiming that they are qualified Chinese physicians. Especially with the pressure of modern society, more people are getting sick and fees for proper medicine by qualified doctors are beginning to rise, definitely the poorer Singaporeans will resort to Chinese medicine. So this danger in fact will rise with time and not diminish.

Mr Yeo Cheow Tong: Sir, the public has a full range of qualified doctors to go to, ranging from doctors in the polyclinics whose fees are very, very affordable and much cheaper than many Chinese physicians, to very high price physicians in very fancy offices. If Singaporeans choose, in spite of the existence of qualified doctors trained to certain standards, to go to a Chinese physician, I think it is important for them to realise that they should choose their physicians carefully.

Mr Chiam See Tong rose -

The Chairman: Mr Chiam, we have run out of time. Encik Abbas.

Encik Abbas Abu Amin: Sir, I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The Chairman: Amendment No. (3), Encik Abbas is not moving. Mr Yeo.

Mr Yeo Toon Chia: Sir, I beg to move,

That the sum to be allocated for Head P be reduced by $10 in respect of Code PD 1500 of the Main Estimates.

Sir, the restructuring of our hospitals has brought about a greater flexibility in the day-to-day running of hospitals. I am happy to note that some areas of our medical services have shown a great number of improvements, especially in our medical facilities and technology. However, there is one aspect of hospital service which I strongly feel needs to be looked into and improved upon.

Sir, I am referring to the long waiting time and overcrowding at Government hospitals, specialist clinics and pharmacies. It is common for a patient who has an appointment with his or her doctor to have to spend 1 1/2 hours or more waiting before he could see the doctor which would take maybe 10 minutes or even less. After this, he has to wait for another 20 minutes or more to get his next appointment. Then he has to wait at least for another one or two hours at the overcrowded pharmacy for his medicine, resulting in half a day being wasted, when all it takes is 10 minutes or less to see the doctor. The time taken in waiting is not only unproductive but it also causes frustration. And this situation is made worse by the fact that staff manning the counters are not familiar with terms and standard medical practices. There have also been occasions where files were misplaced, queries asked had to be redirected to the nurses resulting in a merry-go-round.

Sir, being a regular patient of the Singapore General Hospital and having the benefit of seeing the two systems at work before and after the restructuring of the hospital, I regret that I have to say that the waiting period has not improved, and the overcrowding at the clinics appears to be worse than before the hospital was restructured. On my last visit to the hospital a month ago, a patient was heard asking why he had to wait for more than 1 1/2 hours to see the doctor, when his appointment was made more than two months ago. Another patient asked why it took so long to fix his next appointment.

Sir, in order to cut down on the long waiting time and to improve the efficiency of hospitals ---

The Chairman: Order. Moment of interruption.

Thereupon Mr Speaker left the Chair of the Committee and took the Chair of the House.

Mr Yeo Cheow Tong: Mr Speaker, Sir, I beg to report that the Committee of Supply has made further progress on the Main and Development Estimates for the financial year 1991/92, and ask leave to sit again tomorrow.

Mr Speaker: So be it.