AFFORDABLE HEALTH CARE (Motion)

3.37 pm

The Minister for Trade and Industry (Mr S. Dhanabalan): Mr Speaker, Sir, I beg to move the Motion* standing in my name.

*The Motion reads as follows:

That this House endorses the principles and approaches set out in Paper Cmd 16 of 1993 on "Affordable Health Care" as the basis for Government policies to contain health care costs and to keep good basic health care affordable to all Singaporeans.

Sir, we have a healthy population. Our health education and disease prevention programmes include measures to maintain high standards of water, food and a clean environment. These have resulted in a people whose health measures very favourably with those of the developed countries. Because we have put our efforts in the right areas and put the emphasis on personal responsibility in health care, we have attained high standards of health by spending only 3.1% of our GDP on health care. This is low compared to the US which spends 14% of GDP on health care, Germany which spends 8%, and Canada 9% of GDP.

However, the pressure for health expenditure to increase in the future is very strong. Between 1980 and 1990, expenditure on health care grew at 12% per annum compared to the GDP growth of 10%.

Our population is getting more affluent. Expectations are rising. People are putting more emphasis on the quality and value of life. At the same time, the population is ageing. All these must lead to demand for better and more medical services. We must get our philosophy on health care right and pursue national health policies which prevent over-supply, dampen demand and keep cost increases in check. We must build upon our present sound approach to medical services and health care costs and reinforce the system to cope with the pressures of an ageing population, rising manpower costs and advances of new expensive medical technology and drugs. Otherwise, we too would be sucked into the same problems of exploding health costs faced by the United States and the countries of Europe.

In Singapore, primary health care is provided by our general practitioners in the private sector and by our Government polyclinics. Private sector GPs cater for 75% of the demand for primary health care. They charge reasonable rates which most people can afford. Patients who cannot afford GPs can turn to Government polyclinics where charges are even lower, or where the truly indigent receive services free.

Singaporeans are quite satisfied with the level, quality and cost of primary health care. Their health concerns centre around what will happen to them when they fall acutely ill and need to be hospitalised or need other special attention. The White Paper deals mostly with secondary and tertiary health care, though it also covers other aspects.

Most of the concerns of people centre around the affordability of secondary and tertiary health care - affordability of the individual, the family, the employer and the community at large. I know many people feel that it is wrong for a person to be only allowed the medical care that he or she can afford. It offends their sense of equality and humanity. They would rather the same medical treatment be available to all regardless of income. This is a compassionate and understandable sentiment. But however compassionate we are, we cannot wish away the cost of medical care. The Government accepts that health care should not be a commodity that is available only to those who can afford it. But neither is it a public good that should and can be provided without limits and without regard to affordability. Regardless of how health care is financed, it is the people who ultimately pay for the health service. A person can buy an insurance policy to cover his medical needs. The premium that he pays will reflect the full cost of health care shared among all those in the scheme. The more he uses the insurance cover, the higher the premiums will be. A worker can get his employer to pay for his medical benefits. But the employer will pay them out of the total amount that he is prepared to pay for labour, so it comes out of the wages of labour. If the Government pays, it comes out of the taxes paid by the people. Ultimately, the people pay. We cannot avoid linking the standard of health care to affordability of the individual and society.

The Government undertakes to provide every citizen with the health care that he needs. However, this cannot be an absolute right or an unconditional entitlement. It must be subject to certain conditions. Among them:

(1) It must be confined to a defined basic health care package, and not cover unlimited amounts of medical services.

(2) It will not be for free. The citizen must pay for at least part of the health care he uses, unless he and his family are absolutely destitute and unable to do so, despite having contributed to Medisave and participated in MediShield.

(3) It must not prevent those who want more health care than the basic package, and are prepared to pay the full cost themselves, from obtaining it.

Members in this House in previous debates have asked for a clear definition of what is meant by good basic medical care. What is in the package and what is not in the package?

The basic health package will be defined by the Ministry of Health. It is difficult to list in detail everything which goes into this basic package. In broad pragmatic terms, the basic health package is what is already available in the polyclinics and the B2 and C Class wards of Government subsidised hospitals. But the exact type of treatment available will vary from illness to illness and the stage of the illness. A full description of what is basic health care package would fill a volume on its own. A few fundamental principles will shape the basic package:-

First, it will incorporate good up-to-date medical practice.

Second, it will give patients medically essential and cost-effective treatment of proven value for illness.

Third, the treatment will be delivered without frills, that is, the use of space and other physical amenities will be very economical and the nursing staff to patient ratio will be adequate.

Fourth, the treatment will be by trained personnel of qualified doctors, specialists and other medical staff working as a team.

Fifth, the treatment will use appropriate diagnostic and treatment facilities; drugs provided will be from a standard list which is more extensive than that recommended by the World Health Organisation.

And lastly, the treatment will include use of intensive care unit beds. Intensive care unit beds are not classified by classes and are open to patients purely according to medical need.

This basic package will not include treatment for certain conditions. For example, it will not include cosmetic surgery or cosmetic dentistry other than for burns and injuries or those that are required on medical grounds. It will not include sex change operations, IVF treatment, organ and bone marrow transplants (other than kidney transplants). These excluded treatments account for less than 0.1% of the cases dealt with in the unsubsidised wards. Experimental drugs not of proven value and other high cost investigations and treatment where effective cheaper alternatives are available, will also be excluded. Doctors have treatment protocols to guide them in treating individual patients. In some situations, ordering more investigations and treatments will not improve the patient's quality of life significantly or change the outcome. Examples are treatment of incurable diseases where there is no chance of survival, or using life support systems to prolong death. Under the basic package, patients in these situations will be treated humanely, be relieved of pain and suffering, made comfortable and allowed to retain their human dignity.

The basic package cannot be fixed for all time. The Government will continually review and revise the basic package to take into account medical progress such as new drugs, procedures and equipment, and social and economic progress.

A large part of basic health care will be provided in the polyclinics and by hospitals which receive Government subsidies.

All subsidised hospitals will compete with each other on price and quality, even though some of them will have specialist departments which the others will not. When hospitals are not subject to market forces, the potential for waste and inefficiency is enormous. Competition will improve their services and make them more responsive to market signals.

But free competition alone will not guarantee us an optimal health service. Health care is an example of market failure. The Government must intervene directly to regulate key aspects of the health care system to prevent over-supply of medical services and dampen demand.

In health care, supply creates its own demand. More supply and more competition does not always lead to lower cost or better services. More supply can actually increase demand and cost because of the nature of the consumer. The consumer who pays the bill, that is, the patient or a member of the family, is usually worried, under great emotional stress and is in no position to weigh the advice of doctors and make a rational choice based on the likely efficacy of the treatment and on his ability to pay. The consumer is often uninformed or misinformed, and naively believes that the more expensive the doctor, drug or procedure, the greater the likelihood of a cure. If the family is paying, their love, filial piety, and loyalty can be called into question if they do not agree to order the most expensive or latest procedures. This situation opens the door for health care providers to order more tests, procedures and expensive drugs. Often the patients or relatives themselves may request for these because they have read somewhere or heard from someone about these new medical developments. It is not mere chance that countries with more doctors, especially specialists, tend to spend more on health care.

Government must therefore not only define the basic medical package. It also has to prevent over-supply of medical services by regulating the supply of doctors, specialists, beds in subsidised hospitals and the establishment of specialist and sub-specialist disciplines and the purchase of expensive high-tech equipment. These are described in the White Paper.

In keeping with the primary mission of subsidised hospitals to provide for the lower- and middle-income groups, all subsidised hospitals will have C Class wards to serve the most needy Singaporeans. A minimum of 65% of the beds will be B2, B2+ and C Class beds.

There will be some unsubsidised wards, Class A wards, not exceeding 11% of the total beds in these hospitals. These will be for patients who want more personalised care, creature comforts and non-essential services, and are prepared to pay the full cost for them. Patients in Class A wards pay the full cost not only of the extras, but also the full cost of the basic essential medical care.

I know that some people are uncomfortable that patients in Government and restructured hospitals can get medical care beyond the basic package by paying more. They are especially unhappy that in the same Government or restructured hospital, patients in Class C wards should have spartan facilities, while others in A Class wards enjoy more privacy and creature comforts. They prefer everyone, rich or poor, to have exactly the same standard of medical care.

This is a natural, egalitarian, human instinct. But, unfortunately, complete equality of treatment is neither realistic nor desirable. Logically, there are only two ways for everyone to receive exactly the same medical treatment: either the Government must not allow anybody to obtain more medical treatment than the basic package, or else the Government must provide everyone with all the medical treatment he or she wants, without limit.

The first is an unnecessary and unjustifiable infringement on the personal freedom of individuals. The basic package only defines what the Government will subsidise and make affordable to the population as a whole. If a patient wants medical treatment which the Government does not consider basic, and the Government will not pay for, why should we stop the patient from getting it if he is prepared to pay for it? What moral right do we have to stop him? We will not make other Singaporeans better off by preventing a well-off patient from getting extra or better treatment. If a patient wants more nursing attention, a private room of his own instead of an open ward, or additional medical tests to confirm a diagnosis which is not really in doubt, and he is prepared to pay for it in full, who is the Government to say no?

Even granted this, some may still question whether the extra service should be provided in Government and restructured hospitals. If it is not provided in these hospitals, patients can go to private hospitals. If we disallow Singapore hospitals or private hospitals in Singapore from providing such services, patients can travel abroad for treatment. From the point of view of the C and B2 Class patients, it is better in fact for the Government and restructured hospitals to have A Class patients because A Class patients provide a check on the quality of the doctors and the quality of the hospital. These patients are prepared to pay the full cost in the hospital, even though they can afford alternatives like going to a private hospital. If only subsidised patients go to the Government or restructured hospital for treatment, we do not know whether they are going there because the service is good, or because there is no alternative. But if some patients want to be admitted to these hospitals for non-subsidised treatment, then we can be more confident that the hospitals, specialists and staff are competent, and that the hospital is providing good service. We still need to make sure that these specialists and staff are not neglecting the subsidised patients in favour of the non-subsidised patients, but that is a management problem which we can solve.

The second alternative, that is, providing everyone with all the medical treatment that he or she wants, will bankrupt us. Where do we draw the line? Should hospital in-patients receive four-star hotel treatment? Can every routine operation be done by the top surgeon? Should every patient who complains of a headache be given a CT scan? The list is endless and unaffordable.

In every other area of life, people accept that there is a difference between the essentials and the extras and luxuries. There is a big difference between a healthy square meal and a gourmet dinner. People accept that only the well-to-do can afford a gourmet dinner. There is a difference between a 3-room HDB flat and an Executive flat. People accept that only those who are better off can afford an Executive flat. Medical services cannot escape the same logic.

We need to also ensure that subsidised hospitals keep their costs, and hence their charges, down. Under normal market conditions, we can, after determining the subsidies to the hospital, leave it to competition to keep prices down. But as I explained just now, such self-regulation by market forces does not work because of market failure. Even with Medisave, which is the patient's own savings, patients are more ready to spend their Medisave balances than if they had to pay cash. Hospitals can, therefore, pass higher costs to patients by prescribing more tests and treatments than necessary, or by simply raising charges without losing patients.

The Ministry of Health will therefore control the revenue per patient day by class of ward, by specialties (for example, oncology cases will have a higher cap than paediatric cases), and by type of hospitals (tertiary hospitals will have higher caps than secondary hospitals). The hospital's revenue, comprising subsidies and the charge to patients, cannot exceed this cap. If it does, the Government will recover the excess. This will encourage hospitals to keep their charges down without restricting too tightly how much they can charge individual patients. Hospitals which reduce their costs can keep their savings and improve their services. Those hospitals which cut costs and reduce service or quality to unacceptable levels will lose patients and will earn less fees as well as less subsidies. But those which strike the right balance between cost control and service will attract more patients and earn more fees and subsidies.

Let me now come to financing. How patients pay for health care is an important part of any health care system. Note that the operative term is how, not who pays. Who pays is quite clear. As I have explained earlier, no matter who pays for health care in the first instance, the burden is ultimately borne by the people. The real issue is not who pays, but how and when the payment is made. We must have a system that encourages people to use health care economically and encourages health care providers to minimise inefficiency, minimise costs and prevent over-servicing.

Under Medisave, individual savings form the core of the system. Government subsidies and catastrophic insurance, that is, MediShield, play supporting roles. Patients pay part of the costs at point of consumption. This applies even to the heavily subsidised C Class wards. Patients who demand higher levels of service must pay more. This ensures that they use medical services only when they really need to. We thus avoid the danger of unlimited demand for "free" medical services.

The disadvantage of relying exclusively on savings to meet health care costs is that individuals will need to save more for their medical expenses than they are likely to spend because they must be prepared for unexpected contingencies. High Medisave also increases the temptation for patients to draw more on these balances than they absolutely need to. As I pointed out just now, patients are more prepared to spend their Medisave than if they were to pay cash although the Medisave balances are their own money.

This is why our Medisave system has an insurance component in MediShield. It is catastrophic health insurance incorporating deductibles and co-payments, ie, deductibles in that the insurance cover starts only after the patient has spent a certain amount, and co-payment in that even after the insurance cover becomes effective, the patient has to share part of the cost.

For those who have exhausted their Medisave and MediShield or for some good reason cannot even pay C Class rates, Medifund provides a safety net. Medisave, MediShield and Medifund, together with the Government subsidies, ensure that no Singaporean is deprived of medical care.

Private medical insurance policies generally do not provide for deductibles and co-payments. They also do not restrict what health care providers can charge. Fortunately, the market in private medical insurance is small. But it is growing rapidly. We should act now to guide the growth of the market in the right direction. In the meantime, we can improve our MediShield system in various ways. We can extend the benefits package of MediShield to provide more cover for Class B2 and C treatment by reducing somewhat the deductible amounts. We can also introduce MediShield II for those who want increased daily reimbursement rates so that they can afford higher class wards. MediShield II will be a voluntary opt-in system, unlike the present MediShield which is an opt-out scheme.

When the private sector insurance policies have the same safeguards as MediShield, we can allow people to use Medisave to pay the premiums of approved private insurance schemes.

The White Paper also proposes that employers who provide medical benefits to their employees should contribute additional amounts to the employee's Medisave in lieu of part of the medical benefits in kind. We will encourage but not force them to do so. The Government, as the largest employer, will set the example. The Minister for Finance will present the medical benefits package for civil servants.

Now, let me say something about Medisave in the private sector. Many patients in the private hospitals use Medisave to pay private hospital and specialist fees.

We want the private sector to play an increasing role in health care though Government subsidised hospitals will be the dominant component in our health care system. This is why we are limiting A class beds in subsidised hospitals to 11% of the beds in these hospitals. Government will also encourage private sector hospital development by selling suitable sites for such purposes.

But we need to have some control on the private sector charges as the private and public sector markets are interlinked. The public sector has had to increase the salaries of its doctors and other medical staff, partly because incomes in the private sector increased steadily, especially after Medisave was introduced and widened the gap between the earnings in the private and public sectors. This contributed to the overall rise in health costs. We, therefore, have to control private sector fees and charges when Medisave is used.

We will work out schemes to limit balance billing of Medisave patients by private hospitals and doctors. This will be the private sector equivalent of the revenue cap system in the subsidised hospitals. There will be a limit on how much cash patients can be asked to pay over and above the payment from Medisave. 74% of the patients treated by private hospitals and doctors use Medisave to pay part of their bills. Income from Medisave patients constitutes 50% to 60% of private doctors' total earnings (I am talking about doctors who service hospitals, not the GPs who cannot draw on Medisave). Limits on balance billing should, therefore, be quite effective in keeping down fee and cost increases in the private medical sector.

If the patient does not use Medisave and pays the entire bill in cash, the limit will not apply. But patients, we know, are more restrained when they have to pay in cash and will, therefore, resist high charges more strongly.

We did not invent this idea of limits on balance billing. Germany and Japan have similar schemes to control private sector charges. We will take some time to develop a comprehensive system of limits on balance billing but a start will be made some time next year.

Research and development. Our health policy emphasises primary health care, a good basic health package for all at the secondary and tertiary level at affordable prices and sustained cost control measures at all levels. Cost consciousness must become a deep part of the culture of our health care givers.

Our research and development efforts in medicine and training of doctors must be consistent with and subordinate to the national health policy.

Ever since the establishment of the Medical School in 1905 in Singapore, the medical profession has attracted the best minds in Singapore and the then Malaya. It is not surprising, therefore, that the quality of our medical service is the best in the region. It is also natural for the medical profession and for Singaporeans to expect us to be in the forefront when introducing or testing new medical procedures and drugs, and to be a leading centre for medical research and development. In the past, before the current explosion in experimental medical work, our society could bear the cost of such ambitions. The majority of the population was deeply suspicious of hospitals so that experimental work in hospitals did not result in an immediate demand for more services.

The situation has, however, changed. Our population is now alert to the latest medical advances, however tentative, in the medical world. A short report in the newspapers of some new work results in immediate inquiries and demand for the same type of treatment, whether it is a new treatment for cancer, or a new surgical procedure for heart patients. Research with clinical implications, therefore, results in an immediate demand for more health services.

If we want to maintain our excellent health care system and continue to attract some of our brightest students to study medicine, then we must carry on doing medical research and development. But we should focus more sharply on research with cost effective practical applications and research which can help improve the health care system. We must not be too ambitious to be at the cutting edge of medical technology. We can also do more theoretical research, like that done in the Institute of Molecular and Cell Biology, which is significant research, but has no immediate impact on the demand for health care services. But we should be very careful in undertaking research in areas not within the basic health care package. For example, we should leave it to other countries with more resources to experiment in organ transplantations.

The White Paper proposes the establishment of a National Medical Research Council which will approve, oversee and coordinate medical research which has clinical implications.

The content and emphasis in medical education too must be in line with the national health policy. Undergraduate training must emphasise primary health care, not high-tech medicine. The aim must be to train students to be good family doctors. In postgraduate and specialist training, the aim should be to meet the service needs of the public sector hospitals.

The National University of Singapore will work together with the Ministry of Health and the Singapore Medical Council to keep undergraduate curriculum current and relevant. The Ministry of Health, together with an Advisory Committee on Medical Specialists, will regulate the training of specialists.

Mr Speaker, Sir, there was a time, not so long ago, when few Singaporeans dared to venture into a hospital. To be sent to hospital was considered by many to be a death sentence. A more educated and affluent people now know the value of early attention and treatment. Fears and inhibition about hospital treatment have diminished. People know more about the latest treatments and advances in medical technology, though often their knowledge is partial and even distorted. All these will raise the demand for health care. We must learn to spend the money that we set aside for health care wisely.

The Government undertakes to make a package of essential and effective treatment available to all, not for free, but at affordable prices. It will institute various measures to keep down national health care costs. But the responsibility rests on each of us, as individual Singaporeans, to do all that we can to stay healthy, to save to pay a share of the cost of treatment when we fall ill, and to spend these savings wisely.

We have a good health care system. The proposals in the White Paper will improve it further. Singaporeans must be sensible about what they can expect from the health care system. Then the Government can manage the system rationally, and not dodge tough choices which are unavoidable. That way, we avoid the awful trauma that the developed countries are going through to reform their health care systems and make them affordable to society.

Question proposed.

Mr Lau Ping Sum (Ang Mo Kio GRC): ( In Mandarin): Mr Speaker, Sir, I rise in support of the Minister for Trade and Industry's motion.

Giving birth, getting old, falling sick and dying are the inevitable processes of life. A person who is healthy and full of energy will not only increase his productivity and competitiveness but also enjoy a fulfilling and meaningful life and, therefore, people are very concerned about their health and the cost of health care.

The health of Singaporeans has made very remarkable progress in recent years. Based on the average life expectancy, infant mortality, control of infectious diseases, we are not far behind the standards of advanced countries, some of which we have overtaken. At the same time, many people still feel that medical costs seem to be mounting all the time. Not only the private hospitals have adjusted their fees upwards, Government and restructured hospitals have also increased their fees in order to meet the increasing costs and to prevent a brain drain.

Some people feel that it is the responsibility of the Government to account for the rising cost of medical fees. But I think when people talk about this issue they are very emotional. They do not quite understand the circumstances that have led to this situation and they listen to hearsay and follow what others are complaining about and blame the Government.

The other reason is that between 1984 and 1989 there were no fee adjustments in Government hospitals. In April 1989, there were adjustments in the ward charges, surgical fees and other fees. In August 1990, Alexandra, Kandang Kerbau, Tan Tock Seng and Toa Payoh Hospitals also adjusted their fees upwards and quite substantially. At that time, soon after the implementation of the restructured hospital scheme, to increase efficiency, to simplify administrative procedures and to enhance services, I think the intention was good. But before efficiency was raised, the new rates of fees were already applicable. So some people had the preliminary impression of restructured hospitals that before they could get the benefits, they had suffered from the disadvantages. Since 1990, the Government decided to adjust the fees annually in order to prevent substantial increases over a longer period. I think this is the correct way.

In order to ensure that we have an affordable health care service, the Government has published this White Paper to deal with the various objectives, which are as follows:

(a) To nurture a healthy nation by promoting good health.

(b) To promote personal responsibility for one's health and avoid over-reliance on state welfare or medical insurance.

(c) To provide good and affordable basic health services. (The Minister has already explained the meaning of basic health services.)

(d) To rely on competition and market forces to provide health care service and to raise efficiency.

(e) To intervene directly in the health care sector, when necessary, where the market fails to keep health care costs down.

This shows the basic principles and the right direction of the Government to make everybody responsible for his own health. I think we should be very calm and try not to be emotional in drawing the wrong conclusions. I hope that after the debate in this House, people in Singapore will have a better and more comprehensive understanding of our health care system.

On market forces, theoretically, free market and competition are closely related with the two following features:

First, we have a lot of buyers and sellers in the market and the individual buying and selling are very small which cannot influence prices.

Secondly, there is no restriction on buyers and sellers and they understand the market price and related matters. I think Dr Ow has already told me this.

Nobody can monopolise the prices if there is a balance between supply and demand. President Kennedy of the United States said previously that the free market is not only a more efficient determinant than the best central planning agency, it is also a pillar of the US democratic system. If the free market system is that good, then there would not be so many economic problems in the US. There will not be a wide gap between the rich and the poor and there would not be any inflation in the US. To ensure that, as the Minister has said, the patients do not know the good and bad points of medical treatment and they have no time to choose which hospital, which expert or specialist to see. I think the moral and ethics of doctors are important factors that will determine medical costs. So I hope that the Medical School in Singapore, in addition to inculcating and imparting the medical expertise, should also inculcate the correct attitudes and moral values to relieve people from pain and suffering in the service of society and for the benefit of mankind.

I hope that the subsidised Government hospitals will, through competition, increase service quality and lower operating costs. I think these two are conflicting factors. If you want to improve the quality, you must have more medical, administrative and other staff. But the increase in staff means more expenditure and that will increase operating costs. On the contrary, if the Government wishes to save money by cutting down staff, then the workers will have a heavy responsibility. Morale will be down and the quality of service will also be affected. So between the two factors, I think it is a great challenge for the hospitals to maintain a balance. I hope that the Government hospitals or subvented hospitals should pay attention to improving the quality of service and should not be quibbling too much about cost savings. I think it is very easy to measure the financial performance of a hospital. But if you pay too much attention to financial performance, I think the quality of service will be affected.

The Public Works Department, the PUB and other Government agencies have very good performance under monopolistic situations. It is also because of the right attitude of the people and the management of these statutory boards that they are very competitive. I think these are more important.

According to the White Paper, Mr Speaker, Sir, A class beds should not exceed 9% of the total number of beds in the whole country or 11% of subvented hospitals and the individual subvented hospitals should not have more than 13% of A class beds. This measure is to ensure that the middle and lower income groups have affordable basic health care. I think it is a correct move. But in subvented hospitals, I think this percentage should be further reduced. The reasons are:

(1) Those who can afford A class beds can go to the private hospitals.

(2) Subvented hospitals now face the problem of manpower shortage. To increase the number of A class beds will further aggravate the manpower shortage situation.

(3) The more A class beds there are, the faster will the B and C class beds reach the point of saturation, and some of the patients may be transferred to A class beds.

On community hospitals, I think Mr Chandra Das also said sometime ago that the number of A class beds should be further reduced in community hospitals, because such hospitals are set up to provide affordable health care services and A class beds are not affordable.

Workers' welfare and Medisave. The employers do not want their employees to over-use their medical benefits. So the Government is taking the lead to provide extra contributions to Medisave in lieu of medical benefits for the new civil servants. I think this measure to encourage employees to take care of their own health will enable those who are paying attention to their own health to have more Medisave balances in their accounts. This is a good measure but we should look further into it because it may be unfair to some people. For example, those who are involved in road accidents will have to be hospitalised, and they may have to be operated on several times. It does not mean that they are over-using their medical benefits. The 2% cap may be used to buy medical insurance but they will still have to pay out of their own pockets.

Those people who have hereditary diseases such as diabetes need more medical care. It is not because they do not care about their own health. It is because of their own hereditary reasons and not because they neglect their health. So they need medical care. So the question of how these costs could be distributed fairly should be looked into further. I endorse the Government's view that everybody must be responsible for his own health. But for some other diseases such as heart diseases, diabetics, and with more and more such cases around, I think we should pay attention to them.

According to a survey of the Ministry of Health, 10% of our students have high cholesterol levels and 15% of the students are overweight. It is because they eat more meat, but if you inculcate good eating habits from young you could prevent a high level of cholesterol, excess blood sugar and prevent high blood pressure. I think we must pay attention to this. The Ministry of Health and the Ministry of Education have worked out a scheme to encourage people to take care of their diet by eating less sugar and drinking more water. I think this is a very good way of looking after the health of people.

But apparently, the White Paper has not dealt in detail about preventive health care. I think the Ministry of Health might already have something in mind. I hope that this can be published in due course. Prevention is better than cure. Before the situation gets out of hand, we should think of preventive measures, and this is consistent with the style of the Government. The White Paper is a good example. Apart from strengthening our health care system, a more important message is that every Singaporean must be responsible for his own health. Good eating habits, moderate living, healthy lifestyle, are important things that our people must look into.

Mr Kenneth Chen Koon Lap: Sir, I must commend the Ministerial Committee for presenting an excellent and comprehensive White Paper on Affordable Health Care. It is an extremely complex issue and the Committee has shown deep insight in the magnitude of the problems associated with our health care system.

Against the backdrop of ever increasing health care cost and the limited human resources, not to mention the constant higher expectations from the general public, the White Paper analyses systematically the problems we face in the health care system with pragmatism and compassion, and examines all possible options and proposes a framework to put in place an effective, workable and fair health care system for all the Singapore citizens. But its rationale and analytical approach to the subject, though comprehensive and systematic, may not necessarily find immediate acceptance from the average Singaporeans who always have an in-built fear and apprehension towards the extent of health care that they can receive when they have the misfortune to fall ill. Furthermore, health care has always been and always will remain an emotional issue. It is this emotional dimension that causes judgment to be impaired, resulting in the health care system in some countries getting totally out of control.

The White Paper addresses all aspects of our health care system, right from health care philosophy to medical treatment and training. Today, I would like only to focus on the subject of basic medical care. I have chosen this particular subject because I feel that it would generate the most concern as it is an aspect of health care that affects almost everyone at one time or another. It is important to ensure full understanding and acceptance.

The White Paper has examined in detail the basic medical care in terms of need and cost affecting treatment that an average patient requires. It defines what basic medical care is all about and proposes a basic package of affordable health care, not by inclusion, but rather by exclusion. It includes almost 99.9% of medical treatment available and excludes items like cosmetic surgery and dentistry, sex operations and in-vitro fertilisation treatment, organ transplant, artificial appliances other than the most basic models for heart, hips, knees, etc, experimental drugs and all high cost methods of investigation. If one inspects the proposed medical care package rationally, one can understand fully the reasons for such conclusion because medical treatment is not an exact science and there is no limitation to how far one can go in seeking out the various treatments available, whether proven or experimental. It is obvious that such treatments cannot be given to everyone due to the immense cost and also, in some instances, the futility of such treatments.

However, in time of sickness, the affected person, or those dear to him or her, would often not use rationale to make decision. They are usually in a highly emotional state of mind. For example, if there is the slightest chance, no matter how remote, for a terminally ill patient to be cured by experimenting with highly expensive and untested treatment, chances are that the patient as well as those in the immediate family would clamour for a try, and it is very difficult at that point of time to convince them that this is not included in the basic medical package and therefore will not be provided unless the patient pays for it.

As we so often say, one cannot equate life with cost. How then can we overcome this emotional demand without sounding uncaring and cruel? It is the responsibility of the Government to ensure that everyone has to learn to accept that there is such a thing as cost constraint in medical care. It is not only a question of affordable health care for the individual. More importantly, we must have an affordable health care system for the nation. We cannot let a few isolated cases to cause our whole health care system to collapse.

I must re-emphasise that this basic health care package refers to only Government subsidised medical treatment. The individual is not prevented from seeking whatever level of health care treatment he wishes provided he pays for himself. The Government also has the obligation to assure the general public that the basic health care package is made available to everyone irrespective of whether he is rich or poor. In turn, every citizen must understand that although the level of quality of medical treatment should generally be equal, the degree and comfort of services can vary.

Very often when we hear of a complaint being made against a doctor or hospital, we assume that it is made against the medical treatment received. In actual fact, a great percentage of them are actually against the degree of comfort and services received, and not the quality of medical treatment. These are two completely different issues. A patient staying in Class C ward and a patient staying in A1 ward and having the same sickness would probably require the same length of time to be cured. The fact that those C class patients would have to wait longer for the nurses to attend to them or have to endure a noisier and hotter environment would not in any way make the illness any worse. They may suffer a bit more discomfort, but the quality of medical treatment must remain more or less at par between the patients of those two wards, and this the Government should ensure.

As I have emphasised earlier, this is a very emotional subject. It may not be easy to bring across the rationality of such a decision on defining what constitutes basic health care. It is further complicated by the fact that medical science is not an exact science and there are lots of imponderables and probabilities that even the best of doctors or specialists may not be able to come to the same conclusion. Therefore, in borderline cases where a doctor has to make the decision as to whether a certain treatment can be considered basic or not they can generate disagreement and dissatisfaction. This will no doubt cause a lot of controversy in the future. While one should be caring and understand the plight of those who have fallen ill and that of the relatives and loved ones, the Government must take a firm stand in implementing a long term affordable health care system. We have seen numerous examples of countries, both developed and developing countries, grappling with their health care systems, some of them on the verge of collapse, and we cannot fall into the trap of being over-benevolent and let our emotions cloud our judgment.

Once again, I commend the Committee for putting up this White Paper. I am sure the Ministry would continue to make adjustments and improvements to the system. The tremendous progress and changes in the field of medicine necessitated these adjustments. Who knows that what is considered basic today may be just routine tomorrow. But at this point of time the Government must assure all its citizens that they will have an effective, efficient and affordable health care system. It is hoped that our citizens will be able to take care of themselves as much as possible, but should they be unfortunate to fall ill, they will be given the best possible health care.

Mr Peter Sung (Buona Vista): Singapore as a Medical Centre

Singapore would like to be a medical centre and to succeed in this task, we need a number of specialists in a number of specialised areas. For each specialty, we need to have many specialists in order to provide breadth and depth of knowledge in the field.

Over the last few years, we have, by and large, succeeded in this task. This is shown by the number of patients from the region coming to Singapore to seek medical treatment. This is much to the credit of the doctors in Singapore as well as the people who plan the scheme.

More specialists means more referrals by general practitioners

When a general practitioner suspects that the patient suffers from a serious illness, it is very likely that he will refer the patient to a specialist. This is to enable him to get a second opinion. It is also to ensure that he has the benefit of the advice of properly trained specialists in order to help him with the diagnosis. If no specialists were available, then his conscience is clear. But if a specialist is available, the GP may find it unconscionable not to seek that advice. This is good for the practice of medicine, it would also contribute to the rise in medical expenses.

Specialist Equipment

Sir, specialist equipment is another area. When specialists are available, they would install specialist equipment. When the specialist equipment is available, specialist tests would be prescribed. A doctor would find it difficult not to prescribe tests that are available in order to get all the information that he can get hold of for the purpose of a complete diagnosis before treatment. When more tests are being prescribed, the cost of medical treatment would therefore rise. Some of these medical equipment are very expensive and their capital cost would have to be recovered by means of usage fees and so the cost of medical tests and procedures will also increase the cost of medical attention.

Many family members would also want specialist treatment

GPs are not the only people who would like their patients to be subject to specialist treatment. From time to time, a patient is sent for specialist treatment when the family members think that it is a matter of duty, perhaps their love for the patient, to send the patient for specialist treatment and to get the best possible attention available. Often this is out of a sense of filial piety, even though in some cases the condition of the patient may not be all that hopeful and the cost of specialist treatment may be beyond the means of the family. But many of them would feel that their conscience will not be clear if a specialist is available and his help is not sought for their sick or dying parent.

Choosing the Specialities

In the process of becoming a medical centre, let us choose the specialities carefully. It is clear that in trying to become a medical centre, we have inadvertently and perhaps indirectly raised the cost of medical treatment in Singapore.

I am not saying that Singapore should not be a medical centre. May I suggest to the Health Ministry that we restrict the number of specialities that the Government would like to subsidise and encourage in the hospitals funded by the Government. There are many reasons for these. For example, there is a finite number of people in Singapore who can become doctors. And among them, there is even a smaller number who can become specialists. With just three million people, there is a demographic limit to the number of people who can realistically become specialists and we simply do not have enough men to man so many specialities. Many of this talent ought to be channelled to other areas in Singapore because these other sectors also need a fair share of talent.

Summary

To summarise, Mr Speaker, Sir, the development of Singapore into a medical centre has inadvertently increased the cost of medical treatment. I urge the Government to control this by restricting the number of specialities that it would promote and subsidise, leaving the private sector to promote other specialities if the market demand is there.

On this note, I support the motion.

Dr Michael Lim Chun Leng (Cheng San GRC): Mr Speaker, Sir, reading the White Paper on Affordable Health Care was like de javu. My views on health care are in many ways similar to that advocated in the White Paper.

[Mr Deputy Speaker in the Chair]

4.46 pm

Dr Michael Lim Chun Leng (Cheng San GRC): The Ministerial Committee has produced an excellent report on the macro aspects of creating an efficient health care system, keeping basic health care accessible to all and containing long-term health care cost and Government subsidies. I believe that it is a step in the right direction. However, I would like to make comments on certain areas.

Firstly, health care philosophy. The five fundamental objectives spelt out in the Government's approach to health care philosophy are sound. However, I think that there is one other important objective that should be added to the Government's health care philosophy, that is, to avoid over-subsidy of health care services and to educate the public on the true cost of health care. We should not be too liberal in subsidising health care services, but we must be liberal in ensuring that those who are unable to afford basic health care services will not be denied of basic health care services. By over-subsidising health care, not only will consumption of health care be increased but it will also distort the true cost of health care.

Our present system of health care subsidy in the subvented hospitals at the macro level is not reflected at the micro level. For example, a B2 patient may in effect be subsidised substantially more than 65% of his cost if he requires more investigations. Hence, a patient who, because of his medical condition, requires extensive x-ray investigation, including a CT scan costing a few hundred dollars, may only have to pay a maximum of $50 for all these tests throughout his entire stay in hospital. Likewise, a B2 patient with cardiac disease who requires multiple electrocardiograms, cardiac ultrasound scan, treadmill tests, ECG monitoring costing, say, more than $500, may not have to pay more than $20 for all his tests. In fact, a subsidised B2 patient once remarked that it was ridiculous that a cardiac ultrasound scan is charged only $20 when an electrocardiogram is also charged $20. It seems ironical that a cardiac ultrasound scan which takes a highly trained technologist half an hour to an hour to do on a machine, which costs a few hundred thousand dollars, is charged the same cost as an ECG which can be done by an unskilled technician in 10 minutes on a machine that costs a few thousand dollars.

In line with the objectives spelt out in the White Paper, the Government should take steps to address this issue of over-subsidy. The system perhaps should be revised so that patients should pay a percentage of the true cost of the service or tests provided rather than a flat rate. Those who consume more should pay more and those who consume less should pay less. Hence, those in subsidised wards who use more services should not receive more subsidies than those who use less.

If the true cost of health care is distorted, it will be detrimental to our health care system. An elderly gentleman I met along a corridor of an HDB block expressed great unhappiness about his hospital bill. He was admitted to a subvented hospital for a surgical procedure and his gross hospital bill was more than $1,000. However, after all the Government subsidies were accounted for, he had to pay about $200. He was unhappy not because he had to pay about $200, but he was indignant that the gross bill was more than $1,000. He felt that it was ridiculous that the bill should be such, even though he stayed in hospital for about a week and had undergone a surgical procedure. He was unable to appreciate the true cost of health care. We must not have a generation of Singaporeans growing up not appreciating the real cost of health care or they will not appreciate the health care subsidies given by the Government.

Hence, in whatever way health care subsidies are given, the real cost of health care should not be distorted by over-subsidy. There must be not too big a gap between the real cost and the cost paid by the consumer. Singaporeans must understand that if they want a high quality of health care, health care cost will increase. For example, in the past when dialysis was not available, if you had renal failure, the ultimate cost was death. However, now dialysis is widely available, but it is also costly. So if we take away high-technology medicine, who is to lose out? I think that the rich can always go overseas and seek treatment, but the average Singaporeans will face problems. So sometimes it is very difficult to have good quality medicine and cheap medicine.

Secondly, I would like to say a few words about basic health care. I am glad that the White Paper has tried to give some form to this nebulous term of basic health care. In principle, I agree with the broad definition given in the White Paper. However, some of the principles are completely sound and logical but do not give health care givers clear directions at the ground level. For example, no one will dispute that basic medical care excludes extravagant efforts to keep gravely ill patients alive using high-technology equipment, regardless of their quality of life and prospects of recovery. However, in practical aspects, what does it mean? Does it mean that a young man with a disease affecting his muscles, resulting in his inability to breathe properly, we should put a tube in him? Because if you put a tube in him and put him on a ventilator, he will otherwise be well. But if we do not put a tube in him, he will die. If we do not put a tube in him, is that passive euthanasia? So these are very difficult questions for practitioners on the ground. Perhaps at the national level, or at hospital level, ethical committees should provide clearer direction. If a patient's family insists on high-technology measures against doctor's advice, will he be automatically converted to non-subsidised status, because such measures are not part of the basic medical package? These questions need to be answered.

I support the recommendation that employers contribute more to Medisave in lieu of traditional benefits. If both outpatient and hospitalisation benefits are converted to increased Medisave contribution, the Government may perhaps want to consider allowing the use of Medisave for outpatient care with some caveats. To prevent unnecessary administrative burden and abuse, the use of Medisave for outpatient services should be linked with some conditions:

(1) It must be a co-payment scheme;

(2) There must be a ceiling for the amount withdrawn over a certain period, perhaps, monthly;

(3) It should only be allowed for outpatient treatments which are relatively more costly; and

(4) There should be a cap on the amount to be charged for the services provided. In other words, you should limit the balance billing.

I also support the establishment of MediShield II, and the development of the private health insurance. However, health insurance in Singapore must not evolve in the direction of the US where doctors, instead of being trusted for their expertise, are expected to call an 800 number and get approval for even basic medical procedures from a total stranger sitting in an air-conditioned office miles away. The US system promotes over-consumption and over-supply of services. Any private insurance scheme should involve some form of co-payment.

I also support the concept of balance billing. However, this is something that needs to be looked at carefully. The bill often contains not only the doctor's fee, but there usually is a two-component fee: one, the hospital facility fee; and two, doctor's fee. And in planning to limit balance billing, all sectors should be considered separately so that all sectors will contribute to this effort to limit balance billing. Also, each inpatient visit by each doctor may be different. In other words, we may have to differentiate between the charges by the doctor for different types of visits. A 10-minute routine visit at nine o'clock in the morning for a routine round cannot be equated with an one-hour stay in an intensive care unit for an extremely ill patient. Thus, there may be a need to have different scales for different types of visits.

At the end of the day, what does it mean for the man-in-the-street? I think the message to them is that there will be an affordable basic health care package. But we must educate the public that if they want to continue to have good quality health care, health care cost will increase. Ensuring that the increases remain affordable will require efforts by the Government, hospitals, health care providers, and most importantly, the man-in-the-street himself. At the end of the day, the man-in-the-street must understand that although, at most times, health care is good and cheap, occasionally it will be good but expensive.

I support the motion.

Mr Low Thia Khiang (Hougang): ( In Mandarin): Mr Deputy Speaker, Sir, over the past few years, medical cost has been going up all the time. Although the Government has increased its expenditure on health care, the rates of subsidy have been reduced, eg, from 85% to 84% for Class C beds, and this will be further reduced to 80%, and from 73% to 71% for Class B2 beds in 1992. This will be further reduced to 65%.

The concern of Singaporeans is that after the privatisation of Government hospitals, hospital fees will be further increased. With this trend going on, Singaporeans, especially those in the lower-income group, will one day be unable to afford these medical expenses. Although the Government has, after the last General Election in 1991, introduced the Medifund scheme to assist the lower-income people who are unable to pay for their medical expenses, most of the people in the lower and middle-income groups are unable to avail themselves of the benefit of the Medifund. The ever-increasing medical cost has remained a serious problem.

This White Paper brings forth some recommendations on how to control the continuous rise in medical cost. This is indeed very appropriate and relevant. First of all, I would like to deal with the Government's philosophy on the provision of health care to our people. The Government feels that everybody must be responsible for his own health, and should not rely on the Government's welfare service or medical insurance. Of course, I agree with the Government's emphasis on a healthy lifestyle to encourage more people to exercise regularly to keep themselves fit and healthy. A mentally and physically healthy person is a valuable asset of the country. However, this does not mean that when somebody falls sick and needs medical care, he must be held responsible for having fallen sick. Nobody wants to fall sick in order to enjoy the Government subsidy. Falling sick is something which cannot be helped. Because of his sickness, he has to worry about how to raise the money to pay for his medical expenses. This is really something which breaks his heart. The provision of medical care is the responsibility of the Government, in the same way that it is the responsibility of the people to pay tax, or to serve in national service. So the Government cannot push the responsibility on to the people.

Secondly, the Government is relying on market forces and free competition to improve service and efficiency. The White Paper recommends the overall control of medical service, including the number of doctors and charges of private hospitals, etc. But on the rise of medical cost, it talks about free market forces and cost-effectiveness. The role played by the Ministry of Health is to regulate the rise in medical cost. Government hospitals are privatized to conform to the principle of free economy. On the one hand, the Government wants to have overall control on the medical service market but, on the other hand, when medical cost escalates, it puts the blame on market operation in a free economy. Now, it has come a stage when everyone has to be held responsible for his own sickness. What really is the Government up to?

Mr Speaker, Sir, let me now deal with the contents of the White Paper. First, the basic medical care package. The Government says that it will be unrealistic to make the basic medical care package rigid and inflexible, and the items in the basic package will be reviewed from time to time. I presume that when the Government reviews the package, it is done with the view of increasing the items of medical services in the basic package, and not to reduce them. In my view, if the Government is unable to allow Medisave to cover all the items, then you might as well list out all the items that are to be excluded. Apart from pages 23 to 24, all the basic items should be included in the package. I feel that the general principle of the package must be that wherever lives can be saved by the provision of any service, then it must be included. To save life is very noble.

Secondly, the payment of medical expenses. The Government's basic pay package applicable only to Class B2 and C patients. However, certain major surgical operations are not available to Class C patients. They have to upgrade to B2 class in order to avail themselves of these operations, and hence pay 35% of the cost. Sir, 35% of a major surgical cost is certainly very substantial. If hospital charges keep on going up, then they will become a great burden to the people. The Government's solution is the use of the formula CPI plus X to control the rise in the cost of medical expenditure. How much is X? What will be the actual fees to be collected - $10, $100 or $1,000?

Thirdly, the Government plans to increase the contributions to Medisave. The question here is: Will the percentage increase affect the ability of the people to buy properties, to own shares, etc? Will this not be contrary to the Government's philosophy sharing national wealth?

Fourthly, the Government is encouraging employers to offer more contribution to the Medisave account in lieu of the traditional medical benefits. The question here is: Will this not lead to the employees losing their existing medical benefits? Does it not mean that, with this increased contribution, employers will no longer be responsible for the medical benefits of the employees? The White Paper mentioned that we too should explore ways to make greater use of medical insurance. I am of the opinion that health insurance is a matter that the government must further explore and look into. In order to ensure that the people have the money to pay for their medical expenses, the government encourages more money to be paid into Medisave account. This is not a long term solution especially when the medical expenses are supposed to be fixed byu market forces and the government refuses to spend more to offset rising medical cost; how much Medisave is enough is an uncertain X factor. With a lot of money frozen in Medisave, will it not run against the Government's principle of cost-effectiveness?

Overall, the White Paper expounds the Government's motive in providing medical care. In other words, the people must be held responsible for falling sick. Free market forces must be used to determine medical expenses. Is this the so-called responsibility of the Government, the PAP Government, to the people?

Mr Cheo Chai Chen (Nee Soon Central): ( In Mandarin): The Government has the responsibility to provide affordable health care to the people. This is undeniable because people have been paying taxes. Even those who do not pay taxes, or are paying little taxes, have also laboured for the good of the nation. Therefore, the State has the responsibility to look after their health. Even those handicapped people are also our compatriots. The Government has the responsibility to look after them. Our Government has enough reserves, it should spend more on housing, education and health care, especially for those poorer people. Of course, we do not want people to depend too much on the Government, but nobody wants to fall sick and be admitted to the hospital just to enjoy the Government's subsidy. This point has just been made by Mr Low Thia Khiang, the MP for Hougang. When a person falls sick, he and members of his family will have to worry about the medical expenses.

Although the Government says that it has subsidized health care, most people are still very concerned about the high medical and health care costs. I hope the Government will pay attention to the three following points:

(1) Health care for the senior citizens;

(2) The high cost incurred by patients suffering from serious and complicated diseases; and

(3) Ways to reduce health care costs.

Let me talk on these three points. First, the health care cost to the senior citizens. Because of the changes in society and because of the Government's land acquisition policy, some elderly people, who do not have children or whose children do not have the means to support them, will have problem once they fall sick. If they do not have savings, they will not be able to afford the medical expenses. Many elderly people are jobless and do not have CPF nor Medisave. These people need the help from the Government.

Secondly, the patients who are suffering from serious and complicated diseases. They may be small in number, but these are people who require treatment with high-tech medical skills and equipment. They will have great problems in paying for such high medical cost. The Government should find some ways to help these patients to lessen their burden.

Thirdly, how to reduce medical costs? How are we going to avoid excessive expenditure on health care? For example, we should not readily resort to expensive, high-tech facilities.

The Health Ministry should also consider holding more exhibitions in the HDB housing estates so as to educate people on the importance of keeping a healthy body. Indirectly, this will go a long way to reduce health care cost.

On the other hand, we should also restrict the medical fees charged by the private hospitals. Industrial diseases should be looked into also. The Government should raise the salaries of nursing staff to attract more people to join this noble profession. Minor cases can be managed by the nurses instead of the doctors. In this way, we can save on medical fees, or health care costs. But more importantly, the Government should not privatise all its hospitals. Health care is a public service to be provided by the Government. The Government should not, on the slightest excuse, privatise all its hospitals. Once the hospitals are privatised, the fees charged by these hospitals will be raised. Now that we have strong financial reserves, we should not privatise all the hospitals even if the hospitals suffer a deficit. The Government should continue to subsidise these hospitals. The Government should make use of its budget surpluses to subsidise the hospitals.

Although the Government says that those who cannot afford to pay for their medical expenses can apply for waiver of medical fees, this will result in delay in getting treatment. The Government should think of a more efficient way to make it easier for these people to apply for waiver of medical fees.

The White Paper emphasises on the effective ways to cut down health care cost and that people should be responsible for their own health. This is a correct policy. However, I am of the opinion that, apart from the suggestions in the White Paper, the Government should listen to feedback from the people on health care, to understand better the plight of the elderly people and to give more subsidies on their medical fees. 5.13 pm

Mr Loh Meng See (Kampong Glam GRC): Mr Deputy Speaker, Sir, I rise to support the motion standing in the name of the Minister for Trade and Industry, Mr S. Dhanabalan.

The many debates in Parliament in the last few years culminating in the White Paper on Affordable Health Care show clearly that the health of Singaporeans remains a high priority of the PAP Government.

The White Paper sets out clearly the health care philosophy of the Government and its commitment that good health care will remain accessible and affordable to Singaporeans.

Sir, the recent tragedy of AIDS-tainted blood in Germany is a useful lesson for us. In our drive to contain medical cost increases, the quality of medical care should never be open to jeopardy. In our effort to economise on medical cost, we should not risk a nightmare of disastrous consequences. The disaster in Germany shows that it may take years to uncover the grave and irresponsible error and system failure if no checks are in place. By the time it is found out, irreparable harm had been done to the innocent people. We cannot be complacent but to remain vigilant. I would like the Minister for Health to assure this House that in Singapore we handle all medical cases with care and that the exposure to accidents of the kind reported will not happen and that Singaporeans shall have no fear because their health and safety are in safe hands when undergoing medical treatment in Singapore.

We in the GPC on Health are happy that the Government has taken pains to define what universal good basic health care is. Our people are already enjoying comprehensive and quality health care. In today's B2 and C class wards, Singaporeans are being treated by well-trained and qualified doctors. Sir, Dr Michael Lim just now asked the Government not to give over-subsidy. I hope that the Government does not take his cue to reduce the subsidy for Singaporeans going into the B2 and C class wards. I think our concern is that the subsidy will be further reduced and, if possible, we will ask the Government to increase the subsidies for the B2 and C class ward patients.

The Government has assured us that the basic medical package will be constantly reviewed and expanded from time to time to take into account medical progress and improvement in the socio-economic status of our people. It is advisable and wise for us to go for results and to spend only on essential medical treatment of proven value that enhances the patient's health and quality of life. There are innumerable health care needs but the resources available are limited. We therefore should opt for cost-effective treatment that yields the best outcome possible.

Sir, one item in the White Paper that concerns many people is the exclusion of "unwarranted effort to prolong life and delay death" as part of the basic medical package. There are some who view this as a step towards the practice of euthanasia or mercy killing in Singapore. I am sure that this is not what the Government has in mind even though the Straits Times editorial of 25th October 1993 seems to indicate that "Singaporeans are being prepared for the day when conditions would be rendered acceptable for the plug to be pulled on those patients for whom, in the doctors' judgment, nothing more can be done." Here, I wish to state my position on this issue. I would not agree to euthanasia or mercy killing. We have no right to take away another person's life, not even the person himself.

Sir, in the GPC, we also have the views of the senior citizens. What cheered me is the comment of Mr Lye Thim Fatt at the meeting the GPC (Health) had with the Resource Panel. Mr Lye is the Chairman of the People's Association Senior Citizens' Club Co-ordinating Council. According to him, senior citizens, especially the elderly in their 70s, do not favour the use of expensive life supporting equipment in ICU wards to prolong life and delay death. They take a philosophical view that when their time comes to leave this world, they wish to die with dignity, comfort and in peace. He thinks that it is the children who would be more inclined to ask for such life support equipment to save the parent when taken gravely ill. They normally take the decision on behalf of the parent out of filial piety.

Perhaps the White Paper's mention of this delicate and sensitive matter may serve to bring the discussion out in the open among family members. I agree with Mr Lye' suggestion that the hospital doctors be properly trained and be ready to counsel the young next-of-kin on the possible outcome of any treatment, given the medical condition of the patient, before coming to the decision on the medical care to be given to the patient. The children can then be reassured that they have done their utmost for the parent in the most difficult circumstances when having to make the decision one way or another.

Next, Sir, I come to the standard drug list. The basic medical package also provides for a standard drug list based on World Health Organisation's (WHO) recommendation. However, the perception seems to be that they are of inferior quality as WHO connotes drugs suitable for the less developed third world countries. The President of the Pharmaceutical Society of Singapore, who is a member of the GPC (Health) Resource Panel, told us that the standard drug list provided by subvented hospitals and polyclinics is in fact much longer than those recommended by WHO and are of higher quality. But, Sir, maybe because of certain medical conditions where first-line drugs are needed for cancers and heart ailments, they are expensive no doubt, but they are very much needed, the Ministry should consider including some of them as soon as possible. Therefore, Singaporeans should not worry about the quality of drugs being dispensed at Government pharmacies.

The other interesting item in the White Paper is the need for Government intervention in the structure of the health care industry and the regulation of the health care system. Mr Low Thia Khiang just now made some comments about the contradiction between having free competition on the one hand and Government intervention on the other. I think it is only right that the Government intervenes, because the Government has chosen to intervene particularly where it wants to concentrate its resources on the subsidised patients in the B1, B2 and C class wards, focusing on the middle and lower income groups. I hope that the Government will constantly review the total number of beds in the different class wards so that the public will always have a choice according to their affordability. The changing demographic profile of our population and the disease pattern mean that adjustments will have to be made to the number of beds in the different class wards to meet the demand of the day.

In the area of health financing, Sir, I subscribe fully to the principle that the individual patient pays his own medical bill. Mr Low Thia Khiang suggested earlier that when a person falls ill, it is total Government responsibility. I think the Government should only come in in cases where the individual cannot help himself rather than to make it that anyone who falls ill, it is the Government's full responsibility to take care of every one. I think we should go for the exception rather than the norm. There would be exceptional cases of those unfortunate few, because of their serious medical condition, that will impose severe financial burden on themselves and their family members. And it is right that the Government has started the Medifund scheme to be the source for such people needing help from the State and I think the Medifund scheme has been a boon to all these people.

Sir, there is a group of retired senior citizens who have depended on their life-long savings to keep them going. Because of the small CPF savings in the earlier years and Medisave accounts being non-existent, these retirees, having exhausted their CPF savings, are very afraid to incur high medical bills that impose a heavy financial burden on their children.

Here, the family support is crucial and important. But there are those whose children are not well-off and these people have tremendous difficulty in looking after and supporting their aged parents. I hope that this will be taken into account when the hospital administration assesses genuine cases requiring additional subsidy or waiver of hospital fees. This group of elderly Singaporeans has contributed much in the past by laying the foundation for Singapore's present-day growth and prosperity, yet they are put in the undeserved plight because of the unfortunate circumstances in the old days of colonial government and early independent Singapore. The Medifund Committee should be more sympathetic and accommodating to these Singaporeans in need.

It is right that we focus on the large majority of our population who are gainfully employed. It is good to make a start now to encourage personal responsibility on one's own health, especially among the younger members of our working population. With a cap on companies claiming for tax deduction on medical expenditure at 2% of the payroll and the medical bills of most companies fall below the 2% level, it is timely for employers to revise their medical benefits scheme to incorporate incentives for medical cost containment and strengthen their business competitiveness.

Sir, the issue and challenge is how to make the transition phase in the switch-over more palatable to the affected employees. Staff and workers need to be assured that there will be no cut-back in their existing medical benefits. The medical benefits can be frozen at the present level with no further enhancement without co-sharing between management and staff. If employers wish to introduce co-sharing now, it would be only fair that financial incentives be given in exchange for co-sharing. I would ask the employers to first make a careful and detailed study on their own companies' past experience on medical expenditure and the number of cases involved so that the revised medical benefits scheme worked out could be perceived to be fair and reasonable to all parties concerned - the employer, the union and the individual staff. For those few unfortunate cases where the staff have been receiving medical treatment, the employers should endeavour to help find a cure first before putting them into the revised medical benefits scheme, or to work out some scheme to accommodate these staff who are having a medical condition.

Sir, I come to medical insurance and MediShield. Because of the unpredictability of a major illness befalling any one of us, Medisave savings may not be sufficient to pay for the sudden, unexpected catastrophic illness. The financial burden would be made worse when companies no longer pay in full or in part the medical bills incurred. I would urge the Government to get the CPF Board to quickly extend medical insurance coverage under MediShield. Such extended MediShield coverage will come in handy in instances of sudden and unexpected major illnesses. However, as MediShield is not likely to cover those living to the ripe old age beyond 70 years old, Medisave and other savings will still be needed to pay the sizable medical bill usually incurred in the last 1-2 years of a person's life.

With regard to the supply of doctors and hospitals, I support the Government's move to regulate the supply of doctors and hospitals. I welcome the fixing of a minimum 65% of the number of B2 and C class beds in subvented hospitals and 9-11%, depending on how you look at it, allowed for the A class beds. This demonstrates to whom the subvented hospitals are mainly to serve. I agree with the Minister's explanation on the need to retain a fair number of A class beds in subvented hospitals to ensure that service quality is maintained.

As for the number of doctors, we have been assured that there will be an adequate supply. Here, I think the key word is "adequate" supply, never mind the number, but they should be adequate, and 40% among the doctors being specialists. With the changing population profile and disease pattern, the type and number of specialists in demand will also change over time. For example, geriatric medicine will grow in importance to care for the increasing number of elderly Singaporeans.

On balance billing, I agree to the limit imposed through balance billing in the charging of patients using Medisave accounts by private sector doctors and hospitals. It is right to use the cost of effective treatment as the basis for balance billing as a way to protect the interest of the patients. I think the yardstick must be what is the cost for effective treatment of the patient as the basis. We should not allow it to be over-lucrative for private sector specialists to affect the specialist in the subvented hospitals who would then want to leave Government service. We would want to retain and continue to attract very good doctors and specialists working in subvented hospitals. It is not how much that one earns that matters. But if the differential in earnings becomes too wide between the private and public sector specialists, it gives rise to the feeling of their worth not being recognised working in public sector hospitals. It is therefore right for the Government to recognise this problem and to use balance billing to correct the anomalies in earnings of medical professionals in the two sectors. We have heard that because of balance billing the private specialists' income will likely drop. This should be welcomed by all of us, because it means that the patient will be charged less for treatment.

I must say that from time to time I am quite disappointed to hear medical practitioners mentioning about cutting corners in service because of the lower fees that they are able to charge. I think that is certainly not the hallmark of the medical professionals. As specialists, with the personal reputation to uphold, I am confident that they will maintain the high standard of medical service even if the rate of fees has fallen. We want our doctors and specialists in subvented hospitals to concentrate on the work of treating and healing the patients. Once there is stability in the medical professional manpower, excellent medical service delivery will be maintained.

Sir, the last item is Medical Fee Council. For too long, there has been the overly high dependence and over-reliance on medical experts to influence and decide on health care delivery policies and issues in Singapore. As has been evident from public discussion and comments on the White Paper, the consuming public, though the most affected, are not as vocal as those from the medical community. It is not surprising as the private sector hospitals and medical professionals have vested interest.

It is about time that opportunities were given for greater involvement and participation of consumer representatives. They should be given positions in the Medical Fee Council to represent the interest of the large consuming public. The consuming public has been at the receiving end of decisions made on health standards affecting them. If the consumer representatives are part of the decision-making process, there would be greater confidence in the objectivity and rationality of the decisions made. Once the decisions have been made and accepted, it is a matter of public education and information dissemination to rally the public behind in support of the exercise to contain medical cost increases. We all have a part to play to continue with this happy state of affairs in making health care affordable and accessible to all Singaporeans.

I would like to thank the Ministerial Committee for making the contribution for all Singaporeans.

Sir, I support the motion.

Mr Low Thia Khiang: Sir, may I clarify the part of my speech which Mr Loh Meng See quoted.

Mr Deputy Speaker: All right.

Mr Low Thia Khiang: I did not say that patients should not pay if they can afford to. In my speech, I am objecting mainly to the Government's philosophy to make the individual to be responsible for his sickness and treat health care purely as a consumption item.

Mr Loh Meng See: If Mr Low disagrees, can he state his position on it? Either the person is responsible or not responsible. Is he saying that a person is not responsible for his own medical condition?

Mr Low Thia Khiang: Sir, a person can be responsible for his own health by doing exercise or whatever, but it does not mean that he wants to get sick. On the one hand, a person can be responsible for his health. But how can a person be responsible for his own sickness?

Mr Loh Meng See: Even if he is unfortunate enough to fall sick, if he can afford it, should he not be made to pay for it?

Mr Low Thia Khiang: I did not say that he should not pay for it, if he can afford it. The question is, you cannot treat that as a kind of responsibility. If he cannot afford, the Government should pay for it. You cannot treat that as consumption, and say, "Because you are a consumer, you pay." To me, health care is a need.

Mr Loh Meng See: Am I correct to understand from Mr Low that he agrees that if a person can afford to pay he should be responsible enough to pay for his own medical bill to look after himself?

Mr Low Thia Khiang: Sir, may I get confirmation from the Member that a person cannot be responsible for his own illness?

An hon. Member: Why not?

Mr Low Thia Khiang: How? Even if you exercise the whole day, you can still fall sick. How can he be responsible?

Mr Yeo Cheow Tong: When I was listening to Mr Low just now, I was also equally confused. I am glad that he has thrown a little bit of light. But I think there is still quite a bit of darkness in front of me. Is he saying that even when a person has taken all the necessary efforts, for example, he has paid attention to all our healthy lifestyle messages, exercise everyday, and he still falls sick, if that person can afford to pay his own medical bills, the Government should still intervene to pay his bills for him?

Mr Low Thia Khiang: No.

Mr Yeo Cheow Tong: So what you are saying is that those who can afford to pay their bills, they should pay, but those who cannot afford, Government should intervene to assist them to bear their hospital bills if they deserve it.

Mr Low Thia Khiang: But it is not a personal responsibility. Let us make it clear. It is the individual's responsibility to keep himself healthy. If he can afford to pay, he pays. But it does not mean that when a person falls sick, it is his own responsibility to fall sick.

Mr Yeo Cheow Tong: I agree with Mr Low that when a person is sick, sometimes it is not because of his own responsibility.

Mr Low Thia Khiang: Yes.

Mr Yeo Cheow Tong: That statement, I accept. But, of course, if he gets sick because he smokes, drinks and does all kinds of things --

An hon. Member: He gets AIDS!

Mr Yeo Cheow Tong: Yes, he gets AIDS. But for those who fall ill for various reasons, whether self-imposed or otherwise, he agrees that if they can afford to pay, they should pay, but where they genuinely cannot afford to pay, Government should provide some form of assistance.

Mr Low Thia Khiang: AIDS is not necessarily self-inflicted.