THE NEED TO PRIORITISE PREVENTIVE HEALTHCARE

5.14 pm

Dr Lily Neo (Kreta Ayer-Tanglin): Mr Deputy Speaker, Sir, today I would like to entreat the Ministry of Health to prioritise preventive healthcare as the paramount directive for the next few years.

The adage "prevention is better than cure" succinctly defines a fact that everyone would accept wholeheartedly. In terms of maintaining the best state of health for any population, preventive medicine, rather than an excess of healthcare facilities and services to cure the sick, is in line with the adage and is a fact that each one of us here would also accept wholeheartedly.

Sir, we must pursue all avenues to help the healthy maintain their well-being for as long as possible. In the long run, it will be the continuous and concerted efforts in promoting preventive medicine that provides the best quality life and contains the escalating cost of healthcare for the people and the nation. It is proven that if we can succeed in preventing the development of diseases in the first place, we would have achieved the ideal. Classic examples of this would be in the management of hypertension, diabetes and hyper-cholesterolaemia, which predispose patients to cerebro-vascular diseases. Well-informed patients generally have better outcome and better compliance with their treatment and do lead quality life for much longer. They are spared the incapacitating and results of strokes, heart attacks or renal failure. They are spared the agony of having to suffer and the nation is spared the burden of having to pay for the enormous costs of treatment. Sir, the rewards from preventive medicine will be immense if it is done swiftly and if it is targeted towards the population as a whole. The expenses now will yield abundant savings in the future.

The Ministry of Health allocates only 13%, or thereabouts, of its budget towards primary and preventive healthcare at the moment. Sir, this clearly shows that the emphasis on preventive medicine by the Ministry of Health is dismal. The 1998 National Health Survey has revealed that more Singaporeans have hypertension, high blood cholesterol, diabetes and obesity now when compared to the situation in 1992. The incidence rate of cervical cancer had declined only very slightly despite the availability of pap-smear screening tests for women in Singapore in the past 30 years. The four leading causes of death in Singapore are cancers, heart diseases, pneumonia and cerebro-vascular diseases, in that order. Deaths from these diseases are largely preventable and many potential cases can be averted through preventive healthcare. The resultant effect will be reduced illnesses and increased quality life for Singaporeans.

The Ministry of Health must have a new mindset and approach in terms of preventive medicine if we want to do much more than we have so far. Why should the Ministry take on this job single-handedly when we can tap all our resources to give effective and positive results? Sir, I would like to suggest that the Ministry of Health harness our doctors in both the private and public sectors and have an integrated effort towards enhancement of preventive healthcare. We have already in place qualified and competent doctors that can promote preventive healthcare efficiently. We can have a good go at it and I urge the Minister for Health to implement directives in this important area of healthcare. Perhaps, the Ministry of Health would consider what I have in mind in nine areas as follows:

(1) To take off in this area of healthcare, the Ministry must first want to revamp the existing model of healthcare and put up a bold and comprehensive new method of implementation of preventive healthcare. More funding and allocation of personnel in preventive medicine have to be put in place. The very crux of the issue is to reach out to the people and efforts in this matter must be expanded.

(2) The Government, as the largest single employer in the country, must take the initiative and provide free and basic medical healthcare for all civil servants on a regular basis. Spending in this area now will be worthwhile in the longer term. We will be rewarded in time with a healthier workforce. The quality of life for the workers will be enhanced because they will be less prone to chronic debilitating diseases in the future.

(3) Expanding on the previous point, the Government should work with more companies to facilitate and promote preventive medicine. As an example, more doctors and nurses can be made available to help companies conduct preventive check-ups and to give talks on various topics of preventive healthcare. When Prime Minister Goh launched the "Healthy Lifestyle Campaign" this year, he said that the experience in many countries around the world has shown that health programmes do help control medical costs, improve productivity, reduce absenteeism and heighten staff morale.

(4) There is a projected increase to about 800,000 aged citizens by the year 2030 and it is obvious that those born in the 1950s and 1960s will make up a majority of the elderly of tomorrow. It is therefore urgent that we target preventive medicine on these citizens who are now in their 40s and 50s. Immediate and successful implementation of preventive healthcare now is necessary as many of these people may lapse into chronic ill health very soon indeed.

(5) Mr Deputy Speaker, Sir, there cannot be successful implementation of anything unless the monetary issues are addressed. I would like to urge the Finance Ministry and Health Ministry to facilitate the people who seek preventive healthcare. Perhaps, as a first step, tax incentives could be given to employers who provide preventive healthcare for their workers. In addition, individuals should be allowed to use their Medisave and MediShield accounts to fund their expenses for basic preventive healthcare. I might venture to say that allowing use of CPF funds for this purpose might even be superior to allowing use of CPF funds for life insurance. Thirdly, we should endorse the use of Medifund for the extremely needy as these people would probably be those who are most in need of preventive healthcare but who are most deprived of it, either due to ignorance or lack of funds.

(6) The Ministry of Health should be proactive and remain savvy in keeping up with the changing and pressing problems that arise from time to time and be ever ready to alter course where necessary. Being willing and prepared to re-evaluate and scrap existing unsuccessful methods would be a good virtue to have. Consider the pap smear screening test in its present form. It has been available in Singapore since 1964 and yet the incidence rate for cervical cancer has not declined. We should not have to wait 30 years to re-evaluate this failed method, and should have implemented better methods long before now.

(7) Sir, whilst it would be ideal for us to handle all cancers on an equal basis, we have to be realistic and practical. We should pay more attention to the more prevalent and devastating of the cancers. The Ministry of Health must carry out comprehensive studies and elucidate the necessary course of action. Thus, preventive care in terms of breast cancer should be prioritised since breast cancer is, in fact, the leading cancer amongst women in Singapore. Three new cases of breast cancer are detected daily in Singapore. The incidence of breast cancer is expected to increase from 32.9 per 100,000 women in 1985 to 55.1 per 100,000 in year 2000. By then, we are expecting more than 1,000 new cases to be diagnosed every year. Preventive healthcare is important because early detection is the single most important factor for survival of patients. 25% of patients who presented with breast cancers of 3 cm in size would have died from the disease five years after diagnosis and this would be in spite of their having received all forms of treatment.

(8) This next pointer involves acceptance of a new mindset and a radical approach. The Ministry of Health should involve the primary healthcare doctors in preventive healthcare because they are already looking after 80% of patients at the level of primary healthcare. I must, at this juncture, declare that I am a doctor in private practice. Preventive care often involves giving a lot of advice and persuasion to the people directly. General practitioners, as family physicians, have better rapport and more time with the patients, are eminently suited for this function. It is known that we have efficient and affordable primary healthcare in Singapore very much because we have a good spread of GP clinics, enough competent doctors and relatively inexpensive fees for primary-care services throughout the island. It would be good if the Government could put forth a scheme that harnesses this primary healthcare sector for preventive medicine. Not only will this be cost effective and efficient, this will also give patients the advantage of increased accessibility and convenience to this type of care.

(9) The Ministry of Health should also prioritise preventive healthcare in terms of more public education. It is necessary for the public to be reminded that they should and can maintain good health. We must accept that it will be through continuous education and considerable patience before we can hope for a change of mindset amongst our people. We must impress upon the people that they should not be seeking healthcare only when they have become sick. They should be encouraged to have routine medical check-ups to detect early stage diseases. To provide for more scope in public education, we need to provide for the training of "facilitators" who promote preventive healthcare. These "facilitators" may be polyclinic nurses, neighbourhood doctors, community centre grassroots leaders or various company personnel officers. A more integrated and a more consistent approach island-wide to promote different aspects of preventive healthcare could be initiated. The Community Development Councils (CDCs) or even the community centres can be involved in this area with the guidance of the Ministry of Health.

Mr Deputy Speaker, Sir, the need to prioritise preventive healthcare must not be underscored and should definitely be an important directive for the Ministry of Health. In order to further improve the health of the people and enhance the healthcare in this country in the next millennium, we ought to push for a prompt and serious effort on the implementation of preventive healthcare. Sir, we are fortunate here in Singapore as we have the means to afford a world-class home for our people. Nevertheless, we must always try to strive for the better and desire to improve upon what we have. This Government has always been discerning and knows what is best for Singaporeans and Singapore. I am sure the Government knows that promoting preventive healthcare is one of those items that should be top on the list of what is best for us. My concern, Mr Deputy Speaker, Sir, is that we do not hasten and act on getting what we need as a matter of urgency. We do have an abundance of ideas and a fair measure of means to get what the world can offer, let us go for the quality life that we want all Singaporeans to have in their world-class home.

The Minister for Health (Mr Lim Hng Kiang): Mr Deputy Speaker, first let me thank the Member, Dr Lily Neo, for bringing up this issue. Let me address two broad principles first before I take on the nine specific suggestions that she put up.

First of all, the Ministry of Health agrees wholeheartedly with Dr Lily Neo that prevention is better and indeed cheaper than cure. That philosophy is what is driving the Ministry of Health. Second, on the question of more money and more resources, by and large, I would agree that the spending priorities of a Ministry reflect the priorities of the Ministry but one should be careful in not taking that statistic too far.

Dr Lily Neo mentioned that preventive healthcare takes up only 13% of MOH's budget and that the emphasis is therefore dismal. As Dr Lily Neo herself mentioned, preventive healthcare is not that expensive compared to hospitalisation. So, 13% does not mean that we do not put enough priority on preventive healthcare. The reason why preventive healthcare is such a small percentage is that hospitalisation is very expensive and the Government subsidises hospitalisation costs to a very large extent, to the tune of 80% for our Class C wards, 65% for Class B wards, and so on. If the Government had subsidised our Class C wards at 50% rather than 80%, and the other wards are subsidised correspondingly, then overnight, the percentage of budget on preventive healthcare would more than double, to more than 25%. I am sure Dr Lily Neo would not say that this is a good statistic. But 13% amounts to $130 million which is being spent every year on preventive healthcare and that is not a small sum. We do lay emphasis on preventive healthcare. We are consistently looking out for new ways to improve and how we should approach this issue, and therefore, we are grateful to Dr Neo for bringing up some suggestions.

Let me deal with the nine areas which she has brought up. But for Members to understand these suggestions and put them into context, let me first explain how we approach preventive healthcare in the Ministry. We divide preventive healthcare into four areas. The first component is to make sure we have the foundation for a healthy population and that means very sound pre-natal/post-natal care and a very sound school health and school dental programme. This makes sure that our population is given the best level of care in the early stages of their lives and, therefore, they have the foundation to keep their health sound.

Members know our immunisation programme for our young children is among the best in the world. Our infant mortality rate ranks among the lowest among the developed countries. Our track record is excellent. Our school health and dental programme has done extremely well. We are, of course, on the lookout to see how we can improve this better. So I would say that for the first component on making sure that our population starts off healthy, I think we have achieved that to a large extent.

The second component is how to keep the adult Singaporeans healthy, how to encourage them to maintain a healthy lifestyle, ie, having given them a sound foundation, how to maintain a healthy lifestyle throughout their lives. We have started this campaign on Healthy Lifestyle many, many years ago. We have had some limited successes but we are fighting against strong odds. Singaporeans are getting richer, their food gets richer and their lifestyle is more sedentary.

Our approach to promoting a healthy lifestyle now takes on more than just a general exhortation of Singaporeans but also targetting at different groups, ie, those groups which are more vulnerable to a more sedentary lifestyle and to poorer healthy lifestyle habits. We have taken the campaign to the workplace. We are targetting at people in their 30s and 40s because as Dr Neo herself mentioned, it is this group that would bring along their health problems later on when they grow older. But promoting and maintaining healthy lifestyle is one of the most difficult tasks in our preventive healthcare programme.

The third component of our preventive healthcare programme is screening. We take a very targetted approach to look at those groups who are most vulnerable and try and detect these groups early so that we can prevent the disease from starting or from getting worse. There is a lot in the medical literature on the efficacy of the different health screening procedure. The Ministry of Health here takes a very pragmatic approach. We do not advocate widespread universal medical screening.

We screen the population and we encourage screening where it is effective. If somebody maintains his health and has a healthy lifestyle, there is very little that he needs to do in terms of medical screening. If you do not smoke, maintain your weight within a certain recommended range, every time you see your GP, he takes your blood pressure to make sure that it is within the recommended range and if it is high you try to take measures to bring it down. If every year you take a simple blood test to check your cholesterol level and blood sugar, that would give an indication whether you are diabetic or not. By and large, if people maintain a healthy lifestyle and take simple tests like these, we should be able to screen out those who are more vulnerable. And I think more can be done to target those groups which are vulnerable. Some of the suggestions have been brought up by Dr Lily Neo and I would go to them in detail.

The fourth component is what we call preventive healthcare. That means having detected people who are vulnerable, for example, people who are diabetic, how do you get them to manage their situation so that their situation does not get worse and, in so doing, present more expensive healthcare issues for us. So that is the fourth category. I would say that most of the suggestions that Dr Lily Neo brought up deal with the third and fourth categories, that is, how do we target the groups for screening, those who are more vulnerable, and also how do we better manage the groups which are diabetic or the older groups and that we can manage their health situations well enough so that they do not lapse into more difficult problems for us.

Let me address the nine areas now. First, more funding and more people. I think I have done that. If a measure is worthy of implementation, I can assure the House that the Ministry of Health will find the funds to implement it. So funding is never a big problem with us. But it does not mean that we will throw good money and that we feel proud that we have increased the amount of money we spent. It really depends on the usefulness of the programme.

Second, the Government should take the initiative as the biggest employer to provide free and basic medicare to all civil servants. Members know that is not our approach. For healthcare financing, the minimum that we would want is cost-sharing so that people value the services provided for them. I do not think we should walk away with the idea that anything that is free would solve the problem. I was told that we implemented a mammography screening project from 1994 to 1997, but only half of the women turned up for screening, even though the screening was provided free of charge. In other words, it was not the cost of the screening that deterred the women, but rather the lack of awareness of the need of the screening, the fear of the screening procedure and sometimes, the fear of knowing the result that made half of the women not to turn up for the screening, even though the screening was provided entirely free.

My point is that money cannot solve all problems. I think the more difficult part of the problem is to educate the population, to get them to understand the need and also to target at the groups that are most vulnerable. For example, if you have free mammography screening, the better educated women who can best afford the fees would take this up. But the less educated women, maybe the 50% who did not turn up for the screening, are the ones who are more vulnerable. I would think that the greater effort should be at targetting the groups which are most vulnerable.

The third area is to work with companies to conduct check-ups, etc. I think this is one of the areas that we are embarking on, that is, to take preventive healthcare into the companies, into the workplace.

The fourth area is to target at people in their 40s and 50s. I agree entirely with Dr Lily Neo. I think we must try and address these age groups early rather than deal with them when they turn 60s. By then, the problem is already there.

For the fifth area, Dr Neo suggested tax incentives for employers who provide preventive healthcare. I will pass this on to the Ministry of Finance but preventive healthcare programme, as I say, is not very expensive and therefore, I am not sure how effective this would be.

Dr Neo also suggested the use of Medisave for preventive healthcare cost. There are no clear-cut arguments for or against the use of Medisave. We must realise that Medisave savings can only meet a certain portion of our lifetime healthcare cost. If you spend it on preventive healthcare, and you are unfortunate enough to have an episode in hospital, then you have to dig into your pocket, and that can be a very expensive episode. Alternatively, if people spend this small amount needed to keep their health in good shape, like going to the GP which costs $20 or $30, where people pay out of their pocket, then they keep their Medisave for the more costly episodes in the hospital. So it does not really matter as long as everybody saves and that saving goes towards paying part of the lifelong healthcare cost that all of us will probably end up having to incur.

On pap-smear screening, I agree that our track record has not been such a sterling performance and that is because we have not made it universal. We have encouraged and exhorted the women to go for pap-smear screening but it has not been universally made available. We would look at this programme because I think there are medical merits in running pap-smear screening and we would see how this can be taken up together with mammography. We have encouraged the Breast Cancer Foundation and in the three years since it has started, it has done good work to promote awareness of breast cancer and the effectiveness of early detection through mammography. My Ministry is also working with the grassroots organisations and CDCs to help encourage women to go for pap-smear screening for cancer of the cervix and mammography screening for breast cancer. We are piloting a pap-smear screening programme in Toa Payoh next year with the view to extending this programme on a nation wide basis later so that we can have an effective outreach programme to prevent cancer of the cervix.

The next area that we want to target at is the senior citizens and to address this issue of affordability, we are having a geriatric screening programme with the College of Family Physicians so as to draw in the GPs, and the funding would be made through the Singapore Totalisator Board which had agreed to subsidise 75% of the cost. So an elderly person would co-pay only 25% of the cost, ie, only $5. We would embark this geriatric screening programme together with the College of Family Physicians and the Singapore Totalisator Board.

The Question having been proposed at Fourteen minutes past Five o'clock pm and the Debate having continued for half an hour, Mr Deputy Speaker adjourned the House without Question put, pursuant to the Standing Order.

Adjourned accordingly at Sixteen Minutes to Six o'clock pm.