Hansard, 2002-05-20

asked the Minister for Health what are the steps taken by the Health Sciences Authority to regulate the importation and sale of slimming pills and to ensure that such drugs are safe for consumption.

Mr Speaker, Sir, synthetic pharmaceuticals for treatment of obesity, for which safety, quality and efficacy can be scientifically assessed, are regulated as Prescription-Only Medicines in Singapore. Currently, we have approved five Western synthetic drugs for treatment of obesity in Singapore. Due to the presence of generics, these five approved drugs come in eight brands. These medicines are effective but can only be prescribed by doctors as they may sometimes have serious side-effects. Such medicines are used in the short-term treatment of obese individuals in conjunction with an overall weight-loss programme under medical supervision. All synthetic medicines, commonly known as Western medicines, are stringently evaluated by HSA for their quality, safety and efficacy before marketing approval is granted. After marketing approval has been granted, these products are subjected to post-marketing surveillance that includes quality compliance testing and Adverse Drug Reaction monitoring. Besides these synthetic pharmaceuticals, there are a number of other products, ranging from Chinese proprietary medicines (CPM) and health supplements to other complementary or traditional medicines, which are promoted as being useful for weight reduction. These claims cannot be evaluated by HSA since rigorous scientific data to validate efficacy and benefits are generally not available. Instead, such products are regulated on the basis of safety and quality of the product. This is a risk-based approach that is in line with the systems adopted by regulatory agencies in developed countries like the US, UK and Australia. Compared to synthetic pharmaceuticals, traditional and complementary medicines are generally considered to be relatively less toxic, because they usually comprise herbs in low individual concentrations and, in the case of traditional medicines, because of long historical usage. However, the manufacturing processes may result in contamination of the products with toxic heavy metals and micro-organisms, or the products may be adulterated with Western medicines. In view of this, for CPM, the main group of complementary medicine remedies used in Singapore, HSA's system is more stringent than that of the US and UK which do not have pre-market assessment of CPM products. In Singapore, control measures to ensure that CPM meet appropriate quality and safety standards comprise the following: One, the licensing of CPM dealers - importers, wholesalers, manufacturers and re-packers - to ensure accountability for the safety and quality of their products. Two, pre-market product assessment to ensure that products are from licensed manufacturers, sold freely in country of origin, do not contain Western medicines or naturally occurring toxic substances, and that heavy toxic metals, such as mercury, arsenic, lead and copper, and microbial counts are within permissible limits. Three, submission of test reports and written declaration of the absence of any synthetic drugs or poisons as defined in the Poisons Act by the licensed importers for every consignment imported. Four, approved product labelling in English to clearly specify the ingredients, indications for use, dosages, batch number, expiry date and the identity of the importers and manufacturers. Labels and packages must not stipulate any of the 19 diseases or conditions specified in the First Schedule of the Medicines Act, such as cancer, diabetes and hypertension. Where there is any doubt on the documents submitted by the applicants, product samples are tested by HSA's laboratories to exclude suspected adulterants, and analyse toxic heavy metals and microbial contents. There are currently no licensing requirements for the import, manufacture and sale of health supplements and other traditional remedies like Jamu and Ayurvedic preparations, but dealers are required to ensure that the products do not contain any prohibited substances and the toxic heavy metal content does not exceed legally permissible limits. HSA also carries out regular post-marketing surveillance and runs a quality-testing programme on products sold in the market to ensure compliance with legal requirements. HSA also has an Adverse Drug Reaction (ADR) Monitoring System to detect any adverse reactions of products used in Singapore, and this is tied to international ADR networks to pick up early signals and intelligence on any problems with health products. Health care professionals are requested to report suspected adverse drug reactions encountered to HSA so that unsafe products can be removed from the market as and when they surface. Mr Speaker, Sir, synthetic pharmaceuticals for weight loss can only be used under a doctor's supervision. Where consumers are considering self-medication with other products that claim to cause weight loss, they have to be cautious and discerning and exercise care in the selection and use of these products. HSA will look into how the labelling of complementary and alternative medicines can help the public to make better informed choices as to whether to use a health product or not. HSA will also review and refine regulations and guidelines governing slimming products to ensure safety for users. HSA is developing a regulatory framework for health supplements, targeted for implementation in phases from 2003.

Mr Speaker, Sir, in the case of the Slim 10 product, I understand that the routine laboratory tests discovered the presence of two controlled substances, nicotinamide and fenfluramine, after the product had been put on the market. My question to the Minister is why can the tests not be conducted before the product is put on sale and, in the case of Slim 10, why was it allowed to be sold for five months before any action was taken by HSA?

Mr Speaker, Sir, let me go through the process of how Slim 10 came in. Slim 10 was imported from China, and for the ingredients declared by the company, they claimed that the product contained five common Chinese herbs, with dosages within those recommended in the official Chinese pharmacy literature. So this product was, therefore, classified as Chinese proprietary medicine. HSA had these products tested and found that they were indeed based on the tea leaves and the Chinese herbs. On that basis, they were allowed to come in. Each time a consignment comes in, the importer has to declare that the consignment does not include any of the items in the Poisons Act and that the product does not have any toxic metals or microbial contents exceeding the legal requirements. Based on those declarations, they were allowed to be sold. Then, as I have explained earlier, HSA runs the Adverse Drug Reaction Monitoring System and, based on that system, in early April, HSA received reports from doctors about patients with serious adverse drug reactions. So HSA went to test the product from the shelf and discovered that there were indeed these adulterants in these batches. So HSA took action to withdraw these samples. That is how the issue became public. What I want to say is that for Chinese proprietary medicine, the procedure is, first, anybody who wants to import a Chinese proprietary medicine submits the application to HSA and tells HSA what the product contains. HSA will test the product and make sure that the product is as declared. On that basis, HSA will allow it in. On every consignment, the importer will then have a declaration to say that the consignment of the product coming in does not have any of the items in the Poisons Act, does not have any heavy metals or any microbial contents above the legal limits. It is not possible for HSA itself to test the items because, as you can appreciate, the CPM is a very wide range and, therefore, we use the regulatory regime of making the importer declare that whatever they bring in is in accordance with what they indicate as ingredients, and that they do not have any of the poisons in the Poisons Act and any of the other toxic heavy metals.

Sir, why can the laboratory tests not be taken when the importer submits the declaration at the same time?

As I have explained, this is not a synthetic pharmaceutical. For the Chinese medicine, they claimed that these are the ingredients in it. HSA can test that indeed these ingredients are there, but it is not possible for HSA to test what else is not there. We will be testing for a lot of things. We can test for the poisons, we can test for a few toxic metals, but they could be putting in a lot of other things, eg, steroids, all kinds of adulterants in it. So it is not possible for HSA to put upon itself the responsibility of testing what is not declared by the importer, because you do not know what to look for. Let me give another analogy. When I was in charge of the Ministry of National Development and we imported vegetables from Malaysia and we had this problem of pesticide residue. We could impose a very strict regime because the number of known pesticides used is limited and we can test for the 10 or 15 pesticides and make sure that the residue does not exceed the level that we set. Therefore, we can have a very tough system in testing every consignment for those 10 or 15 pesticides and make sure that it does not exceed the residue level. But when we come to Chinese medicine, we do not have a similar list of things we can say that you cannot put these in the Chinese medicine. We can have a list of the poisons, but they will be put in steroids and all kinds of stuff, and they may put in things which are above the safe dosage. So it will be very difficult for us to do tests on every consignment and to test for what is not declared as ingredients in Chinese medicine. That is why in 1999, when we were looking at how to regulate Chinese medicine, we decided that it is not possible for the HSA to license every product and every consignment. Therefore, we put the responsibility on the importer, the wholesaler, to make sure that whatever they bring in they must declare that the product they bring in does not have the items in the Poisons Act, do not have heavy metals, and the ingredients of the product are clearly labelled.

Sir, may I ask the Minister whether the Ministry has any plans to control other slimming treatments, such as the use of equipment for slimming, the use of slimming oil and body wraps, and also whether the Ministry will help CASE to investigate into all those complaints on slimming treatment?

The whole issue of medical devices is currently not regulated, and we intend to regulate medical devices when we put up legislation towards the end of this year or next year. So, medical devices and devices which claim to have health benefits, these we intend to put under regulation. As for the rest, slimming oil, body wrap, these cannot be regulated. If you want to wrap plastic or elastic around your waist and claim that you will be slim, there is no way we can tell you not to do so. In helping CASE to look after the products, I am sure we can work together. But as I have said, health products cover a wide range and when it relates to pharmaceutical products, the so-called Western medicine, because these are synthetic, and chemicals, they pose higher risks. The HSA's stand is to regulate this stringently. At the other end of the spectrum, when it is Chinese medicine, because these are herbs and plants, and these are traditional medicine which have been in use for hundreds of years and proven to be reasonably safe, we have to take a different approach. Unfortunately, the problem now is that many people bring in Chinese medicine but actually they adulterate it with Western medicine, and they come in under the guise of pure Chinese medicine. This is the middle area that we have to review and make sure that even though we cannot regulate the efficacy, we must regulate for safety, and that is the intention that we set out.

Sir, I was a bit surprised by the Minister's answer. I thought it was the job of HSA to safeguard public confidence in the quality safety and efficacy of healthcare products. Is he not aware that last year, there were 561 cases of people suffering from side effects from approved medicine which were reported to HSA? Does that not say something about the way HSA goes about doing its work?

Mr Speaker, Sir, even for Western medicine, the synthetic pharmaceuticals which are manufactured by the big pharmaceutical companies with very stringent quality control, which have certificates for good manufacturing practice and a series of clinical tests and approved by the home regulatory body, whether it is FDA in the US, etc, even for such drugs, you cannot test for the full range of adverse drug reactions. Sometimes, even after such a stringent process, you do come across unexpected adverse drug reactions. Even for synthetic pharmaceuticals, you get products being withdrawn because some of these after-effects were not encountered during the clinical trials. What I am saying is that even at this end of the spectrum, where we have such a strict regime, together with the western countries, we also have unexpected drug reactions, and through this Adverse Drug Reaction Monitoring System, we have to pull products out. When you look at Chinese medicine at the other end of the spectrum, generally, we do not face this problem because these are low concentrations which have been used for a long time, through historical and traditional use, the adverse reaction is minimal. When we come to the middle area, this is where the problem arises. As I explained just now, we cannot adopt wholesale the Western medicine approach of regulating it, in line with what other countries do. In the US, for example, when they come to traditional medicine or complementary medicine, the approach is that you take it at your own risk. FDA does not regulate. If you take traditional medicine or Chinese medicine, it is entirely at your own risk. In Singapore, we realise we cannot adopt that hands-off approach because traditional medicine or Chinese medicine has a wide following in Singapore. Since 1994 and then in 1999, we have put in place a system which tries to address the unique characteristics of Chinese proprietary medicine and, at the same time, put in some safeguards. One of the safeguards, as explained earlier, is when somebody wants to bring in a product, HSA tests the product and makes sure that it is qualified under Chinese medicine, and not Western medicine disguising as Chinese medicine. Having allowed the importer to bring it in, we make sure that for each consignment, the importer declares that whatever he brings in has the minimum safety standards of not having poisons or heavy metals in it. What happens in some of these cases is that the quality control in the manufacturing of these products in China is not tight and sometimes, it gets adulterated. The laboratories that test these products are not stringent enough, so it gets through the net. We are reviewing the system. One of the things that we may consider is to only accredit qualified laboratories to make sure that the testing is done by certified laboratories, and not just laboratories from different parts of China. This is one of the measures that we are considering. Our objective is to ensure safety but if it is prescription-only medicine, we have a higher level of safety because there are more checks, the doctor is in charge of prescribing it, we ensure that the pharmaceutical companies which manufacture them have good manufacturing certificates, so there are more stringent checks. When it comes to traditional medicine, I am afraid that the regulatory regime is quite different, as practised everywhere else. There are a lot of grey areas, whether it is medical devices, health supplements or food products, they are now coming in with different claims. It is very difficult for us to say that a food product cannot be adulterated. If somebody puts adulterants into food products and thinks he can get away with it, unless you go round checking every item and every consignment, there is no way we can prevent that from happening.

Sir, it seems that the present procedure does not seem to have worked because Slim 10 has got in and has caused harm to the people. May I ask three questions? Firstly, could I ask the Minister to review the procedure whereby in the first instance, although an importer may declare certain substances, he will not be so stupid as to declare disallowed items, so he probably declares all the allowed items. Could the Ministry consider asking the HSA to conduct limited testing of other disallowed products because if the product, for example, is for slimming, they can test the limited range of products that are used for such effects, but maybe not allowed for health reasons? At least, that will help to give better protection to the people. Secondly, after the products are allowed to come in, when the products are being sent in by batches, to do batch testing of the products. At least, they are being tested and monitored regularly by batch testing through the HSA getting samples from each batch being imported. The third question is: if deterrence is the way the Ministry wants to go about doing it, then what is the level of deterrence we are having now? For example, what kind of penalty do we impose on these defaulter importers, and whether this can be reviewed as a procedure?

Mr Speaker, Sir, I agree with the sentiments of some of the Members here that even though our procedures are stricter than in UK or US and about the same as Australia, because of the widespread use of Chinese proprietary medicine in Singapore, we ought to re-look at the procedures and see how we can tighten this up. We are, in fact, doing this review. On the other hand, I do not want to give the House the wrong impression that whatever we come up, it is going to ensure 100% safety. I think we can improve, but it is the nature of such products. I have many meetings with Health Ministers from the region. When I meet the Health Minister from Taiwan or Hong Kong and we discuss the problems we face, this is quite a widespread problem in Taiwan and Hong Kong, where they bring in Chinese proprietary medicine. So, we are all grappling with this. Specifically, with regard to Mr Leong Horn Kee's suggestion, we will take this up. We do conduct random testing. HSA does not have the resources to test every batch and everything that comes in. But HSA will do random testing, and we indeed do that as part of our post-marketing surveillance mechanism. Mr Leong also suggests that we do batch testing. We will review that but it means we are going to slow down and, in fact, it will affect the trade and it will raise costs. For the bulk of the Chinese medicine that comes in, the herbs and grasses are fairly innocuous. They have been used for hundreds of years and they are reasonably safe. But if an importer wants to adulterate such stuff, then it is very hard for us to prevent them from doing so. We must have a regime that does not penalise the bona fide importer. We cannot treat every importer as a possible crook. But I agree with Mr Leong that we must have in place a regime that deters and which can ferret out those who are unscrupulous. As far as deterrence is concerned, our present Act allows for a two-year jail sentence for those who bring in items which are adulterated.

Sir, I have three questions. First, if HSA does not have the resources to test everything that is imported, can this work be done by private laboratories? Second, in the case of Slim 10, I understand that the decision by HSA to ban Slim 10 was made on 15th April. Why was the public informed of the ban through press release only on 30th April? Why was there a wait of two weeks? My last question: is there a way for HSA to inform the public as soon as it is possible of dangerous drugs, instead of having to wait, as in this case, for two weeks?

Mr Speaker, Sir, in fact, this is the current regime. We try to use the private laboratories. This importer came with the declaration from a private laboratory. We accepted the report of the private laboratory. Now, we are saying that maybe not all private laboratories can be trusted, and therefore, we ought to have a shorter list of accredited laboratories. This is one of the things that we are thinking of doing. As to the time difference, according to the report given to me, when HSA first received the report of adverse drug reaction, they went out to the market and picked up samples from different batches to test. They found nicotinamide, which is a B3 vitamin. This is not banned, but the dosage that was found in this Slim 10 was beyond safe levels. It is not a banned item, but it is above the safe dosage. HSA told the importer to withdraw the item and the product was withdrawn from retail. HSA also sent out an advisory to all the doctors to say that they have received these adverse drug reactions and asked for other confirmation from the doctors. It is after HSA sent out this advisory that other doctors also sent in reports and HSA then suspected that what is adulterated is beyond B3. From the kind of reports that they get from the doctors, they came to the conclusion that excessive dosage of Vitamin B3 could not have caused some of these reactions. These reactions were not just hyper-thyroidism but also, in some cases, hepatitis. So they investigated further, and this is where they found traces of fenfluramine, and this is where they put up the press release and took action. HSA took action according to the investigations, because when you bring in these products and send them to the laboratories for testing, the test results do not come in immediately. They take about a few days to a week for the test results to come in. So I have examined the report and the procedures. I do not think HSA was laggard in their reaction. I think what they put out was commensurate with the test results, and when they found this banned item, then I think they make it very clear, not only to withdraw the product, but also to warn the public.

I want to pick up the point from the Minister about the penalty. It seems that the two-year jail penalty is a bit light for a case when the medicine brought in can be very poisonous. Could the Minister reveal whether this needs to be reviewed because if the importer brought in substances that can cause not only permanent damage to a person, but even death to several people, I think the penalty should be even more deterrent than just a 2-year jail sentence.

HSA is still in the process of investigating and the 2-year jail deterrent is under the Act, for the violation of the Poisons Act. If the consequences are more serious, HSA will consult AG's Chambers to see under what other Act we can pursue the importer, which will carry a heavier penalty.

May I ask the Minister whether there is any watchdog body that scrutinises the efficacy claims by drug distributors on over-the-counter drugs and Chinese medicine?

The answer is "No". To be able to evaluate the efficacy claims, if you want to do so scientifically, then you must have the whole process of evidence-based medicine, you must have proper trials. Unfortunately, for some of these products, whether it is supplements, or natural products, or herbs, they do not have this kind of records. So there is no way we can evaluate such items for efficacy claims. That is why we state very clearly that for such products, our primary objective is safety. And, where the rules for safety are not tight enough, I can assure the House that we will tighten them. But there is no way we can evaluate, or justify to the public, the evaluation of efficacy claims.

Order read for consideration in Committee of Supply [5th Allotted Day].

Head T (cont.) - Resumption of Debate on Question [18th May, 2002], "That the total sum to be allocated for Head T of the Main Estimates be reduced by $100." - [Dr Teo Ho Pin]. Question again proposed. 1.05 pm

Mr Chairman, Sir, my time has been slimmed down considerably, so I will get straight to the point. On Saturday, Dr Teo Ho Pin raised his concern about promoting family members' desire to stay together. I agree that it is a very laudable objective. That is the reason why HDB gives higher housing grants for couples who want to buy resale flats near their parents. Also, I think he may be aware that in our balloting exercise for new flats in mature estates, we give a higher weightage to these couples so that they have a higher probability of success. So, as a result of these pro-family measures, HDB estimates that around 40% of HDB residents with married children live with the married children, or within the same estate. This is based on the findings of a survey that HDB did a few years ago. On the question of shorter tenures, I think Dr Michael Lim, as well as Dr Amy Khor, raised the possibility of shorter tenures for HDB flats so as to enhance affordability. The first point I would like to make on this is that even with 99-year leases, currently HDB flats are already affordable. As Members may recall last Saturday I cited the fact that the typical four-and-five room flat applicants last year needed to use only about 15% of their household incomes for their monthly mortgages. That attests to the affordability of flats currently even on 99-year lease, so there is really no need for us to introduce shorter leases on the basis of affordability. But we do have shorter leases for specific purposes. For example, we have 30-year leases for studio apartments for the elderly. So the question is whether we want to expand this to other flat types. One of the fundamental objectives of our housing policy is, of course, home ownership. Should we shorten the lease period significantly, as some Members have suggested, this would actually make housing a consumption item, rather than investment. So how different would that then be, for example, from rental housing? Would that not run counter to our objective of home ownership? And, of course, there is also the question of acceptability. Will such short tenured HDB flats be acceptable to members of the public? So these are some of the issues that we would need to consider, if we are going for shorter tenures. Sir, a few Members have also highlighted the issue of the housing needs of the singles - Mr Ang Mong Seng, Ms Indranee, Dr Michael Lim, among others. Sir, let me remind Members of the House, that public housing is subsidised housing. So the subsidies have to be justified because it promotes some social objectives. And, in this case, the social objectives in question would be the promotion of social cohesion and family values. And that is the reason why public housing comes with many rules and regulations, as some Members have pointed out. We, of course, try to keep such rules down to the minimum. But even then I must admit that the rules are quite bewildering, even for me. But I would like to assure the House that such rules are necessary. Sir, coming back to the question of housing for singles, let me state upfront that our public housing policy is pro-family in orientation, and this is to support our social objective of promoting family formation and bonding. But, at the same time, we also recognise that single citizens have housing needs, and that they have made valuable contributions to our society and to our economy. And that is the reason why we have reviewed the rules and we have allowed singles, age 35 and above, to buy 3-room resale flats, on their own. Contrary to Ms Indranee's claim that they are not eligible for subsidised housing, in fact, they are. Singles can apply for a housing grant of $11,000, if they buy a resale flat. And, if they combine with another single to buy a resale flat jointly, the grant is double, it goes up to $22,000. Why the minimum age of 35? We have to have a cut-off, to be consistent with our pro-family approach. We do not want to inadvertently encourage singles to live away from their parents at too early an age. So we checked with other agencies, and the advice was that marriage rates for singles tend to be much lower after this age, and this is the reason why we chose 35 years as the cut-off. Why are they eligible only for 3-room flats and not larger ones? Sir, anyone who is familiar with a 3-room HDB flat, which has got 2 bedrooms, about 70 square metres, would agree with me that this should be more than adequate for the housing needs of a single person, particularly in land-scarce Singapore. Members have also suggested allowing singles to rent HDB flats on their own. Our current policy on this is to reserve HDB's heavily subsidised rental housing for lower income families who cannot afford home ownership. There is always a certain segment of the population who will never be able to own their own homes, and for them, they will have heavily subsidised rental housing. We do not encourage singles to rent HDB flats on their own, partly because of the limited stock of such rental flats, but mainly because we want them to look first to their family for support. We do not want them to look to the State in the first instance. Mr Ang Mong Seng has suggested that we build HDB flats purely for singles to encourage social interaction. Is that correct? That was what I think I heard him saying. Sir, many Members of this House have actually asked the HDB to review its roles. Some have said that HDB is actually doing too much and it should be doing less. Sir, even while we review the role of HDB, I can categorically say that HDB will not take on this role of providing more opportunities for singles to meet. I think there are many other agencies and many other organisations which are much better placed to play such a role, organisations like SDU, SDS, and so on. Sir, let me take up a point which Ms Indranee and others have raised, and that is that it is difficult to obtain a waiver of policy from HDB. Let me state at the outset that policies are set by the Government, and HDB is the implementing agency. The rules and regulations are put in place to support existing policies, and for good reasons. Nevertheless, as with all rules, there are always gray areas at the margin, and this is the reason why we have got mechanisms in place which will allow HDB to exercise judgement and discretion on a case by case basis. Exceptions to the rule do take place. Camels do get through, quite a few of them, in fact, and big ones too. But they are not the norm, I must admit. In fact, there are not as many as maybe Members of this House would like, and it must be so. Because, if there were too many camels getting through, then surely there is something wrong with the policy in the first place, in which case, we should review the policy. Sir, policies are not cast in stone. Members recall that the housing policy for singles, in fact, was revised, and reviewed, only last year, whereby we allowed the purchase of 3-room resale flats in all estates, not just in the suburban estates. This, I believe, has been very popular with the singles. We will continue to review and refine our policies, when necessary. Sir, MPs sometimes raise specific cases in the House, on behalf of their constituents, and to illustrate their point. There is nothing wrong with that. In fact, that is to be encouraged because they are doing their job. However, I would like to point out that sometimes, there is often more to each case than what MPs are told. And it is only when HDB interviews their residents, to see how it can assist them, that all the facts surfaced. So, my advice is, do not listen to one side of the story before you make up your mind. Sir, let me now go on to the other issues that were raised, particularly the one about the review of public housing. This is a matter which many Members have raised, and I would like to take some time to touch on this. Sir, the budget landscape for the Government in the future will not be the same as before. Our public housing expenditure would have to adjust according to what the Government can afford. In the past five years, we spent about 1.1% of our GDP, or more than $1.5 billion annually on public housing. This includes things like the subsidised flat prices, the housing grants, upgrading and so on - 1.1% of GDP, which is considerable. In the future, we will have to be more prudent and more efficient in the way we spend the public housing budget. For a start, we have already embarked on a review of the way our public housing budget is managed. We will be looking at all options pertaining to the financing of HDB flats, taking into account, amongst other things, our budgetary and financial position. We are also reviewing the roles and functions of HDB, in particular, its role in the development of public flats. HDB has been spectacularly successful in building affordable public housing. The expertise, the experience, and the achievements of HDB in this area, have won world-wide recognition. For example, in 1991 it was conferred the World Habitat Award for developing Tampines Town, and my residents are extremely pleased about that. This was done against strong contenders such as Vancouver and Boston. 1.15 pm Today, however, property development is a much more mature industry. And recognising this, HDB has, over the years, been gradually increasing the involvement of the private sector through, eg, its premium apartments. We can further increase private sector involvement to enable us to respond faster and better to changing needs, and the changing preferences. As a first step, we are looking into the feasibility of corporatising HDB's Building and Development Division (BDD). Since the inception of HDB 40 years ago, the Building and Development Division has accumulated a wealth of experience in the design and development of HDB flats. It has gathered considerable expertise in various areas, from surveying to architectural design, from engineering to project management. It is especially strong in comprehensive township development. All the HDB estates - the new towns - have been conceptualised and drawn up in the drawing rooms of the BDD in HDB.. MND and HDB are currently studying the implications of such a corporatised BDD. A key consideration is to ensure that corporatisation does not bring about any adverse impact on the delivery of our public housing programmes. The benefits of corporatisation include giving them the autonomy and flexibility to build on their current strengths, to venture overseas and to establish an external market leveraging on the HDB brand name. It will enable them to unlock their value and potential, because they have a skill and track record that few organisations around the world have. At the same time, the public housing building programme can be gradually opened up to private sector developers. Whatever the outcome of the review, let me reassure Members that there will be minimal impact on the public. We would ensure that the fundamentals of public housing are preserved. Singaporeans will continue to enjoy high quality housing at affordable prices. At the same time, I would like to assure Mr Othman Haron and Mr Iswaran that the Government appreciates the valuable contribution of HDB's staff. They have given loyal and sterling service to HDB and the public, and their interests will be looked after in the review. Sir, I have announced some changes to our public housing policies and programmes. I have also outlined some of the key areas that MND will be addressing and the considerations that we will bear in mind. We will weigh the various options before us carefully, keeping in mind the impact that fundamental changes in public housing policy will have on Singaporeans.

Sir, the HDB introduced lift upgrading in the last few years as a special upgrading work that will benefit only certain residents in HDB flats. These residents are required to co-pay part of the lift upgrading cost. Yet, as I understand it, in the sales and purchase agreement that lessees sign with the HDB, it is clearly stated that any external works to be done outside the flat at the block will be borne solely by the HDB. Lift upgrading is clearly external works. Can the Minister kindly explain if it is violating a legally signed contract by demanding that the affected residents co-pay for the upgrading works?

Dr Tan Cheng Bock is not here. Mdm Halimah.

Sir, I am indeed very glad to hear the Minister say that there are no policies which are cast in stone; therefore, implying that policies can be revisited. Most certainly, there is one policy which I hope that the Minister will revisit, and that is the current policy of the HDB of not installing lifts in 4-storey HDB flats. Sir, when the flat dwellers purchased these flats 15 or more years ago, they were much younger. There was a spring in their step. They were definitely much more nimble in running up and down four storeys of the HDB flats. But now, after many years, there is less of a spring in their step, the knees are getting a bit wobbly, and I think it is extremely difficult for them to climb up and down the staircase, particularly for the women who have to go marketing in the mornings. They have to carry heavy baskets and climb up the staircase; it can be quite a difficult problem. Sir, I really hope that the Minister will revisit this particular policy, taking into account the fact that the population has aged considerably. I also hope that in his reply, the Minister will not just cite economic arguments, but will also look into the social aspects of the issue that I have mentioned. Sir, on a related issue, which was raised by two of my colleagues, Mr Othman Haron Eusofe and Mr Iswaran, on Saturday, the Minister had kindly given a very good assurance in this House that the restructuring efforts in HDB will not affect the interest of the workers. I am very glad to hear that. I am also happy to inform the House that the HDB management is in close contact with HDB staff union and NTUC on this matter. And I am very glad to say that it is none other than the Minister himself who had instructed the management to work closely with the union on this issue. As a labour MP, I appreciate his concern and I am confident that with his personal interest in the issue, we will be able to face changes without much disruption. Sir, for the information of the House, in our discussions with the Board, the NTUC has conveyed the following: First, the need for adequate notice to prepare workers; Second, effective communication to ensure that everyone understands the rationale and basis for the change, and how it affects them; and Third, appropriate assistance must be given to workers who are affected, particularly in relation to training programmes for the affected staff. In this regard, the NTUC Skills Development Department is currently working out a programme with the management to put staff on training programmes. So, I am very glad to say that we are working very closely. Sir, coming back to my first point, I would appreciate a response from the Minister.

Sir, like my colleagues before me, I am raising an issue on the lift upgrading programme. The lift upgrading programme, which was launched last year, is indeed a laudable project. I suspect that it may have overtaken covered linkways as the single most coveted upgrading item by residents. Every time I visit my residents, the question of when there will be lifts at every floor inevitably crops up. A resident who has a wheelchair-bound father asked if we can speed up this programme, so that it will be more convenient to bring his stroke stricken father out. Many other elderly residents also appealed for the lifts to be upgraded, so that they stop at every floor. Arthritis and rheumatism have made it increasingly difficult for them to climb stairs. Sir, indeed, we have a fast-ageing population, and facilities which enhance mobility and accessibility, such as lifts stopping at every floor, are not only welcomed but indispensable. Such facilities are also much needed by the handicapped whose interest sometimes we tend to overlook. Sir, one of my precincts in Hong Kah North was fortunate to have been selected last year for the lift upgrading programme. All the residents in this precinct are eagerly awaiting their new lift system, except those in the four blocks of 4-storey walk-up flats. My first question to the Minister relates to the 4-storey blocks of walk-up flats which have been excluded from this programme because, I am told, they are very costly and too few residents benefit from this, compared to the high-rise blocks. My question to the Minister is: what medium and long-term plans does the Ministry have for these flats? This is because residents living in such blocks have expressed their concern regarding the lack of lifts. Some, especially those living on the top floors, say that they are thinking of moving out. In fact, during my block visits, I noticed that some flats have been vacated, and I was informed by residents that the flats have been empty for some time. Sir, I am worried that, over time, these blocks of flats may become urban slums when the residents move to other flats with lifts stopping on every floor. Sir, within the Bukit Batok division of my Hong Kah North constituency alone, I have a total of 30 blocks of 4-storey walk-up flats with 603 units. Many older estates would have such blocks of walk-up flats interspersed with high-rise blocks, and would suffer the same fate with regard to the lift upgrading programme. Sir, I would like to ask the Minister to seriously look into and resolve this issue with a definitive plan soonest. Although it may be costly to provide such lifts to such blocks, the Ministry could look at providing, say, only one set of lifts and using a cheaper lift system for such blocks. Sir, I also submit that since these residents have been paying the same conservancy charges as similar sized flats in high-rise blocks all these years, they should also be entitled to the same upgraded facilities. Alternatively, the Ministry could look into selective en-bloc redevelopment for these blocks as clearly, over time, such flats will become increasingly unattractive. Additionally, Sir, I would also like to request that the Minister consider giving the lift upgrading programme priority over the general interim upgrading programme, as having accessibility and mobility with lifts stopping on every floor appears to rank highest on the wish list of HDB residents in the older estates.

(In Mandarin): Sir, with the launch of the Interim Upgrading Programme, the Government is also considering upgrading lifts and installation of lifts to blocks of flats which have no lifts. This has received very popular response from the residents, particularly the aged residents. During my visit to the residents, many of them said to me in Teochew that our Government and Ministers are very good. They said, "They understand our problem and they have installed lifts for us. This is very good. I will vote for them." This response shows that installation of lifts is very important to them, particularly to the elderly. The HDB has also installed lifts to three blocks of 4-storey apartments. These blocks are among the first to be installed with lifts, and the residents are very happy with the lifts. They were very happy when I visited them, particularly the old folks. However, under the new Lift Upgrading Programme, the 4-storey blocks are not included. Two of my parliamentary colleagues have raised concerns about this matter. I think this is a very important issue where the residents are concerned. On the installation of lifts, why is the cost so high? In Bukit Gombak, there is a practical example. When I appealed for the installation of lifts, they said that there must be at least 60 units in the block before they could be considered under this scheme. Under the prevailing policy, ie, linkways have to be built to link the three blocks together and this costs a lot. However, if there are common corridors, these linkways need not be built, and we could save two-thirds of the cost. For high-rise flats, so long as there are 20 units, they qualify for lifts to be installed. Why is the standard different for 4-storey blocks? Also, there may be other considerations if the Government is not willing to install lifts for 4-storey blocks. There could also be redevelopment plans for the block of flats. If this were so, we should announce well in advance so that the residents can decide whether to move out or to stay on. Sir, I hope the Government will look into this matter.

Sir, like several of the preceding speakers, I want to raise a plea on behalf of those who have, as Mdm Halimah Yacob put it, lost the spring in their stride. It makes me wonder whether there is a statutory board they can turn to for help! Sir, the Minister has pointed out, quite accurately, that we have a financial constraint going forward, and we need to ensure that the dollar we spend is spent well. In that regard, I want to raise two points for the Minister to consider. The first is whether we can indeed prioritise the Lift Upgrading Programme over the Interim Upgrading Programme. Because, essentially, the Interim Upgrading Programme has lift upgrading plus covered linkways, and then an assortment of other general municipal works, many of which can be undertaken by Town Councils on a progressive basis from money they generate through the S&C charges. That being the case, the big ticket item is the lift upgrading, and it is also one that is heavily sought. The Minister has overseen the study on the ageing situation in Singapore, and he is well aware of the pressing needs on behalf of those who are getting on in age, and they need this facility, in terms of the lift stopping on every floor. 1.30 pm The second point is whether the programme can be accelerated. In other words, quite apart from prioritising it over the IUP, whether we can, in fact, allocate even more resources to ensure that more flats benefit from this. Sir, it is of scant consolation to a 65-year old to say that the lift upgrading programme is a 10-year programme and it will come to his flat or block in the fullness of time. I hope the Minister can consider this request.

Sir, where I come from, Eunos in Aljunied GRC, we have a relatively high percentage of senior citizens. Eunos is a relatively old HDB estate. However, I am sure I speak for other similarly old estates and older flats built before 1990 where we did not have lifts on every floor. I understand why HDB did not build the older flats with lifts on every floor, as the priority then was to build flats fast and cheap. But now, when that generation of residents has grown older and some aged, this consideration for lifts on every floor is now more urgent, especially when we want to ensure that more of the elderly continue to play an active part in our lives. In Eunos, only one block of those flats built before 1990 has been given a Lift Upgrading Programme (LUP) programme. There are 64 more others waiting. Every visit I make to the older flats, invariably, I get this question asked: when do we get our LUP? I realise that there are 4,000 such flats in Singapore awaiting LUP, and during these days of downturn and expected slow GDP growth, MUP/IUP/LUP could be far from the Government's priority. But can the Minister indicate when we can expect LUP for more of the older estates and flats, including those at Eunos? I urge the Government to expedite the process, as soon as we are ready to LUP.

Sir, it is evident from the Members' comments that upgrading is very popular, particularly lift upgrading. But let me point out that upgrading in general, whether it is Main Upgrading or Lift Upgrading, is very expensive and very heavily subsidised. So, to make the best use of the limited budget that we have for upgrading, MND has to constantly review the scope of these upgrading programmes in order to make sure that we can bring these programmes to as many residents as possible, and also to provide improvement items which residents value. Last year, we introduced the Lift Upgrading Programme (LUP), and this is to allow lifts to be provided on every floor, where feasible. The feedback has been very positive and I can understand why, because it does fulfil a real need, particularly for those who have lost the spring in their steps. But let me also stress that the Lift Upgrading Programme, which we introduced last year, does require a lot of resources. Mr Steve Chia asked why residents have to co-pay. It is precisely for this reason. It is a very heavily subsidised programme. The number of blocks which still requires lifts on very floor numbers something like 4,000. This is not inconsiderable. And he must appreciate, and I am sure every other Member here must appreciate, that, given the limited resources that are available for upgrading, there must be a certain level of priority. I think Mr Chia wants to say something.

Sir, I want to clarify. I understand that it is very expensive and that maybe there is a need to co-pay. I appreciate that the residents have to co-pay, but I am asking whether the Ministry did actually violate a legally signed contract in this case. What is the Minister going to do about this violation of a contract, if there is a violation of contract? That is my main concern.

The short answer is there is no violation of any contract. He can rest assured of that. Of course, external works which are of a general benefit to the residents, Government will subsidise, and residents will have to co-pay. In the case of lift upgrading, it is even more clear that the benefit is to the residents, and this is the reason why we have asked them to co-pay. That has been made clear to residents. I think it is well accepted by our residents. In fact, all the precincts that have polled for the Lift Upgrading Programme have given us full support for this programme. So, it is well understood. It does not violate any legal contract whatsoever. That much I would like to assure Mr Steve Chia. Concurrently with the lift upgrading, of course, there is the Interim Upgrading Programme which preceded the Lift Upgrading Programme. What the Interim Upgrading Programme does is to provide some kind of upgrading works for precincts which are not yet eligible for the main upgrading. Interim upgrading centres more on block and precinct works. But all Members who have spoken have expressed a desire for more resources and more priority to be given to lift upgrading. I do share that sentiment. Within the resources that we have available, we will try to do so. For that reason, my Ministry has decided to combine the IUP and Lift Upgrading Programme (LUP) into a new programme which we will call "IUP Plus". What IUP Plus does is that it will bring IUP and LUP works together at the same time to residents. It would be offered to residents at the same time. It will be carried out at the same time, so that we would no longer have to have two separate programmes, one interim upgrading and one lift upgrading. By combining these two programmes into one, hopefully, we will enable more flat owners to have the lift upgrading works done earlier. At the same time, they will also continue to enjoy interim upgrading works which will be done at the block and the precinct level, including things like linkways, etc, which, I think Members also agree, are well appreciated by residents. So, we will try and have the best of both worlds, as it were. A total of 138,000 flats, which were built between 1981 and 1986, will qualify for this new programme. There will be no change in the polling and co-payment arrangements. HDB flat owners, who will stand to benefit from the lift upgrading works, will be required to poll and pay for such works under the IUP Plus. As for the interim upgrading works, it will continue to be fully funded by Government, and no polling is required. IUP Plus will be introduced later this year. In addition, the Lift Upgrading Programme itself will continue to be available for all high-rise blocks which are not eligible for the interim upgrading type of works, in other words, a separate LUP programme for those which are not eligible for this IUP Plus. These will be flats that were built after 1986 or flats that were in the earlier IUP batches which did not enjoy lifts stopping on every floor. So those that have already been done are still eligible, and they can be nominated as well. Sir, quite a few Members have touched on the issue of lift upgrading for low-rise 4-storey blocks. Again, I must explain to Members that there is a real need for prioritisation. We do not have unlimited funds. Given the circumstances, we need to see where the Lift Upgrading Programme can give more value and more benefits to residents. The Lift Upgrading Programme was introduced last year. We still have about 4,000 high-rise blocks, as I said earlier, which do not have lifts on every floor. Lift Upgrading for high-rise blocks will benefit more residents than low-rise blocks. Furthermore, the provision of lifts to low-rise blocks is expensive, as Mr Ang Mong Seng realised, and I think he has cited some figures. But if there are low-rise blocks with redevelopment potential, as Mr Ang mentioned, we will certainly consider them for en-bloc redevelopment. Sir, I come now to the Main Upgrading Programme. To provide better value for money under the MUP, MND will concentrate on providing improvement items which are of tangible benefit to HDB flat owners. What we are going to do is to classify the upgrading improvement works into two categories - the "core" and "non-core" categories. HDB flat owners, through the MUP Working Committee, will be given greater flexibility in choosing the works which they value most. When I talk about core items, I am referring to things like upgrading of toilets, covered linkways, etc, which are very well appreciated by residents. Certain items, like toilet upgrading, will be enhanced to include the replacement of wash basins. As for non-core items, the list will be expanded to include, for instance, the replacement of refuse hopper. Again, this is based on feedback from MPs where some flat owners have suggested that we include this item as part of the MUP. But we will put this under the non-core category because not everybody would like to have it. Sir, the revisions I have just highlighted reflect the feedback, as I said, from MPs as well as from residents, but also from our own experience with past MUP projects. The changes will give us value for money and optimise the use of our upgrading resources. I am pleased to inform Members that, despite the economic downturn, the Government will be able to sustain the same pace of upgrading this year as we had done for the last five years. In terms of the number of precincts, we are going to announce the number of precincts later. But the number of precincts for this year will be similar to the number of precincts for the last few years. Sir, the Government remains committed to upgrading. We are facing quite significant changes in our social and economic landscape. So, we will have to review our upgrading programme continuously, taking into account our economic performance. The Government's financial position will also have to be taken into account. Of course, as Members will realise, we will also need to look at the competing needs for funds and other priority areas, like healthcare and education.

Sir, in the Minister's reply earlier, he said that the housing policy is pro-family. Many singles are pro-family and indeed take care of their aged parents almost single-handedly. Often, the parent, usually the mother, is the co-owner of the flat with a single. But when the parent passes away, a traumatic experience in itself, the single finds herself or himself ---

Ms Ng, are you making a speech or are you asking a clarification?

No. It is a clarification. The single is faced with the possibility of losing the flat, unless she can find another single to share the flat. But it is not because the single is not pro-family that she finds herself without a mother or a father. Can the Minister consider reviewing this policy? In fact, many singles tell me that HDB has been quite compassionate in their appeals. But I thought if it can remove the uncertainty, and reconsider this policy, it would be good.

I think that is another question. Mr Mah, you do not have to answer it. Mr Iswaran.

Sir, may I seek a clarification from the Minister? The IUP Plus initiative is in addition to the $43 million Lift Upgrading Programme that has already been indicated in the Budget book for the coming financial year. My main concern is whether the LUP will cover more flats as a result of this initiative, or whether it is just a redistribution.

It is partly a review of both the LUP and the IUP programmes. By combining these, we hope that we will be able to get better value for money and therefore more flats will be eligible for lift upgrading.

Sir, before I come to my next cut, can I ask a clarification from the Minister? On the limited resources that we have, and he said that he is lumping together LUP with IUP, in terms of priority, should we not be giving more resources to LUP first, because IUP can wait? LUP is more urgent because of the senior citizens.

Sir, what we will do is that we will have a total block budget for lift upgrading and interim upgrading, but we will combine the two into one. In this way, we will be sharing some of the overheads, etc. This is what I mean by getting value for money. In the process of doing so, I expect that there will be more opportunities for lift upgrading to be done. Of course, in terms of prioritisation, specifically which blocks will get it first, this is ultimately left to the Members to recommend and nominate to the Ministry.

May I remind Members that when asking for clarification, you may ask the Minister something which you do not understand or something you want to be clarified, but not to raise a new question. I do not want to let too many camels in.

I thought that was a clarification I was seeking. My next cut is on economic downturn and home ownership. Much of what I wanted to ask has been answered in the Question for Oral Answer and also the new policy of HDB. But I just like to add one more point and, that is, I agree with the Minister that, sometimes, at MPS, we do get all kinds of sad stories and they may not be the complete stories. But I would like to urge the Minister to take MPS cases seriously and we have more than 80 MPS cases and feedback from MPS cases would serve as an indication about the kind of problems faced by residents, the kind of policy changes that are needed. In the case of downturn and home ownership, it is not just a matter of rescheduling payments but also people who are asking to change, in terms of application for flats, from 5-room to 4-room, 4-room to 3-room. I would like to get clarification from the Minister whether the new policy in fact would take care of that kind of problem without much penalty being faced by the residents.

Mr Ong Kian Min is not moving. Mdm Ho Geok Choo.

Sir, in the last few days, many cries were heard of need to do more for the jobless. Suggestions ranged from rebates to training to job placements. We all know too well that, for some, the jobs lost are gone forever. We are not just battling with structural unemployment. Increasingly, we will be faced with under-employment. In light of the fact that there are a number of our people who have been displaced by the current recession, I feel it is necessary to help some of them to tide over their temporary difficulties by providing them with the opportunities to earn some income in the informal economy. Despite the proliferation of national efforts expended to train and retrain displaced personnel, we have to contend with the fact that there are pockets of our workforce who are not trainable and therefore not employable, and pockets who despite being trained are not able to find jobs. From what I understand from the ground and from my experience at the MPS, many displaced employees attempt to try another means of living. Many have applied to be hawkers and canteen operators, but since the number of stalls in our hawker centres and schools is necessarily limited, they find themselves waiting a long time for their licences to be granted, only to find out that they may not get a licence after all. There was this Malay single mother who came crying with four young children to see me over her plight. She has been seeing me in the last six months and earlier my predecessor for not less than six months, so I was told. She could not go on living on the charity of MUIS, public assistance and the EDRS, so she said. She has only Secondary Two education and finds difficulty in looking for a job. She needs to earn money for a more definite future. But there is hope. She can bake and cook. If she cannot operate a hawker or canteen stall, can she do some home-based cooking and baking as an alternative? As raised by Mayor Yu-Foo Yee Shoon, it is appropriate for an informal sector to be established in Singapore. This sector can also be a spawning ground for the under-employed to unleash their potential, remembering that the giant HP started from the home garage and, closer to the food business, Colonel Sanders of KFC also started from his home kitchen after his retirement. Sir, I am well aware of the possible consequences of nuisance, disturbance and unsightly cluttering of utensils and cartons along corridors. All these could lead to complaints by neighbours. However, such concerns are not good reasons for not exploring ways to address these concerns. Working in concert with the town council and the CDCs, conditions can be spelt out to ensure good housekeeping and orderliness. Vigilant spot checks can be carried out through the CDCs, or town councils, whose set-ups have been premised on the ground as decentralised units. They can therefore be more flexible in serving the needs of constituents under their charge. In fact, to better manage such small-scale food operators, can they not be registered under a central registry for easy access to them? The town councils and CDCs could mount a briefing to inform them of the dos and don'ts. After all, with HDB being an expert in regulations, they should have no difficulty coming out with further rules, except that this time round, the rules may win them better support since they are meant to help create temporary jobs. Sir, I understand that HDB is in the business of housing, and not jobbing. But, Sir, if you wish to nurture entrepreneurial spirit, we must surely allow for MOM and top entrepreneurs to mushroom readily and spontaneously from their homes without their often feared cost of capital of doing business. In fact, that was how Bengawan Solo started years back and it was after it had sufficiently built up its reputation and accumulated gains that it turned into a roaring business. Should not the remaking of Singapore stretch the courage and imagination of the HDB to bring spring to the drab weather that we are now in? And let those who have plucked up enough courage to start something on their own so as to spring forward to reach their dreams. Without being disrespectful to one of our MOSs in this Chamber, I recall reading of his mother's food enterprise of satay prepared from her flat dwelling. I have no doubt that that enterprise had contributed to the nurturing and shaping of one of Singapore's sons who, today, is contributing to the nation. I urge HDB to open up its regulations to accommodate such a worthy request to help the needy and remove the OB markers that may snuff out the entrepreneurial spirit, instead of uniting it. Sir, at this juncture, I will not labour over the issue of food preparation, hygiene and standards, which the HDB may raise as concerns and reasons for not supporting my request. I shall be addressing that with the Minister for the Environment. Sir, I will request that the HDB consider granting temporary permits of 6-12 months to unemployed people to operate small scale food business of a specified approved type from out of their homes. In the meantime, these people will have to work hard to look for an alternative job or eventually transfer their home-based business to proper locations once they are successful.

Sir, I like to raise the issue of heavy vehicle parking. Owners of heavy vehicles often face the problem of finding parking space near their homes. As a result, many of them get fined very frequently and these fines eat into their meagre income. It is not uncommon to find many of the heavy vehicle drivers who have a parking lot which is very far away from their homes. So someone who lives in Jurong may have his parking lot in Tampines, and vice versa. The Ministry may want to consider a once-off rationalisation exercise to allow heavy vehicle owners to change their parking lots so that they can opt for a space nearer their home. This will go some way towards alleviating the problem for these drivers. In the new towns like Punggol New Town and Sengkang New Town, it is surprising that there are no plans for heavy vehicle parks even though there are plans for a light industrial estate on the southern fringe of Sengkang town. Furthermore, there are large tracts of land which are not likely to be used for the next 10 years. Surely, it is better to put a piece of empty land to productive use, rather than to leave it idle for the next 10 years. If the MPs in Pasir Ris-Punggol GRC and Ang Mo Kio GRC cannot be convinced by the reasons given by HDB and URA that there is no space available for heavy vehicle parking in Sengkang or Punggol, how can we convince our residents that that is so?

Sir, Government's policy has been that the cost of ownership of cars would be reduced over the long run, but the cost of usage will increase. Hence, we have increases in ERP charges. We have ERP almost everywhere, or soon to be everywhere, that we are going to have ERP day and night. I think very soon, ERP will mean "every road pay". Sir, the day will be quite soon when the only safe place to leave your vehicle is at home, if you are lucky enough to own a landed property. You can well imagine that, one day, if I drive out of my house, the first thing I hear would be this "beep" sound coming from the little device on my dashboard, and everywhere you go, you will be hearing "beep, beep, beep", instead of car horns. Sir, the Minister of State for National Development was quoted as saying that HDB is going to suffer $99 million loss a year in running the car parks. Therefore, it needs to increase its car park charges to cover this deficit. Whereas his Minister was quoted as saying that the reason why HDB wants to raise the car park charges is that it would have more money to build more car parks in future in order to anticipate the increase in the number of cars in Singapore. So I would like to know which is which, and to be more precise, I would like to hear from the Minister how much does it cost for HDB to build one car park lot, uncovered and covered. I hope we will have enough time so that I can follow up with more questions after we get the figures.

Sir, in this Budget the Finance Minister announced that car park charges would be revised, and he said: "Where HDB residential parking is concerned, the existing charges do not cover the costs of building the car parks, leaving HDB with a large deficit." This, I assume, is the justification for the increases in HDB season parking charges. Of course, I do not know whether the HDB will take this opportunity to revise the hourly parking charges as well. Sir, I have checked from the HDB's Annual Report and found that in 1994/1995, the deficit from car park activities was less than $6 million. In 2000/2001, the deficit went up to $99 million. The bulk of the increases in expenses resulting in deficit were interest expenses and depreciation which formed $62 million in 1995, increased to $140 million in 2001, and interest expenses went up from $84 million in 1995 to $186 million in 2001. Sir, I would like to know how these changes in the financial position of HDB car park activities came about. Is the HDB dumping the cost of building multi-storey car parks in the new estates and upgraded precincts into the account? If this is the case, is it fair to increase all HDB parking charges across-the-board, including those old open car parks in HDB estates built in the 60s and 70s? Is the deficit incurred as a result of HDB building more multi-storey car parks, bearing in mind that HDB continues to collect parking fees even for car parks they already have, probably, zero depreciation value? Building of car parks is therefore equivalent to a long-term investment. And if the depreciation is zero and the cost of building the car park has been recovered long ago, I suppose, those built in the 60s and 70s, where is the justification to increase the parking fees in these car parks by reason of HDB incurring a huge deficit? And if the justification is to recover the huge deficit in car park operations, then is the HDB prepared to just break even for car park operation in the long run? Sir, the other issue I want to bring up is whether the HDB has a cyclical work plan to improve the car parks. I wish to inform the Minister that car parks in the estate in Hougang constituency have not undergone any major improvement by the HDB since they were built together with the flats in the 70s. The condition of most of the access roads and parking lots has been bad. I would like to ask the Minister whether the HDB would pay for improving the car park access roads and the parking lots in Hougang constituency.

Sir, the new towns, such as Sengkang and Punggol, are lovely to look at. However, like all new towns, they were initially beset with the problem of lack of physical facilities and social services. On this note, I must commend and thank the Minister for the town development task force which he set up in Sengkang. This pilot project, which has brought together more than 20 Government agencies and different community organisations, has made it possible for residents in Sengkang New Town to have significant improvements made to their living environment, and a rapid response time to many of the problems that they have faced. The improved coordination and better understanding between the different organisations have vastly improved the quality of life of the residents in Sengkang town. There are two other areas where further improvements can be made. 2.00 pm Firstly, better designs. One of the problems of the new town is that although the facade looks beautiful, there are many problems with the designs which have become regular irritants to many of the residents. The block signs are so aesthetically designed and well concealed that they cannot be easily seen by visitors or residents. The sheltered walkways are bright, airy, with beautifully-designed roofs, but leave the user with little protection from even a gentle drizzle. The drop-off points are strategically placed with arching canopies that invite rain to fall into the shelters, making one wetter than if one stood under an umbrella. The lift lobbies are so cosily designed that you can hardly see each other in the day time, unless the lights are switched on. The lift buttons blend so well that you cannot figure out the numbers. I am all for creativity and aesthetic designs. However, more importantly, we must take into consideration that functionality and practicality must not be forgotten. Much money will have to be spent to correct these design problems. In future, the Minister may wish to consider a feedback committee formed from the community organisations or town councils, which will give feedback to HDB before these designs are approved in the new estates. This will ensure better designed public flats which are both beautiful and functional. Secondly, designation of land use. In this age of increased transparency, URA and HDB should openly state the designated use of land, eg, for churches, temples and mosques. Flats next to a designated religious site may have less appeal for many but at least those who choose these flats do not feel that they have been given a big surprise and will be better adapted to the environment. The Ministry should pre-designate religious sites in advance of flat selection. This transparency will bode well for new flat owners.

(In Mandarin): Sir, in the early days, the HDB always provided for wet markets in the old estates so that the residents could go and purchase their food and market produce. The wet markets have all sorts of produce offering the residents very good choices. The residents enjoy buying their food there because they can pick and choose, and can even bargain for cheaper buys. But, in the supermarket, there are no such facilities. The choice is limited and the prices are fixed and not bargainable. Most importantly, at the wet market, residents can mingle with one another and talk about anything under the sun, even national issues. But, recently, in all the new towns, the HDB has stopped building wet markets. They have only the so-called dry markets which are actually housed in shops. These are very small and there is hardly any space for the residents to move about. The situation is even worse when it rains. These shops, when they are operating as markets, are not hygienic and people are not very happy with them. Residents, particularly housewives, would prefer to go to the wet market because they like this concept of wet market better. For example, in Boon Lay, Jurong or Chong Pang, all these wet markets are very popular with the people and the business there is very good. I have asked the officers in HDB why they have stopped building wet markets, and they told me that the wet markets were very messy, and that was why the Government had stopped building wet markets. I do not believe that the wet markets are messy. Perhaps, they were referring to the great number of people moving about in the area, and the wet markets were always bustling with activities. So, if these officials think that they should not build wet markets because they are messy, then I am afraid they are terribly wrong. I hope that HDB will reconsider this matter. Nowadays, a lot of people queue up to buy HDB flats in the mature estates. When Channel News Asia interviewed these people why they were flocking to buy flats in these old estates, the spontaneous response was, "Because there is a wet market, it is very convenient here. That is why I am applying to buy a flat here." Since most residents like the wet markets and they are popular with the residents, I hope that HDB will consider building wet markets in the new towns like Sengkang and Punggol, and provide better services to the residents. I hope that HDB could conduct a survey among the residents, and find out whether they would welcome the provision of wet markets in the estate, before they formulate their policy. I think that would better reflect the wishes of the residents. In Mr Yatiman's constituency, HDB has built a new wet market to replace the dry market. I would like to find out what is the residents' response to this wet market. I understand from Mr Yatiman that the residents like this wet market very much. If that is the case, would the Minister consider building more wet markets in the other estates, to fulfill the wishes of the residents?

Sir, first of all, let me take the points raised by Mr Zainul Abidin Rasheed on the question of helping residents cope with financial difficulties. He suggested specifically allowing the residents to downgrade or to buy another flat in order to help them with their difficulties. There are certain rules about this but, by and large, there is no difficulty for residents to actually downgrade in order to get some money from their existing flat to cope with their difficulties. However, there are requests from time to time concerning the interest rates that will be charged, and these are considered based on the appeals by the MPs. I would like to assure him that HDB will continue to take a sympathetic attitude to such requests. But it need not necessarily be so. They do not have to sell their flats if they do not want to. In fact, there are many schemes put in place by HDB to actually help residents to cope with their difficulties without having to give up or lose their flats. These have been quite successful. There are quite a number of residents who do take advantage of these schemes. For example, the reduced repayment scheme whereby residents pay a certain percentage of their instalments. Instead of 100%, they pay 75%. Or they can defer their instalment for six months, or they can actually extend the loan repayment period. So all these measures do help the residents cope with their financial difficulties. They are actually very generous measures that have been put in place. In fact, HDB will refine one of these measures even further, to make it more helpful to the residents, namely the reduced repayment scheme. Currently, they can pay 75% of the instalments, but HDB will, effective 1st July 2002, allow mortgagers to pay between 50-75% of their monthly instalment. In this way, the residents will be able to pay something and not have to defer their loan repayments totally. This will be for a period of two years. There will be a 6-monthly review by HDB, because HDB would like to ensure that residents, once they can afford to pay, will actually restart their instalment payments. This will be of help to the residents. But, over and above all these financial assistance measures, the greatest comfort to HDB lessees is really the fact that they are protected from third-party creditors, even if they are made bankrupt. So whatever happens, eg, if they lose money, they are sued by other creditors and are made bankrupt, they will not lose their flat. This is probably the greatest comfort to our residents. Why? Because we have, since we started the public housing programme, made sure that home ownership is one of the cornerstones of our policy. It is a very important social objective. I wanted to make this point because there have been recent calls to allow HDB flats to be used as collateral, in order to provide funds for business. It is an interesting proposal, but I just want to add a word of caution here because, as I said, home ownership is a fundamental principle of our home ownership policy. There are many questions that we need to answer and many issues that we need to look into before we consider this issue. One of the first questions that we ask ourselves is how do we ensure that the funds that are derived from mortgaging the flat is actually used for business and not used for consumption, eg, buying a car, going on holidays, etc. And what if the business fails and they lose their flat? Are they prepared to bear the consequences if things do not work out, or do they look to the Government to provide them housing as a last resort? These are some of the questions that we need to ask ourselves, and we will have to study this proposal carefully before a decision is made. I will just take this opportunity to respond to a question that Ms Irene Ng asked just now. She is not here. This is concerning the issue of singles or other people, who as a result of the demise of a family member suddenly find themselves without a family nucleus and are worried that HDB would turf them out. I wish to assure Members of the House that HDB will adopt a compassionate attitude to such cases, especially where one member of the family passes away because, obviously, this is not by choice. So, in such a case, the family nucleus requirement is waived, and the remaining occupant can retain his or her flat. Let me now touch on the issues raised by various Members on parking. Let me take Dr Michael Lim's first about heavy vehicle parking. This is a perennial problem in our HDB estates, and there are two contending forces here. On one hand, residents are extremely upset when they have heavy vehicle parks next to their homes. They create traffic hazards and noise and smoke nuisance to the residents. Sir, all Members who have heavy vehicle parks in their housing estates can bear me out. Trucks and buses start up at six o'clock in the morning, and residents get woken up from their sleep. As a result of that, we get constant complaints about siting of heavy vehicle parks in their housing estates. On the other hand, of course, there is a demand from heavy vehicle owners or drivers who want to park their heavy vehicles right next to or near their homes. Sir, heavy vehicle parks are popular in HDB estates precisely for this reason - because they want to park their heavy vehicles near their homes. But let me stress that the heavy vehicles that are being used are not meant to be used as their private transport. They are meant to be used for business. As such, HDB cannot provide enough parking lots for heavy vehicles, because there is a real shortage of suitable land in the housing estates. Even if they did find a suitable piece of land, inevitably there will be competing uses or there will be housing blocks nearby and, therefore, MPs will complain, if these empty plots were used for heavy vehicle parks. There are actually enough heavy vehicle parks island-wide for heavy vehicles. In the past, URA and HDB tried to accommodate the demand for such parking lots on an interim ad-hoc basis on vacant lands which are close to HDB estates. But, as I have said, this is no longer sustainable. The existing interim parking lots will be phased out when the land is needed for development, and more parking lots, if these are needed, will be made available near workplaces like Jurong, Kranji, Senoko and so on. In fact, the LTA tells us that there are actually adequate parking lots island-wide for such heavy vehicles. So I would urge Members to understand the constraints that are faced by HDB, and also to help HDB to balance the interest of heavy vehicle drivers on the one hand and residents on the other. 2.15 pm May I now turn to the questions raised by Mr Tan Soo Khoon and Mr Low Thia Khiang on our car park charges. The first question raised is: why are we raising our car park charges? Is it justified? The point is that HDB residential car parks are heavily subsidised. The current charges are way below the cost of providing these car parks. The extent of the subsidy for last year, FY2001, for example, was something like $115 million from the car park operations. Mr Low asked where this deficit comes from. Basically, the cost incurred in running the car park includes the land cost, because HDB has to buy the land to build a car park. It is not given away free of charge. It is charged based on residential rates, because if we do not use the land for car parks, we can use it for housing. The land is sold in one piece. The other cost involved includes construction cost, obviously. Then, there is the cost of maintaining the car park. Finally, there is interest cost, which is the cost of funds used for building and buying the land. All these elements make up the cost. There is a certain depreciation period, and the cost is depreciated over this period. On the other hand, the income from car parks includes the parking charges, which is the bulk of the income. It also includes some fines, but that is a relatively minor amount. If you take the cost and the revenues into account, you will note that there is a heavy deficit, something like $100 million. Even after we have raised the car park charges, the deficit will still be quite considerable. The fundamental principle is this. Government will subsidise the housing needs of Singaporeans in order to enable them to have a roof over their heads, but Government will not and should not subsidise car owners who live in HDB flats. This is simply not fair to all the non-car owners in HDB estates. I would like to inform Members that the majority of HDB lessees do not own cars. If we do not price the car parks properly, what is happening is that HDB will be carrying a deficit in its books as a result of subsidising car owners. Eventually, one way or another, this subsidy is going to be borne by all HDB flat owners. As a matter of principle, it is best for us to make sure that car owners pay what is fair and what is adequate for the provision of car parks for them to use, and not to have this cost lumped to the non-car owners. Why are we doing this now? The reason is because with the new car policy, with the reduction in car taxes, with the increase in the number of COEs which has been announced, we can expect our vehicle population to go up. If we do not reduce the deficit on car parks, and if we continue to have a deficit on car parks, and if we have to build more car parks, the deficit is going to increase in the future. It is not going to get smaller. It is actually going to go up. This is the reason why we have to raise the car park charges in order to recover the cost of providing the car parks. And the reason why we are going to raise it in September this year, is to coincide with the reduction in car taxes, with the implementation of lower road taxes. We are mindful of the impact of these increases on HDB car owners and this is the reason we are timing it for 1st September. Just to give Members some idea. If a person is an owner of a 1,500 cc car, his road tax rebate will be something like $225 a year, which works out to $18.75 a month. The increase in the monthly season parking charges for a sheltered car park lot is $15, which is less than the $18 rebate that he is getting for car taxes. If we are talking about surface car park lots, the increase would be $10, again lower than the reduction in car taxes. Finally, this revision in HDB/URA car park charges is part of the larger package of measures that affect car owners, where the intention is to match the cost of driving with usage, rather than ownership of cars. So, it is inevitable that motorists, who use their vehicles a lot, will have to bear the higher cost of usage. Mr Low also asked whether we will eventually go for breakeven in the charges for car parks. We do not have plans at the moment to reach breakeven level. Let us explain to the public and get the public to accept that the increases that we are going to implement on 1st September are reasonable and acceptable, and also get the message across why we have to raise car park charges come 1st September. We are not looking for breakeven at this point in time. In so far as maintenance of car parks is concerned, in Hougang constituency, if Mr Low has any specific complaints about the car parks in his constituency, he may let the HDB know. As for certain parts of the car parks, I do not know which part he is referring to. Some parts may be under the Town Council, and some under HDB. But if he can let the HDB know, I am sure they will look into it. The point is that there is a need for car parks to be maintained. We do not just build a car park and then after that, we let it be. There is a cost incurred in maintaining car parks, and this cost of maintaining car parks is also part of the cost which I have just cited earlier, which is the reason for the deficit in car parks. I will ask my Minister of State to deal with the other questions on wet markets, as well as on the use of HDB flats for food business.

Sir, may I seek clarification from the Minister? We have now heard another reason for the increase in car park charges because there is a road tax rebate. So the Government is giving money in one hand and taking back from the other hand. Sir, first, I do not see any Government subsidy reflected in the accounts. The amount of deficit, I believe, is a total reflection of the cost. I wonder whether the Minister will agree that if the depreciation of the construction cost is taken over a longer period of time, it will not incur so much deficit and thereby, we can afford to charge lower car park fees. My other question is whether are there cyclical plans for car parks, just like HDB flats and not so much on the maintenance.

Sir, the Minister did not answer my question about the cost to HDB of an open surface car park and a covered carpark.

First of all, Mr Low is quite disingenuous to say that the reason for us to raise our car park charges is because the road taxes have come down. I did not say that. What I said was that the timing of the increase is such that the increase of car park charges will be defrayed somewhat by the reduction in the road taxes. We could have raised it earlier, but we did not do so. The timing of 1st September is precisely for that reason, to make sure that the impact on motorists is minimised. It is not a reason for doing so. I hope Mr Low will not get the wrong impression. Secondly, on the issue of depreciation, yes, we do depreciate over the life of the car parks. I am not sure exactly what the life span is. But the cost, under normal accounting practices, has to be depreciated over the life of the car parks, and I believe this is being done. On cyclical works, yes, of course, the car parks will also have to undergo cyclical works. If we are talking about a multi-storey car park, some of these works would not come under the Town Council, but come under the HDB. As for surface car parks, the cyclical works involved will be minimal, but it still needs to be done. Resurfacing, for example, needs to be done. The more critical work that needs to be done is the replacement of these surface car parks with multi-storey car parks. The demand for car park space is very high in HDB estates, and we have to constantly look for ways of increasing the number of car park lots. One of the ways of doing so is to replace surface car parks with multi-storey car parks. Let me answer Mr Tan Soo Khoon's question about cost. The estimated cost of providing a surface car park lot is something like $11,000, and this includes land cost as well as construction cost. But the construction cost, obviously, is much lower than the land cost. Then, for the covered car park, it is about $20,000. In this case, the construction cost is much higher. The land cost, of course, can be split up over more car parks. These are roughly the ballpark figures at the moment.

Does the HDB do cyclical works such as resurfacing the access roads to open surface car parks?

Yes, I believe they do.

What is the timeframe, Sir?

Sir, I am afraid that I do not have the answer. I would imagine that it is done as and when it is necessary. I do not have the answer, but if the Member wishes to file a Question, I will give him the answer.

Sir, in 1989, the then Minister for National Development told the House that the cost of an open surface car park lot to HDB was $14,443, and $32,581 for a covered car park lot. Based on what the Minister has just told us, it would appear that the cost of providing car parks to HDB has dropped by quite a lot in the last 10 years. Can he still justify the increase in charges if it is based on cost? Second, if it is $11,000 for building an open air car park lot, and if the size of the car park lot is about 60 square feet, that works out to almost $200 per square foot, and this is providing something without four walls, no roof, no water, no power supply. Is this not a very expensive piece of real estate?

Sir, first of all, I cannot comment on the figures that were cited earlier. I will go back and check. But these are the figures that have been given to me now and they are, I presume, the current figures. Even with these figures, there is still a deficit. To answer his question whether we are justified, the point is, based on this cost, we still run a deficit of over $100 million a year. And even with the increase, we are still going to run a deficit close to that amount. The answer to his question is yes, we are justified in raising the charges. On cost of the real estate, yes, land cost is very high. As I have said earlier, the cost of the land for car parks is treated the same as the cost of land for housing. The justification for this is very simple. If we do not use the land for car park, we have to use the land for housing. So we better make sure that we make good use of the land.

Sir, let me answer the points raised by Mdm Ho Geok Choo on promoting the informal sector in HDB flats. In her speech, she mentioned the possibility of coming up with more rules and registration procedures to facilitate this. I am glad to inform her that there is no need for registration and additional rules in this area. HDB already permits various small-scale business activities to be conducted from HDB flats, and these activities will include making satay, tarts, baking cakes, music, tuition and so on. However, HDB's foremost priority is to preserve the residential nature of these flats. As long as these activities do not contravene and change the fundamental nature of these residences, HDB does not require them to even register with us. 2.30 pm With respect to the public health standpoint, I think she can take it up with the Minister for the Environment, whether they will permit food prepared within these flats to be sold to the general public. With all the concerns now on public health, especially after Question time today, I think all Ministers will be a lot more cautious on that note. I want to move on to Dr Michael Lim's points about new towns. In particular, he talked about having beautiful designs, which are not necessarily the most functional. All of us in this House are realistic enough, and practical-minded people, who do want beautiful designs to be, first and foremost, practical. We are mindful of this. We are also mindful of the fact that it is not enough to just have something beautiful, but we want it to be easily maintained, because in the long run this affects our cost. I take his point that the people who have a greater stake in this are the professionals and the residents on the ground. That is why before HDB embarks on any upgrading programme, it will always consult advisors and grassroots organisations, as to the form and the structures which need to be put up. However, I just want to add a cautionary note that it is impossible to please all-comers and to make everybody happy with all the different perspectives. At the end of the day, we have to come out with a design which is workable, and which addresses as many needs as possible. Dr Michael Lim also brought up his perspective about pre-designating religious sites. Let me assure the House again that planning is a most difficult process. We have to trade off sometimes between flexibility and being overly specific at a premature point in time, in which case, we actually constrain flexibility. But having said that, wherever possible, if we are certain on the specific use of a site, the HDB will seek to transmit that information to the advisors and to the grassroots organisations as soon as possible. But I think Members will have to appreciate that sometimes we do not have all the answers at that point in time. I want to move on to Mr Ang Mong Seng's point on wet markets. Prior to 1982, the HDB built wet markets in HDB towns. However, sometimes these things became a bit messy and unhygienic, and I take his point that this, to some extent, would have been caused by the fact that there was relative overcrowding, or too many people using it. But after 1982, a policy decision was made to stop building wet markets, and instead to build dry markets. These dry markets really consist of a cluster of market produce shops and a supermarket. But, in reality, what happened was that the shopkeepers and the residents started treating these like wet markets. This became neither fish nor fowl, and it ended up becoming a hybrid, which was just as messy. After 1992, the HDB stopped building these dry markets and moved on to a new concept, which we called the "new market". These were similar in character to the wet markets, but there was a key difference. They were designed to be more hygienic, easily maintained, better drainage, wider aisles, and there were larger market stalls. These new markets are usually co-located with other retail and eating facilities in stand-alone neighbourhood centres. Such integrated facilities provide a better marketing and shopping environment for the residents. Examples of these would include Rivervale Plaza in Sengkang Town and the Yew Tee Shopping Centre in Chua Chu Kang. Since October 2000, the HDB has also started tendering out designated sites in new towns to the private sector for the provision of retail marketing and eating facilities to meet the needs of the residents. The successful tenderer is allowed to decide whether he is going to construct a new market or a supermarket. But, obviously, this will have to take into account the residents' needs on the ground. We think that, in this way, we will evolve forms of markets which will address the needs of the residents, whilst at the same time being practical and hygienic.

Dr Teo Ho Pin, we are running behind time.

Sir, despite contributing about 5-8% to our GDP yearly, the construction industry is not a sunrise industry. It faces problems of sustainable workload, shortage of labour, lack of innovation, low productivity and a poor public image. To date, not much attention has been paid to the development of the construction industry. The recent failures of some large construction firms, which affected various public projects and many industries, clearly show signs of possible collapse of the industry. The Construction 21 plan does not provide key strategies to develop our industry. There is a lack of focus to nurture local consultants and contractors to be world-class players. I would suggest that the Ministry set up an International Advisory Panel to develop our construction industry. Sir, I wish to ask the Minister the following questions: (1) What are the key strategies in developing the construction industry? (2) What are the plans to nurture local consultants and contractors to be world-class players? (3) What are the strategies adopted by BCA to export construction services?

Sir, when construction companies, which are undertaking the MUPs or the IUPs in our housing estates, are not able to meet the project schedules, the residents staying in the MUP and IUP precincts are greatly inconvenienced. This will be more so where residents want to renovate their flats and cannot proceed because the internal upgrading works to be done by the MUP contractors are delayed. Further, the delay in the completion of the external works can also create problems of safety and security in the precincts. Sir, I therefore would like to ask the Minister whether his Ministry or the HDB can assist where the contractors have some problems. Their problem may be of a temporary nature - sometimes it is just a cash-flow problem. Could the HDB come in to assist so that the work can be carried out without undue delay? Sir, the other feedback we got is that the cause of failure of companies to complete the projects is because of the way we have selected these contractors, which is on the basis of the lowest tender. Sir, I agree that cost is an important consideration, but there are also other critical considerations if we want to ensure that the project can be completed in time. Sir, sometimes the companies that are selected are overstretched and, therefore, they cannot carry out the project in the way that it should be done. Sometimes, the way they manage the projects is also not what we had hoped for. Sir, I hope that the Minister and the Ministry can look into these problems, so that our HDB MUP and IUP projects, which are actually good projects, can be done with the least inconvenience to the residents.

Order. I propose to take the break now. Thereupon Mr Speaker left the Chair of the Committee and took the Chair of the House.

Order. I suspend the Sitting and will take the Chair again at 3.00 pm. Sitting accordingly suspended at 2.40 pm until 3.00 pm. Sitting resumed at 3.00 pm

Debate in Committee of Supply resumed.

Head T (cont.) -

Dr Teo Ho Pin, you have three cuts which you can take together.

Sir, first on sustainable construction. Sustainable construction is hardly practised in Singapore. To achieve the vision of our Green Plan 2012, we need to promote sustainable construction practices in Singapore. This will ensure a balance between sustainable development and maintaining a quality living environment. Sir, there is not much incentive for sustainable construction practices in Singapore. As such, the impact of construction operations on the environment can be undesirable in the long run. I wish to ask the Minister the following questions: (1) What are the initiatives taken to encourage sustainable construction? (2) How many construction firms are ISO 14000 registered? Next, on construction technology. The incentive schemes by BCA have not been successful in encouraging technology innovations among contractors. As a result, many local construction firms have not developed any capability or niches to be globally competitive. Sir, I wish to seek the following clarifications from the Minister: (1) What is the state of technological advances in our construction industry? (2) How does BCA facilitate the introduction of new construction technologies in the industry? (3) What are the R&D efforts by BCA to encourage technological innovations in the industry? Next, on contractors' registry. The existing and proposed new contractor registration system by BCA has some fundamental flaws. It provides protectionist mechanism for consultants and contractors. This contradicts the Ministry's plan to promote self-regulation in the industry. At the same time, it restricts open competition among contractors based upon performance and track records. At present, the BCA registration scheme forces contractors to procure contracts at unrealistic tender prices and adopt substantial sub-contracting of their work to meet the registration requirements. This has resulted in the liquidation of firms causing delays of projects and loss of jobs to many Singaporeans. All these hamper efforts to develop the capability of our contractors and consultants. Sir, I wish to seek the following clarifications from the Minister: (1) Why do we need a contractor registration system while other industries do not? (2) In the proposed contractor registration system, why is there a requirement to have one-third architects or engineers running a construction firm? (3) How will it help in nurturing world-class construction firms?

Sir, precast concrete is now widely used for the construction of HDB flats. It has become important components of flats. I understand that in the past, HDB required the presence of inspectors before the casting was done. However, presently, the system has been changed to that of merely conducting random spot checks on the plant, and testing of the precast concrete. In the light of the above, I would like the Minister to address two concerns. One, how does HDB ensure that the precast slabs are of acceptable quality and do not inherently contain potential problems, such as spalling in the future. Two, will the Minister explain and evaluate the current system of inspection and supervision of precast plants, and how the quality of precast concrete components in HDB flats is determined and assured?

Sir, on behalf of the Minister for National Development, I would like to thank all the Members for the questions. They raised important questions on an important sector of the economy. Sir, I would like to reassure Members that the Ministry is fully focused on the rehabilitation of the construction industry. Contractors in Singapore have made significant contributions to our economy without which our first-class economy could not have been built. The MND is determined to help contractors ride out this very severe recession, at least as far as contracting is concerned. But like other sectors of the economy, Sir, contractors also have to restructure their business. The BCA is there to help them along. The BCA in Singapore is not just a regulator, but is also a promoter of the construction industry. Sir, with your indulgence, I would like to answer Mr Low's question first, just in case I am guillotined by your samurai sword! Mr Low raised a point about the structural safety of precast components, ie, the strength of precast and prefabricated components used in constructing buildings. Essentially, he has asked how assured are we that there is no cutting of corners, there is no collusion and corruption in the precast yards. Sir, all precast components used in buildings have to be certified by a professional engineer. In the trade, we call him or her PE. This PE is personally liable for the structural safety of buildings he or she designs, and this professional liability is a life-time liability. This liability cannot be extinguished until he or she dies. So long as the building stays, his or her liability is there. So, it is unlikely that a PE will treat the matter of safety lightly. In all cases, we require a PE to certify that the structural component precast in the yard is safe; in other words, it is precast according to the working drawing. The working drawing is designed according to the loading of the building. If he or she cannot perform the supervision personally, then he or she can reassign the task to a clerk-of-works. Sir, I come now to HDB, because HDB is the biggest developer in Singapore, and is a concern of the Ministry. Out of the 32 precast yards in Singapore, 28 of them are HDB-approved yards. In other words, we only buy from these HDB-approved yards. These yards provide precast components to HDB buildings. Because HDB is the biggest developer, it has even more stringent layers of checks. First, HDB will require a professional engineer or his clerk-of-works to certify the components before the parts are delivered to the building site. In other words, the checks must be done in the precast yard. This is on top of the requirement that these HDB-approved yards must have a resident engineer to supervise the overall casting procedures. So we have a resident engineer to oversee the yard; then we have a PE to certify each and every beam that comes to the site. If he or she cannot do it, he or she assigns that responsibility to a clerk-of-works. Second, on special production lines, HDB requires that the casting and checking procedures be recorded 24 hours for validation purposes. In other words, the precast procedure is recorded. Third, on site, HDB engineers will also do checks to make sure that the precast components delivered to the site before installation are of certified quality. So, there are three layers of checks. Members can be assured that all buildings in Singapore are safe. If Mr Low knows of any collusion or corruption in any precast yard, please alert the Ministry, or he can report the matter to the CPIB. This is a very serious matter. Sir, I will now go on to the questions raised by PAP MPs. I humbly disagree with Dr Teo that C 21 does not provide any strategic objective to uplift the ailing construction industry. In 1999, a comprehensive review of the industry was carried out. This review was jointly led by the Ministry of National Development, the Ministry of Manpower and all the related consultants, associations and contracting bodies in Singapore. Together, we agreed that the C 21 is the solution, not a problem to the construction industry. Sir, I will be happy to ask the BCA to update the GPC on the progress made by C 21. Sir, one of the key strategies of C 21 is to raise the overall performance of the industry in terms of productivity and capabilities of our firms. After several years of negative productivity, the industry registered a humble but very encouraging positive productivity of 0.2% last year. Measures to raise productivity, including promoting buildability, raising minimum skill levels and cut in foreign man-year entitlements - what we call the MYE - are making good progress. However, it will take quite a while for the true benefits of these measures to be harvested. Sir, to upgrade local capabilities, BCA works with EDB and SPRING to offer a broad range of schemes to encourage the industry to adopt new technologies. Since 2000, about $12 million worth of funds have been disbursed to almost 200 firms under the Industry Productivity Fund, Innovation Development Scheme and the Construction Jump Start Programme. The perception that there is a lack of innovation and technological applications in our industry is not quite correct. In fact, Dr Teo may be pleased to know that, in the last two years, BCA has invested something like $9 million for 20 R&D projects in four strategic areas, namely, IT, buildability, technology, building performance and high-performance materials. Sir, in Singapore, both foreign and local construction companies can compete for our projects. The presence of these foreign companies - many of them with world-class capabilities - have, over the years, set new standards and challenged our local industries to upgrade themselves technologically and to remain competitive. HDB's precast technology, for example, has attained quite a reputation world wide. Some local specialist companies have also developed niche skills such as reclamation technology and marine engineering which can also be exported. Sir, it will be unwise to pick winners and offer them contracts over and above contractors who offer good bids for us. Instead, the Government will provide a conducive environment to enable local firms to grow and upgrade to global standards. Another key strategy to raise standards and benchmarks for contractors is to revamp the Contractors Registry System (CRS). From 1st July this year, companies registering for CRS will have to meet higher firm requirements for financial capacity, personnel and track record to reflect current market conditions. The requirement of one-third of professional personnel be registered engineers or architects with the Professional Engineers Board or the Board of Architects has been introduced to strengthen the technical expertise of construction companies. Given that most projects are getting larger and more complex over the years, the more stringent criterion in the CRS will move firms to upgrade and pool their resources with others. Besides CRS changes, the Government will also be making legislative amendments to facilitate the formation of firms with multi-disciplinary capabilities to allow them to provide the full suite of services from design to build. At the same time, more projects of an integrated nature like design-and-build will be pushed out to allow our local industry to gain experience in this area. Sir, while companies have strengthened their capabilities at home, BCA and IES will also actively encourage them to grow their businesses as a long-term strategy. There is a long-term export plan within C 21 to grow our industries and export them to the region. BCA is concentrating its efforts in cities like Beijing, Shanghai, Sichuan in China, and Bangalore and Hyderabad in India. In March last year, Chairman of BCA led a promotion mission to India. Later this month, the Minister for National Development, Mr Mah, will personally lead a business mission to China to promote the capabilities of our companies. 3.15 pm I would like to thank Dr Teo for his idea of an international advisory panel to develop our construction industry. Indeed, the Economic Review Committee is looking into such ideas. They are looking at reputable construction companies in countries like South Korea, Japan and France, and try to learn from them as to how to remake our industry. The Working Group is still deliberating. I am sure some interesting ideas will come out of this report. Dr Teo raised a point about sustainable construction industry. I am happy to note that this is something the BCA has been looking into in the last few years. In two years' time, all companies on the top two grades of the new CRS would have to be ISO 14000 certified. To-date, something like 32 companies are already ISO 14000 certified, and one-third of the companies on the top two grades, ie, the A1 and A2, are already ISO 14000 certified. Public sector tender - this is an important subject raised by Mr Othman Eusofe and various MPs. The concern that HDB awards tenders to the lowest price, regardless of the performance of the contractors, is not quite correct. It is precisely for this reason that we have the Contractors Registry System. It is to sieve out unscrupulous contractors who have a bad track record with any of the Government agencies. Price is an important consideration, but there are other considerations, like track record, performance record, and also recommendations from other Ministries. It is not necessary for any Ministry to award a contract based on the lowest price. But since we already have a CRS, companies on that list are already pre-qualified. In other words, they are not so bad companies; very often, quite good companies. So there is no reason for us to strike them out, unless there is a very firm body of evidence to suggest that in the last few months, this company has gone bad. On the state of the construction industry, the industry has suffered from the downturn in the economy. The demand for private and public housing has gone down. So the construction industry is at its crossroads. But we are sure that as the economy picks up, the construction industry will rise from the ashes. The revamped CRS is one approach taken by the BCA to make sure that when good times come again, we have good contractors ready to catch the wind.

Sir, I will be brief but flowery. We all are very proud of our Garden City. Having done a successful job in greening our country, we have added more colours and we have also gone fruitful. I think one of the best drives of any airport in the world is the ECP, and we are proud of that. Recently, I was invited to the launching of "Adopt-A-Park" by the Telok Kurau Primary School. I gladly accepted the invitation and went there, but only to find out that the park actually belonged to another GRC. Although I have the beautiful Bedok Reservoir Park at neighbouring ward, belonging to BG George Yeo, and I am still proud of it, I miss the Punggol Park from Punggol East where I came from, from the last term. I really miss Punggol Park as a landmark area. My question here is, coming from Eunos, which is a very old estate, there we have more of a concrete jungle rather than green. So I would like to see the National Parks Board and Ministry of National Development spend some effort to see how they can help old estates, where they have a lot of concrete but less green, add some element of green lungs. If they can look at even small corners here and there, and get the National Parks Board to inject some freshness, some green, some colour and some fruits, I think life will be a lot more meaningful.

Sir, URA is one of the most important land utilisation agencies in Singapore. In addition, there are other agencies such as JTC, HDB and SLA which have land utilisation programmes as well. Very often, more than one agency is involved with regard to the utilisation for the very same piece of land. This has caused problems for those who have purchased land from Government's land sales programmes or tenders. As land is an expensive resource which will tie down the capital of many investors, there is a need for Government agencies to coordinate their requirements and not be a hindrance to investors. As such, a single Government agency should be formed for the purposes of land utilisation so that there can be better coordination between URA, JTC, HDB and SLA. This will allow smoother processing of administrative requirements and better management of the supply of land. Next, Government should also consider reviewing development charges. The glut in commercial and industrial space has resulted in much space that has been left idle. To improve productivity and efficient utilisation of space, companies may have to reconsider change of use of space to improve space usage and increase the chances of viability of the business. Whenever there is a change of use, they have to apply to the relevant bodies like URA or SLA, which may then charge them hefty development charges. This will discourage the commercial space from being put into better use. Bodies like URA and SLA should not be overly concerned about trying to squeeze the maximum out of every business as this will only accelerate the demise of these companies and thereafter, result in a loss of jobs. They should exercise appropriate professional judgement, taking into account that they are not there to make as much money as possible from commercial companies, but rather they are there to ensure that planning norms are adhered to and act according to the prevailing market situation without unduly burdening the companies. To incentivise companies to utilise idle economically inactive space, URA or other land agencies should, in fact, consider giving them a discount on the development charges and allow these charges to be paid over a period of time. Lastly, there is a need to increase transparency and accountability. Land utilisation bodies must also be more transparent and accountable and must not change development charges unilaterally. They must tell the companies that the development charges are for proposed building plans and they should continue to revise development charges after approval has been given. Additional charges must never be an afterthought. A professional body, whether it be the URA, SLA or any other land utilisation agency, must refrain from piling charges. We need a body beyond the land utilisation agencies which can react quickly to resolve disputes whenever they arise. This dispute resolution body which hears appeals should be empowered to act quickly so that it will not increase the cost of business of a Singapore company. In a globalised environment, where the economic challenges to Singapore are significant, our land agencies must be able to act professionally, be transparent, have high service standards and not be obstacles to business growth. It is time for the agencies to adopt a new mindset.

Sir, I would like to seek the following clarifications from the Minister: (1) What measures have been taken to increase the production of fish, eggs and vegetables in Singapore? (2) What is the status and production output of our deep sea fish farm? (3) Can the Ministry support high-rise farming in Singapore?

Prof. Low, we have less than six minutes for your speech and the reply.

Thank you, Mr Chairman, for the long time given. Sir, food supply in Singapore depends almost fully on external sources, except only a small percentage on the high-tech farms in Singapore. Vegetables come mostly from Malaysia; fresh pork only from a small island called Pulau Bulan in Indonesia; fresh chickens only from Malaysia; and rice from Thailand. Due to the dependence on limited sources of supply, our food supply, in terms of quantity and price, fluctuates. The famous case was the ban of pork from Malaysia due to the Nipah virus. The price then increased by almost double. The increase in vegetable prices quite often could be due to the shortage of supply from Cameron Highlands because of bad weather, or it could be due to the ban of imports because of the high level of pesticides being used. Sir, one of the ways to ensure less fluctuation of food supply and also their prices is to depend heavily on the diversification of the sources of supply that we can develop. I notice that there were businessmen following the Minister's visit to Pekan Baru sometime ago, and the objective of the visit was to develop a vegetable growing industry. Singapore also signs a pact with Thailand to ensure priority of supply of rice to Singapore. The Minister also visits Sichuan in order to secure pork supply from China. Recently, during the visit of our Prime Minister to Thailand, it has also been announced that there is a certain degree of agricultural food supply collaboration. We have heard so much and are excited about all this publicity, but we see very little from the results of all these initiatives in diversifying our food supply. Could the Minister enlighten us on the progress of all these projects? The other issue I would like to raise is regarding local farming.

Prof. Low, I presume you do not want a reply.

Let me talk about one important point. In the recent case of a murder in a Lim Chu Kang farm, the authority then realised that the farm hired a large number of illegal foreign workers. The question is: why did it hire illegal foreign workers? In fact, MND, or the former PPD and the current AVA, knew about the problem of shortage of labour. MND has either failed to convince MOM that such a project is important or it is, as what other people have commented, that the existence of all these high-tech farms is just to keep a pool of veterinary and agricultural experts to be hired by AVA. I would like to ask the Minister whether the Ministry is serious about the development of all these local farms and what assistance the Ministry will render to expedite and develop all these projects announced.

Dr Balakrishnan, you have 21/2 minutes.

As the sickle is about to be wielded, I am only going to talk about farming. Given our land constraints, it is impossible for us to be self-reliant. Our key is diversification. I just want to remind the House that we import vegetables from 32 countries, meat from 25 countries and fish from 89 countries. So we have multiple sources of food. The AVA seeks out and is continuously on the lookout for new sources of food. As we identify new sources, we try to transfer technology into these places. As we try to transfer technology, we also look to match-make them with our private sector so that funds from the private sector can invest in these agricultural expeditions, for instance, shrimp and fish processing in Myanmar, Malaysia and Vietnam, shrimp farming in Malaysia, vegetable farming in Indonesia and China, sea food processing and, of course, fresh pork supply in Australia. You can see the nice photos of that in yesterday's newspapers. With respect to local farms, our objective is to provide technical advice to our farms because our farms cannot be the low-tech wide expanses of farms which you see in overseas countries. They have to be high-tech and high-productivity farms. There are no current commercial deep net cage fish farms in Singapore. However, the AVA has just completed a four-year pilot project to show that it is feasible to have good quality tropical fish in deep net cages in Singapore waters. The main constraint, however, is the absence of a reliable supply of fries. In this respect, I am glad to say that AVA has demonstrated that unlike human fertility, we are pretty good at fish fertility and we have been able to produce commercial quantities of fish fries which will be essential ingredients for our deep net cage fish farming. So, Dr Teo, take heart from that. As regards high-rise farming, there is obviously a limit as to how much we can do. We cannot put the farms on top of our HDB blocks. They cannot take the weight of the irrigation systems which will be needed. However, if such high-rise farms indeed are economically viable, and the private sector is willing to bet and put money into it, MND will certainly facilitate this. 3.30 pm

Order. "Guillotine" time. Dr Teo, would you like to withdraw your amendment?

Sir, I would like to thank the Minister, the MOS and SPS for their comprehensive and concise replies. I beg leave to withdraw the amendment. Amendment, by leave, withdrawn. The sum of $350,428,120 for Head T ordered to stand part of the Main Estimates. The sum of $9,150,268,900 for Head T ordered to stand part of the Development Estimates. Head F -

Head F - Parliament. Mr Zainul, you have 10 minutes plus the reply.

Sir, I beg to move, That the total sum to be allocated for Head F of the Main Estimates be reduced by $100. My topic is on the global image of the Singapore Parliament. We have a very new Parliament House and also a new Speaker. I was fortunate enough to be sent by the Singapore Parliamentary Society (SPS) to the IPU Conference. There, I remember, at one session, the head of a delegation from Croatia stood up and started off by apologising and said, "I apologise to the gentlemen who are present here today. Next time, we will bring some male members to represent Croatia." It so happened that all the three members of the delegation were female. Sir, I expect that more and more of such conferences will be attended by female parliamentarians. I would like to see that Parliament be given more resources to prepare itself for this role. We suffer from bad breath from time to time. I think it is important that we are adequately represented in many of the international conferences. We have the IPU, AIPO and the Commonwealth Parliamentary Association. I hope that necessary resources should be given due attention, so that we can get more of our Members to attend such meetings and conferences, and our image be enhanced. We also use this opportunity to show that we have democracy. Many of the conferences are also represented by Members of the Opposition. Mr Chiam was with me in Morocco, and Mr Low Thia Khiang too had been with the former Speaker to many other conferences. I hope Parliament will consider the necessary resources in order to play an effective role at overseas conferences.

Sir, the point that Mr Zainul Abidin made is a very important one, ie, we should take every opportunity to enhance the image of our Parliament in international fora. But let me assure him that this is indeed being done and Parliament is well aware of this. For the last 12 months, for example, 48 MPs actually participated in 16 overseas conferences, seminars, official visits and committees. I have a list here which indicates that the conferences included those in Cuba, Burkina Faso, New Zealand, Barbados, KL, Beijing, Marrakech in Morocco and many, many others. Sir, the expenditure that is incurred in respect of participating in these conferences and seminars is budgeted for in the Parliament vote. And if there is a need to have more funds for such a purpose, I am sure that Parliament will allocate more funds for this purpose. True to Singapore's style, we have not been extravagant in such expenditure, as we are not prone to giving MPs junket trips, but neither have we skimped on participation. When we are invited, we assess whether we can make a contribution and if we can make a contribution, we have a role to play, we will go. Our contribution has not been insignificant, if we judge by the role that we are playing in these conferences, considering the fact that we are a small state. At many of these conferences, we are represented in many of the committees. We sit on the committees, for example, in the Association of Asian Parliaments for Peace (AAPP) meeting in Beijing. At the Annual Meeting of the Asia Pacific Parliamentary Forum (APPF) in Honolulu, we were represented on the committee. In fact, we are also represented on several Standing Committees, and this includes the Commonwealth Parliamentary Association (CPA), the Commonwealth Speakers' Standing Committee and the Southeast Asian Regional Branch of the CPA. Sir, we will do our best, even though we are a small Parliament, to be represented in as many parliamentary conferences and committees as we can. Our MPs are very busy people. They have their own jobs to do, they have to look after their constituencies, and they have to carry out their parliamentary duties. Having said all that, I think our Parliamentarians acquit themselves creditably in all these overseas conferences, including our MPs from the Opposition parties, Mr Chiam and Mr Low. Mr Zainul made special mention of the role of women MPs. Here, I am pleased to inform him that the calibre of our women MPs has indeed been recognised by parliamentarians in other countries. If I may cite several examples, recently, Mdm Ho Geok Choo served on one of the committees at the AAPP. And likewise, Ms Irene Ng had served on a committee at the APPF. At the AIPO Conference in Thailand, two women parliamentarians, namely, Mrs Lim Hwee Hua and Dr Lily Neo, served on several committees and panels, including WAIPO, which is the Women Parliamentarians of AIPO. When we are talking about the global image of the Singapore Parliament, there is the website that we maintain on the Internet. There are also the Parliamentary Reports that we put up on the Internet and LawNet, and all these are accessible world wide. We also hosted many attachments and study tours for Members and officials from foreign Parliaments. We have Parliamentary Friendship Groups with many other countries like Australia, China, Japan, Korea, Peru, etc, and many of our Members here are involved with such groups. We also have Regional Groups - West Asia group, Africa group, Asia Pacific group, Southeast Asia group, Europe group, Americas group - which also involve many other MPs. And, finally, of course, what Mr Zainul mentioned just now, the Singapore Parliamentary Society (SPS), which is a society which fosters relations with members of the CPA and IPU. Sir, let me just say that we appreciate the Member's concern about upholding the global image of the Singapore Parliament. I would like to assure him that we will bear in mind his suggestion for more women MPs to be adequately represented at the relevant conferences.

Mr Zainul, would you like to withdraw your amendment?

Sir, I am very grateful for the long reply given by Mr Mah. I am sure by that reply alone, the image of the Singapore Parliament is enhanced. I beg leave to withdraw my amendment. Amendment, by leave, withdrawn. The sum of $27,787,800 for Head F ordered to stand part of the Main Estimates. The sum of $3,972,700 for Head F ordered to stand part of the Development Estimates. Head O -

Head O - Ministry of Health. Dr Lily Neo.

Sir, I beg to move, That the total sum to be allocated for Head O of the Main Estimates be reduced by $100. Sir, the current quota of 33% on the admission of female students into the Faculty of Medicine, NUS, was introduced in 1979. No other faculty in NUS has such a quota. There is no other highly ranked university in the world that denies entry to qualified people on the basis of gender. The reason for introducing the quota for female medical students was that the attrition rate for female doctors prior to 1979 was 12-15%, and women doctors could not be assigned duties as freely as their male counterparts. However, these reasons are not valid any more. Currently, the attrition rate for male doctors is 2.8% and for female doctors is 4.2%. As for duties for doctors, women doctors have been assigned duties as men have, without distinction. They share night calls equally, attend to the same number of patients and perform the same medical and surgical procedures. Sir, it is time to review the female quota for medical students now for the following reasons: (1) The latest statistics reveal that the attrition rate is not significantly different for male and female doctors. The figures show that 95.8% of female doctors are still working compared to 97.2% of male doctors. (2) The percentage for women part-time doctors is 13.5% and for male doctors is 4.1%. However, part-time practitioners are still contributing to Singapore's healthcare system and the use of part-time is an entirely arbitrary and self-declared status. Women who work four full days each week may well declare themselves as part-timers whereas men who take two or three afternoons off a week will still consider themselves working full-time. (3) Women live longer than men. Therefore, the higher number of non-working female doctors may be accounted for in part, by the higher number of retired women doctors. This may also mean that the working life of women doctors is longer and hence total productivity over their lifetime may equal or exceed that of their male colleagues. (4) Both male and female doctors serve their compulsory five-year bond for newly qualified doctors. This should count as partial fulfilment of their responsibilities for their educational subsidy. Even allowing for the greater social responsibilities of doctors whose training is subsidised, it seems illogical that doctors should be singled out and expected to be "serving" in the medical profession for life. No other professional faculty, or Government scholarship programme, has a similar quota on women. Thus, the quota appears to rest on an unreasonable "moral" obligation on all doctors. (5) Studies in other countries have shown that due to better communication skills of female doctors, mothers prefer to take their young children to see women doctors whom they feel may interact and empathise better with children as well as with themselves, as women and mothers. Since women comprise more than 50% of the population in Singapore, they should not be denied access to sufficient women doctors to cater to their needs. (6) Many of the qualified female students who were rejected by NUS have gone abroad to study medicine. Many of them get married and stay on to work there. As a result, we lose highly skilled talent. (7) With the strong push for the life sciences industry, Singapore needs better trained personnel who can bridge the gap between the pure scientist in the industry and the medical practitioner. Women doctors would be well placed to take up these jobs, as such jobs have more regular working hours. Sir, Singapore prides itself on being a meritocratic society. On this issue, our women are only asking for equal treatment in the competition to enter medical school. Sir, my next cut is on ElderShield. It was announced last year that ElderShield, the national insurance plan to help older people who become disabled, will start in September this year. While I welcome help for the older disabled, I would like to raise some of the inadequacies of this proposed national insurance plan. 3.45 pm This opt-out scheme will entitle a subscriber to draw $300 a month for up to five years if the subscriber is unable to carry out unaided at least three of the following activities: eating, bathing, walking, dressing, getting up and going to the toilet. I would say that application of such criteria means that the subscriber is, in fact, totally dependent on another person daily. Sir, may I ask then how such a person can survive with $300 per month? The situation will be even worse for those who are less well-off and have no other savings. Those who do not look into the details of the plan may, in fact, get a false sense of security and think that their old age woes will be taken care of by this national insurance. The majority of cases of severe disability are the result of diseases, such as stroke and so on. Sir, usually this means that the dependent elderly will also need long-term medications on an outpatient basis. At the moment, patients can only claim from Medisave or MediShield for medical care if they are warded in hospitals. A tendency for patients to opt for institutional care, costing as much as $120 per day, therefore arises. It is really a pity if any national insurance scheme does not address this issue. There is always the argument that higher disbursements and coverage will mean higher premium at the outset. I accept this argument, but I also feel that it is not much good having an insurance plan that cannot adequately serve the purpose it is intended for. I am sure the Ministry of Health has the statistics and resources to better plan and package a really sound scheme. The probability of our Government subsidising the premium, especially for the poor and/or non-working, must be on the cards. Sir, in view of our fast-aging population, it is better to help with a small outlay in terms of insurance premium at the outset than to carry the heavy burdens later. A Government subsidy will also reduce the percentage of those opting out. More attention should be paid to the less well-off in our society. In relation to family income, some sort of cut-off point, below which a subsidy for higher disbursements may be given, would also be a reasonable consideration. I hope the Ministry of Health can reconsider the implementation of ElderShield with the above-mentioned points.

Sir, I agree that the ElderShield scheme is a good scheme, and it will help older Singaporeans who truly deserve something in return. But I have a couple of issues to raise with regard to the application of this scheme. Firstly, I find that the scheme has too many conditions and appear to have restricted application. To benefit from it, an elderly Singaporean will actually have to be almost bed-ridden. This is because it applies to those who cannot do at least three of the following: they cannot move, feed, transfer, dress, wash or go to the toilet unassisted. Secondly, the elderly person's claims can be disputed by a joint panel of assessors and, if there is a dispute, then the elderly person will have to engage his own doctor, at his own expense, to dispute the assessment made by the insurance company's panel of doctors. Most of the elderly disabled will not be able to afford paying for this extra cost. In order to ensure greater objectivity, I would like to suggest that MOH appoint the assessors instead of leaving this to the insurance companies. Thirdly, those with pre-existing disabilities and those above 69 years of age will not be covered. True, they will be covered under the IDAPE, but this scheme covers only those with household income not exceeding $700-1,000 per month, which is very low. Fourthly, Sir, the scheme provides payment for only up to five years. Beyond that, the disabled elderly will be unprotected. May I ask the Minister to be more flexible and to review all these restrictive qualifying conditions, so that the ElderShield scheme can be more effective and can cover more elderly Singaporeans. I would also like to ask the Minister what more can be done to facilitate the development of step-down care in Singapore, so that disabled elderly Singaporeans can have more proper home care and community-based services; in other words, providing this ElderShield scheme should be but one facet of a holistic scheme of caring for the needs of elderly Singaporeans. Finally, Sir, as the ElderShield is an opt-out scheme, I would like to know what measures the Ministry would take to educate the public not to opt out of the scheme, as they may not need it now but will do so as they grow older.

Sir, our healthcare system is based on Medisave, MediShield and Medifund. They reflect the principles of individual responsibility through Medisave savings, shared risk-pooling through MediShield, with the Government providing a universal layer of safety net through Medifund. These three schemes ensure that Singaporeans will have access to quality medical care. Sir, in a way, the MediShield scheme is a portable scheme that has a wide coverage. Although it has been continuously fine-tuned and improved after it was implemented in July 1990, I would like to find out if the Ministry plans to enhance the scheme further. I have four specific suggestions. First, bring more Singaporeans under MediShield coverage. The scheme is voluntary and Singaporeans can opt out of it. I understand that quite a big number of people have actually opted out. Should we make it compulsory? What is the number of Singaporeans who are not covered by MediShield or any of the approved CPF medical insurance schemes? What more can be done to bring more Singaporeans under such coverage? Second, include enhanced coverage of non-working spouse and children. This will allow a CPF account holder to cover his wife and the whole family under the insurance scheme. Third, under the present system, the older members have to pay a higher premium. Would the Ministry consider pre-funding features for the MediShield scheme? Fourth, enlarging the pool of approved medical insurance schemes, so that more insurers can build portable features into the basic schemes. This will facilitate the implementation of portable medical benefits. Apart from MediShield, would the Ministry consider more Medisave-approved medical insurance schemes offered by private insurers to make the proposed portable medical benefits scheme more responsive to their needs?

Sir, the MediShield scheme was introduced in 1990 to complement the Medisave scheme in helping Singaporeans meet their medical expenses from major and prolonged illnesses, which the Medisave alone may not have sufficient balances to cover. Sir, MediShield is an important safety net to ensure that Singaporeans will not be denied critical medical treatment when they are suddenly struck by chronic illnesses which may require protracted and costly treatment. It is a risk-pooling mechanism to reduce the overall cost of obtaining medical treatment for those who are unfortunate enough to need it. It is, therefore, crucial that all Singaporeans are covered under the scheme. I, therefore, share the same sentiment as Mr Yeo Guat Kwang that we should encourage all Singaporeans to come under this scheme. Otherwise, when they cannot afford the medical treatment they need, they will invariably turn to the Government for help. I would, therefore, like to ask the Minister whether his Ministry has plans to encourage those who are not yet covered under the scheme to sign up for the scheme as soon as possible. One of the main setbacks of the MediShield scheme really is that it is an insurance scheme and, as such, the premium that is paid is not recoverable. For a person who remains healthy, he actually gets nothing in return. Perhaps one could argue that his greatest return is his health. This perspective is not wrong. But we should still ask: is the scheme cost-effective? Therefore, I would like to ask the Minister whether he could let us know how much premium has been collected over the last five years and how much has the total pay-out been. If there is a significant surplus, then would it be possible to either reduce the premium to encourage more Singaporeans to sign on, or to enhance the scheme without increasing the premium? Sir, as we continue to enhance the MediShield scheme, I am not sure we can afford to always do so without raising the premium. I believe that there is no free lunch and we will need to raise the premium at some point in time. However, it is important that the premium remains affordable, especially for the lower income group, as they need it most. I would like to urge the Minister to ensure that future increases in the premium, if any, should take into account affordability.

Sir, in 1993, the Government published the White Paper on affordable healthcare in Singapore. Despite this, Singaporeans today remain concerned about the affordability of healthcare. There is some basis for this concern as, on average, healthcare costs have been increasing at the rate of 6% per year. Singaporeans are asking what are the main causes for the increase, and is there no control on such increase in costs? Is the increase in costs due to the increased salaries and fees of doctors and specialists due to the need for the Government and restructured hospitals to catch up with the private sector's pay scales and fees? If so, then, surely, some long-term solutions will have to be found, such as increasing the supply of such specialists or providing more competition for specialist care in Singapore. Or is the rising cost of healthcare in Singapore due to improvements in medical technology? If new technology is the culprit, then I am a little bit puzzled as to why the logic that prevailed in the case of new technology in other sectors did not apply in the medical services. If we look at technology in other sectors, such as computers, for instance, we will see that, over time, the price of such technology invariably goes down. So, should not one expect the same for medical technology? The new products will be expensive but, over time, the same product should be cheaper, and this should translate into cheaper medical costs. At the very least, it should not be cited as a reason to justify the increasing medical costs. Also, on the point of technology, is there any control over new technology that is being used to determine whether they are really necessary, or just good to have? Sir, Singaporeans are also asking, and they want to know, whether all these big hospital buildings that we now see are adding to the increasing costs. For instance, will it not cost more to maintain these buildings and keep them clean, compared to the minimalist and spartan hospitals of old? After all, what anyone who goes to the hospital wants is good and affordable medical care, and he/she will be too sick to appreciate the wonderful ambience. Sir, I hope that the Minister could throw some light on this very fundamental issue of why our healthcare costs are increasing, and what productivity and control measures have been put in place to prevent the spiralling of healthcare costs in Singapore. Would the Minister consider setting up an audit committee, a body, for instance, comprising health economists and members of the public, to audit increases in healthcare costs in Singapore similar to the role played by the Public Transport Council? I would also like to ask the Minister whether with the average 6% yearly increase in healthcare costs, the current Medisave contribution rate will be sufficient to meet the medical needs of Singaporeans. The Ministry of Health has explained before that the Medisave amount is sufficient for Singaporeans to pay for about 10 or 11 bouts of hospitalisation. Could the Minister enlighten the House as to whether in making this estimation, the Ministry has taken into account the fact that many Singaporeans today are not taking care of only their own hospitalisation needs, but they also have to provide for elderly parents who do not have Medisave savings of their own? Sir, the truth of the matter is also that, today, those who feel the most pressurised are those in the middle income, as the poor and the lower income have a lot of assistance in the form of grants and subsidies from the Government. I would appreciate a response to these issues which I have raised for the Minister.

Sir, I share the concern of rising healthcare cost, as highlighted by the hon. Member, Mdm Halimah. Sir, healthcare cost is rising because of several factors, such as aging population, introduction of new medical technology, use of newer drugs which are still under patents and, therefore, the cheaper generic drugs are not available, increasing demand of better-informed customers, ie, the patients themselves or their family, and rising labour costs. May I urge the Minister to look at the ways to contain the rising cost before passing them on to the patients and their family? When it comes to paying bills, our healthcare financing policy has always been to rely on co-payment to minimise abuse and wastage of our healthcare resources. This is well and good. However, I am concerned that in our haste to recover costs and to balance the budget, perhaps we have been pricing our healthcare costs too high to the patients, beyond the affordability of some of them. I feel that a bigger burden has been passed on to the patients and their family, sometimes more than they can afford. One point to note is that MOH has actually introduced means testing for step-down care services, such as nursing homes and chronic sick hospitals. It will apply to community hospital patients in July this year and I understand that, eventually, all acute hospital patients will also be means-tested. Here, I must first declare my interest as the Medical Director of Ren Ci Hospital, which will be opening its 200-bedded community hospital this year. I agree with the principle of means testing, so that the poorer patients actually get more subsidies while the better-off should bear a bigger burden of their medical bills. However, I find that our policy to subvent only the poorer half of the population's healthcare will make it unaffordable to many who are caught in between. Under the means-testing for a community hospital, for example, only the poorer half will get the Government's subvention between 25% and 75% of the cost. The cut-off is per capita household income of about $1,000. 4.00 pm Let me illustrate my point using a very simple example. The norm cost of a "C" class in a community hospital's stay is about $200 per day, and the average length of stay is about four weeks. The average cost per hospital stay will therefore be about $5,600. Using our national statistics, the median household income is about $3,600. So if one is unlucky and probably has about $5,000 household income, most likely, he would not pass this means test and he would have to bear the whole amount, which is more than one month's income of the whole household. Even for those who just pass the means test and are eligible for 25% subvention, 75% of $5,600 would mean a hefty bill of $4,200. Compare this to the existing system which allows the patients to choose the class they wish to stay, if they stay in "C" class, they will get 80% of the subsidies. I feel that more people will be left out with this new means test. Therefore, I would like to urge the Minister to reconsider the policy of subventing only the poorer half of the population. Precisely because the healthcare cost is rising, more people are in need of subsidised healthcare. I would urge the Ministry to grant more subventions to patients and to make our healthcare more affordable. Otherwise, I am afraid the coffeeshop talk of "can die, cannot sick" may one day come true, which I certainly do not hope to see.

(In Mandarin): Sir, the points I wish to raise on this amendment are somewhat similar to what my parliamentary colleagues before me have just mentioned. Singapore has been said to come a long way in improving the standard of health and providing good medical and healthcare services to its people. Today, the state of health of the people in Singapore has attained international standard. In 1993, a White Paper entitled "Affordable Healthcare" was published, spelling out the Government's commitment to provide good affordable basic healthcare to Singaporeans. This is done through the provision of heavily subsidised medical services in Government hospitals and polyclinics. In the early 1990s, the Government hospitals were restructured with the objective of providing quality medical services comparable to the private hospitals. In 1999, the public healthcare delivery system was reorganised into two vertical groups - National Healthcare Group and the Singapore Health Services. One of the suggestions of the Remaking Committee is to develop Singapore into a medical hub. This kind of foresight and spontaneity is a driving force in sustaining our long-term survival. As our colleagues have said, we have been constantly introducing more advanced medical technologies to Singapore to further enhance our healthcare standards. However, my concern is whether this will cause our medical cost to go up even further. Of course, rising expectations of our people for better medical and healthcare services may also be a contributing factor to our escalating medical cost. But a lot of people are saying that the Government is trying to recover its cost, even the cost of building hospitals, and that is the main reason for raising the medical fees! Sir, I am raising this issue because our healthcare delivery system is based on individual's responsibility plus Government subsidy to make the basic healthcare service affordable. The medical expenses keep going up, very soon the lower-income group and the elderly in our population will not be able to afford them. One resident in my Constituency, who is a hypertension patient, told me that when he was taking the medication from the polyclinics in Singapore, it would cost him $1-2 per day. But when he bought the same medicine from Johor Baru, he paid only 60 cents for it. He told me that he had been taking the cheaper medicine he bought from Johor for the last two years. He is happy and he is still alive and kicking. I would like to ask the Minister whether there is some form of control on the prices of medicine sold in Singapore. Since we are controlling the type of medicines that can be sold in Singapore, can we not also check on the prices at which they are being sold to the end consumers? If these medicines can be sold at Johor Baru at much lower prices, why cannot something be done to ensure that our retailers sell these medicines at comparable prices? The rich people, of course, can go to expensive, air-conditioned hospitals and enjoy the comfort there. For the poorer patients, they can only go to a third-class hospital. The rich people take expensive ginseng and bird's nest, but a poor man can settle for an inexpensive glass of soybean drink. Can we not allow some form of generic medicines with the same therapeutic effect to be sold in Singapore, so that the people in the lower income group could find them more affordable? Dr Ong Seh Ong has just mentioned that Singaporeans like to say, "you can die, but you cannot afford to be sick here". We should give the people the impression that in Singapore, even when you are sick, you will not die.

Sir, affordable healthcare has been a key policy of the PAP Government. Medisave, MediShield and Medifund (3M framework) have been the three main pillars of our health payment schemes. I am glad that the Ministry will be improving on the 3M framework, a review that is long overdue. Primary healthcare services continue to be affordable for most Singaporeans due to the significant presence of general practitioners in the HDB heartlands together with the polyclinics. This has resulted in a very affordable primary healthcare system. It is when Singaporeans go to hospitals that their cost start to escalate. This is not unexpected in hospitals where highly-trained staff, expensive up-to-date equipment, well-trained specialists and branded drugs are commonly used. What the Ministry needs to do is to review the 3M framework to help Singaporeans meet the cost of hospitalisation and outpatient specialist care. Medicine has come a long way, where in the past, heart disease, kidney failure or cancer spelt a dismal outcome or even death for many Singaporeans. Modern medicine has enabled many to be treated, with a good quality of life. The only problem is cost. As such, the Ministry should consider allowing the use of Medisave for diagnosis or management of major chronic illnesses, on an outpatient basis. This should include conditions like heart disease, kidney failure, cancer and diabetes. The Medisave withdrawal limit, for many of the procedures done in the hospitals, has not been revised for a very, very long time. As a result, many of these procedures that have become routine, have not been adequately covered by the Medisave withdrawal limit. It is time for it to be reviewed. For most patients, the last six months of their lives is the period when their medical bill will be the highest. MediShield should be revised to provide adequate coverage for major catastrophic illnesses and to take into account this fact as well. Finally, it is important that our public health institutions must realise that their aim is not to make money from Singaporeans. I wish to quote a case which has troubled my heart greatly. A resident had come to see me at the meet-the-people session because his child was born premature in Mount Alvernia Hospital and required intensive care and surgical treatment. He sought my assistance to have the child transferred to KK Hospital. KK Hospital's specialist told him that the child needed surgery that could not be performed in Mount Alvernia but only in KK Hospital. After their appeal, KK Hospital agreed to have the patient transferred to them provided that the family put up a $20,000 deposit to the hospital. The young couple was at their wits' end and had to borrow the $20,000 from friends and relatives. Just when they thought they had solved the problem and they went to the hospital, they were told by the hospital's administrators, "No, no, not enough. Now we need $60,000 as a deposit before we are willing to take your child". They came to see me, utterly devastated. Finally, the patient was taken only when Mount Alvernia Hospital had given a guarantee. I wonder how this event would have turned out if Mount Alvernia Hospital did not provide a guarantee. Our public hospitals have rallied to the cause of foreign patients with poor prognosis, such as in the widely publicised surgery of the Siamese twins and the Indonesian child with hydrocephalus. Would our public hospitals let the Singaporean baby suffer and perhaps, even perish, as long as the parents were not able to raise the money or no one was able to provide a guarantee? Are Singaporeans to be denied access to our public activities because they are unable to meet the high fees demanded of them? The final letter I got from the hospital was that if I wished to pursue the case further, I should know that the hospital was a cost centre, and economic consideration was an important factor. I am extremely saddened by the entire incident and I hope it does not signal a policy shift in our public hospitals. Can the Minister reassure all Singaporeans that they have a right of access to taxpayers' funded public hospitals and affordability will never be the reason for denying them admission to a public hospital?

Sir, the Medifund was an endowment fund set up by the Government in 1993. With an initial capital of $200 million, the fund has now grown to $800 million. A total of $27 million has been disbursed in 2001, out of $30 million available. This represents a 90% utilisation rate. This implies that the fund has been well utilised and has served its purpose of helping the lower-income families cope with their healthcare cost. However, I am rather concerned, like other MPs before me, with the consistent increase in healthcare costs. If we look at the Economic Survey which was distributed last week, at page 98, there is a table showing the consumer price index, broken down by categories. First quarter 2002 saw the overall CPI decline by 0.9% over the same quarter in the previous year. In contrast, healthcare cost increased by 2.4% over the same period. The healthcare category has the highest rate of increase. If we take the whole of 2001 compared to the year 2000, the overall CPI increased by 1%, while healthcare costs increased by 3.3%, more than three times. Again, it is the highest category. If we take a longer time horizon and compare 2001 with 1997, the overall CPI increased by 2.1%, while healthcare costs went up by 10%, almost five times, over the last four years. Again, it is the highest category. Perhaps, the quality of healthcare services has improved. But we need to keep in mind the affordability of healthcare cost. Sir, even when the economy recovers, the job situation will remain weak for some time, as the same Economic Survey has already pointed out. Unemployment will worsen before it improves. Wages are likely to be further reduced. Given this likely scenario, Sir, our people would be very concerned with the rising healthcare costs. I am glad that the Government has promised that it will absorb the proposed GST increase for healthcare services. But if healthcare cost continues to rise, it will negate the goodwill gesture of the Government. I would, therefore, like to urge the Government to monitor the situation and take steps to contain the rise in healthcare costs. The increase in healthcare costs over the last few years, coupled with the unemployment and wage reduction, may also result in more people needing help for their basic healthcare services. It is, therefore, important for us to ensure that our basic safety net, such as the Medifund, is adequate in responding to the needs of the people. The fact that the utilisation rate of Medifund is high is also evidence that perhaps more people would need help. Therefore, I would like to ask the Minister to consider expanding the Medifund scheme to meet the greater needs arising from higher healthcare costs. 4.15 pm

Order. On behalf of hon. Members, I welcome the Iranian Parliamentary delegation led by the Honourable Mr Mohammad Javad Haghshenas, Deputy Minister from the Ministry of Culture and Islamic Guidance, who are present in our Gallery. [Applause.]

Debate in Committee of Supply resumed.

(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.

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.

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?

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.

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

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.

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?

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.

4.40 pm 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.

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.

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.

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?

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.

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?

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.

Mr Chairman, may I just disagree with the Minister on what he just said?

Can you please proceed to your next cut?

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.

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.

Dr Tan Cheng Bock you may take both cuts together.

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.

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.

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

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.

I think where a GP refers a patient to a Specialist Clinic ---

No, it is not a Specialist Clinic. It is just to the hospital.

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.

I think I agree with you. But I would not want to prolong this. I will bring it up with the Minister.

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

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.

Dr Neo, can you withdraw your amendment?

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

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

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 ---

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

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.

Dr Neo, can you withdraw your amendment?

Can I not have further clarifications, Sir?

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

I beg leave to withdraw my amendment reluctantly. Amendment, by leave, withdrawn.

Amendment No. (2), Dr Chong Weng Chiew.

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.

You may speak on the next cut, Dr Chong.

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.

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

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.

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.

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.

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

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.

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.

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.

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.

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.

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?

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.

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.

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 -

Head K - Ministry of Education. Dr Wang Kai Yuen.

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.

(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.

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.

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

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.

Order. It is 7.00 pm. Thereupon Mr Deputy Speaker left the Chair of the Committee and took the Chair of the House.

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.

So be it.

Resolved, "That Parliament do now adjourn." - [RAdm Teo Chee Hean].

Adjourned accordingly at Seven o'clock pm.