MINISTRY OF HEALTH'S PRIORITIES

Column No : 3224

MINISTRY OF HEALTH'S PRIORITIES: 5.55 pm

Dr Lily Neo: Mdm Deputy Speaker, I support and welcome the eight priorities set out last July by the Ministry of Health to embark on. I would, however, like this House to consider the prerequisites necessary for such aspiring targets to be achieved with the best outcome for Singaporeans.

Priority One on building a healthy population or promoting healthy lifestyle in an aggressive and comprehensive way

I cannot agree more on this first on the list of priorities as it is better to prevent the occurrence of diseases through healthy living than treating end-stage diseases. Madam, healthy lifestyle will prevent many common diseases, for example, healthy living with eating healthily, exercising regularly and not smoking will prevent diabetes, obesity and lung cancer respectively. For better outcome of healthy lifestyle promotion and a wider coverage of the population, there is a need for much creativity, funding and enthusiasm.

Since about 1.9 million or 65% of Singaporeans are working, healthy lifestyle promotion on workers would be a key factor in influencing the health of our people and this can be most effectively administered at the workplace. Essential in workplace health promotion includes having good programmes and guidelines as well as getting the support for them from the various companies. Also, providing adequate support to the administrators or health facilitators and expanding the scope of occupational health and safety to include the promotion of workers' health through healthy living and financial assistance in the form of grants would help jumpstart health promotion programmes, particularly for small workplaces. One group of the population that may be left out of reach from health promotion is the housewives and more should be done to target this group. Perhaps, we may reach them with programmes organised through community centres and grassroots organisations.

Madam, it is vital to look at the most prevalent diseases in Singapore and tackle them head on when promoting healthy living. The aim should be preventing people from getting such diseases and preventing those already afflicted with such diseases from disabling complications. A good example here would be diabetes which afflicts about one-tenth of the population between the ages of 18 and 69 and one-third of those between 60 and 69, and carries complications like kidney failure, heart diseases, strokes, blindness, just to name a few. Other examples of prevalent conditions are hypertension and high blood cholesterol.

As morbidity and mortality from any disease can be dramatically reduced when the disease is treated in its earlier stages, preventive healthcare should be targeted at the entire population, especially to include the younger people. The young may erroneously assume that they are less vulnerable because of their age and therefore have no need for regular checkups.

Our Primary Care Partnership Scheme (PCPS) for those who are 65 years and above and have a per capita income of $700 per month or less, excludes the care for such chronic diseases like diabetes and hypertension and this should be adjusted. Our PCPS beneficiaries are the vulnerable ones that most crucially call for good treatment and follow-up to prevent the complications that eventually require hospitalisation and incur higher healthcare costs.

Priority Two on managing diseases holistically instead of episodically and on maximising overall cost-effectiveness

Preventive healthcare must be the hallmark of all issues concerning healthcare affordability. Adequate allocation of funds today and success of preventive measures will save us millions in the future. The Ministry's priority is to continually identify prevalent diseases that need greater attention and to continuously monitor and study the trends for prevention of such diseases. We should have more detailed epidemiological studies of disease patterns and base our medical research and life sciences studies on them to better plan and cushion our long-term healthcare. Appropriate investment in medical research and life sciences directed at our prevalent needs, like finding the cures for the common diseases and cancers that affect most Singaporeans, can help address long-term healthcare affordability. If gene therapy can be found to treat and prevent heart diseases, diabetes and hypertension, the amount of savings will be enormous.

Emphasis on the strategy and health promotion on eldercare with innovations and prediction of future trends is increasingly important because the higher life expectancy is associated with increase in the incidence of chronic diseases. The recent improved surgical procedure by our local doctors on reshaping the heart in order to give patients with chronic heart failure a new lease of life for a third of the price of a heart transplant is a good example of this.

On managing any disease through the combined efforts of the Government, community and the individual, I would like to suggest that MOH look at our homecare services that are almost non-existent at present. Community volunteers and home-help for families to care for the dependent elderly in their homes through domiciliary, daycare and rehabilitation services and home adaptations will translate into lower costs and more convenience for a happier people. The need to stay in tertiary institutions and the ancillary costs will lessen. It is vital we aim to have more patients looked after in their homes, anticipate an increasing demand for homecare services and recognise this as an integral part of our healthcare system.

Priority Three on exploiting IT maximally and maintaining secure electronic medical records

The third priority is still a relatively new concept here. A good electronic data system with comprehensive, well-organised and useful health database providing accessible and high-quality information will be useful, especially if we can link all medical facilities electronically and avoid the problems of medical records transfer. The resultant easy availability of medical information on the patient will enable better continuity of care, avert unnecessary repeats of medical investigations and so on. Connectivity and the use of IT can also be used as a means to tap up-to-date medical resources. Medical informatics will facilitate and provide an integrated and seamless healthcare system from primary to secondary and tertiary levels or to homecare. Telemedicine and video-conferencing will overcome distance boundaries and will provide efficient and seamless transfer of information towards better patient care.

Priority Four on plans to counter disease outbreaks

Here, our recent SARS experience gave us much insight and ideas to follow on. That episode exemplified our strength. But it also showed up our inadequacies. Our inadequacies in prevention of infectious disease spread in our public hospitals resulted from our complacency in terms of infrastructure and measures in infectious disease control. Improving upon our inadequacies is crucial towards coping with future eventualities.

Even as of now, a person with an undiagnosed highly contagious infection, like SARS, who seeks treatment in one of our public hospitals is likely to expose the disease to about 50 to 250 people in that one hospital alone. This calls for a concerted effort to revamp our hospital set-up to curb the problem.

Communication and

dissemination of useful information amongst the medical personnel proved to be such an important tool in combating infectious diseases which was almost non-existent before SARS. Many medical facilities in the private sector were in the frontline as they were preferred to hospitals by the patients. Although they were most vulnerable, they were left to fend for themselves with no support.

The level of preparedness to combat any infectious disease can only be maintained with the determination to be vigilant and to ensure that all the various resources are in readiness.

Our laboratories here deal with many dangerous microbiological organisms that can be disastrous to our community and country if mishaps happen as in the recent case where a researcher was infected at the National Environment Agency (NEA) laboratory. Urgent measures must, no doubt, be taken quickly to prevent a repeat of such occurrences. Having a 'safety culture' as a priority is the cornerstone for us to succeed as a biomedical hub. Stipulated biological safety standards must be in place and regulated. And, very importantly, all our laboratory personnel should be well-informed, well-trained and always mindful of safety standards.

Priority Five on managing healthcare inflation

The fifth MOH priority on managing healthcare inflation is indeed welcome and I am confident MOH will do this with tenacity and without jeopardising patient care.

Our National Health Expenditure (NHE) increased from $4.4 billion in 1999 to $4.7 billion in 2000. As a percentage of GDP, NHE formed about 3%. Per capita health expenditure rose about 6% from $1,360 in 1999 to $1,439 in 2000. The NHE proportion was borne two thirds by the people and only one third by the Government. NHE for the year 2002 increased to $5.5 billion or 3.5% of GDP. My point is that, with the increasing NHE over the years but without increased Government's share of NHE, the extra burden on the people was great indeed, especially during an economic downturn. The WHO recently ranked the Singapore health system as sixth in the world, in terms of performance. In other words, we seem to be getting relatively excellent value for money in relation to the health status of our population. However, it did not rank Singapore favourably, in terms of equity in financing. This is based on its criteria of estimating the extent of financial burden in healthcare costs that are borne by individual households relative to total public expenditure.

Today, I would like to beseech the Government to address this concern of many Singaporeans and find ways to ameliorate their worry with some expedient actions and with further and better planning to soften the future burden. Finding a sustainable way to fund health services and the challenge of cutting costs are key issues in need of urgent attention. Our public sector accounts for a high percentage of our NHE and it must, therefore, focus on cost discipline through eliminating waste and duplication and implementing best practices. We need champions that see to it that it is their mandate to prioritise on cost savings while maintaining good patient care.

It is, indeed, useful to have some systems in place which can continuously monitor, adopt measures, encourage contributions, recognise new ideas of best practices and study from the experiences of others.

The Harvard University School of Public Health had a comparative study on the healthcare systems of several countries, Singapore included. It had referred to Singapore in this way: Two countries opted for competition in health financing: United States and Singapore. These two countries expected that competition would drive down prices while providing incentives to improve efficiency and quality. However, evidence suggests the contrary: the USA and Singapore have experienced the highest growth in healthcare expenditures.

Madam, whilst cost containment through competition is the desired intention, we are inadvertently having more ill-effects from having our two clusters. The impression of many is that there are duplication and wastage of resources, such as personnel, administrative costs, specialised services and more high-tech equipment. Even institutions within the same cluster seem unable to cooperate in cost saving measures. Let me cite you an example: Hospital X did not own a certain radiology diagnostic machine and had to refer its patients to Hospital Y within the same cluster. It was ludicrous that Hospital X eventually decided on buying its own machine simply because it was charged so highly by Hospital Y. This is certainly not maximisation of resources, especially when the equipment is expensive and gets outdated very quickly. Is this approach ideal for a small country like Singapore with a limited and small pool of medical personnel and other resources?

Drug costs are a big expenditure item. There is a proliferation of more and more expensive drugs. Prudent prescriptions to ensure that only what the patients require are given and on the use of generic drugs require more emphasis. While central bulk buying adopted by the two clusters has achieved cost savings, further reduction can be gained through better sourcing of products and more vigilant on other best practices.

Capital expense needs reviewing especially in an economic downturn. Better postulation of our present and future needs is necessary to avoid ending up with unjustifiably overbuilt facilities requiring tremendous cost.

Newer medical technology can contribute towards efficient usage of hospitals by allowing for more day surgeries and obviating otherwise expensive hospitalisation. Technology acquisition is closely linked with manpower considerations and doctors are a major factor in the demand for and the use of technology. Thus, more specific training of physicians to use high-tech devices should be encouraged.

The cost of in-patient care accounts for a greater share of total healthcare expenditure. Therefore, the challenge is to provide continuing care of the many diseases and problems of ageing through primary care. The strategy should be on greater emphasis on step-down care and primary care as it is recognised that they are an effective means of reducing healthcare costs.

Last year, as many as 3,083,458 attendances at the Specialist Outpatient Clinics (SOC) were recorded at our public hospitals. This may have stemmed from the ease for people to self diagnose and use specialists as first-line medical care. Perhaps, patients were not discharged as readily from the clinics because of the system. Of course, the premise that our Public Primary Healthcare Outpatient Clinics would be developed further to take on a bigger role to ease the SOC overload must be seen to.

There is growing evidence that much of the demand in medical care could be generated by the providers themselves. This supply-induced demand is due to the fact that patients usually cannot exercise their sovereignty in getting the appropriate amount and level of medical care. Therefore, a review should be done to remove policy that encourages such practices, especially on the remuneration of personnel that favour such practices. A further effective watchdog body or systems of checks and balances can reduce on such unnecessary spending. This will also safeguard the medical standard.

Priority Six to ensure long-term healthcare financing with our 3M (Medisave, MediShield, Medifund) framework

On the sixth priority to ensure long-term healthcare financing with our 3M framework, this is the time to enhance our 3M financing with our present and future circumstances. Due to the globalised market and the fluid labour market, especially during an economic downturn, employers' offered insurance may be diminished or cut. The present Medisave system, where we save and pay as we go financing for healthcare, is becoming increasingly inadequate to serve our needs. Risk pooling through a good health insurance expansion, with nationwide coverage to involve the entire population, dependable coverage year after year and adequate benefits with stable premiums together with a combination of co-payment and strict enforcement of uniform fee schedules should have a bigger role.

There is also a need to allay the concerns of many, especially the elderly, on the affordability of the hospitalisation bills should they fall sick. We need immediate action towards assuring people that affordability of hospitalisation presently is ensured with our 3M scheme (Medisave, MediShield and Medifund). Remarkably, many people still do not understand their usage fully and opting for hospital care that they have to pay out from their own pockets substantially. Now with ElderShield and Elderfund added to the list, it may be worthwhile for MOH to rope in the MPs and their grassroots workers to help disseminate the message to their residents and support them with materials to explain the available schemes and how to best use them according to the individual's affordability and on moderating expectations.

Priority Seven on safeguarding medical standards

The Ministry of Health's seventh priority is on safeguarding medical standards. We must ensure the care of our subsidised patients in the public sector to the extent of having relevant policies enforced to prevent attention being skewed towards looking after paying patients. Public hospital 'A' class beds should be limited to no more than 13%.

Our "research culture" was not great and our "clinical research" was never the emphasis. There has to be a complete mindset change and a radical system revamp in the institutions if we are going to make the various aspects of "clinical research" meaningful. Doctors in the public sector have expressed disappointment in the high rejection rates on research projects and the lack of grants for what they proposed. Research activities on the worldwide prevalent diseases should be expanded expeditiously. Research on prevention, early diagnosis and drug therapy to combat coronary heart diseases is an example.

In order for Singapore to remain competitive, we need to pay attention to training of our future healthcare providers. By continuing to invest heavily on our undergraduate and postgraduate medical education, we ensure that our doctors are competent and we help them to be conversant with new developments in medical sciences. We must encourage and facilitate those who are willing to teach and those who are willing to learn by providing them with the opportunities. We ought to enhance our investments on the Health Manpower Development Programme (HMDP).

It is worthwhile to include the extension of the service hub to become a training hub as this will boost our aim of being a medical hub in the region. This will have the effect of promoting collaboration with doctors in the neighbouring countries and of gaining their acceptance of us. The goodwill and mentorship will continue long after the training period is over.

Priority Eight on establishing Singapore as the Regional Medical Hub

On the last priority of Singapore being the Regional Medical Hub, I have spoken, at length, in this House before. I would not, therefore, repeat myself, except to say that there is a need for both public and private sectors to come together for it to be successful and preferably through integration. Hopefully, there is the will and the tenacity to see to it that we succeed before it is too late.

I commend the Minister and his Ministry for the initiative to set the eight priorities for our healthcare needs. I support them and hope to see many positive changes going forward.

The Acting Minister for Health (Mr Khaw Boon Wan): Mdm Deputy Speaker, I thank Dr Lily Neo for her strong support and her comments on our health priorities. She has deep knowledge and experience, both as a doctor and as a parliamentarian specialising in healthcare policies. I therefore value her views on this subject. Indeed, as part of my preparation when the Prime Minister assigned me the health portfolio, I read up all her comments in Parliament in recent years on healthcare policies.

Shortly after I rejoined the Ministry of Health, I also had a working lunch with Dr Lily Neo and her GPC members. I thought we had a good exchange of views and I was struck by how much we agreed than disagreed.

To be sure, healthcare policies are complex. At the core of the complexity is the fact that healthcare services are, what economists call, a public good and non-excludable. Unlike other goods and services which can be left to the market to allocate through pricing and consumers' ability to pay, we cannot deny the sick and dying with basic healthcare, just because they cannot afford to pay.

So governments all over the world, and Singapore included, subsidise to varying degrees the provision of healthcare services. With subsidy, however, comes distortion of both supply and demand. So the challenge is to subsidise, but with minimum distortions. And this is the healthcare dilemma: how to ensure subsidy goes to the right person, but without it being abused.

No government has a perfect solution to this healthcare dilemma. When I first joined the Ministry of Health 25 years ago, I read about the many healthcare problems faced by UK, US, Japan, Germany and many others. As I restarted my reading of healthcare journals, I was struck by how little the problems had changed in these 25 years. Indeed, in some countries, the problems seem to have worsened. For example, in the recent California Governor election, the issue of rising uninsured was a hot item.

Then-Governor Gray Davis had to rush through a Bill in the last few days of his term, shortly before elections, to require employers to insure their employees based on an 80-20 co-funding formula. But that was not sufficient for him to prevent his term from being terminated. And people remain unhappy. In the last few days, supermarket employees - and today I read in the newspapers transport workers - have gone on strike over rising health insurance premiums.

In comparison, the Singapore system has not done too badly. Compared to my first day in the Ministry of Health in 1978, we have made significant progress.

First, we now have more money set aside for healthcare. Singaporeans now have $28 billion in their Medisave Accounts, and Medifund has built up to $900 million.

Second, we have rebuilt all our pre-war hospitals, with the exception of Alexandra Hospital. Even Alexandra Hospital has had a facelift and is no longer the same British Military Hospital that we inherited.

Third, we have many more doctors and nurses: 6,000 doctors and 18,000 nurses on the registers, and these are double or triple the numbers 25 years ago.

Mdm Deputy Speaker, my job is to build on this very strong foundation which I have inherited and to build on it, so that when it is my turn to pass on the responsibility, my successor will have something even stronger and better.

I have, therefore, spent the first few weeks of my appointment to MOH talking and consulting a wide range of stakeholders in healthcare - doctors, nurses, sinsehs , pharmacists, administrators, the public and private sectors, politicians, journalists, patients, etc.

My first task is to settle the priorities for my term. There are many things worth doing, but we need to focus our energy, if we are to be effective, and we have settled on the eight priorities. These are all long-term issues. They are not easy nuts to crack. There are no quick fixes or instant results. We need patience and perseverance. It will be a slow push up the hill, but worth doing.

For example, healthy lifestyle, which Dr Lily Neo mentioned a few times. Imagine: if every Singaporean can be as disciplined as Senior Minister Lee - whether it is in his diet or exercise routine - what a dramatic difference that will make to our total healthcare needs. Of course, I am not naive. It is not possible to get 100% of Singaporeans to be like Senior Minister Lee. But, if every five years, we convert another 20% of Singaporeans to join the healthy lifestyle club, we can potentially reduce healthcare need by 10-20%. That means hundreds of millions of dollars saved per year. This is not a trivial sum.

I agree with Dr Lily Neo that Singaporeans are worried about rising hospital bills, and this is also one of my priorities. We are getting our hospitals to pay close attention to this and to slow down the medical inflation rate. Medical inflation rate in recent years has exceeded general inflation rate. I hear the concerns and I will do my best to strike a balance and address them. Let me explain this.

We cannot over-manipulate the prices of healthcare services. It is not possible for us to artificially induce deflation in medical fees, especially when the rest of the economy is doing well by, say, suppressing or cutting the wages of our healthcare workers. Otherwise, our hospitals will suffer a brain drain, which will be detrimental. Similarly, we should not allow medical inflation at an excessive rate, beyond what the economy as a whole and Singaporeans can bear. But what we can and should do is to make sure that the medical inflation rate does not diverge too much from the general rate of increase in wages and other factor prices. I think that is a fair proposition.

So, while I will try to maintain current hospital charges when the economy is down, you know that I cannot do this forever. When the economy recovers, we must accept that general price levels will go up. And when other workers are enjoying wage increases again, we will also have to let our healthcare workers enjoy their fair increases. In order that hospital budgets can be balanced, you know that we will have to let some hospital charges adjust.

But the heavy subsidy that we provide to Class B2 and Class C will remain. In Class C wards, MOH picks up 80% of the cost. In other words, for a $100 Class C bill, we pick up $80 and the patient pays $20.

Meanwhile, we will do our best to keep the cost low, by doing more with less, squeeze out productivity and share best practices. That is why I pushed through the publication of hospital bill sizes for common illnesses. It has caused some stir in the hospitals, as it should. Along the way, the right questions are being asked and, hopefully, there will be useful lessons learnt and applied. We have published data for 28 most common medical conditions. In the next monthly update on 1st November 2003, we will increase the data to cover 45 medical conditions.

For each priority, I have appointed a champion to drive the work, and I will ask the champions to carefully consider what Dr Lily Neo has suggested and, where practical, we will adopt them.

I take an inclusive approach, involving other Ministries, agencies and other stakeholders. For example, in pushing healthy lifestyle, we cannot do it alone. We need MOE, MCDS, PA, MNCs, NTUC, SMEs, students, teachers, etc, to help champion the cause, if we are to make a significant difference. And Dr Lily Neo is absolutely correct that we need creativity and enthusiasm in healthy lifestyle promotion, involving all and sundry, young and old, men and women. And I was glad that when we launched the Healthy Lifestyle Campaign this year with a run in Bishan Park led by DPM Lee, among the runners was a representative from the Government Parliamentary Committee for Health. I hope to see the entire GPC at our next campaign. And Mdm Deputy Speaker, we will be honoured if you can also join us! And hearing Mr Chiam just now, who was very passionate about running and about fighting obesity, I think he will also join us!

Last week, I read in the IHT how a US telco MNC, Sprint, a large company, is promoting fitness among its employees. It is targeting obesity and, in its brand-new global headquarters in Kansas City, it bans cars, forcing its workers to park and walk - I suppose they can cycle - from one kilometre away. Although a brand-new building, it chose old-fashioned hydraulic lifts, very slow, but the staircases have wide windows, to encourage the workers to walk between floors. And Sprint is not alone in taking more aggressive measures to get its workers to move more and to eat less. The new measures are going beyond putting gymnasiums in office buildings or promoting the eating of broccoli. These are useful tips for our companies here, including Parliament House!

In short, Mdm Deputy Speaker, I am cheered by Dr Lily Neo's support and advice. Like fighting SARS, we are in the same team. I intend to use the same SARS approach to fight obesity, diabetes, hypertension, rising healthcare cost, and that means you and I together, with many others outside of this House, united as one team, fighting one common enemy. That way, we increase our chances of achieving progress in all the eight priority areas.

Mdm Deputy Speaker: Order. The time allowed for the debate has expired.

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

Adjourned accordingly at

Twenty-five minutes past Six o'clock pm

to a date to be fixed.