ESTIMATES OF EXPENDITURE FOR THE FINANCIAL YEAR 1ST APRIL, 2002 TO 31ST MARCH, 2003

Debate in Committee of Supply resumed.

Mr Yeo Guat Kwang: (In Mandarin): Sir, in March this year, the Ministry expanded its Primary Care Partnership Scheme (PCPS) to provide subsidised dental and primary care to low-income elderly Singaporeans, and extended the scheme nationwide. It was a significant step to bring affordable healthcare closer to low-income elderly Singaporeans. The implementation was unfortunately not given enough publicity. Not many people know about it.

As other MPs have mentioned, the general impression among the people, particularly the old folks, is that primary healthcare is very expensive and not easily accessible. Some are even afraid to seek treatment when they are sick. It is therefore necessary to allay their fears so that they do not have to worry so much about having to pay exorbitant medical fees that deters them from going to the doctor when they are sick.

Let me cite two examples. The ElderShield scheme will be launched later this year. It is an affordable disability insurance scheme that provides insurance coverage to Singaporeans aged 40 years and above who require long-term care. It is a significant step in looking after the medical needs of elderly Singaporeans. However, after the initial coverage over the media when the scheme was announced, we have not heard anything about it thereafter. The vast majority of our elderly people in Singapore do not know about the scheme.

Secondly, the Ministry of Health and the Health Promotion Board's websites have a wealth of useful health-related information. For example, I found useful materials such as "Ten Tips to Stretch Your Health Dollar", and a section dedicated to elderly health issues. This information must not just sit in the websites. There must be some ways to bring them to the elderly Singaporeans and, more importantly, to their families. No doubt, there are many people, particularly the elderly ones, who are not computer savvy. They cannot make full use of this service. I urge the Ministry of Health to do more to reach out to these elderly people and their families and educate them on such health-related issues.

Dr Michael Lim Chun Leng: Sir, I must first declare that I am a doctor in private practice.

Healthcare in Singapore is at the crossroads. The White Paper on Affordable Healthcare set the policy directions for the 1990s. Notably, there was no emphasis on Singapore as a centre of medical excellence. The present decade shows a marked shift in the direction of our healthcare policy. While still holding on to the principle of affordable healthcare, the public healthcare system has now set on two very divergent courses, which are set to strain its resources, and create an identity crisis.

The public healthcare system was funded on the basis that basic healthcare service was to be affordable and accessible to all Singaporeans. There is little doubt that healthcare service has improved over the years in tandem with the improvement in the quality and standards of living in Singapore. This policy is the cornerstone of our healthcare system.

In recent years, there has been a marked shift in public healthcare policy. In the 1990s, the Ministry of Health was content with letting its specialists earn private fees from patients who were seen within the hospitals. Recently, it has allowed some of its specialists to do part-time private practice in the private sector, through its Faculty Practice Plan. It has also set up night clinics to compete with the over-crowded and highly-competitive family practice clinics in the heartlands.

Next, the public hospitals have set up private clinics in private hospitals, such as Mount Elizabeth Hospital and Gleneagles Hospital. The public hospitals are now looking to provide services for new private hospitals, who lack certain specialist services. These policy shifts have tremendous implications for the future of the public healthcare system in Singapore. The use of public sector resources to do private practice beyond its traditional confines has far-reaching consequences.

First, it will strain the existing resources. With the consultants spending more and more time in serving private patients, how much time will subsidised patients get from consultants? How much time will there be for consultants to train and teach the Registrars and the junior doctors? Already, some of the consultants tell me that they have no time to see new subsidised patients in their clinics. Registrars in the public hospitals have told me that they did not have any structured training programmes, and these will be the consultants of the future.

Second, there is also non-optimal utilisation of existing resources. In the specialist private sector, the public sector is competing where there is an over- provision of hospital beds. With the public sector being unable to fill its own private beds, and occupancy of the private beds in the public sector ranging from about 50-70%, it does not make sense that the public sector consultants should be encouraged to use services in private hospitals, resulting in further under-utilisation of public sector resources. In the general practice sector, where there is an over-provision of services, the operation of night polyclinics further exacerbates the over-provision of services. The night clinics will also require more doctors, and this will exacerbate the shortage of medical officers in the public sector.

Third, this is a contradiction of Government policy. The move to allow public sector doctors to practise in private hospitals in public sector funded private clinics creates an anomaly which has gone against the grain of what Government has preached. On the one hand, the Government encourages Singaporeans to become entrepreneurs and take risk, and yet in the healthcare sector, it is willing to provide an umbrella for the public sector doctors, so that they will not have to brave the rain and the sunshine, or to be subjected to the financial risk of a private sector practice. If we want to extend this even further, the Government might as well run private hospitals for private patients and justify this by saying that it will help them retain their consultants in the public sector. If Government is serious about growing healthcare as an economic driver, it does not make sense to use public sector resources to eat into the same private sector pie in Singapore.

Growing healthcare, as an economic driver, goes beyond attracting foreign patients to come to Singapore. Healthcare services in Singapore have to expand beyond its shores to where the patients are, by expanding services to overseas facilities. It will expand our patient pool and give our doctors increased experience through a greater caseload. If the Ministry's aim is to retain specialists in the public sector, I fear that the moves it has taken will cause more harm than good for the public healthcare sector in the years to come. An unintended effect of this is the demoralisation of other specialists who are unable to participate in these schemes. In the end, the Ministry may have retained the specialists it wants, but the policies adopted will result in the loss of innocence, a diminution of their passion for the subsidised patients and skew their value systems.

Mr Zainul Abidin Rasheed: Sir, we have heard the expression "It is cheaper to die than to fall ill." That, of course, is an exaggeration. But we do hear that more and more people, especially those in the lower income who believe that this is so. Sir, I think the Ministry should take this seriously and find ways on how to assure our people that, in fact, there are enough healthcare schemes to cover them.

I know of a case of a person who came to see me at the MPS, and told me a sad story. Her father fell ill, and she thought that she would just send him to hospital for observation, maybe for 2-3 days. Thinking that the father had done so much for the family and made a lot of sacrifices, she admitted the father to a First Class Ward. And before she knew it, the father's condition got worse, and he was sent to the ICU. The case got protracted, and the family was shocked to receive a bill of $70,000. In fact, she came to see me and tried to get some help. She said that they may have to sell their flat to settle the bill.

Sir, I think there is a serious problem of people who actually do not know the full picture, or the ramifications of the cost of medical care. I think hospitals and the Ministry must try to make sure that they know the consequences of such a decision.

Another case I know of is quite a well-to-do couple. Their home had been paid for but, unfortunately, they had a child with a heart problem and had to go for surgery. They appealed for use of their CPF, because Medisave was not sufficient to meet the bills. We applied to the CPF, and as expected, CPF said no because of the policy.

Sir, I think one calls for more information, and the other calls for flexibility.

Sir, the other point I would like to raise, is about healthcare for the elderly - the senior citizens. I know we have a primary healthcare programme, which is growing in terms of its reach. But I would like the Minister to share with us on the progress of this scheme, how pervasive it is, and whether there are ways we could improve the scheme to reach out to more people. I gather from feedback that some doctors are not willing to come on to this scheme, because they find there is a lot of bureaucracy and a lot of paperwork. Could the scheme be extended to people from age 60 onwards, instead of 65? Could this primary healthcare scheme be also extended to cover chronic illnesses, and not just simple illnesses like cough and flu?

Dr Lily Neo: Sir, it is a known fact that there has been a shortage of junior doctors in the public sector for many years. The Ministry of Health's projected need for doctors had been skewed. There should be more accurate projections, and the projections must be reviewed at regular intervals to take into consideration any changing needs and trends.

This is an urgent problem that we need to solve, but we should not take any short cut. To me, the Ministry of Health's reflex response to recruit junior doctors from our immediate neighbours is not acceptable. Sir, these doctors are graduates from universities which we never recognised before. Singapore has been known, or at least we want it to be known, as a medical centre of excellence, and this has been built upon the years of excellent training of our own doctors from the best centres. This prestigious status is in danger of being tainted by recruiting junior doctors from our immediate neighbours to work here. I worry. If there should be any mishap caused by these doctors, the confidence our patients from the region have when they seek treatment in Singapore, would slowly but surely erode. I feel that we will lose headway in our effort to be the regional medical hub.

Sir, this matter is made worse when the Ministry is continuing to implement the 1993 policy of not recognising the graduates from over 150 previously recognised foreign universities, and is sticking to accepting only graduates of 20 foreign universities. The Ministry should now revise the list of recognised overseas universities. Not only can we get foreign doctors from more reputable overseas universities, we can also get back more of our own Singaporean doctors who have graduated from them. This is especially significant when the cost to train a doctor in Singapore is so much higher in comparison to medical schools overseas. Yes, it apparently costs at least $500,000 here as compared to $170,000-$250,000 at the universities of Sydney, Oxford and Cambridge.

Mr Low Thia Khiang: Sir, Singapore has become a de facto regional medical centre. It is common knowledge that many patients from our neighbouring countries come to Singapore for medical treatment and, despite the economic downturn, business is still good. However, there are some concerns which I would like to ask the Minister for Health.

(1) Would the Minister evaluate whether we do have sufficient doctors and specialists in Government sector healthcare? (2) Are we doing enough to attract, and to encourage doctors' training and research, to spearhead Singapore's drive towards the attainment of a bio-medical centre? (3) Whether the shortage of specialists is a factor in the long waiting time for patients in SGH specialist clinics and National Cancer Centre.

Sir, a truly world-class medical hub should be a responsible one that cares not just its mega-bio projects and medical technology, but also one that cares for the patients and doctors who are the backdrop of the entire healthcare system. This brings me to my fourth question, ie, whether our medical officers in the Government hospitals are being overworked and maybe potentially unsafe, as reported by the Review Panel led by Lord Ronald Oxburgh.

I would also like to know whether there is an element of truth that the morale of junior medical officers in the Government sector healthcare hospitals is low and they are overworked. And has the Ministry of Health any plan to improve the service conditions of the medical officers in the hospitals? 4.30 pm

Dr Lily Neo: Sir, nurses are important and an integral part of any healthcare system, and I want to beseech the Ministry of Health to look further at making nursing a more attractive career option.

Sir, it is better to increase our own pool of local Singaporeans in nursing, as they tend to remain in nursing for good. Many foreign nurses do not have the sense of permanence in Singapore and, in fact, may just use Singapore as a stepping stone to go elsewhere. Furthermore, recruitment of many foreign nurses can pose attendant problems because of language barrier, differences in nursing attitudes as well as other social problems.

At the moment, we have only the Diploma Course from Nanyang Polytechnic and the Certificate in Nursing Course from ITE. We do not have an undergraduate nursing programme for nurses. Sir, it is about time this latter option was made available for the following reasons:

(1) There is a fast-changing technological advancement in science and healthcare that requires nurses to master complex information. We need to train more professional nurses not merely as nursing care deliverers but also as care managers, coordinators and innovators to keep up with the changing needs.

(2) The provision of an undergraduate programme for nursing will also address the shortage of nurses, as this will provide another channel for the students with better examination results, who would not do nursing, by going to ITE or Nanyang Polytechnic.

(3) The undergraduate programme will enhance the image of nursing and address the presently "no glamour" perception of many.

(4) An undergraduate course will allow the discipline to grow, as nurses can then upgrade themselves after having graduated in the Diploma and Certificate Courses.

(5) Having "higher trained" nurses will fulfill the public's expectations of getting better and quality nursing care, much in line with their demands for better healthcare on the whole.

(6) As we need to expand the delivery of home care and step-down care, we do not just need more nurses but we also need better qualified nurses that can independently look after patients in their own homes without the hospital-setting supports.

(7) Degree-holding nurses may reduce healthcare costs because they will have the extra training that allows them to perform some of the duties that can otherwise be done only by doctors.

(8) We definitely need higher trained nurses to perform more diverse duties, as required in scientific and clinical projects, to be part of a team with doctors and scientists.

Dr Michael Lim Chun Leng: Sir, there is a nursing shortage in our hospitals, and this is acknowledged by everybody. Everyone knows that nurses play an extremely important role in our medical healthcare services, being partners with the doctors and carrying out doctors' orders and working with the doctors to perform procedures and surgeries.

Currently, the two main sources of nurses are through the educational institutions, like Nanyang Polytechnic and ITE, or direct recruitment by the hospitals. Having recruitment directly from many countries, like Malaysia, China, Myanmar, Philippines, and having a sizable intake of about 600 students through Nanyang Polytechnic, it puzzles me why there is still a significant shortage of nurses. If that is the case, perhaps we should look at what is the rate limiting factor. If it is because our institutions are not able to provide adequate places for people to study nursing, then perhaps we should look at either expanding Nanyang Polytechnic or allowing other institutions, or even hospital groups, to start nursing colleges to provide for this absence of educational opportunities to train nurses.

The other way to manage this problem is to allow the private and public hospitals to increase their direct recruitment of nurses from elsewhere to join the hospitals. I understand from them now that the Ministry has significantly restricted the number of nurses that they can recruit directly. I cannot see the reason for this though. Will the Minister advise us as to what measures are currently being considered or undertaken to resolve this problem of nursing shortage?

The Minister for Health (Mr Lim Hng Kiang): Sir, first, I would like to thank the Members for raising the various issues on healthcare.

Let me, first, address Members' concerns on healthcare cost, the affordability of healthcare, because that receives the most number of cuts.

Let me just give Members the background. To make sure that healthcare is affordable in Singapore, the first thing we must try to do is to keep the overall National Healthcare Expenditure (NHE) down. Today, our National Healthcare Expenditure is about 3% of our GDP. It is low when we compare it with other OECD countries. They spend, on the average, between 8-10% of their GDP. In the US, healthcare expenditure is creeping up to 14% of GDP. For us, 3% of GDP is very low, compared to the 8% or 10% of the OECD countries. Therefore, as a country, it is very affordable. So we are already ahead in the game. As long as we keep our NHE down, we are ahead of the game.

The next question is, having kept the NHE down, who should pay for it, especially with healthcare cost increasing every year? Should it be the individuals? Should it be the Government? Should it be the employers? Or should it be the insurance companies?

In very round numbers, about one-third of our NHE is borne by the Government, one-third by the employers through the employer-provided medical benefit schemes, and one-third by the individual through his Medisave and through his out-of-pocket cash payments.

So the question many Members have asked is: is the individual's share at one-third of the healthcare affordable? Our response is that if every Singaporean saves diligently, through his Medisave and if he is covered by MediShield, then he is able to afford B2 charges. That is how we have calculated the level of savings for Medisave. The cash component is also affordable to the majority of Singaporeans. If we look at the Household Expenditure Survey, each household spends, on the average, 3.3% of its household expenditure, or about $120 per month, on healthcare. I know that the last time I compared healthcare cost with hairdo, some segment of the population took offence. I promised my wife that I will not compare healthcare with hairdo anymore.

Let me just compare healthcare cost to other forms of household expenditure. $120 per month, which is the same expenditure as a household spends on telephone or mobile phone, SMS, fax and Internet. So, is that affordable? In fact, the average household spends more on his annual vacation. The average household spends $162 per month on vacations, which is 26% more than healthcare. I would say that, on the average, we have kept healthcare cost down, and it is affordable. The cash component is affordable by Singaporeans, by and large.

As for the low income household Singaporeans, I have told Members before that if they have any MPS cases about Singaporeans having difficulty in paying their hospital bills, send the case to the Medical Social Worker of the hospital concerned. We have a team of very competent, effective Medical Social Workers in the hospitals, and they will deal with the case. I have made this offer to Members before, ie, if they have any cases that have been rejected and they still feel that the cases have merits, send the appeals either to MOS or myself. I am happy to report that in the last three years, both MOS and I have received very few cases of such appeals. So it shows that our system works and that low income families, who face financial difficulties in the hospitals, are adequately dealt with. In fact, 97% of the applications for Medifund assistance are approved. Our safety nets do work.

[Mr Deputy Speaker (Mr Chew Heng Ching) in the Chair]

4.40 pm

The Minister for Health (Mr Lim Hng Kiang): But going forward, when our population gets more aged - today, it is 7% of our population above 65, in 20-30 years, this will more than double to 16-17% of the population - we have to strengthen our healthcare financing system to deal with the aging population. When the population gets more aged, we will find that the component borne by the employers will come down, because the working population will be a smaller proportion. And, therefore, the employer's share will reduce. The Government's share will have to increase, because we have to look after a greater proportion of the aged population. The MediShield and the Medisave will have to take on a heavier burden because the individual has to pay for his healthcare expenses as he grows older.

Going forward, there are three main things we have to do. First, for the employers, I support the Ministry of Manpower and NTUC's move to make employers' medical benefits more portable, so that even when an employee changes jobs, he is covered. Better still, make employers' medical benefits portable beyond retirement, so that it covers post-retirement period.

Second, for the Government, we would bear our fair share of the healthcare cost. But if we want to keep to our share at between a third to half, then Members must realise that we cannot subsidise the entire spectrum of the population. We must target our subsidies to the most deserving, and that means, at some point in time, we would have to introduce means testing, so that whatever subsidies the Government is prepared to fork out, those subsidies are targeted at the low income, at the most deserving.

The third prong is, as many Members have raised, how to reinforce the financing system through allowing better use of the Medisave, through expanding the scope of MediShield and when we introduce ElderShield, to make sure that ElderShield works. Sir, I will cover these points in turn.

First, on means testing. Both Mdm Halimah and Dr Ong Seh Hong raised this. The idea of means testing is not new. This was mooted way back in the 1993 White Paper. It is a mechanism that will allow us to target subsidies at the lower income group. As Dr Ong himself has said, philosophically, I think most of us would not disagree that Government subsidies should be targeted and given to Singaporeans who are the most deserving.

Today, we have some form of self-selection. Singaporeans who are better off would opt for B1 or A class and therefore do not avail themselves of the subsidies. Singaporeans who are better off would not go to the polyclinics and therefore do not compete for the subsidies in our polyclinics. As long as this self-selection takes place, then I think we can postpone the date of means testing. As long as the demand is within what our subsidised healthcare system can supply and there are no serious accessibility problems, such as long queues and waiting times, then there is no need to implement means testing in our hospitals and our polyclinics. But if the subsidies keep expanding and we need to target, then I am afraid, at some point in time, means testing would have to be introduced. So it is inevitable that, at some point in the future, we may have to introduce means testing. So how do we gradually ease this in? One approach is that whenever we introduce new programmes in our polyclinics and in our hospitals, and if it is appropriate, then we introduce means testing selectively. For example, when we introduce the Primary Care Partnership Scheme where we allow our senior citizens to see their private GP clinics and still claim subsidies from the Government, then I think that should be means tested. Whenever we introduce new programmes and it is appropriate, then we will incorporate means testing.

Dr Ong raised a point about means testing in the step-down sector, particularly in the community hospitals. Let me reassure him that we will phase in the target subsidy rates gradually and we will work with the community hospital to moderate the impact on the patients' bills. We will also give the community hospitals additional funding so that they would not need to increase their fees and charges substantially. We will work with the other community hospitals and other step-down care operators to ease means testing in. But this is a transition. In the end, we have to decide on the fundamentals.

Mdm Halimah asked whether we should just subsidise the lower half, or should we also subsidise the upper half of the population, in terms of income. If today, we are spending one-third of the overall national health expenditure, then it is inevitable that our subsidy is targeted at the lower half. Once we start subsidising beyond the median into the upper half, then Government's share of expenditure must increase substantially, beyond one-third to more than half to two-thirds. 4.45 pm

Today, the budget for health is $1.6 billion, 1% of the GDP, and that constitutes one-third of the national health expenditure. If we expand it to half, or two-thirds of the national health expenditure, then we are talking about increasing the budget to 2% of the GDP. Every percent of the GDP, as Members now realise, is equivalent to nearly 2% of GST. So we cannot say do not raise GST, but increase the healthcare expenditure. Some where, the budget must balance.

With the budget that we have, there are still quite a number of things that we can do to improve the healthcare financing system. Let me just name some of these. First, is universal coverage. A few Members raised this, especially Mr Gan Kim Yong and Mr Yeo Guat Kwang. We have decided that our healthcare system lays emphasis on personal responsibility. It is not the national health system in the UK and it is not the private insurance system of the US. But our system puts a great store on personal responsibility, and that is the reason why our schemes insist on opt-out. By and large, a person is in, but we give him a choice to opt-out. So he is personally responsible for that decision. It is not a mandatory national social insurance scheme. We try to achieve universal coverage through an opt-out scheme.

But an opt-out scheme means that some segments of our population may not be covered, for example, MediShield. MediShield today applies only primarily to Singaporeans with CPF accounts. As a result, about 74% of our resident population is covered by MediShield and 26% are not covered. This is largely the non-working spouses and children, who are not covered. If we look at the working population, our coverage rate is not too bad, at 90%. But there is still a small segment who are not covered - some of the self-employed and low income people.

So, how do we increase the coverage? Mr Yeo Guat Kwang pointed out that we need to watch out for this group - the self-employed, the low income, the non-working population - as they are outside the CPF network. I agree with him because if they are not covered by MediShield and they are struck by catastrophic illnesses, then they will have problems paying for their share of the healthcare costs. So, in this regard, my Ministry will extend the opt-out, or the auto-coverage mechanism, to non-working spouses, so that they will have the opportunity to join the MediShield. We will introduce a new MediShield opt-out point for non-working spouses when couples register for their marriage. This will take effect in 2003. The thinking is that when a couple registers for marriage and if one of the couple is a non-working spouse and is not covered, then we will send a little polite note to the couple and say, "Congratulations! One of the spouse is not covered, you are now automatically in, unless you sign an opt-out form." And we hope that the spouse who is covered will not sign the opt-out form for the non-working spouse. I do not think it will happen.

Some of my more enthusiastic staff say, "What about children? Why do we not send similar letters every time we get the registration in the birth certificate?" I told my staff, "Let us take this one step at a time. If we do this too much, then we will be accused of being too intrusive." In any case, when the children grow up, when they work and get their CPF account, they will be covered by MediShield. So I think we have some time. Meanwhile, we will mount more public education programmes to get people to sign on their entire family under MediShield.

The next thing we can do is, of course, to extend the use of Medisave and MediShield. We will gradually do so, but I would urge that we do so cautiously. The first thing we can do is to allow Medisave for ambulatory care. Because of the rapid advances in medical technology, some of the medical treatments, which are traditionally done in an inpatient setting, can now be done in an outpatient setting. But because Medisave and MediShield currently only cover primarily hospitalisation expenses, we inadvertently discourage the right setting of care. In other words, there is little incentive for the patients and the providers to seek or provide treatments at the outpatient settings since they are unable to access Medisave and MediShield.

I have therefore decided to extend the use of Medisave and MediShield to several outpatient treatments, which are in lieu of inpatient treatments. This will reduce the need for inpatient hospitalisation and will save costs. The changes for Medisave extension will take effect in October 2002. My Ministry will put out a press release on this.

Similarly, to facilitate patients who need to use step-down care facilities, MOH will also revise the Medisave withdrawal limits for step-down care on 1st July 2002. We will raise the Medisave annual withdrawal limit for community hospitals from $3,000 to $3,500, and the daily withdrawal limit for hospices from $125 to $160. Singaporeans who need community hospital, or hospice care, would therefore be able to use more Medisave and, in turn, less out-of-pocket cash.

But here, I would like to caution Members that these changes should not and do not signal that we are liberalising Medisave and MediShield for general outpatient care. We must proceed cautiously because an overly liberal use of Medisave would necessitate higher Medisave contribution rates. We therefore need to strike a balance.

The third area is to reset the Medisave withdrawal limits and the MediShield claimable limits based on the Diagnosis Related Group (DRG). Today, the limits are based on the number of days a patient is hospitalised, the so-called "per-diem" basis, and the complexity of the surgical procedures, a set of tables. They may not truly reflect the level of resources needed to treat the different medical conditions.

We are therefore revising the Medisave withdrawal limits and the MediShield claimable limits for inpatient care and day surgery based on the Diagnosis Related Group, so that they will be better commensurate with the medical conditions of the patients. The intention is to enable patients with more severe medical conditions to withdraw more Medisave and claim more from MediShield to pay for their medical bills as compared to today. These changes are scheduled for the first quarter of 2003.

The fourth area is really to expand MediShield so that it can better cater to the needs for old age. This is what several Members have advocated, for example, Mr Yeo Guat Kwang. We are looking into this. And there are two stages that we will proceed. The first is to enhance the features of MediShield in the first quarter of 2003. In that first phase, we will increase the claimable limits, we will lower the deductibles and the co-payment, and expand the coverage to additional outpatient treatments and neo-natal care, so that MediShield can play a bigger role in our personal healthcare financing.

The second phase is to expand MediShield to provide lifetime coverage, instead of just stopping its coverage at the age of 80. To do so, we will have to introduce some form of pre-funding of MediShield. We will do so in 2004. Under this scheme, currently what happens is that Singaporeans pay a higher premium as they grow older. So it becomes less affordable as one grows older. With pre-funding, what we can do is to get Singaporeans to pre-fund, or collect a higher premium, when they are younger and then when they reach 65, they will be covered for the rest of their life. This is a major change and it means quite a major restructuring of the MediShield, and we target to do this in 2004.

Mr Gan Kim Yong said that we need to raise the premiums if we want to do such a major change. Indeed, we have to. Today, MediShield plays a fairly limited role because it is a catastrophic insurance scheme. We collect about $90 million in premiums every year. If we look at the national health expenditure (NHE) of about $4.2 billion, $90 million is between 1-2% of the national health expenditure. So MediShield is only playing a piffling role in our overall structure. If we want MediShield to undertake, say, 10% of our NHE, something like $400-over million, then we need a four-time increase in the premiums to make it really effective. So I am giving Members early warning. When I come next to the House with a major restructuring of the MediShield, and if we want MediShield to play a major role and be the foundation for the portable medical benefits scheme, then we need a fairly quantum leap in the coverage.

Mr Yeo Guat Kwang also suggested that we accredit more insurance schemes as Medisave-approved schemes. To-date, besides MediShield, we have four other Medisave-approved catastrophic illnesses insurance schemes, namely, IncomeShield, HealthShield Plus, SupremeHealth and MaxHealth, of which the last two were just introduced last year. Let me just sound this word of caution. If we have a number of such private schemes and they each take 5-10% of the market share, the danger is that the private sector will then cherry-pick the good risks and leave the bad risks to MediShield, and that will make MediShield untenable.

So we have to review the guidelines governing the use of Medisave for approved insurance scheme. We will consult the industry players. Our intent is to give private insurers greater flexibility to offer more products as long as key safeguards, such as deductibles and co-payments remain to deter the "buffet syndrome". But we must also make sure that each player carries a fair share of the good risks and the bad risks. Sir, as I said, we are targeting to do this study and for the major reform of the MediShield, it will take us about a year and we will be in a position to come to this House with the new scheme before 2004.

The next area is ElderShield. We introduced the concept of ElderShield and we got the private sector to tender for it and we are in the position now to implement it in September this year. Dr Lily Neo and Mdm Halimah raised several questions about ElderShield. Let me just go through some of the key principles in the ElderShield. First, we decided that it should be an actuarial insurance, rather than a social insurance. If it is an actuarial insurance, then it means that the pre-existing disabilities cannot be covered. That is the industry practice. Second, we have to decide on the payout ratio. The current industry norm is 3 Activities of Daily Living (ADLs). If we lower it to 1 or 2 ADLs, then the payout ratio will be higher. Today, at 3 ADLs, the payout ratio is 1:12. So that is the whole idea of insurance. We collect from 12 persons and we pay out to one person. So the premium is low. If we lower the ADLs to 1 or

2 ADLs, then the payout ratio will be much higher. Then we have to collect from fewer people to pay out to more people, in which case, the premiums will be higher. As a start, we have decided to stick at 3 ADLs, which is the industry norm, and that means a payout ratio of about 1:12. 5.00 pm

The next feature is the level of payout. We have decided on $300. Why? Because if you are a low-income person and you are disabled and you have to go to a nursing home, through our means testing, you will qualify for 75% subsidy. The Government will pay 75% subsidy if you are the bottom 10%. If you are the bottom 30%, the Government will pay 50% subsidy. The nursing homes today charge around $1,000-$1,200. So, your share will be about $250 or $500. Therefore, a $300 payout will go quite a long way to help you pay for your share of a nursing home. That is why we decided on $300. We decided on cash rather than claims for service, so that it gives you flexibility. As Dr Lily Neo said, if the patient also has chronic illnesses but stays at home, he could use the $300 for outpatient services, for home medical or home nursing. But in the more severe case when you have to end up in a nursing home, then the $300 is a significant percentage of the co-sharing of your component of nursing home fees.

The other feature is the payout period. We decided on five years or 60-month payout because our survey shows that the average length of stay for nursing home patients is normally between two and five years. So a 60-month payout is sufficient.

But let me just say that we are launching ElderShield and we want to make it as simple as possible to get it started. We have got two private insurers to provide the service. The intention is that after they have run this scheme for one or two years, we will encourage the private sector to have top-up to this scheme. So this is a basic scheme. In one or two years, when the private insurers running the scheme have more experience, I see no reason why they cannot offer enhancements, eg, higher payouts, longer payout periods and different types of coverage. So this is just the basic coverage.

To make this scheme work, we need to ease it in. For somebody who is 40 years old today, it is not a problem. You pay the premiums, at the age of 65 you are covered for the rest of your life. For somebody who is 65 now, to pay the premium to be covered for the rest of your life, the premiums will be very high. So we need to find a way to ease it in. And the way we have done so is to allow people to pay premiums over a 10-year period, from 59 years old to 69 years old. So we have a cut-off at 70. Anybody who is younger than that will have a 10-year payout, and the Government will, in fact, contribute almost a third of the premiums to help make the premiums affordable. This subsidy will amount to $360 million. So we have persuaded the Government to give us $360 million to help pay almost one-third of the premiums of the senior citizens.

Then, there are two groups - those above 70 and those with pre-existing disabilities. They are not covered. For these, we have the IDAPE scheme in which the Government really becomes the insurer. If they are above 70 or are already disabled, the Government will, in fact, pay them $100 or $150 for up to 60 months. So the Government undertakes to be the insurer, because it is not fair to load them onto the actuarial system. If we load them onto ElderShield, then the rest of Singaporeans will pay. For this group, in fact the Government becomes the insurer, but they will receive half of what they will get from ElderShield. To run this transition scheme will cost the Government $300 million. Just to introduce ElderShield, we have to go to the Government and seek a total of $660 million to ease the scheme in. After this transition, when the scheme is on a sure footing, then it will be on its own.

Mr Yeo Guat Kwang asked why we have not promoted the scheme more rigorously. For pragmatic reasons, if I do a major promotion last year, most Singaporeans would have forgotten by now. So we target to go out and promote this scheme more aggressively between June and September when the scheme will be launched. We are enlisting the help of all the Mayors to help us work the ground and launch the scheme from June to September.

Finally, for the low-income group, Medifund is a very important safety net. As Mr Gan Kim Yong said, it is very effective. 97% of Medifund applicants are successful in their applications. We continue to review the Medifund eligibility criteria regularly. Each hospital has a Medifund Committee and it has the flexibility to deviate from the Medifund criteria and approve deserving cases under exceptional circumstances. That is the reason why we have such a high approval rate. But it is still within the interest income that we are earning from the capital sum of $800 million in the Medifund.

On public education, I agree with both Mr Yeo Guat Kwang and Mr Zainul Abidin that we have to do more and get Singaporeans, particularly our elderly Singaporeans, to understand the system and to navigate the system. A key component of this is counselling at the point of service, in the hospitals.

When Mr Zainul Abidin raised the example of one of his MPS cases, where one of his constituents decided to send the parent to an A-class ward despite our financial counselling, then there is very little we can do to help. If I may just reinforce this point. As I have said here before, we have universal accessibility to our healthcare system. As long as a patient chooses B2 and C-class wards - I used to give the example, unlike lawyers, when Mr Chiam raised this question - we do not collect deposits when a patient chooses a B2 or C-class ward. So when Dr Michael Lim raised the example of KK Hospital wanting a deposit of $20,000 or $60,000, this refers to private patients. Our rules are straightforward. If you are a subsidised B2 or C-class patient, you are guaranteed access to our healthcare system. There is no deposit. We treat you first and settle the bill later on. We have done so in all cases. We use Medifund for the deserving cases. However, if you choose to come in for B1 and A-class, that means you have self-selected, you have decided for yourself that you are above the median and you can pay for the healthcare costs. Therefore, we will treat you just like in a private hospital. We will evaluate what kind of condition you are coming in for and we will ask you for the relevant and appropriate deposit. I think that is fair.

When you go to a private hospital, you have also decided for yourself that you do not need subsidies and you can pay for your medical bills. We are very happy that you are able to go and can afford private healthcare. But, when you want to switch from a private hospital to a public hospital, we will deem you as a private patient and, therefore, we require you to put up a deposit.

The example that Dr Michael Lim raised is a neo-natal case. We face several of such cases every year. They deliver the babies, the babies are premature, complications, so the bills mount. One way is to tell the private hospital that since they have accepted the patient, it is their moral responsibility to look after the patient. If they have accepted the patient, if there are complications, they carry on looking after the patient and, if there is a bad debt, it is part of their operating costs. We should not have a situation where the private hospitals encounter such cases and then encourage the patients to go to the public hospitals. Then the public hospitals become the hospital of last resort. The other approach is to cover this under MediShield, and this is what we intend to do. So when we make the changes next year, we will allow MediShield to cover such neo-natal cases.

Dr Michael Lim also asked about the role of public healthcare institutions. Let me assure Dr Michael Lim and all Members here that, today, more than 90% of the beds in the public-sector hospitals are subsidised beds. That is our primary role and remains our primary role. However, we do run a small percentage of beds for A-class patients where we treat them as private patients, whether it is Singaporean or foreign patients. In NUH, for example, foreign patients account for less than 5% of the patient-load. When we allow the hospitals to run the Faculty Practice Plan, less than 1% of the specialist manpower in the public sector is involved. When we allow them to do so, the hospitals have to do so strictly at arm's length, and all their services are priced at market rates. So it is proper accounting. There is no cross-subsidy. Hence, it is not true that we are using public resources to compete with the private sector.

Dr Michael Lim also queried why the polyclinics have gone into night clinics. The reason why I have allowed the polyclinics to go into night clinics is because I consider that as providing better services for Singaporeans. Unfortunately, it also means a little bit more competition for the private clinics in the area. But all of us should be able to take competition in our stride.

We have restructured our public-sector hospitals and polyclinics so that they are more efficient, productive and responsive. I think this is one of the areas contributing to our lower NHE. If we had continued running our polyclinics and hospitals like the old Government departments without subjecting them to competition and without subjecting them to productivity pressures and efficiency pressures, the costs would have been higher. The idea is not for these institutions to maximise profits but, really, to bring costs down and offer a better service to Singaporeans. Last year, we went one step forward to position the public sector, both the Singapore Healthcare Services and the National Healthcare Group, the two clusters, as "Not-for-Profit" entities explicitly. We designate them as not-for-profit organisations so that our two clusters will preserve their sense of public service and have a different organisation culture from the private hospitals. But that does not mean that they do not make surpluses. They must be efficient and, with the private patients, they must charge what the market can bear, and they should make surpluses. They should not be embarrassed by it. But, having made the surpluses, these are not-for-profit organisations, and they will then use these surpluses for research, better services and training of their staff.

Let me now turn to the doctor situation. Compared to December 2000, in December 2001, we had a nett increase of 345 doctors, or 6.2%. Our doctor to population ratio has improved from 1:720 to 1:700 now. If you ask me, the overall doctor situation is all right. If we look around, do we have a shortage of private-sector GPs? I think the answer is no. Many of our private-sector GPs have to compete and are struggling. So there is really no shortage of doctors. We do have a shortage of specialists. Not enough doctors are becoming specialists, and we do have a shortfall of specialists in a few areas, eg, cardiac surgery, radiology and geriatrics. But, by and large, the total number of doctors is sufficient. We do have a shortage of doctors in the public sector. By our norms, we have a shortfall of about 12%. This means that our doctors in the public sector are heavily worked. Instead of working eight or nine hours per day, they have to work 10, 11 or 12 hours. This is obviously not sustainable and we have taken action to try and recruit more and improve the manpower situation. 5.15 pm

On a national basis, NUS has increased its intake for medicine starting in 1996 and, therefore, we should start seeing more doctors graduating from this year. The Singapore Medical Council has also exercised greater flexibility in approving temporary registration of foreign-trained doctors. That allows us to bring in a few more foreign-trained doctors. Dr Lily Neo is not very happy with this and she feels that we are bringing in doctors from neighbouring or immediate countries and that would diminish our reputation and lower the standards of care here. Let me assure her that when SMC allows these doctors in on temporary registration, it means that these doctors are strictly supervised. They are not allowed to practise on their own. They practise within an institutional framework under close supervision. It is not our intention to diminish the reputation of Singapore as a healthcare centre. But we do need them as a way of building up our supply. Singapore has a very small population and it cannot just depend on Singaporeans to be doctors. At the steady stage, if we can train between 230-250 Singaporeans in our university and we supplement it by an annual recruitment of between 50-80 doctors trained overseas, both Singaporeans and Malaysians, as well as other nationalities, I think it will provide for a fairly robust system. So we are not having a group of doctors that are overly represented by foreign doctors.

On the medical intake quotas, there are three sound reasons why there is a quota. First, we still believe that we need to have a finger on the supply of doctors. Second, we have a limited talent pool. We cannot have all our brightest students going to be doctors. And third, the cost of training doctors is very expensive. There are still reasons for us to have a quota.

With regard to the one-third quota on female students, unfortunately, the data still shows that more female doctors work part-time than male doctors. You can either look at it as a container being half-full or half-empty, but that is a fact of life. I have said earlier that we are reviewing this quota. In fact, the Economic Review Committee's Services Sub-committee, chaired by Mr Khaw Boon Wan, is studying the medical manpower requirements, including the quota on female medical students, in the light of the overall medical services review to promote the healthcare services industry. I would urge Members to be a little bit more patient and give Mr Khaw Boon Wan a bit more time to complete his study.

On nurses, the situation has also improved a little. We have a 3.3% increase in nurses compared to 2000. Our nurses to population ratio is now 1:300. In the public sector, we have vacancies of about 6.6%. This is a slight improvement from last year's shortfall of 7.5%. We have taken steps to address this shortfall. First, we have increased the total nursing student intake in Nanyang Polytechnic and the ITE by more than 100 places. We have looked at salary reviews, increased the salaries of nurses by an average of 13% in the year 2000, and 6% last year. We have worked out a clinical career path for nurses. Our intention is that we will facilitate around 25% of our nurses in taking up degree courses. Whether the degree course is done locally or overseas is something we have to work with the Ministry of Education. But we have worked out a career path and our intention is that 25% of our nurses should have the opportunity to progress to degree courses.

Dr Michael Lim suggests that maybe we can set up overseas training facilities. We have the resources here. Our problem is not training facilities. Our problem is attracting Singaporeans to take up nursing as a career. There is an article in the Today paper. It is a three-part series on nursing. The most striking feature of that article is that some of the students, who take up the courses, drop out when they realise quite early in the course that it is a very, very demanding career. If you do not have the commitment, then many of them do not make it. It is a very challenging and a very demanding career. Our job is to make it attractive and make sure that enough Singaporeans are attracted to nursing to serve Singaporeans. But for the immediate future, we still need to depend on between 20-25% foreigners to fill up the nursing positions in our hospitals.

Mr Chairman, I believe I have covered most of the items. Let me just say that for the point on PCPS, I have answered this previously in Parliament, so there is no need to go through it again. Mr Low Thia Khiang also raised about the MOs being overworked. We are reviewing the situation. Today, there is some disparity in the hospitals and also between departments in the hospitals, where some MOs, who are posted to some departments, because of the shortage of junior MOs there, they end up having more than a fair share of their night duties. We have asked the hospitals to review this and rationalise the situation. We are keeping a close watch on this.

Let me just end by saying that healthcare cost will continue to go up. I cannot stand here and tell you that we can control healthcare cost to the extent that it will not go up. As Dr Ong Seh Hong summarised, there are so many reasons why healthcare cost goes up, many of these are beyond our control. The more sensible approach is to recognise that if you want a level of healthcare equivalent to what is available in the developed countries, then we must accept the fact that healthcare cost will go up. It will go up by between 4%, 6% or even 8% every year. So far, we have been very fortunate because our economy also grows by 6%, 8% and even 10% in the first seven years in the 1990s. Our national healthcare expenditure is able to maintain at 3% of GDP. If we undertake all the changes put up by DPM Lee in his tax review and we generate the 4-6% growth, that will be the best bet for us to keep up with healthcare costs. If healthcare cost goes up 6-8%, our economy grows by 4-6%, we maintain our national health expenditure at around 3-4% of GDP, and that is the best solution for affordability of healthcare. If you do not generate the growth, healthcare cost will still go up because Singaporeans will still want good healthcare. Then, we will be in a fix, trying to find the money to pay for healthcare cost. Having maintained the growth and we contain healthcare cost to between 6-8%, then we are still ahead in the game.

What we need to do, recognising that healthcare cost will go up, is to prepare for the situation in 10-20 years from now when a higher percentage of our population is aged and we have to spend more on healthcare. This is what the tax changes are all about. What we do in Health is to prepare for that day. This means we introduce ElderShield, we expand MediShield, we build up ElderCare Fund. In case Members need to be reminded, we launched ElderCare Fund less than two years ago, and because of the budget surpluses that we were able to generate, we are able to set aside $1 billion already in ElderCare Fund. We build up all these endowment funds during this period where we are enjoying good growth and these endowment funds will serve us well when we are in a period of lower growth because of a maturing economy.

Dr Michael Lim Chun Leng: Mr Chairman, I would like to seek some clarifications with the Minister. The Minister said that night polyclinics are a good thing but in the next breath, he himself said that the GP market is a very competitive market, there is an over-supply and they are struggling. At the same time, he said that there are not enough medical officers in the service. He appears to be contradicting himself because this is an over-supply situation, and you are not allocating resources properly.

Secondly, I would like to seek clarification with the Minister whether the $20,000-$60,000 deposit that is required, in the example I quoted, is the norm that they ask of foreign patients who get admitted to KK Hospital as well. Because in the private sector, none of the private hospitals do that. They accept patients from other countries and they never ask for $20,000 or $60,000. If they do that, they will all shut down!

Thirdly, in the example I quoted, where the surgery can only be done at a public hospital, does it mean that if the family cannot fork out the expenses and no guarantor was available, the public hospital will not accept this particular patient and would rather let the patient perish in the private hospital?

Fourthly, another clarification is that, as the Minister pointed out very correctly, most of the patients in our hospitals are subsidised, yet our consultants are spending more and more time looking after private patients. I cannot see how the consultants have so much time as I have told him, from the ground, already the consultants are telling me that they do not have time for subsidised patients. I am not sure how he can balance the limited resources, encouraging private sector practice for the consultants and, at the same time, most of his patients are subsidised patients.

Mr Lim Hng Kiang: First, on the primary care sector. In the White Paper, the Government is committed to serving 25% of the market. This means the Government undertakes that in the primary care, through our polyclinics, we will service the bottom 25% of the population. Today, we are around there. We think that with the investment that we have put into our polyclinics, we should provide night services. This means, of course, stretching the doctors further and the CEOs in charge of the polyclinics have to go out there and recruit doctors. My Ministry has given them the mission that they should service the bottom 25% of Singaporeans and if that service includes night clinics, then they must provide the night clinics, and if they do not have enough doctors, they jolly well go out there and recruit the doctors and they have the budget to do so. So that is not a problem of resources.

The second question is on the deposit. This is a special case of a neo-natal admission. So when KK Hospital receives or evaluates a premature baby, KK Hospital has to make an assessment to take over the baby and to look after the baby for the next few months, and in fact, in one case, they looked after the baby for the next one year. It is going to cost a lot of money, and therefore, the family should pay a deposit commensurate with the severity of the case. It is not to say that all private patients coming to restructured hospitals have to pay a deposit of $20,000 or $60,000. It depends on what case he is coming in for. 5.30 pm

I know neo-natal cases are very emotional examples. We had one appeal, probably the same case. KK Hospital admitted the baby, even though they were very reluctant to do so. Because the appeal came to me, we asked KK Hospital to admit. I regret making that decision because, in the end, the baby continued to be in intensive care and KK Hospital now runs up a total bill of more than $300,000. These are very expensive cases. When a baby is born prematurely, it requires a lot of resources to keep the baby alive. I had a long discussion with my Minister of State, Dr Balaji, and I said, "Is there any way you can tell whether there is brain damage?" Being a neurosurgeon, he said, "There is no way you can tell. It is only after one or two years that you will know whether the whole period of premature birth has resulted in brain damage."

So it is a very sad situation, but unfortunately we do have these types of cases of neo-natal babies, premature babies. If the family is unfortunate to have such a case, I sympathise with them. If they want to keep the baby alive, the hospitals want to help, but they must find the resources. And that is the reason why I have decided to include neo-natal coverage within MediShield. It may not be the best decision because, in the end, somebody has to pay for the cost. What we are doing is then sharing the cost among all of us, Singaporeans, and not just on the families that are unfortunate enough to have such a baby. So anyway, from next year onwards, we hope to incorporate neo-natal coverage within MediShield.

On the extension of the specialists in the faculty practice, let me again assure Dr Michael Lim that it is not the MOH's policy to ask our specialists in our restructured hospitals to set up clinics in a private hospital or to undertake faculty practice. We leave that decision to the CEO and to the departmental heads. The CEO and the departmental heads, in managing the specialists under them, must make sure that allowing these specialists to look after private patients through the faculty practice, that they do not compromise the level of service to the subsidised patients. The Ministry of Health signs a 3-year contract with our restructured hospitals. We set down very strict conditions of service standards, etc, etc. They have to undertake to meet these service standards. If the CEO and the departmental heads allow their specialists to undertake faculty practice and fail to deliver on these service standards to the subsidised patients, then under the service contract that we have with them they will pay a very heavy price.

Mr Low Thia Khiang: Sir, may I seek two clarifications from the Minister? How long does the Minister expect to ease the problem of shortage of doctors in public hospitals? Secondly, Sir, has the current shortage and overwork of doctors in the hospitals affected the medical standard of public sector hospitals?

Mr Lim Hng Kiang: Sir, as I mentioned in my response, we are currently facing a shortage because our population expanded since 1993, and our medical intake only expanded since 1996. So, for these 6-9 years, we have a mismatch. But, starting from this year, we will be getting a higher intake of graduates from our medical school, and we are also bringing in more foreign doctors. So that would relieve the situation. I expect the doctor situation to improve over the next five years. But that is not a guarantee. We still have to continuously adjust our working conditions, adjust our remuneration structure, to make sure that our public hospitals are competitive, and that we are able to attract our fair share of doctors.

The service levels are not so adversely affected. As I mentioned last year, we engaged a group of operational research consultants to look at the queuing system and the waiting times. We are now finalising the study. If we introduce some of the proposals that the consultants put up, I am confident that we can improve the level of service in our public hospitals.

Dr Lily Neo: May I seek clarification, Sir? The Minister did not reply to my earlier question regarding recognising the graduates from over 150 previously recognised foreign universities. May I also ask the Minister whether it would not be better to review this policy rather than recruiting junior doctors from neighbouring countries, whose universities we had never recognised before?

Mr Lim Hng Kiang: Sir, even though we do not recognise or we stop recognising some of these institutions since 1993, they are still allowed to come in under temporary registration. So we are not forgoing these sources. Even if I make a decision, or we get a decision to recognise these institutions, it would be another 5-6 years before people decide that, now that it is recognised, they send their children there and then they come back after graduation. So what I am talking about is a temporary shortage. We have increased the medical intake. When we start taking the 230-250 doctors from our local NUS and we continue to recruit between 50-80 doctors overseas, we will have a complement of about 320-350 doctors, and that is enough for our needs. So there is no need to change the rules of the game. The current shortage is temporary, transitional shortage, and within 2-3 years we should get over the worse of this shortage.

Dr Lily Neo: Mr Chairman, may I just disagree with the Minister on what he just said?

The Chairman: Can you please proceed to your next cut?

Dr Lily Neo: The importance of preventive healthcare is a foregone conclusion, and I am glad about MOH's visible increased effort in this area presently.

I would like to specially mention the success of the Check-Your-Health (CHS) programme in identifying those elderly with undiagnosed diabetes, hypertension and high blood cholesterol. From the launch of CHS in July 2000 to February 2002, 40,230 persons have been screened, and the overall participation rate is 24%. But, more importantly, among those screened, about 60% had not attended any screening before, and 60% of the participants, who had no previous history, were detected with abnormal result at the screening. 70% of those who were referred for further management consulted a doctor within three months of their screening. Therefore, this programme has been useful in helping residents diagnose the three common diseases, and in enabling them to seek early treatment, and in ensuring them to lead a healthier and happier life. I do believe that CHS is a worthwhile programme and should continue to receive funding for screening even more of our elderly. I hope the Minister will consider this.

Sir, the National Mammogram Screening/Breast Screening in Singapore, a population-based breast cancer screening programme launched since January 2002, has been so successful that it was overwhelmed by the demand for such screening. Two months after its launch, the Breast Screen Call Centre received about 12,500 calls. About 9,000 women have been given screening mammography appointments, but of these only 5,380 have been screened as there are only four polyclinics offering screening mammography services. I know that MOH plans to open more screening centres to cope with the huge demand, and I hope MOH will do this expeditiously to cut the waiting time for women who have registered for screening so that more women can be screened more quickly.

The Ministry of Health, Sir, must ensure continuity and lasting follow through of all efforts on preventive healthcare. For example, in those cancers affecting Singaporeans, especially those with hereditary predisposition, there should be a programme in place for immediate family members of affected individuals to be screened for specific cancers. There should be public education targeted at these families to improve understanding that they are more prone to certain cancers. By being target-specific, it will be more cost effective, especially for those cancers that are too expensive for screening as a national programme.

Another example concerns mental health, which has not received its due attention. There must be new emphasis on mental health as the present rate of depression in Singapore is 8.6% now.

Sir, since morbidity and mortality from any disease can be dramatically reduced when the disease is treated in the early stages, more emphasis should now be given to our people in the younger age group. Heart diseases are a major cause of death presently, and are likely to increase in incidence under present trends. Heart diseases would take root when people are still young, in view of the kind of diet, lifestyle and predisposing medical conditions which they have. We need to target them for increased public education in this respect, and facilitate them in early disease detection and early prevention.

Sir, targeting this adult group population needs much creativity, funding and enthusiasm.

Mr Yeo Guat Kwang: Sir, as reported in the Business Week, 27th May issue, the American National Mental Health Association estimates that 19 million or one in every ten adults suffers some form of depression in a given year. The total retail sales of the anti-depressant medicine in year 2001 alone was US$12.5 billion. Why I mentioned this is because, Sir, we are not much better. Our Annual State of Health Year 2000 Report, for example, cited a study on depression, that found a prevailing rate of 8.6%. The number of new cases of young people under 18 visiting psychiatrists in our Government clinics also doubled from 1,126 in 1990 to 2,491 cases in the year 2000.

Sir, we have done quite a bit for the promotion of physical health. I think now we need to do more in preventive mental healthcare. I would like to ask the Ministry, whether it has plans to do more in mental health promotion.

The Chairman: Dr Tan Cheng Bock you may take both cuts together.

Dr Tan Cheng Bock (Ayer Rajah): I remember in the last Parliament we were talking about case-mix, and I often wonder whether Members of this House really understand what this term means. But, I think Members in this House must understand case-mix because the subject that I am going to talk about actually is related to case-mix.

I would try to be very brief and just be as simple as possible so that you all can really appreciate what I want to say. Very briefly, case-mix to me is actually a patient-management programme, ie, to improve the care of the patients in hospitals with minimal wastage. So guidelines were then set to make sure that doctors manage patients effectively, and discharge them at the earliest opportune time. To make sure this happens, funding to the hospital is related to this, so that you will have to make sure that the patients you see are within that funding limit.

Let me give you a very easy example so that you can follow me. Let us take the example of a patient with acute appendicitis, and assuming that they have gone through all the records, and they think maybe a 4-day stay would be sufficient, to manage and treat patients with appendicitis. And, that should be the length of period that he is allowed to stay. Let us say, if he exceeds that period, then funding would be reduced or even stopped. So it makes administrators of such hospitals to think very carefully and to advise doctors that they should try to treat the patients within that 4-day period. However, I am sure sometimes the patients have no choice. Cases do get complicated at times and therefore it exceeds the 4-day stay, and when you do that, I think administrators of hospitals will be a little bit uncomfortable because they see that their funding will be curtailed. You cannot blame them because they have to look at the bottom line.

So what actually happens is that you might really get some patients being discharged earlier than they should, because as I said, they need to look at the bottom line. In fact, I was so sad when I heard Dr Michael Lim mention about a young couple with a child going to KK Hospital and finding difficulty to seek admission. And what is more is the content of the letter, the reply to Dr Michael Lim, attaching the importance of cost to this. We all understand cost, but sometimes the way the letter was written, I think, really hurt him. That is why he probably brought up this matter. Now, you also can understand how case-mix, because the fear of less subvention, I suspect that some of the cases may be discharged earlier.

5.45 pm

That is why I am coming to this House to ask the Minister to be more generous in the funding to all these step-down care facilities that are provided by volunteers and also by some of our own Government agencies. Step-down facilities are of various kinds. You have the day-care centres. You have your occupational centres. You have your rehabilitation centres, and so on. But I think these high-end step-down cases are quite special because the patients really need post-hospital care - hospital setting to manage that difficult period. I think our outpatient clinics are not able to do that because they do not have in-staying patients. Community hospitals can do the job but when I heard Dr Ong mention about the new funding, there is a means test that is being bandied around, and they want to have a different way of funding. When I heard Dr Ong talking and being worried that subvention grants may be curtailed, I worry that some of these facilities, ie, the high-end ones and even the lower end ones, they might trim facilities or they might even close down some of the facilities.

So I hope that the Minister will give assurance to all these people who put so much effort in setting up all these facilities, not only grants but also a lot more support.

The means test has been mentioned. So to cut short, I shall not speak so much on means test. It has been very well articulated by Dr Ong. I think he can do it better than I. I shall now move on to ask just a few questions about outpatient clinics.

The outpatient clinics have done a remarkably good job. They are the first line of defence, the primary healthcare. Since we are talking about remaking of Singapore, I was wondering whether the outpatient clinics would also remake their role. Perhaps we should make some collaboration studies with the private practitioners to open up the facilities for better use. We spend so much money providing all the facilities to outpatients. Maybe we could share these facilities with the private practitioners to ensure better service to our Singaporeans.

Mdm Ho Geok Choo: Sir, like my colleagues before me, I am concerned with the way in which the prices of prescriptive drugs are being regulated in Singapore.

From anecdotal evidence, and as well as illustrated by Comrade Ong Ah Heng earlier on, we know that the cost of prescriptive drugs in this country can be just as expensive, if not more expensive than similar drugs found in countries such as Australia and New Zealand. As a matter of fact, it is not just patients but even doctors in Singapore are driving up to Johor to buy prescriptive drugs for their clinics because they are cheaper than those found in Singapore.

Could the Minister enlighten us as to whether there is a regulatory body in Singapore that monitors prices by which drugs are sold in Singapore to ensure that there is no overcharging? If there is indeed such a body, may I ask the Minister to share the measures that his Ministry has taken to keep drug prices affordable? If there is not such a body, would the Ministry consider setting up one?

My question stems from the concern that there is an absence of transparency in the pricing of proprietary medicines and vitamins in Singapore and from the concern that our costs may be too prohibitive relative to that prevailing in developed countries. Just to give two examples on vitamins. For vitamins like Nature's Farm vitamin E 500 soft gel pack of 50 tablets, I know that they can be purchased in Johor at half the price of what we have to pay in Singapore. I was also told by a resident during my meet-the-people session that for calcium tablets that come in a pack of 30 tablets that he purchases from SGH pharmacy at something like 30% discount, he has to pay $21 per pack. For a similar type of calcium tablets, he was told by his son that he needs only to pay A$7.00.

On a related matter, I would also like to ask the Minister to clarify whether there are measures taken by the hospitals to make sure that patients are not being prescribed drugs which are marginally more effective than other drugs, but for which the price is far higher than the other equally effective drugs.

The Minister of State for Health (Dr Balaji Sadasivan): I thank Dr Lily Neo for having good things to say about our preventive healthcare programme. The community health screening programme has indeed been very successful since its implementation two years ago. My Ministry will continue to promote and provide for this community screening programme. Forty districts have already been covered. We intend to cover another 48 by next year, and after that this will be an on-going programme. And those who have gone through once will go through again. So this will be an on-going programme.

The national breast cancer screening programme has also been extremely successful and large numbers of people have called to have appointments for the screening. But I think, with time, the demand for the screening will level out and then the waiting time for screening would become much shorter. The Ministry is also increasing the number of polyclinics that will have this facility from eight to 11 by the end of this year.

Both Dr Lily Neo and Mr Yeo Guat Kwang have brought up their concerns about mental health. We need a healthy mind to deal with the current problems that Singapore is facing. My Ministry recognises the importance of promoting mental health among Singaporeans. To place greater emphasis on mental health, a mental health education programme, called "Mind your Mind", was implemented in 2001 by the Health Promotion Board and the Institute of Mental Health. The programme aims to promote mental wellness and raise awareness of the importance of early screening, detection and treatment of the common mental conditions such as stress, depression, anxiety disorders and schizophrenia. The programme is targeted at all Singaporeans, children and adolescents, adults and the elderly. We are using a variety of strategies to reach out to the target groups. Mass media, talks and forums are carried out to create public awareness of the importance of mental health. To impart skills to healthcare professionals for the early detection of these mental conditions and mental stress problems that patients may have, workshops and training courses are being carried out.

I now come to Dr Tan Cheng Bock's concerns about case-mix and step-down facilities. First of all, I want to clarify what case-mix is. Case-mix is a statistical way of reimbursing hospitals. What happens is that an average is taken for a condition, based on the cumulative cost of treating the condition in the population divided by the number of people who have that condition. So the hospitals will make some profit in some cases and losses in other cases. But, overall, the hospitals will not be worse off.

It has been found in the United States that the introduction of case-mix or case-mix like systems leads to efficiency in the hospitals. For case-mix to work, it requires doctors to be professional and that doctors would treat patients not using case-mix criteria but treat patients according to what patients need. If administrators do their job and look at the bottomline, and if doctors act professionally and treat patients as they should be treated, what we will end up having is an efficient system that provides healthcare for Singaporeans as well as providing the correct treatment for patients.

With regard to step-down facilities, over the last 10 years MOH has been putting in place facilities and programmes to meet the requirements of an aging population. We have five community hospitals, 16 VWOs' nursing homes and 21 day rehabilitation centres. These have been set up at a total Government subsidy of $225 million for capital cost and $200 million for recurrent funding. Another $82 million has been provided for the financial year. So my Ministry has a great concern that there are sufficient step-down facilities for patients.

With regard to means testing, the Minister has already explained the rationale for means testing, and I will not go into it.

Dr Tan also asked about the polyclinics and their cooperation with general practitioners. Our polyclinics try to work with general practitioners in the community to provide effective and efficient service for the community. Among the areas of cooperation between GPs and the polyclinics are that polyclinics allow patients referred by GPs to use their services such as X-rays, mammography and laboratory services. These patients are charged non-subsidised rates. X-rays and mammography services are relatively well utilised by the GPs. Patients referred by GPs constitute half of X-ray workload and a quarter of the mammography workload in some polyclinics. These are clear indications of the level of cooperation between the GPs and polyclinics.

In addition, patients referred by GPs can undergo diabetic eye screening at polyclinics. They can also refer patients to purchase drugs from the retail pharmacies in polyclinics.

Mdm Ho brought up the question of cost of medication. In Singapore, as a whole, we spend approximately $450 million on prescription drugs annually. Generic products make up just over 10% ($54 million) of the local market. Various branded proprietary drugs account for about 90% ($396 million). Branded drugs are produced by the major R&D based pharmaceutical companies. They are generally higher priced. These companies control the prices of the medication while they are under patent protection, in order to recover their R&D costs. They might price their products differently in different countries, and we do not have direct control over these companies.

But there is a great difference in price between a generic and a branded drug. So, it is possible, for example, in calcium supplements, if you buy branded medication, it may cost many, many times more than a generic calcium supplement. So this may explain why there is such a difference in price with regard to the person who has bought it.

In Singapore, we do not have a regulatory body to control drug prices, and the market is allowed to set its own price. The Ministry of Health does not intend to set up such a regulatory agency. However, the Ministry of Health does monitor the price trends of pharmaceuticals through the data available from the group purchasing office that buys medicines for the two hospital clusters. However, in response to concerns expressed by the public on the high prices of medicines in Singapore, the Ministry did commission a study by a task force. The task force has made several recommendations. We are studying the recommendations and would decide on some measures maybe later in the year. 6.00 pm

Dr Tan Cheng Bock: Just a small point of clarification on GP and OPD cooperation. I just want to find out that, in the past, when a GP referred a patient to the outpatient clinic and he was referred to the hospital, he paid very little, ie, only the C class rate if he could not afford. But now I learn that, by way of the same procedure, let us say, if a patient is referred from the GP to the OPD and then to the hospital, he is now charged more when he goes to the hospital. I am not sure whether this is true or not. Without the GP's letter, he is charged less, that means, there is no point for the patient to go and get a referral letter from the GP any more. If he gets a direct referral by the OPD to the hospital, it is cheaper. But through a GP's letter, it is more. In the past, it was not, because some of the patients have told me. So I am just seeking clarification. You may not be able to answer it, but never mind, you can give me an answer later.

Dr Balaji Sadasivan: I think where a GP refers a patient to a Specialist Clinic ---

Dr Tan Cheng Bock: No, it is not a Specialist Clinic. It is just to the hospital.

Dr Balaji Sadasivan: In this area, the two clusters have been working with the GPs to try to come out with an efficient system of admitting patients to the hospital. And in fact, the clusters are working by allowing GPs to admit patients directly to the hospital. With regard to the specific case, if he can send the information to my Ministry, we will look into it.

Dr Tan Cheng Bock: I think I agree with you. But I would not want to prolong this. I will bring it up with the Minister.

The Chairman: Mr Lim Hng Kiang, you have got something to add?

Mr Lim Hng Kiang: I just want to supplement what MOS Balaji has said about case-mix because it is a very important point that Dr Tan Cheng Bock raised. As MOS Balaji said, if the doctors do their job professionally and, say, your appendicitis case, the patient needs to stay in the hospital for 10 days, what happens is that the Ministry will subvent the average of four days under case-mix and the additional six days will be subvented on a per diem basis. So as long as doctors do their job correctly and, say, this patient, in fact, needs to stay 10 days, we will give the patient the subsidy for the average of four days, the statistical method under case-mix, and the additional six days on a per diem basis. So we are not pushing people to be prematurely discharged.

The Chairman: Dr Neo, can you withdraw your amendment?

Dr Lily Neo: May I seek further clarifications from the Minister as I am not satisfied with the Minister's earlier reply?

The Chairman: I think we are behind schedule, Dr Neo. Okay, I will allow for one more clarification.

Dr Lily Neo: The Minister said earlier that he did not want to review the policy of recognising the 150 previously recognised universities because the doctor shortage is temporary. May I ask him whether his Ministry's projection of doctor shortage is again skewed, especially in view of our long-term emphasis on life sciences? Was it not recommended by a foreign university don that, in fact, Singapore needs another medical school to train more doctors? The Minister earlier also said that the junior doctors from our neighbouring countries are working here under strict supervision. May I then ask the Minister what is the point of having junior doctors working here when they need supervision? Surely, this defeats the purpose and therefore taxing our senior doctors further by having to look after these junior doctors from our neighbouring countries. The Minister also said earlier that competition ---

The Chairman: Dr Neo, I said I will allow only one clarification. You have raised more than one. Will the Minister reply first?

Mr Lim Hng Kiang: I shall reply to one clarification. All junior doctors work under supervision. So when we bring junior doctors from neighbouring country, the senior doctors also continue to supervise them.

The Chairman: Dr Neo, can you withdraw your amendment?

Dr Lily Neo: Can I not have further clarifications, Sir?

The Chairman: We are running behind schedule. Why not raise your question to the Minister on a separate occasion?

Dr Lily Neo: I beg leave to withdraw my amendment reluctantly.

Amendment, by leave, withdrawn.

The Chairman: Amendment No. (2), Dr Chong Weng Chiew.

Dr Chong Weng Chiew (Tanjong Pagar): Sir, I beg to move,

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

Sir, since we are short of time, I would like to forgo my first cut and go to the second cut on home medicare. Sir, there is a quiet revolution going on in our healthcare system. In the 80s, we have rejected the means testing in deciding who is eligible for what kind of subvention and, presently, we are seeing the implementation of means testing from outpatient to step-down care services and, eventually, also to acute hospitals. This is a significant change in our healthcare policy.

There are also more subtle changes in our healthcare delivery system. For instance, in our attempt to take away some of the pressure on the demand for hospital beds, we have introduced step-down care services. In other words, when someone suffers from an acute illness, for example, a stroke or heart attack, he will be admitted to a hospital, such as SGH or NUH. After that, the patient is on a recuperative stage and, hence, does not need the services of an acute hospital. Step-down care services henceforth will be in greater demand and will increase in importance, in the near future, in our fast ageing population.

Sir, I would like to urge MOH to place emphasis on one of the newer approaches to healthcare delivery systems and, that is, domiciliary medical care, a form of step-down care services. When a patient is discharged from an acute community hospital, most of these patients still require follow-up treatment. In many of these cases, they are not fully ambulant, such as post-stroke patients and patients after amputation. It would be a chore for these patients to go for follow-up treatment at the institutions. Thus, there is a need for the concept of domiciliary care.

What this consists of would be a team of professionals, such as doctors, nurses and physiotherapists. They will get referrals from hospitals and conduct home visits, giving treatment and follow-up in the comfort of the homes of the patients, who probably are home-bound. The physiotherapists in the team could provide much needed treatment, especially for post-stroke patients. Currently, these services are provided by a handful of voluntary welfare organisations and the demand far exceeds supply.

Another advantage of such a system will go towards bringing down national healthcare expenditure (NHE). When this type of service is in place, it will release demand for hospital beds, as there are certain groups of patients who could be discharged earlier to recuperate in the comfort of their homes. And this group of patients would include those on intravenous drugs, those who are recuperating from stroke, as well as those post-operation cases. And this would benefit very much from home physiotherapy, or home medical treatment.

Thus, I would urge the Ministry to (1) encourage more organisations to provide domiciliary medical and physiotherapy services; and (2) to provide funding for such organisations who are willing to take up this difficult task.

The Chairman: You may speak on the next cut, Dr Chong.

Dr Chong Weng Chiew: I would now go on to the cut on AIDS patients. HIV or AIDS patient is a feared and, yet, misunderstood disease. As a medical doctor, I am of the opinion that we should not be judgemental. Presently, under the ElderCare Endowment Scheme, the Ministry of Health has recently sent out a circular requiring all approved healthcare providers, meaning nursing homes and hospices, to admit all Singaporeans and PRs, regardless of disease condition, including HIV positive or AIDS patients. Failing to do so might result in revocation or suspension of subvention.

Sir, AIDS patients, like all patients, desire to be treated fairly. They should not be discriminated against because of their disease. Since the disease is such a dreaded one, I would urge the Ministry of Health to be a little bit more sympathetic to approved providers in requiring them to accept AIDS patients. Many of the approved providers are prepared to accept patients, regardless of their diseases, and are preparing their staff for the eventuality. However, they appeal to the Ministry of Health for a little more flexibility and time as they find it tough convincing their staff.

Some service providers are already experiencing a loss of staff over this issue. Others are prepared to lose Government's subvention if they have no other choices. There are also some approved providers who have volunteer caregivers in their set-up. And it is difficult to retain voluntary help over the issue of accepting and working with AIDS patients.

Sir, while some of us are comfortable in dealing with HIV positive or AIDS patients, I am afraid the community at large is just not ready. Thus, I would urge the Ministry to give the approved providers more flexibility and time in preparing the staff in accepting AIDS patients under their care.

Dr Balaji Sadasivan: Sir, Dr Chong Weng Chiew brought up the issue of domiciliary home care. This is something that my Ministry supports. There are now six VWOs providing home medical services. Home medical care is the provision of a doctor's care in the person's own home as the person has difficulty leaving his home because of severe disability.

Home nursing services usually involve dressing of wounds, injections, changing of catheters, etc. The availability of home medical and home nursing can help to reduce the need for nursing home beds. MOH is in the process of finalising the norm cost for home medical care and home nursing care after which subsidised home medical and home nursing care will be available to those who pass the means test and will seek such care from the various VWO providers.

The availability of Government subvention for home medical and home nursing will also encourage more service providers. This is an expansion of current services which have been limited to the seven approved providers under the Ministry's framework for integrated healthcare for the elderly.

With regard to physiotherapy, home medical and home nursing providers will instruct the patients and their relatives on basic physiotherapy exercises. For patients who require more specialised physiotherapy inputs, home physiotherapy is provided by four restructured hospitals. There are eight private physiotherapy providers and they do not have a waiting list. The Ministry is currently reviewing the continuum of rehabilitation services and whether there is a need to expand home physiotherapy, particularly as the previous severe shortage of physiotherapists is being addressed with the local diploma course.

With regard to Dr Chong's concern about HIV/AIDS patients, MOH has announced in December 2000 that hospices, nursing homes and community hospitals should accept HIV/AIDS patients, and they will receive subsidies for them as for other patients. A comprehensive training programme on infection control and HIV/AIDS has been organised for step-down care staff and is on-going. This programme teaches the staff how to manage patients with infectious diseases so that the handler knows how to take precautions. Caring for HIV/AIDS patient is no different from caring for patients with other infectious disease. Universal precaution should be practised by all service providers for all patients to prevent infection. It is not medical knowledge that is lacking, but the fear of nursing these patients.

The training programme will further address such psycho-social issues to reduce discrimination against HIV/AIDS patients. Currently, the number of HIV/AIDS patients requiring nursing home care is small. We feel that nursing homes should not discriminate against HIV/AIDS patients or patients with other conditions who meet MOH's admission criteria for nursing homes. We believe, with education and training, nursing home care providers and nursing staff and other caregivers can be taught to look after these patients without fear of catching the disease. 6.15 pm

Dr Chong Weng Chiew: Sir, I would like to thank Dr Balaji for the answers he has given. I am more than happy with them. Thus, I would like to beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

Dr Ong Seh Hong: Sir, I beg to move,

That the sum to be allocated for Head O of the Main Estimates be reduced by $10 in respect of Code OD 3600.

Sir, there is a perception that all herbal products are safe because they are natural. As a result, many members of the public take herbal medicines freely for various ailments and as health supplements. Even our regulation shows a lack of knowledge of the pharmacology and toxicology of herbal products. This is evidenced by the fact that our regulation is only concerned with the contents of heavy metals and adulteration of western prescribed medicine in the herbal products.

Even the Minister commented that these herbs have been used for hundreds of years and, therefore, they should be safe. The fact is that a number of herbs themselves actually contain chemicals that may interact with other drugs or cause various bodily damage directly, if taken in sufficient quantities. Many such cases have actually been reported in various medical literature. They resulted in kidney, liver and other organ failures. Sometimes, some of these cases were even fatal.

I urge that while the Ministry tightens up the control on adulteration of western medicine in herbal products, it should also build up a pharmacopedia of all the herbs commonly used locally, and use this knowledge to better regulate the importation and production of herbal products since so many Singaporeans actually use them regularly. Then, with this knowledge, I also urge the Ministry to educate the public on the safety aspect of herbal medicine.

Dr Michael Lim Chun Leng: Sir, alternative medicine is also widely practised in western countries like the USA, so it is not surprising that alternative medicine is also a choice of therapy for many Singaporeans. While the Ministry finds it difficult to regulate efficacy as it is just primarily regulating safety, the Ministry can perform a role in letting the public know what forms of alternative medicine are allowed to be practised here, because the public does not know what is an accepted form of alternative medicine and what is not. For example: is chelation therapy or other forms of aromatherapy accepted as regular types of alternative medicine? So the Ministry can perform a role by helping us understand what types of alternative medicine can be practised here.

Secondly, while it may not be able to regulate efficacy, it can perform a role in preventing unsubstantiated claims from being made. For example, some of these preparations claim that they can cure cancer or diabetes. The danger in doing so is that this will mislead persons into taking the medication, leading to further complications. What I would like to know is whether there are any agencies to look into these advertising claims. While I can understand that some of these alternative treatments can claim to improve well-being, I think that is fine. But once they start making claims about curing diseases, the Ministry has to draw a fine line. Otherwise, it can easily result in harm to our people who know no better.

The Chairman: Dr Chong is not here. Dr Balaji, would you like to respond?

Dr Balaji Sadasivan: On the topic of alternative medicine and Chinese traditional medicine, much of it has been extensively covered by the Minister earlier today, so I will just be very brief.

MOH has started to regulate TCM, including Chinese proprietary medicine, to safeguard patients' interest and safety. The TCM Practitioners Act 2000 came into effect on 7th February 2001 with the commencement of registration of acupuncturists. This was successfully carried out in 2001. The registration of TCM physicians started on 28th February 2002, and all TCM physicians are required to be registered, as a condition to practise, by 1st January 2004. The control of TCM was carried out in three phases and completed on 1st September 2001.

Sir, it will be very difficult for us to impose standards of western medicine on Chinese traditional medicine. But many of these herbs and medications have been taken for thousands of years and patients have felt better as a result of taking these medications, and very few reports of actually serious illness have been reported from taking these medications. Where there have been complications, it has been because of adulteration of these Chinese medicines. If we were to impose western standards of trials on these traditional Chinese medications, what will happen is that Singaporeans will be deprived of the ability to have these medications. So a certain balance is required in the way we deal with traditional Chinese medicines.

Dr Ong Seh Hong: I just want to clarify that I am not saying that Chinese medicine is not safe or to that extent. What I am saying is that there is a lack of knowledge on the part of our regulator about the pharmacology and toxicology of the various herbs in their original form. What I actually want to urge is to build up this knowledge base, this pharmacopedia of all the herbs commonly used in Singapore. To my knowledge, China, Taiwan and Hong Kong have done a lot of research on this area, and we can actually tap on these resources and to build up our knowledge so that we can prevent any mishaps in future. This is my suggestion.

Dr Michael Lim Chun Leng: Sir, I would like to seek clarification because the Minister of State has not answered my questions as to whether the Ministry will let us know what forms of alternative medicine can be practised here, and whether the Ministry will clamp down on unsubstantiated claims like curing diseases or being able to treat particular diseases.

Dr Balaji Sadasivan: Sir, I will answer Dr Michael Lim's question first. With regard to advertising claims about curing cancer and other diseases, there is an advertising code that regulates claims with regard to curing diseases like cancer. If importers of these medications contravene this code, then action can be taken against them.

With regard to Dr Ong's suggestion that research be done on traditional Chinese medicine, I personally do not have much knowledge about traditional Chinese medicine, but there is a board for traditional Chinese medicine in Singapore that has been formed and we will pass on his suggestion and encourage them to do research and collect information on traditional Chinese medicine.

Dr Michael Lim also asked about forms of alternative medicine that can be practised in Singapore. Sir, we have very strict regulations on how western medicine is practised in Singapore, including most of the medications used in western medicine being placed on the Schedule List of Poisons. Nobody can prescribe these medications except a person registered with the Singapore Medical Council. However, there have been many forms of treatment that have traditionally been done. These include treatments like binding of the abdomen after pregnancy, which is quite common among the Malay population. It is not the intention of the Ministry to regulate all these practices. Our goal mainly is to ensure that there is no practice that would pose a danger to the public. I believe our current system gives the public access to the greatest number of choices that they can make and, at the same time, safeguards them.

Dr Ong Seh Hong: Sir, just a quick clarification. I just want to say that when I raised the question of herbal products, I do not confine it only to traditional Chinese medicine because there are now a lot of herbal products from the western part of the world. For example, St John's Wort is touted as one of the herbs to treat depression and I have been asked this question many times, whether it works. The Malays have certain herbal preparations like jamu, and so on and so forth. So we really need to build up this knowledge in order to safeguard our public.

In view of the constraints of time, I will take this issue up with the Minister on another occasion. I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

Dr Lily Neo: Sir, I beg to move,

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

Sir, medical experts believe that cases of Hepatitis C have reached epidemic proportions and predict that the lingering liver disease will kill more people than AIDS over the next two decades.

Hepatitis C has emerged from obscurity as a disease familiar to only a few experts to become recognised as a major public-health problem worldwide. Some medical experts believe deaths from Hepatitis C will triple in the next 20 years. Many infected with the blood-borne virus would require liver transplants, and between 1% and 4% of sufferers would develop liver cancer. Hepatitis C is now the major cause of liver disease requiring liver transplantation among adults in most countries.

Sir, the development of reliable diagnostic tests has shown how widespread the disease is but, because few victims show symptoms, it is often detected during routine examinations or at blood donations.

May I ask the Minister for Health whether any study has been done to ascertain the prevalence of Hepatitis C in Singapore. Will the Ministry of Health embark on preventive measures in tackling Hepatitis C?

Sir, there is no vaccine against the Hepatitis C virus, unlike Hepatitis B and Hepatitis A. Will the Ministry of Health prioritise research to find a vaccine for Hepatitis C, much in step with our present emphasis on medical and bio-scientific research? Also, will the Ministry of Health consider screening of Hepatitis C in routine ante-natal check-ups so that gynaecologists can take precautions in minimising the transmission of Hepatitis from mother to child?

Mr Yeo Guat Kwang: Sir, in the February issue of Readers' Digest, there was a report that cigarette companies are targetting young Asian women and teenage girls in a campaign to persuade them to take up smoking. I was troubled by the report. Nowadays, when we look around, we see more smokers among our Singapore youths, particularly young females. Most female smokers smoke with friends and they perceive smoking as socially desirable.

In Singapore, tobacco taxation has been used to discourage smoking. The tax has been adjusted to increase from $180 to $210 per kg of cigarettes. The tax increase, perhaps, of course, will further deter smokers, but more needs to be done. 6.30 pm

I urge the Ministry to step up its efforts to tackle the problem of youth smoking. In the United States, 90% of all adult smokers report that they began smoking before the age of 18. Most researchers agree that prevention should begin early and continued intervention should be provided for young people. If tobacco companies focus their advertising to encourage young women to take up smoking, we too, the Ministry of Health, must also step up our drive.

Dr Balaji Sadasivan: Sir, my Ministry shares Dr Lily Neo's concern about Hepatitis C because both Hepatitis B and Hepatitis C infections can cause liver cancer.

The impact of Hepatitis B on the incidence of liver cancer is a greater concern as about 4% of the population are Hepatitis B carriers. The Hepatitis B Control Programme, of which immunisation is a main strategy, is in place to address this concern.

Hepatitis C virus, like Hepatitis B virus, is transmitted through blood and body fluids containing the virus. Acute viral Hepatitis due to Hepatitis C virus is uncommon in Singapore. Acute viral Hepatitis, including Hepatitis C viral infections, is a notifiable disease but no case of Hepatitis C virus infections has been reported since 1993. The prevalence of antibody against Hepatitis C indicating active chronic or resolved infection in the general population is low, less than 0.5%. As no vaccine is available to protect against Hepatitis C infection, the only way to control the disease is to prevent transmission of Hepatitis C through infected blood and blood products.

Sir, the Ministry has taken several measures to limit the spread of Hepatitis C. Since 1992, all blood donors are routinely screened for anti-Hepatitis C virus antibody. Those found to be positive are excluded from blood donation. Since 1994, all haemodialysis centres are required to screen dialysis patients every six months. A separate dialysis machine is to be designated for use of any patient who is found positive with Hepatitis C. All potential life and cadaveric organ donors are screened for Hepatitis C and those found to be positive will be excluded. Healthcare workers are continually educated on the importance of practising standard precautions to minimise the potential risk of transmission of blood-borne infections, including Hepatitis C.

There is an on-going public education on the risks of transmission of blood-borne infections through unprotected sexual activities and sharing of contaminated needles. We think the current measures taken are adequate to prevent the transmission of Hepatitis C virus in Singapore. However, the Ministry would continue to monitor the situation. We would welcome research on this virus by any of the big R&D companies. With regard to the specific question of whether gynaecologists should screen patients for Hepatitis C, we will leave that to the professionals involved to decide.

My Ministry also shares the concern Mr Yeo Guat Kwang has on the increasing number of smokers among young Singaporeans, particularly those aged between 18 and 24 years. We recognise the importance of implementing programmes to prevent young people from taking up smoking. A study shows that it is more difficult for a person to quit smoking if he starts smoking at a young age. The National Smoking Control Campaign this year will be targeted at youths. Strategies adopted will include mass media and face-to-face education programmes. The Health Promotion Board is also working with the Ministry of Education and the community organisations to implement programmes in schools and the community to encourage youths to stay smoke-free and to assist those who smoke to quit smoking. Among the programmes that are being implemented are programmes like youth student peer leaders, programme to train teachers to conduct smoking cessation sessions, the promotion of soccer and rugby as a healthy alternative to smoking.

To address the increasing number of young female smokers, the Health Promotion Board will be implementing specific programmes targeted at young females. A renowned female international model will be our spokesperson in this year's media publicity programme. Participants in this year's Teens Model Contest must also be smoke-free and the winner will be our ambassador to speak on smoking issues. We hope these measures will reduce smoking in the young.

Dr Lily Neo: Sir, I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The sum of $1,483,013,300 for Head O ordered to stand part of the Main Estimates.

The sum of $157,824,500 for Head O ordered to stand part of the Development Estimates.

Head K -

The Chairman: Head K - Ministry of Education. Dr Wang Kai Yuen.

Dr Wang Kai Yuen (Bukit Timah): Sir, I beg to move,

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

Mr Chairman, Sir, I can say with full confidence that our school education system is among the best in the world. It has served us well since the founding of Singapore. Today, it has two important objectives, namely, to prepare our children for the knowledge-based economy, and to provide a common development experience for all our children as part of nation-building. However, it is also the source of much headaches and heartaches for our parents. Its pull on the heartstrings of the nation is reflected in the number of cuts against this Ministry, 66 in total, the highest in the Committee of Supply this year.

This sentiment was also reflected in the five dialogue sessions on education organised by the Feedback Unit recently.

Sir, stress in our schools remains a major concern for Singaporeans. Many parents believe that the adverse effects of the school ranking system on principals and teachers contribute to this problem. Ranking, for instance, has resulted in schools selecting subjects that would enable them to score well in their ranking and neglected subjects that would cause them to rank lower. English Literature, for instance, is no longer being offered in some of our best secondary schools. In one dialogue session involving primarily teachers, most of them were negative about school ranking. This is interesting - the teachers themselves are very negative about school ranking. The teachers felt that ranking tilts the balance of education in favour of academic excellence versus the development of the young. Many do not feel this singular pursuit that fulfilling.

Sir, streaming of primary school pupils is another perennial issue. There is broad consensus that labelling of pupils as EM1, EM2 and EM3 brought about stigmatisation of slow pupils at a very young age. Our angst about labelling has been captured very well by the movie "I Not Stupid".

In my view, school ranking and student streaming are both conceptually sound. However, given the culture of our people, its implementation has produced undesirable side effects. We should adapt the implementation to real life situations where possible. If appropriate, we should modify the current policies on streaming and ranking after so many years of experience. For instance, we could offer, as a benchmark experiment for certain schools to abolish ranking or to curtail streaming to see whether the outcome would be better.

Sir, our mother tongue policy is a cornerstone of our education system. There are altogether five cuts on this topic and two more on Chinese language. I shall leave it to my colleagues to elaborate on these topics. Suffice to say that mother tongue policy has so far been sacrosanct. Nevertheless, I think we should review our implementation of the mother tongue policy in view of the irreversible trend of increasing number of families speaking English as their mother tongue regardless of their ethnic background.

As regards secondary school curriculum, I believe there is too much emphasis on academic performance, but insufficient attention on character development of students and cultivation of values in them. I would like to see greater emphasis to be placed on developing soft skills, such as critical thinking, research, presentation, communication, leadership and inter-personal skills. These skills would enable a person to deal with uncertainty in a rapidly changing world. Currently, we have the "A" level examination which has a specialised and narrow focus. On the other hand, the local universities are reforming to provide a broad-based education along the line of the US universities. Thus, we have this peculiar 'coca-cola' bottle shape when it comes to the focus of our school curriculum, narrowing after the "O" level and broadening again after the "A" level. I believe we need to address this anomaly as soon as possible.

Sir, it is a bold step for the Ministry to approve the setting up of a sports school. Regrettably, it is being off-loaded to the Ministry of Community Development and Sports. Furthermore, the Minister has disclosed recently that his Ministry is prepared to consider the establishment of speciality schools in arts and music if there is a demand for them. Presumably, he would like to off-load it to MITA as well. I personally would like the Ministry to continue to be responsible for these speciality schools, taking inputs from the other Ministries to buttress it.

Sir, coming to the "A" level examination, I am happy to note that the Senior Minister of State, Mr Tharman Shanmugaratnam, has disclosed in this House that project work will be introduced to "A" level examination to inculcate process skills and independent thinking amongst our students. I think all these could be but the first steps of a continuous process.

Sir, the Ministry has been floating the idea of the through-train programme for a few years now. I believe this is timely, as close to 20% of our cohorts proceed to university anyway. Conceptually, if these students could be identified early, they could skip the "O" level examinations. Then, the students will avoid having to prepare for two examinations in the last three years of their pre-university education. This through-train concept finds broad support among school principals and teachers, as well as students. Many students feel that this system will allow them to skip the "O" level examination and give them more in-depth education and a greater choice of subjects. Some felt that the integrated programme would reduce time wastage and provide better linkage between the upper secondary and the JC education.

However, the Ministry has not indicated when the selection of these students would take place. The PSLE seems to be a convenient choice. However, this might be a bit early in a child's development and that would leave out the late bloomers. Given our culture, every parent would want their children to get onto the through-train as they would likely review it as a gravy train. There is every likelihood that the through-train programme would end up being another streaming programme, with all its attendant negative side effects. We need to be very careful in implementation to avoid these pitfalls.

Sir, when we come to education, we must talk about teachers as they are the anchors of any education system. I have participated in several rounds of the best teacher award selection. I am touched by the commitments of our teachers. Also from talking to my own school-going children, I gather that teachers play an important role in their motivation. I am glad that we have improved on the remuneration of teachers and the recognition of teachers' contributions. The NIE has no shortage of applicants this year because of the recession. Hopefully, when the economic recession is over, we will be able to continue to retain them. This is an area the Ministry should continue to monitor closely. 6.45 pm

Mr Chairman, Sir, the Government has pledged that it would leave no stone unturned in remaking Singapore. Whatever we do to remake Singapore would be an exercise in futility, if we do not, at the very least, throw away our historical baggage, and look at the issue of the education system with a fresh perspective. Although we have not mentioned what is the size of the stone we are turning over, presumably these stones could be turned by a single person with his hands. The question is whether we have been turning the same stones, over and over again, such that there is really nothing crawly and creepy underneath them anymore. Instead, I believe we should be bold enough to turn over some of the bigger boulders. In the area of education, streaming, ranking, mother tongue, could be some of these boulders. We should be true to our words, and not hold any concept, so sacrosanct, that we are prevented from making fundamental changes that will mould Singapore for the future. In the case of education, we truly have the future in our hands.

Mrs Yu-Foo Yee Shoon (Jurong): (In Mandarin): Mr Chairman, all along, we are of the firm belief that only through education can we raise the quality of our people, extend their capability and enhance Singapore's competitiveness in the rapidly changing world of today.

The integrity and excellence of our educational system is beyond doubt. The knowledge and technical education which we have been emphasising since independence has received international recognition. Even developed countries in the west are using our educational system as a reference and model for emulation. This is something we ought to be proud of.

As a parent, an MP and a grassroots leader, I have the privilege to work very closely with the Ministry of Education and the schools. I agree with my parliamentary colleagues who have spoken before me that the Ministry of Education and the schools have done a lot of good things, and we can see that the contents of our education and the students that we have produced have attained international standard.

I have attended a number of dialogue sessions with the women's organisations with Dr Aline Wong. At first, I thought that they would be most concerned with the role of women in politics. But, to my surprise, this ranks 5th in priority whereas education topped the list.

As we face internationalisation, globalisation and more competition, our education must be more flexible, more diversified and with more options available. Our targets are parents and students. Experts have said that because of advancement in telecommunications, Internet and so on, people are becoming more self-centred and their interests are also more focused. I believe Prof Pukumayar has said that the social clubs in the future will all be centred around very limited scope of interest. There will be a lot of focus-groups. In the case of education, if our educational system is to be thoroughly reformed, it will eventually evolve into one in which students will be selecting only subjects which they are strong in and according to their personal interest.

I would like to raise a few points. Apart from knowledge and technical education, we should also emphasise on emotional, practical, adaptive and creative education. Because of time constraint I will only speak on two of them: emotional education and creative education.

Senior Minister of State, Mr Tharman, has already given an answer to this aspect of education, and we can expect a lot of improvement in this area. In a report in the Straits Times yesterday, columnist Richard Lim mentioned that in the future, a country's wealth will depend not on its size or the size of its population, not on its natural resources, but on how you leverage on your advantages, that is, how you build up the intelligence, the knowledge and the potential of every individual in the country. If you have a Bill Gates in Singapore, then at least half of our economic problems would have been solved.

Now, let me talk about the emotional education. Nowadays, Shanghai is talking about "one change a day", not a change in 10 years or a change in 20 years. When Singaporeans go to do business in China, we were said to be "able to work but unable to behave appropriately". There is a saying that when Taiwanese go to China to do business, they practise karate or kongshoudao, implying empty-handed. But when Singaporeans go to China, we practise tae-kwando or taiquandao, implying carry your money there. The talk among women in China is that the Taiwanese men are wu qing, (heartless), the Hong Kong men are wu yi (ungrateful), while the Singapore men are wu zhi (ignorant): This is of course just a joke. But my personal feeling is that the talents that we produce must not only know how to work but also know how to behave appropriately. We must make some adjustments in this area so that our educational system will not only concentrate on training students to score high marks in examinations, but to build up their character.

What is emotional education? Emotional education involves the appreciation of arts, culture and how to deal with people, human relations, caring and love; own strife for betterment. We must train our students to learn and appreciate more about the various religions, languages, history, politics, sociology and philosophy. To achieve all these, we cannot just depend on the teachers alone. It is not fair to expect the teachers to carry these responsibilities all by themselves. The Ministry of Education should be more open-minded and draw from the collective wisdom of people from all walks of life, the politicians, the businessmen, the parents, etc. The Ministry of Education can also involve other ministries such as the MCDS, MOH, MHA to form an inter-Ministry task force to look into this.

To me, heartware is more important than hardware. When we are building a school, do not go for fanciful designs, such as those fantastically looking roofs, which cost a lot of money but not really practical. Why not save the money and use it to send the students on overseas study tours instead? The students could learn more by interacting with their counterparts in the neighbouring countries and see for themselves the customs and culture of our neighbours.

Recently, I met a number of scholarship holders who have recently returned to Singapore. I asked them whether they had been to Shanghai. To my surprise, none of them had been to Shanghai and had shown no interest in going there. But, every one of them said that he or she had been to the United States or Europe, and expressed the wish to visit these places again. With the opening up of China and the huge potential in the China market, these bright young people should make an attempt to visit China and see for themselves how China has prospered.

Now, let me go to my main points. There are two aspects that I would like to take some time to talk about. In the meeting of the women's organisation, the participants were very concerned with our system of streaming and the philosophy of teaching according to the children's potential and ability. When we talk about teaching according to the different abilities of the students, we can implement modular system in schools. Besides the core subjects such as English, Mathematics, and mother tongue, the students can opt for subjects at a higher level. Outstanding primary students can opt for subjects at the Secondary level; outstanding Secondary students can opt for subjects at the Junior College level or university level.

The students should be taught according to their interest and ability on these selected subjects. In addition to the core subjects, they can opt for subjects they are good at. But they should not be stigmatised.

Sir, I am very proud of our ITE students. But, something must be done to improve on the image of ITE. ITE should be integrated into the mainstream.

I would like to appeal to the Ministry of Education to extend their scope of review to cover pre-school education, along with the primary, secondary, junior college and university education. This is because pre-school education is very important in the building up of a good foundation for the students to advance to the primary school later on.

The last point I would like to raise is on the SAP schools. I fully support the SAP schools and it is my firm belief that the SAP schools do not affect racial harmony in Singapore.

Mr Inderjit Singh (Ang Mo Kio): Sir, it has been a long time since the Ministry announced and identified initiatives to promote creativity and thinking in schools, and I understand that it was supposed to cut curriculum down by about 30% to make way for creativity and innovation development. The key issue now is that Singaporeans, particularly, parents, have not felt the impact of these changes yet, because they continue to be stressed and pressured by the children's need to achieve higher grades, and the children, no doubt, continue to be stressed too.

There is nothing wrong with higher grades, but the system is creating an obsession with grades at this point of time.

To support the national objective of promoting entrepreneurship, I believe the real long-term impact has to come from our education system. We have many examples to follow from. The US is a very good example. In my opinion, we can nurture the entrepreneurial spirit through our education system in three ways.

First of all, we need to train our students to be not just academically smart, but also street smart. In other words, developing both the IQ and the EQ measures for our children, and we should value each child and value the talent of each child, and to find ways to groom them so that they can excel in their talent and in their area of interest so that they can achieve something significant.

The second is that we really need to create channels and expose our children to the concept of entrepreneurship, particularly at the secondary school and at ITE, or higher levels, and I suggest that the Minister thinks about implementing programmes that teach entrepreneurship at the CCA or ECA programmes and just like we do with the uniformed groups and with societies like the Debating Society, Rotract Club, and so on.

Thirdly, we need to develop a culture to promote tolerance to failure and giving people more second chances. We can achieve this by fine-tuning some of our policies as two Members before me have spoken. And, of course, I feel very strongly about fine-tuning the streaming system.

Sir, I have two specific issues I would like to ask. The first one is about the small cross-section of our society, and I am talking about the students who are taking the minority Indian languages, the non-Tamil Indian languages. Currently, students who study Hindi, Punjabi, Gujarati, Urdu and Bengali, are not given full recognition for their subject, despite their meeting many requirements. I know that the self-help organisations responsible for teaching and assessing each of these languages have put in tremendous effort over the last 10 years to ensure international standards are met. They have gone through the extent of forming a coordinating council among themselves, although they started separately, to standardise curriculum, as well as setting common examinations and setting marking standards. It is a pity that despite their effort, they have not been given the full recognition of the languages. I recall a few years ago the Minister in his reply to a similar question raised the issue of standards of curriculum, and of results. I believe the situation has changed drastically now. Can the Minister please look into the issue and advise on what else these people need to do so that the above languages can have full recognition?

The final question I would like to ask the Minister on the system is on the progress of implementing Tamil as a second language at a higher level.

The Chairman: Mr Singh, you can move on to your next cut.

Mr Inderjit Singh: Sir, the streaming system, in my opinion, is a very destructive system, simply because it affects the self-esteem of our children. We start segregating and labelling them at such an early age. I mentioned about how the education system can support developing the entrepreneur society. I fully understand the intention of streaming, and that is to allow each child to develop at his or her own pace, to avoid early drop outs from the education system, by giving an easy curriculum for weaker students to follow. Should not our system also focus on how we can try to make the slower children catch up with the rest? Even if it means just a small percentage of slow learners who catch up, it will be a huge gain for our nation of such a small population.

What special things has the Ministry done to help the weaker children catch up? Has it channelled the best teachers to EM3 classes? Has it made EM3 classes smaller, so that there is more attention for the children? Has it spent more money per child for an EM3 than an EM1 or EM2 class? The real answer, in my opinion, is that the Ministry and schools have done the exact opposite. And, along with it, we are labelling our children, first risking creating a class society.

The Chairman: Order. It is 7.00 pm.

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

RAdm Teo Chee Hean: Mr Deputy Speaker, Sir, I beg to report that the Committee of Supply has made further progress on the Estimates of Expenditure for the financial year 2002/2003, and ask leave to sit again tomorrow.

Mr Deputy Speaker: So be it.