ACCESSIBILITY TO BASIC HEALTH AND LIMITING NUMBER OF DOCTORS

Dr Wong Kwei Cheong asked the Minister for Health how the Government can ensure that basic health is accessible to all if it is the Government's policy to limit the number of doctors by maintaining the intake of medical students at the National University of Singapore at 150 a year.

The Minister for Health (Mr Yeo Cheow Tong): Mr Speaker, Sir, the number of doctors in Singapore has increased significantly in the past 20 years. We had about 3,600 doctors in 1990, compared to only about 1,400 in 1970. This is an increase of 2,200, or about 160%, compared to the increase in our population of 45% over this period. The doctor to population ratio improved from one doctor to 1,500 population in 1970 to one doctor to 830 population in 1990.

The total number of doctors in Singapore will continue to increase significantly, even at the present intake into NUS of 150 medical students a year. This is because, in addition to the medical graduates from NUS, there are also Singaporeans returning from abroad with medical degrees as well as non-Singaporean doctors working in Singapore.

My Ministry projects that we will have about 5,200 doctors in the year 2000. The number of doctors will therefore increase by 1,600 in this decade, compared to an increase of only 2,200 in the past two decades. Our doctor to population ratio by the year 2000 will be 1:650. This will be comparable to the current ratios of Switzerland and the United Kingdom. Members should note that these are countries with more dispersed and older populations than ours. Their need for doctors would consequently be higher than Singapore's.

We therefore have enough doctors now, and will have even more in the future, to ensure that Singaporeans have at least good basic health care.

Dr Wong Kwei Cheong (Kampong Glam GRC): Sir, can the Minister not subscribe to the basic economic principle that the more doctors we produce the lower will be the medical cost?

Mr Yeo Cheow Tong: Sir, contrary to conventional wisdom, this does not apply to medicine. Let me quote from some well known authorities in this area. Prof. Brian Abel-Smith from the London School of Economics and Political Science has done much research in this. In 1989 he published a paper, and I quote him:

'An excess of doctors is likely to lead to excessive prescribing and use of medical procedures and diagnostic tests in addition to the cost of paying them.'

He goes on to say that:

'In 11 of the 12 countries of the European Community, doctor supply is limited by planning the number of medical students or, in countries where this is not acceptable, raising the standard of the examination at the end of the first year of the course.'

So they have their own mechanism for ensuring that the number of doctors is appropriate to meet the needs of society.

From the United States, Prof. U E Reinhardt, professor of political economy at the Princeton University, also stated that:

'The bulk of health care is received by rather sick patients who typically may not be able to act as a well-informed rational consumer depicted in textbooks of economics. They are easily exploited financially in a so-called free market for health care.'

He therefore concluded that:

'The conventional, completely free market of the sort extolled in textbooks of economics is not applicable for health care in a civilised society.'

So contrary to conventional wisdom, it is not possible to apply the free market principles to the provision of health care.

Mr Low Thia Khiang (Hougang): Sir, how does the Ministry of Health propose to prevent the increase in the number of doctors who graduated from foreign universities?

Mr Yeo Cheow Tong: Sir, doctors who obtained their qualifications from foreign universities will be vetted by the Singapore Medical Council and only those with qualifications that meet the specified standards will be allowed to practise in Singapore.

Dr Wong Kwei Cheong: Sir, the Minister has given only a qualitative statement. Can he come out with figures to show that an increase in the number of doctors will actually lead to an increase in the cost of health care?

Mr Yeo Cheow Tong: Sir, one should learn carefully from the experience of others. In the US, this same philosophy was widely espoused in the 60s and this led to a tremendous increase in the number of doctors in the US. In a period of 17 years in the US, the number of doctors increased by a quarter million. Plenty of free market competition. Did it result in a reduction in health care cost? On the contrary, Sir, health care cost in the US increased very, very rapidly. And as a percentage of the GDP, total health care expenditure in 1970 was only 7.6%. In 1987, it increased to 11.2% and today it is in excess of 12% of the GDP.

Dr Wang Kai Yuen (Bukit Timah): Mr Speaker, Sir, is the Minister not making a sweeping statement in saying that in the provision of medical health care, free market forces do not apply? Because in the provision of hospital services to the country, within the confine of that particular arena, in restructuring the hospitals the Ministry is also applying the free market forces to determine what is the rate to be charged to the patient. Furthermore ----

Mr Speaker: Dr Wang, are you making a speech? I think you have already asked your question.

Mr Yeo Cheow Tong: Sir, I quoted noted authorities who say that the principles of free market cannot be fully applied in the health care sector. It does not mean that the principles do not apply totally. Of course, principles of free market will apply in certain sectors. For example, in the supply of manpower, if the service providers do not pay according to the free market forces, they will not get enough nurses and administrators. Similarly, if they do not pay the prices of drugs as determined by free market forces, they will not get the required drugs. For the Government's restructuring of the hospitals, we are allowing free market forces to prevail in terms of setting salaries, but I can assure you that the free market forces are not allowed to apply in the setting of fees. If that is the case, then I can assure you that the hospitals would be charging a lot more, because that is what the market would be prepared to pay when people are in need of health care. So in the interest of the public, we have had to influence the cost of health care.

Dr Wong Kwei Cheong: The Minister has only quoted examples in the United States. How could he see that the same will apply in Singapore?

Mr Yeo Cheow Tong: Sir, he is talking of free market forces. We learn from others whether those theories work. It is in our interest to learn from them. And if it does not work, not just in the US but elsewhere in the developed countries, we better learn quickly before we fall into the same problems that they find themselves in.