SINGAPOREANS WHO DIED FROM KIDNEY FAILURE

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SINGAPOREANS WHO DIED FROM KIDNEY FAILURE: 10.

Ms Eunice Elizabeth Olsen asked the Minister for Health (a) how many Singaporeans, since 1998, have died every year from kidney failure because they could not pay for the cost of dialysis; and (b) what is being done to stop this.

Mr Khaw Boon Wan: Sir, there are many medical reasons why patients with renal failure die. In addition, each year, a small number of them, usually with other serious illnesses, choose not to go on dialysis, after taking into account the quality of life and the many complications that dialysis brings. The ability or inability to pay for dialysis is not a significant factor in the survival of renal failure patients.

The pathology and mechanisms of death in renal diseases can be better explained by renal doctors, but the point I want to highlight is that, even under the UK 's health system where free dialysis is available on demand, their 5-year survival rate of renal failure patients at 45% is lower than Singapore 's rate which exceeds 48%. Indeed, compared with developed countries, such as the US

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which has 38% 5-year survival rate, the UK and continental Europe, Singapore has the highest 5-year survival rate in its renal failure patients.

In any case, with Government subsidy, Medisave, MediShield and Medifund, all renal patients can access the medical care that they need. Renal patients with financial difficulties are subsidised by the Government. In public hospitals, Government subsidies range from $850 to $1,300 per month, depending on the mode of dialysis that the doctor and the patients decide upon.

In addition, Medisave covers up to $450 per month. The reformed MediShield pays up to $1,000 per month, while the enhanced Medisave-approved catastrophic illness insurance plans now cover up to $3,000 per month. At $3,000, it exceeds the highest dialysis charge in town.

VWOs also provide subsidies to their patients. Those who are eligible can, in addition, get a Government subsidy, ranging from $200 to $600 per month.

For those who are still unable to pay despite subsidies, Medisave and MediShield, Medifund provides the final safety net. Last year, 14,000 renal patient applications were supported by Medifund, to the tune of about $2 million.

In short, no Singaporean will be denied dialysis because of an inability to pay.

Nevertheless, is it possible to further improve the outcome for renal failure patients? One answer that other countries have adopted is transplantation. As there is a limited number of kidneys available from deceased persons, those countries have approached this problem through transplants from live donors. It is common for a family member, relative or even a close friend to donate a kidney to the patient.

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Norway , for example, had about 58 kidney transplants per million population, and the US and Spain both had more than 50 transplants per million population. The corresponding figure for Singapore was only 17, way below 50.

In Norway , the vast majority of renal failure patients undergo transplantation. Only 28% of them are on dialysis. In Singapore, it is the reverse: 73% are on dialysis with a small minority going for transplantation.

After a successful transplant, the average recipient can expect to survive with a functioning kidney for 21 years for cadaveric transplant,

and 32 years for living donor transplant. The experience from these countries suggests that, if we want our renal failure patients to lead better quality lives and to live longer, we should actively encourage transplantations instead of mindlessly expanding dialysis centres.

Ms Eunice Elizabeth Olsen: Sir, I would like to thank the Minister for his very detailed response. Since there are figures before 1998 showing that there are quite a number of Singaporeans that have died every year from inability to pay for the cost of dialysis, does it imply that after 1998, almost everybody has been able to afford treatment since there are no figures to show how many Singaporeans have died because of inability to pay for dialysis?

Mr Khaw Boon Wan: I quoted 1998 because the Member's question asked about 1998. I did not check the figures before 1998. But my belief is that no one is denied dialysis purely because they have got no money. But there is a small minority of patients where dialysis would not help.

Dialysis is not like going for a picnic because the quality of life is very different and you are stuck there every other day

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for half a day. It is quite miserable. And when you have other co-existing illnesses, especially those which are severe, very often, the patients, after discussing with the doctors, would say that they do not want to go through with it. People die for various reasons, but I can confidently say that it is not because of money. It is never the reason. If you need a dialysis, you will get one. And among the 10% in the NKF data which I talked about, who pay less than $100, in fact, quite a number of them pay less than $10-$20 a month. So those are more symbolic payments.

Dr Tan Sze Wee (Nominated Member): I would like to ask the Minister a question to clarify the issue about the living donor transplantation rate which is pretty low in Singapore. I think it is very important that we should try to encourage the rate of transplantation to increase. We would like the Minister's thoughts on the low rate of transplantation. Is it because of the awareness issue? Is it because of the cost issue, resulting in Singaporeans getting transplants overseas that we hear about? Or is it a cultural issue such that, particularly among the minority races as well, there have been very low participation rates? What can we do to encourage and also to improve this, because this is one important solution to bring down and also improve the lifespan of kidney patients?

Mr Khaw Boon Wan: Mr Speaker, if you do not mind, I will give a slightly long-winded reply. One thing good out of the NKF saga is it has focused the mind, at least mine, as well as my colleagues in the Ministry of Health, to rethink this whole issue of how we manage renal failure patients.

I think, for many years, because of the success of NKF in raising funds, building and expanding dialysis centres, etc, we just assume that the problem is well taken

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care of. But it is only in the last few months, as I began to gather data, think through all these and compare with other countries, we stood up like an outlier, whether it is in terms of very low transplantation rate or in terms of very high haemodialysis rate per capita.

So for various reasons, just spending money, raising money and building kidney dialysis centres is not right. If you have too few, you should build. But there is such a thing as over-built. If you ask me, I think we should rethink, and I am reflecting on those issues. Maybe, during March, when I will be more ready during the Committee of Supply discussions, we can devote some time discussing how we should handle renal failure patients.

I have already been asking the new NKF Board to think through, in the long-term, as they put themselves in 10 years' time, what they want NKF to be. Is it still more of the same? I hope not. I do not think that is correct or wise. But, instead, we should be pushing other modalities, peritoneal is definitely in, and, of course, live donor transplantation, including cadaveric. I remember two years ago, I came to this House and with Members' support, we amended the Human Organ Transplant Act (HOTA) which has saved a couple of dozens more lives last year, but those are from cadavers.

But live donor transplantation is something that we must push. Norway is quite outstanding. Norway's standard operating procedure - once you have a renal failure patient, the doctor would confront him - it is very natural to ask, which of your relative or friend is going to donate a kidney. Therefore, you have this 70:30 split, only 30% on dialysis, 70% on transplantation. We are a complete reverse. Asian culture value is one; awareness is another. And we have to change that. We cannot achieve it

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overnight, but let us take our time slowly, so long as it is in the right trend, to promote more.

Mr Steve Chia Kiah Hong: Sir, if the public stops donating to the NKF and the NKF reserves become completely depleted, will the Government come up with emergency funds for the NKF to help it sustain its operations until it meets its new objective?

Mr Khaw Boon Wan: The short answer is yes. But let me again give a little long-winded reply.

NKF is not the only game in town. I think public perception is such that they see dialysis is all NKF, and if NKF collapsed, dialysis collapsed. NKF, after many years, is a major player but is not the only player. In fact, its market share is less than 50%. The rough figures are: about half, NKF; one-quarter, public hospitals; the remaining 20%, private dialysis centres; and 10%, the other charities. So this is the rough market share. But 50% is still a large part of the market share. Should it grow or should it just stay put and let the other players expand? Those are issues that we can discuss in March during the Committee of Supply. I have my own view, you may have different views. But I believe in diversity, and I think the whole healthcare model, including dialysis management, will be a lot more robust if we have multiple players. I am quite glad when I look at even the industry structure today, among the private providers, there are about a dozen of them. So my bottomline is: NKF is not the only name in dialysis, although it may be the most prominent name.

But back to NKF reserves, I asked the new management this question a few weeks ago: with your $200-over million reserves, assuming you stop completely your fund raising and, therefore, you could shave a lot of your administrative

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cost, how long can $200-over million last you? More than 10 years.

Mr Speaker: Ms Olsen, last question.

Ms Eunice Elizabeth Olsen: Sir, since the Minister mentioned about Norway, I would like to ask him whether or not studies are being done on comparative countries, ie, countries that do not adopt a free healthcare model, on how they juggle subsidies or how they manage renal failure.

Mr Khaw Boon Wan: We have always studied the different healthcare financing models all over, not just for dialysis. But specific to dialysis, I have my own view about how something like this ought to be funded. Renal failure is a catastrophic event. When it hits, it is very bad - disastrous, but low-risk - in fact, measurable risk. On a per capita basis, you can calculate it and it is quite stable. The way to fund those things is really insurance. That is why I spent a lot of time last year reforming MediShield and part of the things that I tweaked was to raise the dialysis claim rates from MediShield and the private MediShield equivalent. And really, the way to handle renal failure patients, whether it is through transplantation or the various modes of dialysis, is insurance. When you are healthy, young and working, please sign on to the MediShield or its private equivalent, so if you are in bad luck, you are one of those few unlucky chaps with renal failure, you have the money for treatment. And when you have the money, you can shop around. My job is to publish the various charges by these one dozen dialysis centres, and then you can pick and choose. Do you want an aquarium next to your couch or you do not want an aquarium, and therefore, slightly cheaper, and so on. That should be the way. But it does not mean that there is no role for charity or Government subsidy. But the main way of funding dialysis ought to be insurance

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complemented by Government subsidy and charity.

I asked NKF for some data. I said, "Of your patients, how many are on MediShield?" And I was greatly encouraged by the data that I got. Now, 60% of their patients are already on MediShield. Not too long ago, 50% and the trend is looking good. I am quite sure that eventually, maybe 70%-80%, and I think we would then reach that logical position of funding dialysis.