Hansard, 2006-03-07

Under the provisions of clause 2(d) of Article 46 of the Constitution of the Republic of Singapore, the following Members have been granted permission to be or to remain absent from sittings of Parliament (or any Committee of Parliament to which they have been appointed) for the periods stated: Name From (2006) To (2006) Mr Alexander Chan Meng Wah 08 Mar 08 Mar Dr John Chen Seow Phun 08 Mar 11 Mar Mr R Ravindran 08 Mar 09 Mar

ABDULLAH TARMUGI Speaker Parliament of Singapore

1. Ms Indranee Rajah asked the Deputy Prime Minister and Minister for Law in view of the restructuring and consolidation of the legal services sector in recent years, as well as the changing market for legal services, whether his Ministry is considering the measures needed to ensure that the required legal services are available to support the strategic services of our economy.

As I have said in this House before, our legal system, legal services and legal expertise are important to our economy. We have seen the demand for more specialised legal services growing in recent years as our economy and the regional economy develop. To meet this new market demand, our legal services sector needs lawyers with the requisite knowledge and skills. But because Singapore is a small jurisdiction we need to be able to tap the expertise of lawyers from around the world.

In 1999, we launched schemes to allow local law firms to enter into Joint Law Ventures (JLVs) or Formal Law Alliances (FLAs) with foreign law firms. We wanted to provide a convenient and efficient mode for delivery of legal services in cross-border financial transactions. At that time, we agreed to review the Schemes in 2005.

Accordingly, a Review Committee, headed by the Attorney-General, recently completed a review of the Schemes.

They found that the range of legal services in foreign laws and in Singapore law available in Singapore is satisfactory and meets the current legal needs of the strategic service sectors of the economy. In addition, the Review Committee found the Schemes to be structurally sound and appropriate to their objectives. They have achieved the objective of providing an adequate 'one-stop shop' service in foreign laws and Singapore law in cross-border financial transactions in the region.

With this legal framework for collaboration between local and foreign firms firmly established, the Review Committee has proposed that we can now expand the scope of practice of JLVs and FLAs. Looking ahead, this will enable JLVs and FLAs to provide the necessary legal support for the emerging strategic

To help Singapore law firms grow their practices abroad, the Review Committee also considered how they can acquire in-house foreign law expertise. Some foreign lawyers with the skills and experience that we need may not find a consultancy relationship with a local firm to be satisfactory, even if the compensation package is high. To ensure that we can continue attracting experienced and talented foreign lawyers to work in Singapore law firms, the Review Committee has recommended that foreign lawyers be permitted to own equity shares in local law firms, subject to an aggregate limit of 25% of the total equity shares or profits of the local law firm. Sir, this will help our local firms to expand their capabilities and reach out to the region. This proposal, I believe, will also help Singapore law firms in the region, especially in China, to grow by giving a stake to local lawyers.

The Government has accepted these recommendations of the Committee and we are working to implement them as soon as possible. The Government has also agreed that the Attorney-General be given the discretion to grant a JLV or FLA licence for any other area of law practice either as a complementary or principal practice of a JLV or FLA if it enhances the quality of legal services in Singapore or supports the development of Singapore. This way, we will give flexibility to include

Apart from this recent review of the JLV/FLA schemes, let me say that we are also addressing the question whether we will have enough lawyers for our future needs. My Ministry has set up a Committee, which is headed by the Attorney-General, to look into the supply of lawyers. We will work closely with the Ministry of Manpower and the Ministry of Trade and Industry and the report of this Committee should be completed by the middle of this year.

Let me end, Sir, by saying that our existing framework for admission to the Singapore bar is primarily based on a Singapore law degree. For the purposes of admission, however, we have recognised certain specific LLB degrees obtained by our citizens and permanent residents from some universities in England, Australia and New Zealand. In order to encourage the creation of a more diverse generation of lawyers here in Singapore, we will soon give our students more choice by adding to the list the Juris Doctor degrees from four US universities, namely, Columbia University, Harvard University, New York University and the University of Michigan. This is pursuant to the US-Singapore Free Trade Agreement.

Finally, Sir, my Ministry will continue to work closely with the various legal institutions and organisations to develop the legal services sector in Singapore.

service sectors of the economy. The new areas proposed are arbitration, intellectual property law and maritime law. Arbitration, Sir, is a very fast growing area of law practice and Singapore is an ideal venue for international arbitrations. Singapore is also an IT and maritime hub in the region. We will develop and support these areas by including them in the JLV and FLA schemes. Furthermore, the Review Committee has also proposed JLVs or FLAs for any or a combination of these practices will also be considered on a case-by-case basis. other areas of law practice for which there may be future demand for legal services.

I have three supplementary questions, Sir. First, is on the opening up of the JLVs and FLAs to cover arbitration. I would be grateful if the Minister for Law could explain the rationale behind extending it to arbitration, given that foreign law firms are already able to conduct arbitration in Singapore, whether under SIAC or any other mode of arbitration.

The second question: DPM and Minister for Law mentioned that foreign lawyers would be allowed to own equity shares in local firms. I would like to know whether the foreign lawyers would also be required to be admitted to the Singapore Bar and, thereby, practise Singapore law, or whether by virtue of their admission through equity in a local firm they can automatically practise Singapore law.

The third question: for the Juris Doctor degrees, in the US, of course, it is a post-graduate degree. What I want to know is whether people who get degrees from the US and want to come back to Singapore to practise would also be required to undergo the Singapore Diploma conducted by the NUS, something that students who graduate from the UK and other countries are required to undertake before they can practise.

The Member is right about our laws permitting foreign lawyers to practise arbitration. We are not just looking at foreign lawyers/counsels flying in when retained to appear for specific cases. What we are trying to encourage really is full service firms that specialise in arbitration, especially in specialist fields. So, Singapore law firms can form such an association to boost their capabilities. Foreign law firms would be able to establish a presence or base here, so to speak, to serve the region, bring dispute resolution work from various parts of the region to Singapore.

The firms that may be interested in this may not be the same firms that are already here for international financial transactions. So, we are thinking that collaboration with Singapore law firms could allow the foreign firms become more competitive in terms of pricing their services for work involving Singapore law - China work, India work, perhaps. So the FLA, local and foreign partners,

Her next question was about the proposal to allow foreign lawyers to have an equity stake in Singapore law firm - whether that foreign lawyer who takes such a stake can, by the very act, practise in Singapore. The answer is, no. That person will have to comply with whatever requirements that already exist for practice of Singapore law.

The third question is with regard to the four degrees in the United States that would be recognised for the purpose of admission. Students who have obtained their degree from the universities, like students who have obtained their degree from other scheduled universities, will have to comply with the requirements for admission to the Singapore Bar.

through that mechanism, can then market their arbitration service as a global service, as it were, that includes Singapore law services in arbitration.

I would like to ask the Minister why only four American universities are selected and why some of the more notable and major US universities with respectable law degrees, like Yale and UCLA, are excluded.

We have this issue, whether it is with United Kingdom, Australia and New Zealand, as to why certain universities are included or not included. Let me say that these four universities are arrived at after consultations with the United States authorities.

2. Mr Steve Chia Kiah Hong asked the Minister for Trade and Industry (a) what is the purpose of legislating for compulsory

membership of the Singapore Business Federation ("SBF"); (b) how can business owners who find SBF irrelevant to their needs, terminate their membership; and (c) if the Minister will rectify this legislation to make it non-compulsory for small and big businesses which are not interested in joining the SBF.

Mr Speaker, Sir, the establishment of the Singapore Business Federation with mandatory membership was proposed by the former Singapore Federation of Chambers of Commerce and Industry (SFCCI), as a new apex organisation to represent Singapore's business interests more effectively both locally and abroad.

The Government supported the Singapore Federation of Chambers of Commerce and Industry's recommendation and enacted the SBF Act in 2002. SBF membership was made mandatory as the earlier practice of voluntary membership by business chambers and associations had not been effective. The business community had remained fragmented, and lacked a strong and united private sector umbrella organisation. Compulsory membership would ensure that SBF has a strong membership base, and has the mandate of the entire business community. Compulsory membership of business chambers can also be found in France, Germany and Brazil, for example.

However, only local companies with paid-up capital and foreign companies with authorised capital of $0.5 million and above are required to be members of the SBF. So a total of 136,000 small companies, 26,000 partnerships and 114,000 sole proprietorships, have been exempted.

In addition, the SBF (Exemption) Order was passed by this House in 2002 to exempt all companies with zero

If SBF decides that there should be further exemptions based on other clear criteria and recommends them to me, I will consider them.

SBF has been in existence for only four years, and we are seeing encouraging signs that more members are finding its services useful. Last year, members' participation in SBF events doubled from 12,000 in 2004 to 22,000. We are told that the recent Budget 2006 briefing, organised as part of SBF's regular updates on changes affecting businesses, was attended by over 1,000 members. We encourage the SBF to come up with more such activities, services and programmes that will deliver value to its members.

employees. As a result, 6,000 more companies were exempted. To date, SBF has about 15,000 members or just 9.6% of all companies in Singapore.

Mr Speaker, Sir, the Minister has not answered my questions (b) and (c). How can business owners who find that the SBF's programmes and all those things not relevant to them, terminate their membership? And for those who do not want to join, can it be made non-compulsory for them?

Mr Speaker, Sir, I have answered the question. I said that if the SBF decides that there should be further exemptions based on other clear criteria, then I will consider them, meaning, if the members who think the SBF is irrelevant to their needs,

they should put up their case to SBF. And if there is a group of them who can demonstrate that the SBF is irrelevant and SBF also agrees, like what SBF has done previously for the small companies and companies with zero employees, then it is for SBF to put it up to the Ministry.

So people who are not interested would have to

petition to SBF to get themselves exempted. Am I right to say that? If the SBF does not agree for them to be exempted, there is no way for them to be exempted in this case. Am I right?

Mr Speaker, Sir, I have already explained that membership is mandatory. So people cannot say that they want to join or they do not want to join. At the same time, we have exempted significant groups of companies, so that only less than 10% are required to join. So companies who are in this 10% group, if they think that the SBF is irrelevant or they do not find value, then it is for them to put up a case to SBF so that they can get exemption as a class or as a group.

Last question, Mr Chia.

Sir, I do not know whether the Minister has read Today's article on 2nd March by Mr Cheng Soon Tat. I think he gives very good arguments why membership should not be compulsory in the SBF, and also that the NTUC is able to actually advance collective interest.

What is your question, Mr Chia?

My question is whether the Minister has read this article and agree with the point that there should not be compulsory membership for business associations, other than those that are required by law for the regulation of professional standards.

I have read the article and I have also read the responses by different groups. As I have explained in my answer, if you do not have mandatory membership, there is a problem of free riders. People will enjoy the benefits put up by SBF but do not pay the subscriptions. This was debated in 2002 and we decided to make it mandatory.

Mandatory membership is not unique in Singapore. It is practised in many countries. In these countries, they find an apex umbrella business organisation is a very useful mechanism. Next, I have explained that even though it is mandatory, we have exempted a large portion of companies, especially the small companies. Finally, I have explained that more than two-thirds of the companies pay less than $400 subscription, or less than $1 per day. So it is not a very significant financial burden on these companies to subscribe and to be members of an umbrella organisation which is increasingly providing value for its members.

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

Head L - Ministry of the Environment and Water Resources. Dr Amy Khor.

Emerging Environmental Challenges

Sir, I beg to move,

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

Sir, the NEA has stated that it aims to reduce CO2 emissions by up to 190,000 tonnes by 2012, by reducing energy wastage and promoting its conservation. In relation to this, I would like to ask the

Going forward, what does the Ministry see as other global trends and challenges facing us on the environmental front, and how does the Ministry plan to tackle them?

Sir, Singapore's pole position in the region for its stringent controls with clean air and water and green urban designs is undisputed. However, we will be hard put to say that we have the same high standards of public hygiene and cleanliness or recycling habits. To me, these relate to basic behavioural patterns and social graces. Cumulatively, shaping them is even more important in environmental conservation than mere programmes or campaigns which have limited shelf life.

Every year, after the New Year countdown or the Chingay parade, there never fails to be letters to the Forum pages on the amount of litter left at Orchard Road. In 2004, it was reported that two tonnes of litter were left behind after the Orchard Road Chingay parade. On 31st December last year, it was reported that the litter generated at the Orchard Road New Year countdown amounted to some six kilotonnes! The writer further noted that rubbish was simply thrown to the ground even with the many rubbish bins available.

Sir, we have been trying to tackle the littering problem since the 1970s, but like stubborn stains on white shorts, it refuses

Sir, another fundamental issue relates to our standard of public hygiene and cleanliness of our public toilets. Since the retreat of SARS, it seems that the standard of hygiene and cleanliness in many public toilets has also retreated, and many of the toilets which have been given the "Singapore OK" mark seems to have k-oed. In fact, the label itself has k-oed, because it is faded and filthy. I would like to ask the Minister whether the Ministry plans to review and revamp the whole initiative to improve the standards of cleanliness and hygiene of our public toilets.

Sir, it is noted that households here do produce less rubbish than in the West, but they lag behind in recycling. It is also noted that whilst the number of homes participating in recycling is high, the volume of recyclables collected is low compared to those overseas. I would like to ask the Minister if the Ministry could look into improving our infrastructure, such as having more recycling bins at convenient locations in housing estates and commercial areas, as well as working with the MND to have flats with separate rubbish chutes for food waste and other recyclables like paper. This would help to improve the participation rate as well as the amount of rubbish recycled. I would also like to ask the Minister, besides educating and encouraging individuals and companies to participate in recycling, what other measures are being taken to reduce the amount of waste produced in Singapore. For instance, what is being done to encourage companies to use recyclable packaging and is there any attempt to reduce the amount of plastic consumption in Singapore?

Minister to provide us with an update of these efforts and, in particular, whether the Ministry would implement a mandatory energy labelling scheme, at least on all airconditioners and refrigerators, which are guzzlers of energy, and whether the Ministry will be ratifying the Kyoto Protocol as yet another sign to the international community of our earnest efforts and commitment to promote energy efficiency and reduce CO2 emissions.to go away. I would like to ask the Ministry how it plans to meet this challenge in the coming year.

Prof. Low Seow Chay is not here. Mdm Cynthia Phua.

Clean Air and Water

Sir, we have, over the years, promoted Singapore as a garden city, cleaned up our waterways and bright green bins proudly line what were once litter-filled street alleys. I just heard Dr Amy Khor say that some areas are filled with rubbish.

The introduction of the Mass Rapid Transit trains contributed towards a cleaner mode of transport. Today, I understand that the main bulk of fine particles in our ambient atmosphere is from vehicles. These particles are in the form of elemental carbon and from fuel oil combustion in the form of sulphates. One of the main sources of suspended particles or particulate matter, commonly referred to as PM, affects the people's health. The big particulate matter is PM10 and the smaller one is PM2.

5. Both PM10 and PM2.5 particles can cause health problems, in particular respiratory problems. Because PM2.5 travels deeper into the lungs and it is made up of things that are more toxic, like heavy metals and cancer causing organic compounds, PM2.5 can have worse health effects than the bigger PM10.

In the US, it was found that PM2.5 was linked to some 95,000 cases of chronic and acute bronchitis. In Singapore, as I understand, we are able to meet the US EPA standards for PM10 but not for PM2.5, which is mainly emitted by diesel vehicles. What efforts are being done to ensure that we can meet the US EPA standards for PM2.5? With more pharmaceutical, chemical and petrochemical plants being set up in Singapore and with the growth of vehicular traffic and new criss-crossing flyovers, the amount of pollution will naturally rise. Singapore is becoming busier and busier with higher people density, from the residents to the ever rising transient tourist traffic. People are becoming more

We may need to have an inter-Ministry panel to look into how we are going to cope and to put in place a plan to control pollution before it is too late. What is the Ministry's plan and effort on the control of air quality in our living environment?

A pertinent question after the COS debate on transport makes me wonder whether our small island-state is able to sustain the 3% vehicle increase annually, in terms of the pollution impact to our environment. I know that LTA and NEA are already working closely, and on 1st October 2006, we will adopt the Euro IV emission standards for all diesel vehicles registered henceforth. My suggestion is that the MEWR should work closely on an inter-panel basis, to encourage and persuade, and also to ensure that our economic and social activities of all the other Ministries should not cause undue stress to our environment.

I am of the opinion that NEA should also rope in the health officials to monitor the relationship between pollution and the rise in, say, cases of people falling ill from respiratory and other diseases. I think there is more to public and private relationship, and the Ministry has to look into inter-Ministry policies and guidelines on other economic activities as well.

affluent and the rise of consumerism also gives rise to the burning of more fuel. Power plants are generating electricity due to higher electricity consumption. More people movement results in higher vehicular traffic. More garbage thrown means more waste for incineration. The pollution situation is going to get worse and worse, and we have to put in a lot of effort before it can get better.

Climate Change

Sir, climate change is a key challenge on the

The question now is no longer "Is climate change happening?", but "What are we doing about it?" Even countries which have not ratified the Kyoto Protocol are coming up with strategies to prove they are doing something. An effective energy policy must include climate change issues - and the possibility of a carbon tax or carbon trading - on its agenda.

I would like to ask the Minister how is Singapore playing its part in this global challenge. What are our present and future strategies for improving energy efficiency and reducing greenhouse gases? How does the Government see its role in the local, regional and global arena in meeting this challenge? Will Singapore be a leader, a follower or a slacker?

With regard to the private sector, does the Government intend to lead or is it waiting for the private sector to take the initiative? In fact, several Singapore companies have already leveraged on the huge potential in the carbon services sector, cutting-edge technology and alternative fuels. I believe that they have already taken the initiative. But are Government organisations working in partnership with the private sector, both MNCs and SMEs, to support them in tapping into this growth market?

Are we looking at areas of significant knowledge gaps, eg, environmental management and environmental law as well as environmental R&D where the potential for jobs is increasing rapidly? Will we build expertise in these areas? How much of our R&D funds will be invested in clean development mechanisms? Environmental R&D is one of the three growth areas identified by the

With regard to the people sector, what is the Government doing to raise public awareness and change mindsets? Will Government walk the talk in this area? I quote Sir David King, the chief scientific adviser to the UK government: "We must initiate a massive mindset change that is supported by governments in the forms of policy change and fiscal incentives."

Finally, are different Government agencies approaching this challenge in an integrated way? Are we studying Clean Development Offices and other government regulatory mechanisms and policies around the world so that we can determine the most appropriate and effective climate change policy for Singapore?

If Singapore aspires to be a global city, we must face global challenges, and climate change is the greatest of these challenges.

global agenda. Since the Kyoto Protocol came into effect a year ago, there has been a significant shift in scientific, political and public opinion, galvanised by events such as hurricanes Katrina and Rita and escalating oil prices.Prime Minister in the National Research Foundation. Does this include energy efficient and alternative fuel technologies?

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Mr Chairman, Sir, I would like to thank Dr Amy Khor, our GPC Chair, and other Members for their questions and suggestions. I will try my best to answer all their queries. If we cannot, we can probably follow up after the COS.

Sir, let me begin by highlighting some of the key environmental challenges facing us.

As noted by Members, it is increasingly clear that climate change or global warming is one of the major environmental challenges of our time. Extreme weather patterns in 2005 have threatened lives and disrupted economies

In the area of public health, there was a resurgence of dengue cases throughout the South-East Asia region, including Singapore. Through the combined efforts of the Government and the community, we succeeded in bringing the dengue situation under control very quickly. From a peak of 713 cases in one week in September last year, this has fallen to an average weekly of 66 for January 2006. So I wish to take this opportunity to thank the many grassroots, volunteers, officers and residents who have supported my Ministry's efforts in this area.

Worldwide concern over environmental issues, however, also means that there is increasing demand for better and more efficient environmental and water technology and services, and this presents us with opportunities. My Ministry has been a pioneer in increasing private sector involvement in the provision of environmental and water infrastructure and services. In 2003, we awarded a public-private partnership (PPP) contract for the first desalination plant in Singapore, followed by a PPP contract for a NEWater plant, and one for Singapore's fifth incineration plant last year. Besides boosting our water supply and improving our environmental services, such partnerships have helped companies to gain valuable expertise and track record for expansion overseas. We can also contribute to the enhancement of environmental well-being in other regions.

Sir, we have also made good progress in job creation in the environmental sector. Between April last year and February this year, NEA, together with the

Our various environmental efforts have ensured that the quality of Singapore's physical environment remains good. Singapore has continued to be highly rated in the 2005 annual surveys by Condé Nast Traveller and the Political and Economic Risk Consultancy (PERC). In fact, under the PERC survey, Singapore scored particularly well for our air quality.

Another example of international recognition of our excellent environmental efforts is the decision by the United Nations Environment Programme (UNEP) to host the annual award ceremony of the "Champions of the Earth" Award in Singapore for the next three years. The first one will be held next month. As the UNEP Executive Director, Mr Klaus Toepfer noted: "Singapore is a natural choice for such a global environmental event, as it is a country that has become an inspiration for other nations striving to achieve the goal of sustainable development". A high-quality living environment benefits all. It also bodes well for our tourism and business sectors, where Singapore's reputation as a global city with a clean and healthy environment will continue to attract visitors and investments to Singapore.

We must not forget that our high-quality environment is the result of years of sustained effort by individuals, organisations and the community. Many are doing their part in recycling, conserving water and adopting energy-efficiency practices. In a recent public

Sir, indeed, we cannot take our clean environment for granted. As Dr Khor had mentioned earlier, littering remains a key environmental challenge we need to address. Discarded containers such as drink cans are among the top three sources of mosquito breeding in residential estates. Litter can also blemish the image of our cityscape and clog up our waterways. From the public perception survey, cleanliness of public areas such as roads, drains and canals is identified as the top environmental concern.

NEA has been working with the community to promote anti-littering behaviour. In 2005, 19 national events such as the National Day Parade and the Singapore River Regatta, as well as another 230 community events, implemented litter-free initiatives. These included providing adequate litter bins during the events and reminding the participants on the proper disposal of their litter. Close to 120 primary schools have also participated in the Litter-Free School programme, where students are encouraged not to leave unwanted items around.

While we continue with public education and enforcement efforts, NEA will extend the Litter-Free Campaign to include Litter-Free Premises this year. We will work with operators and users to

Dr Khor has correctly pointed out that waste management is another one of our key environmental challenges. We are on track to achieve our target, which is to recycle 60% of the total waste generated by 2012. Our recycling rate in 2005 was 49%, up from 40% in 2000. We are setting up centralised recycling bins in all HDB estates by 2007 to encourage more household recycling.

Beyond recycling, however, we can do more to reduce waste at source. Last month, we launched the campaign to reduce excessive use of plastic bags and encourage the use of reusable shopping bags. The response from the public as well as from retailers, including the major supermarket chains, has been encouraging.

Sir, another major type of waste is packaging waste, as noted by Dr Khor, which makes up 35% of household waste in Singapore. My Ministry is working with manufacturers and distributors to develop a voluntary agreement to reduce the amount of packaging used and enhance the recovery of packaging materials. To date, several major food and beverage companies and the Packaging Council of Singapore have indicated their interest to participate in this proposed agreement.

I have sketched out the key environmental challenges facing Singapore and what my Ministry is doing to ensure that we continue to enjoy a high-quality living environment. Singapore's blueprint on tackling these environmental challenges is spelt out in the Singapore Green Plan 2012, which was released in 2002. Last year, we embarked on a review of the Green Plan to update its targets and action programmes, and I am pleased to inform the House that the revised Green Plan will be made public

Sir, as I have mentioned earlier, climate change or global warming is one of the major global environmental challenges of our time. Both Dr Amy Khor and Dr Geh Min have pointed this out. There is general scientific agreement that greenhouse gas emissions from human activities have contributed to climate change effects such as rising global temperatures, rising sea levels and extreme weather. There is also agreement that the international community needs to take concerted action to deal with climate change before it is too late.

Singapore's commitment to climate change is consistent with our good record on environmental issues. We have been a signatory to the UN Framework Convention on Climate Change since 1997. Last year, in this House, I mentioned that we were studying the timing of our accession to the Kyoto Protocol, which is the primary international agreement on climate change. Sir, I am pleased to inform Members that Singapore will be acceding to the Kyoto Protocol in 2006.

Singapore intends to engage in the ongoing international debate on how to manage greenhouse gas emission levels in a manner that is not harmful to our economic growth. By balancing environmental quality and sustainable economic development, Singapore will continue to prosper economically and provide a high-quality environment for residents, investors and visitors.

Singapore will continue to take actions domestically to address climate change. Dr Khor and Dr Geh Min have asked about our efforts to reduce greenhouse gas

In 2002, NEA introduced a voluntary Energy Labelling Scheme for air-conditioners and refrigerators. The labels provide energy performance information to help our consumers choose energy-efficient models and thus save on their utilities bills. As of January 2006, 121 air-conditioner and 77 fridge models were labelled, representing 27% and 20% of available models respectively. However, as most air-conditioner and fridge models are not labelled, the voluntary scheme remains limited in its ability to help our consumers.

Sir, we will thus make it mandatory for all air-conditioners and refrigerators to carry energy efficiency labels from mid-2007. I see Dr Khor smiling. This, as Mdm Cynthia Phua has also pointed out, would allow consumers to make more informed choices on appliances whose energy consumption forms a significant part of their utilities bill. My Ministry is now working with suppliers to ensure a smooth transition to the mandatory labelling scheme. We will also study the possibility of expanding the labelling scheme to include other energy-intensive appliances such as clothes dryers, dishwashers and water heaters.

Mandatory labelling will complement the existing domestic measures on climate change. For example, to promote energy efficiency in buildings, NEA launched the Energy Smart Buildings Scheme together with NUS in December 2005. This is the first energy-efficient building label in Asia. To promote the purchase of green vehicles such as compressed natural gas (CNG) and hybrid vehicles, we have

There are also opportunities arising from action on climate change, as noted by Dr Geh Min, and Singapore should capitalise on these. There is now growing worldwide demand for low-carbon technologies and fuels. We are thus encouraging companies to explore alternative energy technologies such as solar energy, as well as to test-bed emerging technologies such as fuel cells. Dr Geh Min has asked whether this will be the focus for NRF. As I replied earlier in the House to one of the questions, I will leave it to Dr Tan, as Chairman of NRF, to announce this. But in the cut on environmental technologies, I will update the House on the efforts by my Ministry to work together with the NRF to grow the environmental industry in Singapore.

Sir, under the Kyoto Protocol, developed countries can buy carbon credits to help meet their emission-reduction targets. As a result, carbon trading markets such as the EU Emissions Trading Scheme have developed. To look at opportunities relating to emission reduction and carbon trading, IE Singapore has helped form an iPartner consortium of Singapore-based environmental technology companies. This consortium is led by Asia Carbon, one of the first-movers in the carbon emissions trading industry. I hope all businesses and industries, in playing their part in addressing climate change, will also view such actions as opportunities.

My Ministry has also been working with other agencies, as noted by Dr Geh Min, Dr Khor and Mdm Cynthia Phua, to develop a holistic climate change strategy that actively engages the people and private sectors in climate change action. The climate change strategy will explain how Singapore can address climate change in an environmentally and economically sustainable way. It will examine four key prongs of action: adaptation to climate change, mitigation of our carbon emissions, raising awareness on climate change as well as competency building. This strategy forms a key focus area of the Singapore Green Plan.

In the coming months, we will be carrying out public consultation on the climate change strategy, to gather ideas and feedback on Singapore's proposed response to climate change. I will strongly encourage all members of the public to offer their views.

However, Sir, to contribute to climate change action, the public first needs to understand the causes of climate change and how it affects our lives.

in many parts of the world. Increasing scientific evidence suggests a link between global warming and such natural disasters. This calls for greater efforts around the world to slow down or reduce the emission of greenhouse gases that contribute to global warming.Town Councils, Workforce Development Agency, NTUC and environmental companies, has successfully matched more than 580 workers with jobs paying more than $1,000 a month. NEA and its partners were also given the Job Recreation Programme "Top Achiever Award" last month by NTUC for its efforts in this area.perception survey carried out by my Ministry, a large majority of respondents were positive about the state of our environment. 79% rated Singapore's state of the environment as "good" or "very good", and 64% rated it as better than that three years ago. In the same survey, more than 90% said they can play a part in energy and water conservation. My colleagues and I are heartened by this positive feedback and keen interest, and we encourage all to keep up these efforts in sustaining a clean and healthy environment.keep premises frequented by the public such as hawker centres and coffeeshops litter-free.later this month. The revised Singapore Green Plan is a product of extensive consultation between the Government and the private and people sectors. I am happy to see Singaporeans taking greater ownership of our environment. emissions. In Singapore, the primary greenhouse gas is carbon dioxide generated from energy use. A range of measures has therefore been adopted to improve energy efficiency and increase cleaner energy usage. doubled the Green Vehicle Rebate and extended it till 2007. At end February 2006, after just two months of the extended rebate, there were 208 green vehicles on the road, more than double the number last year. Motor traders have started marketing green vehicles to car buyers and reported positive response. We can thus expect to see more green vehicles on the road. So, to answer Dr Geh Min's question, we are taking the lead, given our context in promoting energy efficiency in Singapore.

My Ministry's public survey shows that about one in two persons still have not heard of climate change or global warming.

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So NEA will be working with the Singapore Environment Council to roll out a public awareness programme on energy efficiency and climate change in April. This programme aims to raise its awareness on the link between energy use and climate change. It will also show how households and motorists, by making simple adjustments in their daily habits, can reduce energy use, thus saving money and reducing our greenhouse gas emissions. This programme, I hope, addresses Dr Khor's question on

In contributing to the global climate change effort, my Ministry will continue to explore other programmes to improve Singapore's energy efficiency over time.

Sir, let me turn to the issue of particulate matter (PM) 2.5, which was raised by Mdm Cynthia Phua. Energy use in Singapore is also linked to air quality, as the burning of fossil fuels emits not just greenhouse gases but other air pollutants. While our ambient air quality generally compares favourably with other cities in the world, it was right for Mdm Cynthia Phua in highlighting the emerging issue of PM2.5 or particulate matter finer than 2.5 microns as a key challenge. PM2.5 has been linked to respiratory diseases and heart diseases. Singapore's ambient level of PM2.5 today is 21 microgram per cubic metre which is above the standard of 15 microgram per cubic metre set by the US Environmental Protection Agency (EPA). Unless we do something, our ambient PM2.5 level will increase further, largely due to vehicular growth, as noted by Mdm Phua.

Sir, we reduce PM2.5 levels by replacing diesel vehicles with CNG vehicles which emit negligible amounts of PM2.

5. This is why we have enhanced and extended the Green Vehicle Rebate for CNG vehicles and why CNG taxis will continue to be exempt from the special tax until December 2007. To improve CNG support infrastructure, NEA has also provided $2 million to support the building of three more refuelling stations across the island this year. We will continue to work with our public and private partners to promote measures that contribute to better air quality.

Sir, I think I have addressed most of the issues.

promoting energy conservation and efficiency practices in Singapore.

Water Management and Conservation

Sir, I commend the great strides the Government has made in the area of water technology, extracting every drop of water out of the very little we have from every conceivable source towards sustainable water management.

Sir, now that we have already turned on our fourth national tap, which is desalination, I would like to ask the Minister to comment whether we can one day be truly self-sufficient for our water needs and no longer need to import water from elsewhere. In addition, to help ensure that Singapore has sufficient water and at affordable cost, I would like to ask the Minister if there are any initiatives to further reduce our domestic consumption of water on a per capita basis. Would the Government make it mandatory for all flush systems to be switched to the water saving dual-flush low-capacity cisterns? Furthermore, with some low-income households being unable to pay their water bills, how can the Ministry help particularly such households, to reduce their water consumption and, hence, their water bills?

Prof. Low Seow Chay is not here. Dr Ong Chit Chung.

Water Policy

Sir, over the years, Singapore has diversified its resources of water supply. We will not be negotiating with Malaysia for extension of one of the water agreements when it lapses in 2011 - I refer to the 1961 Water Agreement. I therefore wish to ask the Minister on the success of our water diversification programme and whether in the long run, we ourselves can be fully self-sufficient and self-reliant in water supplies.

Sir, with the Marina Reservoir, we will have urban catchment areas for

Lastly, I also wish to ask the Minister how successful is our water conservation effort in reducing water consumption in Singapore.

water. It is good to enlarge our water supplies. Last Sunday, I had the privilege of taking a cruise by boat of the Marina area, and it is beautiful. We must keep it beautiful. We must ensure that the water collected is of high quality and is usable for drinking and recreational purposes.

Sir, I wish to thank Dr Amy Khor and Dr Ong for their questions. 2005 has been a significant year in Singapore's water history. In September 2005, our Prime Minister turned on our fourth National Tap with the opening of SingSpring's desalination plant in Tuas. Our first three National Taps are water from local catchment, imported water from Johor, and NEWater. I am pleased to inform the House that our ongoing projects to increase supply from our local reservoirs are progressing well. By 2009, when the various reservoir schemes are completed, our catchment area will increase from half to two-thirds of Singapore's land area.

Dr Ong Chit Chung asked about our strategy to secure sufficient water for Singapore. Sir, with all four National Taps now in place, we are well-placed to meet our future water needs. If need be, Singapore can be self-sufficient beyond 2061. Besides ensuring a sustainable supply of water, we will also continue to uphold high standards of water quality, water supply security and reliability.

PUB will continue their stringent Water Quality Monitoring Programme, involving both PUB's and external laboratories. We will also continue to engage an International Audit Panel to provide independent reviews on PUB's management of water quality.

Sir, everyone of us needs to play our part to ensure that the rain water

Sir, as noted by Dr Ong, the Marina Reservoir once completed will be a freshwater lake which will be created with the completion of the Marina Barrage. While we are confident that the raw water collected can be treated to high drinking standards with advanced membrane technology, the challenge, as noted by Dr Ong, will be to ensure that the water is good for recreational and other lifestyle activities. Once the Marina Barrage is built, the basin will be free from the influence of the ocean tides and ideal for various water activities. So we need to ensure that water flowing into the basin is not polluted.

PUB is working together with other agencies to draw up a comprehensive programme to tighten pollution control, and with industries on housekeeping measures to manage pollution. In 2006, we will reinforce our efforts in two key areas. Firstly, we will continue to upgrade the sewerage network system to minimise sewer leakages. Secondly, PUB is working with the construction industry to adopt earth control measures such that silt from construction sites does not end up in our reservoirs. Concurrently, we will also step up enforcement to deal with recalcitrant offenders.

Sir, as we continue with our efforts to diversify and increase our supply of water, we must concurrently pursue conservation strategies to manage water demand effectively. Both Dr Khor and Dr Ong have asked how we can further encourage water conservation.

PUB adopts a multi-pronged approach in managing water demand through pricing, mandatory water conservation requirements and encouraging voluntarism. This strategy has worked as our per capita domestic water consumption has decreased from 176 litres per day in 1994 to 160 litres per day in 2005.

There is however room to do more. Following feedback from the Singapore Green Plan (SGP) 2012 review process, PUB will set a new target to lower our per capita domestic water consumption to 155 litres per day by 2012. To achieve this target, PUB will be rolling out additional new initiatives in 2006.

Sir, let me first update the House on our existing programmes. Our ongoing Water Efficient Homes and Water Efficient Buildings programmes have been very successful. In our recent public survey, 87% of Singaporeans indicated that they practise water conservation at home. A further 231 commercial and industrial buildings and premises joined our Water Efficient Buildings programme in 2005. In July 2005, PUB launched the Water Detective Programme to educate primary school students on how they should conserve, value and enjoy water. We will continue with these efforts to spread the water conservation message.

In addition to the existing programmes, PUB will roll out a new programme in 2006 called the "10-Litre Challenge". This programme aims to get every individual, you and me included, to reduce daily water consumption by 10 litres. The "10-Litre Challenge" programme will comprise various initiatives, such as water volunteer groups, a labelling scheme for water-efficient appliances, and promoting the use of dual-flush low-capacity flushing cisterns (LCFCs). Allow me to elaborate.

Firstly, PUB is working with the Singapore Environment Council to set up

Secondly, PUB is working with PA and CDCs for grassroots organisations to form water volunteer groups. These water volunteer groups, supported by PUB officers, will conduct visits to educate households on water conservation practices and help them install water saving devices. The water volunteer groups will also visit lower-income and needy families to help them save on their water bills.

Thirdly, we will put in place a voluntary water efficiency labelling scheme for water fittings and appliances by the end of this year. Like energy efficiency labels, water efficiency labels will enable consumers to make better informed choices before purchasing items like washing machines and flushing cisterns.

Fourthly, PUB is looking into the mandatory installation of dual-flush low-capacity flushing cisterns (LCFCs) in all new buildings, as well as existing buildings undergoing renovations by end 2009. Compared to single-flush cisterns, the dual-flush models use less water as they allow users the choice of a half-flush versus a full-flush. Based on a market study, dual-flush and single-flush types cost almost the same. HDB will be carrying out pilot projects to install dual-flush LCFCs in flats for selected HDB Main Upgrading Programmes (MUP).

Dr Amy Khor also asked how we are helping low-income families so that they have a constant supply of water. I have earlier mentioned the Water Efficient Homes Programme and the Water Volunteer Groups, and how they would

For households that are in arrears, PUB has made arrangements with SP Services to offer instalment plans for households to settle their utilities bill arrears over a period of time. Instead of having their water supply cut, PUB reduces the flow rate of water to these households by installing flow restrictors. This enables such households to continue to have access to water for their basic needs.

Besides utilities rebates provided under the Utilities Save (U-Save) Scheme, CDCs also offer financial assistance to help low-income and needy families offset their utilities bills. All these measures will help to ensure that low-income families in Singapore are not left behind.

collected in our network of drains, canals and rivers is free of litter and pollution. As more and more of Singapore's land is utilised as catchment areas, pollution caused by people and industrial discharge is likely to find its way into the reservoirs. It is important that we minimise such pollution.a dedicated web portal to show how easy it is to save 10 litres of water a day. For example, I was told that just by reducing shower time by one minute, each person can save up to nine litres of water.visit lower-income and needy families to help them save on their water bills. For example, volunteers from the Sunlove Home Neighbourhood Link and Indus Moral Care visit needy senior citizens in South East and Central CDCs respectively to help them install water saving devices and share with them water saving habits.

Environmental and Water Technologies

I am pleased that the environmental and water technology development has been identified as one of two key areas of focus for the $5 billion R&D Trust Fund under the NRF. I understand that the environmental and water technology sector is forecast to grow by 10%-12% a year in the area of water technologies. Since 2001, 10 groups under the PUB have been studying areas like membrane technology, water and used water treatment. PUB also provides facilities and on-site support to private companies for testbeding initiatives. In line with the key thrust of the NRF, I would like to ask what the Ministry's plans are for R&D into environmental and water technologies and what other aspects it would be looking into. How would the Ministry encourage

private sector participation in this area of research and will collaborate with them so that the private sector can also benefit from this growth sector? How can the Ministry encourage and help our environmental and water sector develop and expand abroad?

Sir, I would also like to raise some questions on the environmental and water technology sector. I think this is one sector which the Prime Minister has identified in his Budget Statement. This is a sector which will bring about good growth prospects and also perhaps good employment opportunities for our people.

Sir, I would like to ask the Minister what are the Ministry's plans to facilitate the development of environmental and water technologies

and expertise. I think there is also scope to tap on opportunities to export Singapore's water and environmental technologies and expertise.

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Sir, on the development of the water industry, following the successful involvement of Hyflux in the supply of desalinated water, do the Ministry and the PUB have plans to involve more companies in the private sector in water projects and initiatives?

Sir, I had also wanted to ask some questions on sustainable water management and conservation, but the Minister has already replied most comprehensively. But let me add that the public has also an important part to play to be more disciplined and to have good water consumption habits. They will benefit, because they will receive smaller water billings.

Sir, I would like to thank Dr Amy Khor and Mr Othman Haron Eusofe for their questions on environmental and water technologies.

Sir, the National Research Foundation (NRF) has identified Environmental and Water Technologies (EWT) as one of the two new areas for strategic research and development initiatives that would generate economic benefits for Singapore. My Ministry is working closely with the NRF to further develop plans to grow the environmental and water technologies sector.

We will intensify our efforts to attract global research laboratories and companies to set up their operations in Singapore. We will offer more Government facilities for companies to test and try out their new technologies. Through the NRF, we intend to create a pool of specialist manpower, such as engineers, researchers and technicians, to support the increased R&D work. By doing these, we will strengthen Singapore's position in applied water and environmental research, as well as Singapore's ability to commercialise and use the new technologies. We will also build up our capabilities in the area of basic research so that Singapore will be better placed to develop the next generation of cutting-edge technologies.

The Public Utilities Board (PUB) has ensured that Singapore has enough water to sustain its growth and development through our Four National Taps strategy. In doing so, Singapore turned weakness into strength, and is now a growing water hub, a recognised leader in adopting new water technologies and in integrated management of water resources.

Sir, our efforts have not gone unnoticed by the international community. I am pleased to announce that at the

In the area of water technologies, PUB is working with companies and research institutes to test the use of new membrane systems to treat used water to further enhance our water sources. The Membrane Bio-Reactor (MBR), the Membrane Distillation (Memstill) and the Variable Salinity Plant (VSP) are just three examples of recent technological advances which have the potential to drive down the cost of water production, enhance our water sources, and provide Singapore with a leading edge in the global water industry.

Sir, we have also been promoting applied research and test-bedding of emerging environmental technologies in Singapore through the Innovation for Environmental Sustainability (IES) Fund. One project supported by the IES Fund is the development of a process by GPac Technology (S) Pte Ltd to produce pallets from recycled horticultural and wood waste instead of timber. We hope that more companies will come forward and tap on the IES Fund to test new and innovative technologies in Singapore.

Sir, both Dr Amy Khor and Mr Othman asked about the private sector participation in the environmental and water sectors. My Ministry has been helping to build up the companies' experience and

To further develop the water industry, my Ministry will explore the possibility of giving the private sector a larger role in the supply of NEWater to the Kranji cluster. This will be studied in greater detail in the coming months before finalising the plan.

In addition, we leverage on Singapore's strong networks and ties with other countries to facilitate the companies' expansion abroad. We have strong government-to-government links, for example, with ASEAN, China, the Middle Eastern countries and India. IE Singapore also has strong networks and links with potential overseas partners. We have also been organising business missions for environmental and water companies. My Ministry will continue to support and encourage our water and environment companies venturing overseas.

Sir, both environmental and water technologies have played a significant part in our efforts to enhance our environmental and water resources, and to sustain the high environmental standards that Singapore enjoys today. 2006 Global Water Awards held in Dubai last evening, PUB won the prestigious Water Agency of the Year award. This award by the Global Water Intelligence Magazine is a prestigious symbol of achievement in the global water industry. PUB won the award against competition from reputable water agencies from the UK, US and Saudi Arabia. Our homegrown company Hyflux was also named the Water Company of the Year. These awards reaffirm the good work put in by PUB and our industry partners in ensuring a sustainable water supply for Singapore. track record to expand overseas. Through the Public-Private Partnerships projects that I mentioned earlier, companies have built up plant operation and maintenance experience, and can now offer their services as a more complete package to potential clients. Members may have read that some of our environmental companies are bidding for projects overseas, including the Middle East and China.

Green Procurement

Sir, I am delighted to hear the Minister's announcement that we will be acceding to the Kyoto Protocol this year. I know that the Government does not regard this as an empty gesture, but a commitment backed by firm action.

Many countries have a governing legislation that includes the procurement of environmentally sound technology and products based on their proven track records and endorsements, so that the public sector is required to request for

Commitment and support from the Government would promote green procurement practices in the private and people sector. It would lead to the increase of imports and local development of more eco-friendly products and technology. It could propel the expansion of the range and quality of such products locally and promote the export of eco-friendly products to external markets. It will also give greater substance and an additional dimension to Singapore's clean and green image by going one significant step further. By taking the lead for sound eco-friendly practices, the Government agencies will enhance their credibility and Singapore's reputation, both locally and abroad.

The Minister Mentor's vision of a clean and green Singapore as good for business, good for people and good for the environment pre-empted the triple-bottom line of an economically profitable, socially responsible and environmentally sustainable practice. But while visions are timeless, their interpretation and implementation need to be reviewed regularly to remain relevant to the changing global environment and to new challenges. In today's context of global warming, limited supply of fossil fuels, and rising costs of energy, "clean and green" requires new mindsets, policies and practices.

products under an Eco Label category within its tender requirements. Many of these products and technologies are affiliated to Singapore's Green Labelling Scheme, and a number of foreign companies based in Singapore have also already committed to integrating such practices into their businesses here, eg, Fuji and Xerox. But there is still no official policy in the public sector yet for promoting the procurement and use of environmentally sound products and technologies. Why? I believe that the introduction of a Green Procurement Policy in the public sector is an obvious one - low-hanging fruit that is in our garden. Singapore may be clean and green, but there are some "black holes" in our green image, and one of these is our lack of a green procurement policy in the public sector.

Public Health and Dead Birds

Sir, before I start, I would like to declare my interest as the CEO of a diagnostic company developing rapid tests for Avian flu.

My question relates to the recent world-wide fears about the emergence of bird flu in the region. Does the Ministry have safety guidelines for workers on how to deal with the disposal of dead birds found in public areas, such as roadsides, schools, parks and other public places? The reason is because the current outbreak is primarily in migratory birds that have been propagating the Avian flu. In particular, do these guidelines dovetail with our national H5N1 flu surveillance efforts? Does the public have to be educated on the safety guidelines for handling dead birds as well?

Sir, I reiterate my concern, as we cannot afford not to be too careful, what with the recent bird flu outbreaks in the neighbouring countries and Singapore's situational position.

Mr Chairman, Sir, I would like to thank Dr Geh Min and Dr Tan for their questions.

Dr Geh Min has asked about green procurement in the public sector. We recognise that green procurement can offer environmental benefits and lead to

In this regard, Sir, the Government has put in place a number of measures to encourage green purchases. For example, we have extended the green vehicle rebates to encourage more to choose such vehicles. In addition, my Ministry will be making it mandatory, as announced by the Minister a few minutes ago, for air-conditioners and refrigerators to be energy labelled, so that consumers have the necessary information when buying those appliances. We are also encouraging energy audits among companies and building owners to improve their energy efficiency.

A key principle of public sector procurement is to secure value-for-money for goods and services purchased. While the public sector does not have an explicit green procurement policy, public agencies are free to procure environmentally-friendly goods and services, based on their own needs and circumstances. We encourage them, where possible, to purchase green products within those guidelines. I am heartened to see that the public sector is piloting a number of green procurement initiatives. For example, the Singapore Police Force has procured two hybrid cars for trial as patrol vehicles. Eight public sector agencies, including MEWR, MOF, MOM and SGH, are also participating in a pilot scheme on performance contracts for energy audits. Under this scheme, the contractor designs and finances the installation of energy-saving equipment and gets paid according to the savings achieved. The agencies put in nothing, or very little. If successful, Sir, we will encourage more public agencies to implement such green contracts.

Besides green procurement, it is equally important for us to internalise environmentally-friendly habits. Recently, MEWR and NEA were awarded the Green Office Label under Project Eco-Office. This is an initiative launched by the Singapore Environment Council to encourage office workers to incorporate environmentally-friendly practices in their daily routines. Since certification, my Ministry has achieved a 5% reduction in both energy and water consumption - very green practices. Recovery of recyclables, such as paper and drink cans, has also increased significantly.

My Ministry will continue to work with the Ministry of Finance to further promote the adoption of green procurement and practices among public agencies.

Sir, Dr Tan has asked about the guidelines on the disposal of dead birds and whether these guidelines dovetail with our Avian flu surveillance efforts. The answer is yes. AVA has put in place an Avian flu surveillance system as well as an inter-agency action plan to respond to an Avian flu incident. As part of the surveillance system, NEA will respond to calls on the presence of dead birds and send these for H5N1 virus testing in AVA laboratories.

In carrying out this work, Sir, NEA officers and cleansing workers are equipped with personal protection equipment, such as gloves and masks, and are trained to follow safety procedures.

So far, AVA has not detected the presence of the H5N1 virus in Singapore. Notwithstanding this, as a precautionary measure, the public is advised not to handle any dead birds they come across, but to contact NEA. As we have learnt in our fight against dengue, maintaining Singapore's high standard of public health requires the public to be our eyes and ears on the ground.

greater efficiency and savings. Hence, we welcome the use of green products and services, and encourage the adoption of green procurement practices, not just in the public sector but throughout Singapore.

Hawker Centres

Sir, our hawker centres are part of "Uniquely Singapore". They are the special attractions to both Singaporeans and tourists.

A few years ago, when I was with MFA, a Malaysian Minister on transit at Changi Airport asked me to take him to a hawker centre. As he had only 90 minutes to spare, I took him to the Bedok North Avenue 4 hawker centre near the SBS depot, the nearest from the airport. He was impressed not only by the quality of prata served, but also the way stalls were neatly arranged, the manner in which tables and chairs were cleaned, how the eating plates were removed and cleaned, etc. More than this, he commended on the good sanitation and sewerage system, and the multi-racial nature of the hawker centre.

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He said, and I quote, "Your hawker centres are good models to emulate." Sir, it was in the light of this special position enjoyed by our hawker centres that I am heartened to learn that the upgrading work for 48 out of the 113 centres which started four years ago had made them look more attractive to their customers. With improved floorings, better tables and chairs and stall designs, more airy environment, improved disposal system and better and more airy toilets, many found the upgraded hawker or food centres more comfortable.

However, we need to do more to make it vibrant. I had been to the upgraded East Coast Park, Adam Road, Bedok Corner, Pasir Panjang hawker centres during the weekdays and weekends. My impression is that they

But, Sir, how many of these 50 or so centres really have all the attractions mentioned by the newspapers? Why not also consider placing television sets so that diners can eat and update themselves on news and enjoy the entertainment such as football matches? Or provide stages for buskers or music performance at the site?

Sir, one of the reasons for the constraints faced by those managing the hawker centres is the location. It is either too cramped or too near residential areas that neighbours get unhappy over the noise generated apart from the fumes coming from the kitchens. Perhaps, we could build some of these hawker centres near to parks or water bodies.

Sir, over the past year, we have seen more recreational activities taking place near the water bodies such as reservoirs. I remember hearing about a plan to build hawker centres and recreational facilities near the water areas. Bedok Reservoir has been mentioned as one of the possible new locations. May I ask the Minister whether there is a plan to move towards this direction island wide? If indeed there is, when would such a plan be completed?

have not shed their old characteristics of a place for one to "come, eat and go". To make them more vibrant, we need more than just improving the gastronomic aspect. So when I saw the Lianhe Zaobao report on 23rd January and the Straits Times on the same day that said, "Flea markets, buskers jazz up hawker centres; over 50 food centres now have added attractions.", I say we have done well in energising our hawker centres.

Sir, I would like to thank Mr Yatiman for raising an issue which is close to our heart and our stomach, which is on the hawker centres. I am impressed by his ability to

Sir, the Hawker Centres Upgrading Programme was launched in 2001. To date, a total of 48 centres have been upgraded. With increased ventilation, wider aisles, larger stall spaces, and aesthetically pleasing landscape, these upgraded centres have enjoyed improved patronage and business.

Besides being key amenities, hawker centres are places for social interaction and community bonding. Mr Yatiman asked what we can do to make hawker centres more vibrant. Sir, I mentioned in the COS last year that my Ministry would study the feasibility of introducing activities to increase the vibrancy of our hawker centres. I am pleased to announce that since August last year, a variety of activities such as busking, cultural performances and flea markets have been organised in more than 80 centres. Television sets have also been installed in some of our hawker centres.

Sir, we have received positive responses from both stallholders and patrons on these activities. Stallholders have reported an increase in customer volume. 71% of the respondents in MEWR's recent survey indicated that they would visit hawker centres more often if there were such activities. In fact, we have been told that the singing and dance performances at hawker centres have become so popular that some customers are requesting for singing and dancing contests to be organised for them to take part.

Sir, the Hawkers Associations have played a key role in organising these activities. In fact, Hawkers Associations have a better feel of the uniqueness, strengths and shortfalls of their respective

Let me cite an example. The hawker centre at Blk 137 Tampines Street 11 is a good example. The Hawkers Association, together with the Merchants Association and grassroots have worked together to increase the centre's vibrancy. It is the first hawker centre to provide wireless broadband services. In addition, with five 29-inch television sets placed around the centre, diners will be entertained while they enjoy their food. To top it off, the centre has a customer service counter where customers can charge their mobile phones and borrow umbrellas when it rains. PR consultants have also been engaged to help stallholders improve the presentation of their stalls.

Sir, I would like to encourage Hawkers Associations to work with the grassroots and NEA to organise activities at our hawker centres. NEA is also developing a set of guidelines to help the hawkers associations in introducing more activities.

Sir, let me now move on to the second part regarding our water bodies. In 2005, the PUB adopted a new approach to engage our 3P partners to value and enjoy our water resources. We opened up our reservoirs for more recreational activities and launched Our Waters programme that encouraged public adoption and ownership of our waterways.

As more and more of our population live and work within water catchment areas, these efforts encourage the public to form a closer bond with water and appreciate the need to keep our catchments clean. Singaporeans can play a part by not littering or polluting the catchment so that our water sources remain clean and our water quality remains high.

Mr Yatiman has asked about the plans to enable the public and community to better enjoy our reservoirs and waterways. In 2006, we will continue the outreach efforts under an umbrella programme known as the Active, Beautiful and Clean Waters Programme, or ABC Waters Programme. Our waterways and reservoirs should not be just for water collection, storage and drainage purposes. The ABC Waters Programme will transform the waterways and reservoirs into vibrant and aesthetically pleasing community spaces with activities for everyone to enjoy and participate in. I have circulated some pictures to Members of the House so that they have a better sense of what we are talking about.

Members in this House are aware of the concept plans that have been drawn up for Bedok and MacRitchie Reservoirs which were developed after much public consultation and feedback. In the next two to three years, PUB will be working with the relevant stakeholders and grassroots organisations to implement the plans. Sir, with the experience gained, PUB intends to work with other stakeholders and 3P partners to develop similar plans for our other reservoirs such as Pandan, Upper and Lower Seletar reservoirs.

Sir, another initiative which will be implemented under the ABC Waters Programme is Watershed Management. The PUB will appoint private sector companies with the relevant experience and know-how to manage our water bodies. These Watershed Managers will contribute ideas to enhance and redevelop our waterways and reservoirs. This is not new. It has been done in some other countries.

More can also be done to improve the aesthetics along and surrounding the waterways to provide further opportunities for Singaporeans to enjoy the environment. Projects of similar nature

Another potential area for redevelopment is upstream of Kallang River that runs adjacent to Bishan Park and the HDB housing estate. By maintaining a constant level of water in the canal and integrating landscaping and recreational facilities, the canal could be transformed into a focal point for residents to engage in recreational activities and enjoy the serenity of the waterway.

For the Marina Basin, its strategic location in the heart of the city presents a wonderful opportunity to promote the Basin as a lifestyle attraction with lots of activities in and around the waters. We have heard the announcement about the Bridge. More can be done. With the closure of the Marina channel, expected to be in July this year, the Basin will become an enclosed water body ideal for recreational activities to take place. PUB is working with relevant agencies through the Downtown Ministerial Steering Committee and other inter-agency forums, as well as with stakeholders to manage the activities in the Marina Basin so that these can be conducted safely and smoothly.

Sir, in building the Marina Barrage and beautifying the waterways leading into the future Marina Reservoir, PUB, as the

Sir, PUB is working towards a public exhibition early next year, and all Singaporeans will have the opportunity to share their ideas on how we can make our living environment, including the waterways as a more vibrant and enjoyable place. This will give new meaning to living in a garden city where beautiful waterways run through it.

Sir, we have outlined how the Ministry will spare no efforts in tackling the environmental challenges which face us in preserving and enhancing our natural resource endowments of water, land and air. We have put in place many programmes and plans, but we cannot achieve and sustain this without a strong partnership with the people and private sectors, ie, a 3P partnership approach. We also need individuals to do their part, so that as a nation, our collective efforts would make that quantum difference to our continual quest of being a clean, vibrant and beautiful global city.

read Mandarin apart from his knowledge of Tongkat Ali. centres. They are thus best placed to work with the grassroots to determine the nature, extent and frequency of such activities.have been attempted overseas with great success, like the Cheong-gye Stream in Seoul and the Isar River in Munich, Germany. As a pilot project, the PUB, NParks and HDB will provide landscaping and recreational facilities along a short stretch of Kallang River in the second half of 2006. Learning from this pilot project, the PUB and NParks will then develop the remaining sections of Kallang River in the next stage, which could even incorporate water features. With these in place, residents could look forward to carrying out activities amidst the greenery by the river, such as leisure strolls, jogging, or simply socialising with neighbours and friends.custodian of our water resources, has shown us a host of possibilities for bringing us closer to water and transforming the waterfront view in many of our neighbourhoods. In order to realise the full potential of our waterways, this undertaking cannot be PUB's alone. We need to harness the ideas and efforts of many parties in the private, public and people sectors, especially those living close to these waterways and who have a stake in bringing this vision to fruition. This will take time, and can only be possible if we continue to enjoy good economic growth.

Mr Chairman, just two points of clarification. I would like to thank the Minister and PUB for their support in working with the MPs and grassroots leaders of Aljunied GRCs in making our Bedok Reservoir a jewel in Aljunied GRC.

However, I just want to appeal to the Minister to allow certain areas in the Bedok Reservoir for children or even adults like me, who love water, to be able to walk into the water or to dangle our feet in the water. Currently, the edge itself is very rough with rocks.

The second question is on the hawker centres. Our hawker centres have matured, like what our Member of Parliament has said. Could the Minister look into the guidelines of the operating hours of these hawker centres? At the same time, we should consider allowing the stallholders to sublet their stalls. The reason is that we have already matured so much and a lot of them have actually assigned their stalls and they are paying market price for the stall itself. Can the Ministry allow some subletting so that the hawker stalls can operate longer hours?

Sir, I am glad that Mdm Cynthia Phua sees the value in what we are doing at Bedok Reservoir. I will take her feedback and discuss this with the PUB. As I mentioned just now, we will be having an exhibition next year. These are some of the inputs that PUB would like to gather to better understand the needs of residents. She is the Member of Parliament in that area, so she understands the needs of her residents. We will take her feedback but, at the same time, she must also appreciate that we have to balance this with safety. If children are involved with water, we must balance all our objectives so that we achieve the desired outcome.

On hawker centres, I appreciate her concern about extending the hours of operation and whether subletting is one way to go. She is aware that we have to be careful. If we do allow this, that means we will promote a second sector which could be illegal altogether and we do not want that to happen at our hawker centres. But having said that, there are instances whereby families have been

able to re-assign it to a relative where they can extend their operating hours. We understand the concerns of some of our hawkers and NEA is now reviewing this on how best we can help our hawkers, especially those who are in need, to be able to operate longer hours, so that they can earn some extra income.

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Sir, I am really glad to hear of the Minister's vision for the revived waterways. Can I ask whether he might include plans for Sungei Sembawang or Katib Bongsu canal?

Certainly, we will include all our waterways. I have been told that we have done something at Sungei Sembawang. Katib Bongsu, if my memories serve me right, would be part of a new reservoir, but that will be later. If we succeed in our pilot project on the ABC Waters Programme at Kallang River, we will explore all the other waterways in Singapore to see how we can enhance it.

We will continue to review all the opportunities across our waterways in order to enhance the living environment there.

Any more requests? Mr Yatiman.

Sir, I am heartened to see the plan for the various waterways as elaborated by the Minister. I targeted my question at MND yesterday, but now I have MEWR replying to my question. I would like to add a point here, Mr Chairman.

Are you making a speech or asking a question, Mr Yatiman?

Asking a question.

Please do.

I would like to ask whether this concept would be incorporated together with the parks development, and whether MEWR is working closely with the National Parks Board.

Yes, Sir. As you know, for example, in the case of Bedok Reservoir, we own the waterways but the surrounding part is managed by NParks, so we have to work together with other agencies. As I mentioned in my reply, we work closely with NParks and HDB to ensure that we integrate our plans.

Dr Geh Min, you want to ask something?

Thank you. Two points of clarification. First, may I congratulate the Minister on the very effective work on the waterways. Just a point of clarification here. It says in the first photograph on Sungei Api Api, "Instead of lining the river with concrete, mangrove plants were used to soften the look". Obviously, I think this was formulated by the Ministry of the Environment, and not NParks. I know that the Government believes in substance but not style and I would just like to clarify here that mangrove plants do more than soften the look. They are ecologically-friendly, reduce pollution, reduce erosion and they reduce greenhouse gases. So I think that would be a more fitting subtitle.

The second point of clarification is for the Senior Parliamentary Secretary. I would like to thank him very much for his comprehensive reply on the green procurement policy for the public sector. He has stated that he thinks that it is effective as a voluntary process and he cited some good examples of Ministries or Government agencies.

Dr Geh Min, please ask your question or clarification.

My question is this: some agencies are better than others. Some Government agencies are better. Of course, the Ministry of the Environment is at the top there, but it is quite evident that some agencies, even Government agencies, are not as good in their energy efficient and green practices. So, what is MEWR doing to raise their level?

First of all, thank you very much for Dr Geh Min's compliments. I think the process takes some time. We need to proceed slowly. What are we doing? First of all, we are trying to persuade the different Ministries to be as green as the Ministry of the Environment and Water Resources. So we set the example and then whisper in the ears and lobby the Ministers and the Prime Minister. There is no explicit green procurement policy. There is an implicit one because the Government has agreed to energy labelling for appliances. In that sense, all the agencies must buy energy-labelled refrigerators and air-conditioners. So that is the green procurement policy in kind. I think, slowly over the next few years, you will find that more agencies will buy more green products and also when more of these products are available in the market. But, again, in saying so, we would like to emphasise that the public sector procurement policy is one that is based on value-for-money for goods and services purchased. So, the green procurement policy must not be on top of that. It must be below that.

I would like to ask the Minister regarding our Singapore OK programme. It does not seem to be very okay now for many toilets. Is the Ministry going to review the whole initiative to see what else we can do

because many of the toilets have really deteriorated in cleanliness?

I apologise to Dr Khor for not answering that. I agree with her that after the campaign we noticed a slight deterioration. My officers have stepped up efforts and we are going to work very closely with the operators. I mentioned in my reply that we are going to work with coffeeshops and places where people gather, for litter-free premises and we will extend this to looking into toilets and how best we can maintain the standard. So it is an important part of our work and I thank her for raising it up and we will continue to review this.

Sir, there is an important waterway between Coney Island and Punggol end. There is a short stretch where it is covered by water. The island itself is really very good for recreation, except that it is in the boundary of Changi side rather than Pasir Ris-Punggol GRC per se. What I want to ask is if this stretch of water could be used for recreational purposes. Is the Ministry looking into it or could it be used as water catchment area as well?

Sir, our first priority is to exploit all our water bodies for the purpose of our water consumption. I am not sure which part is she talking about. Under the plan, that is part of the Seletar-Serangoon reservoir scheme, which we are now upgrading to turn it into a reservoir. This is part of the Masterplan I mentioned earlier to achieve basically our four National Taps to ensure that we maximise our water resources. But, along the way, after we have achieved our first basic objective, which is to provide drinking water for all Singaporeans and water for use in industry, we will explore other opportunities like beautifying the waterways and the areas around it. In this instance, as I

have replied to Mr Yatiman, we work closely with our partners, NParks. So, as and when, we can actually open up the waterways for public recreational use, we will do so because this is the way, as I mentioned in my reply, we contribute to this uniquely global city that we have in Singapore. In fact, as we basically build up more reservoirs in Singapore, build up more of our areas to become catchment areas, the need for Singaporeans to be more careful about littering our waterways becomes all the more important. So rather than taking the approach that you cannot approach our waterways, we think the best way is to open up our waterways and educate Singaporeans to be responsible so that they can enjoy the water, dangle their feet in Bedok Reservoir, whatever the case may be but, meanwhile, do not litter our waterways.

I would like to thank the Senior Parliamentary Secretary for the clarification regarding not handling dead birds per se. But I have a clarification. It is a fact that, as we know from recent cases, quite a majority of the human cases have been children who have come in close contact with dead poultry or birds that have been exposed to H5N1. This question arose because one of my friends, who is a parent, had seen with her eyes, how in a school, when there was a dead bird in the compound, the way it was handled upset her because it seems that the school does not really know what to do as well. Perhaps it is for the Ministry to consider public education because although we do not have it here yet but, because of migrating birds, we never know when it will come. Schools too would also have to be educated on how to handle dead birds within their compound, especially how to educate the children not to touch the birds as well.

Any more clarifications? Dr Geh Min, make it brief, please.

I asked for a clarification from the Senior Parliamentary Secretary and I thank him for his reply. I understand the green procurement policy must work with, rather than against economic considerations. But the point that I was trying to make is that if the public sector supports green practices, this would jump-start and make it more affordable for everyone, the private and the people sectors, to practise energy-efficient and green technology practices because the Government is such a large sector in the industry.

Sir, if I may clarify, the Government is for procuring green products. We are not saying that we do not buy green products. Where possible, we will buy green products but it must be value-for-money products. Yes, we take the point that Dr Geh Min is trying to inform us. We will move forward the process and see how large this implicit green procurement policy can be widened to.

Any more clarifications?

I was going to answer Dr Tan but Dr Geh Min stood up to ask another good question. He asked for public education policy to be disseminated to schools. We will take up on that suggestion. Again, we want to emphasise that dead birds are not to be handled by hands without gloves.

If there is no other clarification, Dr Khor, are you withdrawing your amendment?

Sir, I thank the Minister and his Senior Parliamentary Secretary for their very comprehensive replies. I would also like to thank the Minister for bringing us many good news today regarding the conservation and protection of the environment and improving the quality of the environment,

Sir, I am pleased to withdraw my amendment.

including our very own and very unique Singaporean-style hawker centres.

Amendment, by leave, withdrawn.

The sum of $440,608,750 for Head L ordered to stand part of the Main Estimates.

The sum of $613,,946,500 for Head L ordered to stand part of the Development Estimates.

Head O - Ministry of Health. Mdm Halimah Yacob, you have two cuts. Take them together. Total time is 8 1/2 minutes.

Healthcare

Sir, I beg to move,

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

Sir, many positive changes have taken place in the healthcare sector over the last one year, for which I must credit the Health Minister. We now have a more robust MediShield scheme where more of the bigger hospital bills are covered, providing immense relief to many Singaporeans suffering from ageing illnesses. Another development is the higher daily Medisave withdrawal limit which will benefit 50,000 Singaporeans. These changes have made our healthcare system much more robust and sound. However, we all know that healthcare is not a static subject, but is constantly evolving with new issues emerging all the time.

I would like to raise three issues. Firstly, Sir, healthcare costs continue to be a concern to Singaporeans. In a 2004 Feedback Unit survey involving 1,064 Singaporeans, 67% were worried that they would not be able to pay for their future healthcare cost, while 60% were worried they would not be able to pay for their dependant's future healthcare cost. These concerns are not without basis. Healthcare costs have been rising as reflected by our medical inflation rate which, at 5.9% in 2004, was the highest in a decade and definitely higher than the general inflation rate of 1.7% in 2004. Households are also spending more on healthcare, with the lowest 20% of the income groups spending the most, about 7% of the household income compared to the highest 20% of the income group, which spends about 4.7% of the household income on healthcare.

Although healthcare is not something that we consume all the time, it is a subject that occupies our mind all the time. Even those who are now healthy worry in case they fall ill one day and are unable to provide for themselves or their families. While I agree that we can contain our own healthcare cost by keeping healthy and cost increase is also due to advancement in diagnostics and medical technologies, I also believe that the Government can do more to control the increase in healthcare costs and to boost the productivity and efficiency of our healthcare providers. Otherwise, I do not see how we can maintain a tight lid on our national health expenditure and Government subsidies without the population suffering a fall in medical care. I believe, Sir, that we can better leverage on economies of scale, a more efficient use of manpower such as the advanced practice nurses and greater control over the use of new medical technologies, just to name a few areas.

I would like to ask the Minister what measures would be taken to control

Secondly, Sir, we need to pay greater attention to the long-term healthcare needs of our elderly Singaporeans. Those above 65 years have on average only about $5,300 in their Medisave, barely sufficient to pay for their MediShield and ElderShield premiums as well as the smaller hospital bills of specialist outpatient treatment. As our population is ageing rapidly, I would like to ask the Minister whether our 3M system is sufficient to take care of the long term healthcare needs of our elderly. I would like to suggest that the Ministry undertakes a comprehensive study of the long-term healthcare needs of our elderly and assess whether our 3M system can sustain their needs financially. I am not talking here, Sir, about the ability of our 3M system to pay for the needs of the elderly today,

medical inflation and ensure that healthcare costs remain affordable to all Singaporeans.

but rather to assess how demographics, cost increases, advancements in diagnostics and medical technologies and many other factors would impact on the 3M system and its ability to provide for the future healthcare cost of the elderly.

1.45 pm

On another matter, Sir, related to the elderly, I note that the Committee on Ageing Issues had concluded its work, and made many recommendations pertaining to our ageing population. I would also like to ask the Minister when the Ministry will be giving its response to the recommendations of the Committee on Ageing Issues, particularly on those matters related to health. My concern is that sometimes we have a lot of committees making recommendations but the follow-up may not be sustained. On the elderly alone, Sir, there have been many reports and committees, and what we need now is to ensure that there is effective follow-up on these reports.

My third point is on the need to continuously improve medical standards. Singaporeans are concerned not only with cost but also whether they are provided with a good standard of medical care in Singapore. The quality and standard of healthcare that we receive is important to ensure that we recover quickly, do not stay in the hospital longer than needed or develop serious complications, all of which will add to our cost and agony. Yet, unlike the purchase of other goods and services where the customer can easily make a distinction in the quality of service or goods, it is not so simple for the average patient to do so. While the publication of hospital fees is a laudable move and has ensured that hospitals do not overcharge for the same type of procedure or treatment, much more needs to be done to inject transparency into our healthcare system. For example, if someone wants to have a cataract operation - the price being equal - how is he to decide whether to have it done at SGH or NUH? Yet, this is an important point. An ignorant or ill-informed patient may breed complacency in our healthcare system as he is not in a position to demand high standards.

In March last year, Sir, Prof. Robert Brook of the US think tank, RAND Health, recommended that health institutions here start providing information about the quality of its services as well, so that people can choose a healthcare service based on price and quality. According to him, if the Singapore healthcare system wants to have meaningful competition and be world-class, then it must provide more than just pricing information to patients. I would like to ask the Minister what initiatives are in place to enhance medical standards and to publish quality indicators of our medical services in Singapore. With quality indicators, patients will be better able to make informed choices on where to seek treatment, and this will also provide transparent benchmarks on the

I note, Sir, that the Joint Commission in the National and American Accreditation Agency already accredits some of our public hospitals. Patients treated at accredited hospitals can expect more consistency in hospital processes and treatments. The question is: why have all the hospitals not achieved accreditation from this Agency, and are private hospitals covered? Also, in what way can the Ministry educate the public so that they can better understand the significance of quality indicators and, in this way, help them to seek better quality treatment and therefore further boost standards?

Medisave

Let me come to my next point, Sir, and this is on Medisave. Currently, the use of Medisave is allowed only in limited areas. I urge the Ministry to allow greater flexibility in the use of Medisave. Singaporeans' need for their long-term hospitalisation needs is well understood and cannot be denied. But it is difficult to explain to Singaporeans, who need cash to pay for their immediate medical needs, why they cannot make use of their Medisave savings but instead have to borrow or seek assistance from the CDCs or other places to pay for their medical bills. Those desperately in need of help cannot be expected to worry about future needs. But if they neglect taking medicine regularly or fail to seek regular treatment and fall seriously ill resulting in hospitalisation, that would put a serious strain on the resources of our hospitals. I would like to request for greater flexibility in the use of Medisave, particularly in the following areas - I am sure the Ministry can look into other areas as well - long-term chronic illnesses, such as diabetes and hypertension, purchase of medical

comparative efficiency of our healthcare providers.consumables, purchase of medical equipment, eg, ventilators, payment for medical tests, such as MRI for those already diagnosed with a serious illness, cost of home rehabilitation and step-down care. To prevent over-consumption and ensure prudence, the Ministry can consider imposing an annual withdrawal limit from the Medisave for these purposes or even limits based on each procedure or treatment.

Sir, I would like to ask the Ministry of Health and the CPF Board to allow married couples to use their Medisave to pay for IVF and any Assisted Conception Procedure (ACP). Couples who need ACP would like to ask for the following:

to allow Medisave withdrawals for up to five treatment cycles instead of the current three;

to subsidise the cost of drugs required for assisted reproduction;

increase the age limit for women for acceptance into ACP from the current 45 to 50 years but only if they are deemed medically fit;

increase the number of treatment cycles for women who enter the ACP programme at above 40 years of age, from a maximum of five treatment cycles to 10 cycles.

Instead of taking a pragmatic approach, Sir, both the Ministry of Health and the CPF Board should take a more compassionate view in helping childless couples.

Sorry, Mr Chiam, your time is up. Mr Low Thia Khiang.

MediShield

Sir, rising healthcare costs remain a concern

During the course of privatisation of MediShield Plus, whilst making basic MediShield compulsory for all insurance plans covering Singaporeans last year, the Minister for Health accepted the principle that the younger you are, the less healthcare you consume, as the basics of healthcare insurance. I would like to ask the Minister to consider requiring all foreign talent - employment pass holders and workers - to be covered by basic MediShield insurance. This would expand the risk pool of basic MediShield. I hope that with the added injection of funds from the expansion and with the relative lower risk of the new pool in which most are in their prime of their working life, MediShield can provide better coverage for all Singaporeans. This will also allow Singaporeans to see that all the foreign talents are, in a manner of speaking, contributing to the health and well-being of Singapore.

of most Singaporeans. At the same time, many Singaporeans feel aggrieved by the large number of foreign residents in Singapore competing for jobs. I would like to ask the Minister whether he has thought about expanding the coverage of the basic MediShield scheme to cover foreign employees as well.

Healthcare Policy

Sir, may I first commend the Minister for Health for improving the financial affordability in our healthcare which I support wholeheartedly? May I now request the Minister for Health to look into the following healthcare issues for further improvement?

Homecare enables the semi-dependant to live in their own homes for as long as possible with appropriate support. Homecare translates into convenience and much lower costs for many and hence a happier populace. Our homecare is almost non-existent presently.

Step-down care allows for seamless integrated care services for all elderly patients discharged from public hospitals. This is necessary to coordinate and to facilitate placement of patients to step-down care facilities that look into the multi-facet medical, social and psycho-social needs of the patients. At any one time, there will be some 8% of the elderly that require step-down care of varying levels of intensity. Currently, there are multiple service providers with minimal coordination. There is a need for better coordination and effective implementation of the various healthcare services.

Sharing of best practices, preventing over-servicing, maximising limited resources, avoiding duplication, better integration and cutting down wasteful practices by public hospitals.

Expediting plan for Singapore to become the regional medical hub, such as integration of our healthcare clusters and sectors for better economies of scale and maximising our limited resources to compete globally and not competing internally, structured aggressive marketing on our high quality and efficiency, innovative packaging with other products, such as insurance, travel arrangements, hotel and shopping needs, to make it more attractive for consumers to come here.

Better management of chronic diseases, such as diabetes and hypertension, to prevent morbidity and mortality from such diseases.

Heart disease is the number one killer of women in Singapore. Women are less likely to survive heart attacks than men. Many women do not seek treatment as early as men, as the symptoms of heart disease are manifested differently in women. Could MOH raise the awareness on heart diseases among healthcare providers and the public?

Drug Costs

Sir, the Government provides outpatient clinics so that Singaporeans can get affordable and good healthcare. So it is the usual practice for general practitioners and hospital doctors to refer patients to the outpatient clinics for more affordable treatment. But if the cost of drugs at the outpatient clinic is higher than the cost of hospital drugs, then it defeats all the Government's purpose of setting up such outpatient clinics, because it is meant to allow Singaporeans to have a cheaper form of treatment.

Recently, I was shown two bills from a patient - one for drugs taken from a hospital and the other bill for drugs taken for an outpatient clinic. The hospital's prescribed drugs cost $48.

30. The same prescription from the outpatient clinic costs $85.

25. Of course, when I look at the two bills, I was thinking that maybe the difference could be due to the difference in the quantity of drugs prescribed. He could have been given more drugs at the outpatient clinic and less at the hospital. So I studied the unit cost per drug and I found that the unit cost per drug at the hospital side was much lower than the unit cost per drug at the outpatient side.

You are running out of time, Dr Tan.

Six out of the nine items were much more expensive.

Sir, I am asking why is there such a difference. Is this a one-off incident or is it going to be a norm? How can doctors in the hospital then refer patients back to the outpatient clinic if the patient is going to pay more?

Sir, I often hear from patients, especially patients with medical conditions, such as heart problem, Hepatitis B, etc, and those who

Sir, I would also like to ask how the Ministry of Health decides what types of drugs should be subsidised. Feedback to me seems to suggest that MOH's prime consideration in the selection of the types of drugs for subsidy is primarily based on the price of drugs, rather than whether the drug itself is more beneficial to the patients in terms of its clinical effect or lesser side effects on the patients.

are chronically ill who need long-term medication, complain of high cost of drugs. I would like to ask the Minister for Health whether he foresees an expansion of centralised drug buying by the Ministry of Health from generic to non-generic branding drugs. As medical technology advances and hospital stays and operations are replaced with pills, I urge the Government to move beyond the basic bulk buying of generics, so that Singaporeans can benefit from lower drug cost. I would also like to know whether we have a unit within the Ministry of Health which functions like the National Institute of Health's clinical excellence in the United Kingdom where clinical efficacy and cost-effectiveness of new drugs are evaluated and recommendation made for bulk purchase.

Means Testing

Sir, when I first filed this cut on means testing in polyclinics and public hospitals more than a week ago, I was planning to ask the Minister about the implementation timeframe. Then I came across an article in Sunday's Lianhe Zaobao mentioning that the Minister said that he would not be in a hurry to do so within the next one to two years. This is due to the inherent difficulties of deciding which households qualify for subsidies. So I guess I do have an indication with regard to the timeframe.

However, I would still like to ask the Minister to share with us the Ministry's

findings and views to date.

Are we still studying it, or is it "no go" for now?

2.00 pm

I do agree with the Minister that means testing in practice is fraught with difficulties. I have some experience myself when I was working in a community hospital. The processes and tools we use for means testing can certainly be improved. We have to find ways to reduce the paperwork and cut down on our long waits for family members to submit their income documents.

Unfortunately, the disparity now between our acute hospitals and step-down facilities does not encourage our patients to move on from acute hospitals to community hospitals and nursing homes. This is because patients in the latter are means tested but those in our public hospitals are not. As a result, we have more crowded C class wards. This is undesirable because it is an inefficient use of our medical resources. Also, a good portion of our subsidies is going to patients who do not need it. Due to the difference, our total healthcare subsidy costs are being elevated.

I understand the Ministry's caution. If we were to proceed to implement means testing, the scheme has to be carefully conceived. It has to be fair and preferably tiered to be as inclusive as possible. It should also be responsive and flexible, easy to administer and not require too much bureaucracy. This is a pretty tall order. Still, we have to find a way to align the disbursement of healthcare subsidies in all our public medical facilities. The longer we wait, the more our resources will be utilised inefficiently.

ElderShield

Sir, I would like to urge a thorough review of our

Secondly, I do not see why when a person is certified as disabled by a specialist in a public hospital, he still has to be assessed by a GP appointed by the insurance company. This restriction should be removed as it unnecessarily adds to the patient's cost. If an assessor is used, the fee should also be absorbed by the insurance company, and not the person claiming which causes hardship, as this insurance is different from motorcar or fire accident insurance.

Thirdly, the waiting time of three months is too long and should be shortened.

Fourthly, the restriction to five years of payment causes hardship and should be removed. At a time when a person needs the money the most, he is left stranded.

Fifthly, $300 monthly payment is too little and should be regularly reviewed, taking into account the medical inflation rate.

Finally, 42% of those who opted out of MediShield were low-income earners earning less than $1,500. Can the Government do something so that more of them can be covered under the scheme?

ElderShield Scheme which I think can be better utilised and specifically in the following areas: Firstly, relax its eligibility criteria. The rigid definition of "disability" which requires a person not to be able to do three out of the six daily routines can result in a ridiculous situation, where even someone who is wheelchair-bound is not considered as disabled.

Sir, I thank Members for their comments and especially their suggestions on how we can improve our healthcare system.

I will be the first to acknowledge that our system is not perfect. But I think it is not bad. The World Health Organisation (WHO) ranked Singapore number 6 out of 191 countries on overall healthcare system performance. Only two Asian countries made it to the top 10 list: Singapore and Japan. So, obviously, we must be doing something quite right.

Singaporeans acknowledge our high medical standard but many hope that it could be cheaper, or even free, at least for the poor. I will do my best to meet their aspiration, but such heavy subsidy has to be highly targeted for the poor and not something freely available to all in a uniform way. Despite good intentions, cheap healthcare for the masses ends up being of low standard, hurting the poor and needy the most, because unlike the rich, they have no alternative. They cannot turn to the higher standard in the private sector.

There are two ways that a government can render healthcare free or cheap. One, the government pays the bills out of the taxes it collects from the people. Or the insurers pay for them out of the insurance premiums they collect from the people. But either way, it is the people who pay for healthcare. So the so-called free healthcare is actually not free.

But because healthcare in such systems can sometimes appear to be free, it causes two major problems which we are familiar: the buffet lunch syndrome of over-consumption by patients; and the motorcar repair-shop syndrome of over-servicing by providers. As a result, the US spends 16% of their huge Gross Domestic Product (GDP) on healthcare, UK spends half of that - 8% of GDP - but both have very little difference to show in their health status. Instead, there were large-scale disappointments on both sides of the Atlantic. Nearly 50 million low-income

In Singapore, our health is not poorer than the Americans or the British. In fact, in some areas, we fare better. We live longer on average than the Americans or the British. Our infant mortality rate is much lower than in the US or UK. And we have achieved this commendable outcome at a lower cost, at only 4% of our GDP. This does not happen by chance.

We have over the years evolved our own model of providing and funding healthcare. We have no ideological bias. On funding, we are neither in love with the British taxation-funded model, nor the American insurance-funded model. On delivery, we neither favour public hospitals run by civil servants, nor prefer private-for-profit models run by people like Dr Loo Choon Yong.

We have forged a middle way, going for a mixed system of public and private sectors. In that way, we tap and incorporate the strengths of each sector and allow both to co-exist and flourish. Such a mixed system offers the best outcome for our people, giving them choices as public and private compete for patients, in that way keeping the medical standard high.

Last month, when I read the New York Times, there was a commentary - a good one - on the Canadian healthcare system. It reported that their publicly-funded health system was "gradually breaking down", with public hospitals sending growing numbers of patients, whom they can no longer cope, to private hospitals which are cropping up despite laws against their existence.

In Canada, it is illegal to have private hospitals because no hospitals are allowed to charge patients for treatment they would otherwise receive free of charge in

The Canadians dread the excesses of the private model that they see in their American neighbour. That is why they embrace the public model. But now, they appear to have come to the conclusion that both systems were wrong and a mixed system is more viable.

I know Singaporeans worry about healthcare cost. This is a common worry all over the world. I am afraid healthcare cost will continue to rise. Why? Because new technology and new drugs will continue to come out of the research laboratories, at great cost, even as they bring about some improvements in healthcare.

It is actually quite easy to run a cheap low-cost public healthcare system. There are many such examples in our neighbourhood, just compare our public hospitals with the standard of the public hospitals there. We can keep our hospitals cheap or low cost by denying our patients of medical advancements, thus pushing patients to private hospitals. But who can afford to go there? Only the middle and upper-income group. The poor are stuck with the public hospitals. I would never accept such an approach for Singaporeans, for the simple reason that the poor cannot afford the private hospitals. My job is to ensure that the poor and the very sick get a good standard of healthcare.

I therefore agree with Mdm Halimah that we should not allow medical cost to escalate beyond our ability to pay. Mdm Halimah noted that medical inflation was 5.9% in 2004, higher than general

When I probed for the year 2004 about this sudden blip of 5.9%, I found the culprit - TCM consultation fees, Chinese physicians. It doubled from an average of $4 in the year 2003 to $8, average, in 2004. So even though TCM is a small part of our total healthcare system and the weightage is low, but because the increase is 100%, it has skewed the total calculation of medical inflation. If you remove TCM from the calculation, our medical inflation would have been 1.3%, lower than the general inflation of 1.7%. Mdm Halimah would be pleased to note that last year, 2005, medical inflation was 0.4%, again lower than the general inflation of 0.5%. I do not think your Health Minister has been sleeping.

But some medical inflation is to be expected as medical and nursing staff, like other workers, receive some wage increases too. I think they deserve it as well. Last year, general wages in Singapore rose by 3.5%. This must, in due course, flow down to impact on medical inflation. In any case, inflation control cannot be decreed by law or achieved through moral suasion. It never works. The most effective way is through the market.

First, we should ensure that wage increases in healthcare sector keep in step

That is why we watch over the supply and demand of doctors. At present, we are slightly short in some specialities although the situation is tolerable. But I see significant shortages going forward, if we succeed in our drive to promote Singapore as a regional medical hub.

I noted Dr Lily Neo's comment that we should move faster on SingaporeMedicine. I will, and I believe in that. In fact, our efforts in the last three years have shown very promising results. Foreign patients coming here for treatment in Singapore increased by an average of 20% per annum in the last three years. Wonderful! I am sure Dr Loo Choon Yong can testify to this. We will press on with this.

I know that this will increase staffing pressure on our public hospitals. But we can try to achieve both objectives, raising Singapore as a medical hub and at the same time trying to ensure that medical inflation is acceptable. How? We are ramping up the recruitment and training of medical specialists. The Singapore Medical Council (SMC) will be expanding the schedule of recognised medical degrees.

Americans go without medical insurance. In the UK, long waiting times for surgeries are very common complaints.a public hospital. But in response to public demand, private hospitals are openly defying the law. This is how one private hospital medical director lamented about their healthcare system: "This is a country in which dogs can get a hip replacement in under a week and in which humans can wait two to three years."inflation rate of 1.7%. When it was published, I noted this figure too. I was personally a bit upset because this is during my watch in year 2004 and, after having made it one of my top priorities on managing medical inflation, I probed and discovered a number of things. Medical inflation is computed based on a basket of medical services that you get. It includes doctor's consultation, hospital charges, dentistry, payment to TCM, Chinese sin seh, tui nai, drugs, both generic as well as vitamins or supplements, perhaps even tongkat ali, and things like that.with general wage increases. Again, this cannot be decreed. This requires us instead to match medical manpower with demand. If demand rises while we restrict the supply of doctors, nurses, pharmacists and therapists, their wages are bound to go up sharply.

Currently, we recognise 71 medical degrees, largely from the British Commonwealth.

2.15 pm

I have shared my view before that all the top medical schools ought to be on our schedule, not just from the US and UK, but also from Europe and Japan. We should also include the top medical schools from India, where some of their

But medical manpower is not just about doctors. It is also about nurses, pharmacists, radiographers, other health sciences professionals, even patient care assistants. We should make sure that supply keeps up with demand.

Second, I agree with Dr Lily Neo and Mdm Halimah that we should push our hospitals and clinics to be more efficient. There is really no ground for inefficiencies, wastages or duplications. We will continue to encourage innovations and skunk works and share best practices. Last year, in this House, I mentioned a major skunk works in Alexandra Hospital where it partnered with Microsoft to exploit the benefits of IT. Within a year, they successfully computerised the operations of the A&E Department. The software is intuitive and also very flexible, allowing doctors and nurses to easily make continuous process improvements. I want to record here my thanks to Microsoft for their help. I understand that

Hospitals are expensive resources. To keep cost affordable, hospitals need to use their beds efficiently. For example, once a patient is discharged, they have to quickly get the bed cleaned up so that a new patient can get in. But the entire process is complex, involving many groups of staff. But through standardising policies, streamlining processes and using WiFi technology provided by Cisco Systems and Fujitsu, Alexandra Hospital has reduced the processing times by 30%. This means less waiting for the patients in the admission room. Today, half of the patients admitted to Alexandra Hospital are settled into their beds within 30 minutes.

Alexandra Hospital and Cisco Systems are now exploring how WiFi and VOIP (Voice over Internet Protocol) technologies can be used to reduce the time it takes for doctors and nurses to respond to medical emergencies. This can make a real difference in life-and-death situations.

Third, the market works best when consumers are well-informed. That is why, as soon as I went back to the Ministry of Health three years ago, I got them to compile and publish hospital bill sizes. I am very pleased with the outcome. I am now ready to push this initiative further, in two ways.

One, I will extend the exercise to private hospitals. They have so far joined the initiative voluntarily, but the submitted data is often incomplete and sometimes misleading. I am considering getting their fullest participation, to disclose their hospital bills on a fully comparable basis when they submit Medisave claims on

Next, in response to the call by Mdm Halimah, I will expand the initiative to include qualitative outcome data, eg, surgery complication rates, surgery success rates, etc. Like the bill size exercise, I will begin with public hospitals first to gain sufficient experience, before extending it to private hospitals. Last year, I started a study on cataract operations, one of the most common surgeries done in public hospitals, so I wanted them to measure and track down what were the complication rates of cataracts in the various centres in Singapore. We are concluding a study on this, and the data will be released quite soon.

Mdm Halimah asked about quality accreditation. All hospitals must comply with the standards that we set under the Private Hospitals and Medical Clinics Act. JCI accreditation is an added external endorsement that our local hospitals are comparable to international standards. All our public general hospitals are already accredited. The private hospitals are at various stages of this quality journey.

Making the market work better is the best way to help manage healthcare cost. When customers vote with their feet, healthcare providers will sit up and work to fight the competition. That was how Lasik surgery fees dropped from $2,300, on average, in 2003 to below $1,400 now, saving patients almost a thousand dollars per surgery.

At the same time, we must continue to remind Singaporeans to: (a) save up for their healthcare needs; and (b) insure themselves against catastrophic illnesses.

Our healthcare system is unique in the world because of Medisave. Medisave has now entered its 21st year. Every year, the average Medisave balance of Singaporeans just gets bigger. Among working Singaporeans, four out of 10, ie, 40% or nearly half a million Singaporeans, have Medisave balances exceeding $25,000. This happy outcome applies to low-wage workers too. Those nearing retirement have an average of $12,545, enough for many, many hospitalisations.

In their earlier manifestos (1994/1998), the Workers' Party wanted to abolish Medisave. "Phase out the Medisave Scheme as soon as possible", they said. Luckily, they did not succeed. As a result, we now have collectively $35 billion in our Medisave accounts, for many, many rainy days ahead. I am glad that the Workers' Party has since achieved some enlightenment. Their latest manifesto no longer wants to phase out Medisave. But they have replaced the medicine with another. They are now proposing that Medisave be used for "a comprehensive Public Health Insurance scheme".

When I read the manifesto, I was reminded of a very interesting cartoon published by Zaobao a few days ago. President Chen Sui-bian suspended the Reunification Council, so there was this cartoon that shows President Chen leading the way and there was this big manhole, with Taiwan about to walk into the manhole. If we go the Workers' Party's way, I see this cartoon, maybe of Mr Low Thia Khiang waving Singaporeans into this hole. And you will find this hole is crowded. There are many people there trying to get out. So, I think, let us beware.

Mr Low Thia Kiang suggested that we allow MediShield to include foreign workers. I do not think we exclude foreign workers, because MediShield is open to all Singaporeans and PRs. So, if they are PRs, they are included if they want to. But MediShield is not compulsory. So, you will have to make an effort if you want to join in, although it is opting out. But, as far as I know, many foreign workers may have been covered by their employers, so they may not see the need. But it is really up to them. The point about the foreign workers is that if they are non-Singaporeans, basic MediShield is based

In fact, just last month, there was a specific case. One of my residents, the maid fell down while cleaning windows. So major surgery in Tan Tock Seng. The bill came to $15,000. They forgot to buy insurance for the maid. So they came to my MPS and say, "Please help." But I cannot help because she is a foreigner. How can I use taxpayers' money to subsidise foreigners? I hope there is a lesson there, ie, employers, please make sure you buy insurance both for yourself and your loved ones, including any foreign domestic workers with you.

I am enhancing Medisave. From lst April 2006, the daily withdrawal limit will be raised from $300 to $400. This will particularly benefit the middle-income group and save them hundreds of dollars per admission.

This is the first step. My next step is to allow Medisave to help cover costly outpatient treatments. But this is not straightforward. That is why I am taking some time to think it through carefully. If we are not careful, Medisave accounts will be prematurely depleted, becoming insufficient for hospitalisation. That would be tragic. However, meanwhile, I have noted Mdm Halimah's various suggestions on this subject and will take them into account.

In this exercise, I will give priority to chronic diseases, a subject which I will discuss later, in the second segment of the debate.

Let me now respond to Mr Chiam's comment on the use of Medisave for IVF and various assisted reproductive technologies. It does. Medisave covers them and, in fact, as part of the Baby Bonus scheme last year, we raised the

On ElderShield, I thank Mdm Halimah for her various suggestions. I will take note of them. We are bound by the contract governing ElderShield which does not allow changes for five years. The five-year period will run out in September next year. But I will begin the review process this year. I will certainly bear in mind

graduates have gone on to head clinical departments in the US, particularly because we have an FTA with India, where one of the commitments is to open up our medical register. We are not opening up yet, because there is still disagreement with India. India wants every medical school in India to be recognised. I cannot accept that, because we all know there is a wide range of standards and we cannot just open the door to every Indian medical graduate. But there are two, three or four very good medical schools. Entry is so competitive that one must be absolutely bright to be able to enter, and their graduates are proving themselves in the US and Europe. I think there is no reason why we should exclude these top medical schools and their graduates from coming here to help us make Singapore a regional medical hub. The SMC is actively reviewing the subject, and will progressively expand the list. I expect to make the first announcement soon.Microsoft has decided to extend their skunk works to Changi General Hospital and even enlarge the scope of their work to include the community hospitals and nursing homes that partner Changi General Hospital in providing integrated care.behalf of their patients. This will be welcome by their patients, I am sure. Such transparency will also help convince their foreign patients that Singapore offers very competitive pricing for healthcare services.Mdm Halimah asked if our healthcare model can cope with the ageing of our population. In particular, what about the healthcare needs of our future elderly? Will 3Ms be enough? This is really a very dynamic situation with many unknowns. What are the new technologies that are coming in? At what cost? What are the changing population attitudes towards sickness, health, etc? And, of course, how much can we afford, which is economic growth? That is why I agree with Mdm Halimah that we need to periodically review and update our 3M system. And we do. Last year, we updated MediShield. This year, my focus is on Medisave. We do allow Medisave for medical insurance. I believe in Medisave insurance, because pooling of risks is a very important part of healthcare financing. But Medisave must not unwittingly support comprehensive medical insurance which will only lead to disappointment and very high healthcare costs. This is not a theoretical argument. The argument has already been settled empirically. We only need to see the experiences of those countries with such comprehensive medical insurance schemes. Let us not repeat the mistakes of others. They are now trying to get out of that hole. Let us not walk into that hole. on Class B2, which is heavily subsidised and, therefore, we keep the subsidy for Singaporeans and, in fact, at the moment, also PRs. But non-citizens are not included. quantum. Relying on memory here, I think you can claim up to $6,000 for IVF, which will therefore cover items like drugs, etc. But we made a distinct decision to limit it to three treatment cycles, and the reason is properly and rationally grounded. You can check the data on the success rate. Each time the couples repeat, it is greater and greater disappointment and, after the third cycle, the chance of a success is very, very low, and you are really throwing away a lot of money. Yes, maybe we are a little bit paternalistic here by saying that Medisave ought to be for other uses and therefore we limit it to three cycles. But it is for a very good reason. If we just open it up - imagine $6,000 per treatment - and we have, say, run it to five cycles, that is a lot of thousands of dollars. Medisave, even though it is significant for some middle-income group, there is an upper bound to it. So it is not as if it is a lot of money and you can just waste it to pursue IVF and the various techniques. So I hope Mr Chiam can accept that explanation.

the various suggestions made by Mdm Halimah.

2.30 pm

Dr Chong Weng Chiew asked about means testing. He has always been a strong supporter of means testing and I appreciate his support. I believe in it and I have always felt that our 3M model would be stronger if we make it 4M and the fourth "M" is actually means testing.

But two years ago, when I started exploring this subject, I remember at that

Dr Tan Cheng Bock and also Mr Low spoke about the cost of drugs. Dr Tan quoted an example of a patient being referred to a polyclinic from NUH, thinking that it would save him money, only to find that his drug bill there cost him more. I have looked at the example which he handed to the Ministry of Health. Of the nine medications in the bill, indeed, as Dr Tan noted, some were cheaper at the polyclinic but some were more expensive. The costlier drugs tend to be cheaper in polyclinics, in other words, the more expensive patented drugs are cheaper. The reason is this. First of all, the polyclinics and hospitals are different entities, so identical items may not attract identical prices. It is just like X-rays. There is a whole range of X-rays, but they do not coordinate - maybe they should - until every item is the same. But, on an overall basis, we should ensure that the total treatment cost in a polyclinic is less than that in an acute hospital for the same treatment. Otherwise, I agree with Dr Tan that there will be no incentive for patients to move out of expensive acute hospitals.

Mr Low talked about our bulk purchase of drugs and whether we would do so not just for generic drugs but also for non-generic drugs, ie, patented drugs. Bulk purchase covers both, in other

Mr Low also asked who decides on what is subsidised and not subsidised. Really, the question is who decides on what are standard drugs and what are non-standard drugs. I think we have explained this previously in this House. There is a panel of experts because these are clinical issues. They will review, when new drugs come in, and decide whether to substitute this normal drug with another drug. So it is a purely clinical decision. Of course, they take into account efficacy as well as cost to the patients. But it does not mean anything that is expensive is non-standard; and everything that is cheap is standard. That is not the criterion.

Mr Low mentioned a unit in UK. Yes, there are several such efforts in various countries, because drugs are now so expensive, and for every new drug, before it comes into the market, they will evaluate the cost benefit of it. Should we start such similar units? I do not believe in doing so because our scale is small. Let us leverage. I have always advised our people to leverage, because why reinvent the wheel. The UK and US publish all their analysis and we just go and take a look. We may want to do some local analysis because Singapore's situation might be different. But that is always a good starting point, instead of trying to

Finally, Dr Lily Neo has made a number of comments on step-down care, homecare and heart diseases affecting women. We will respond to those points later today.

time the GPC Chairman was Dr Lily Neo, and she gave me very good advice and a word of caution, because there are a lot of complications, as outlined by Dr Chong. She felt that I should only start working on it after we have fixed a few other things, especially MediShield reform which, at that time, I was exploring with her, and now, Medisave. So that is why when Lianhe Zaobao interviewed me, I said that it is something that we would do next year or the year after. We cannot rush this sort of thing even though it is a good policy.words, so long as there are economies of scale to be exploited, we will go for a major tender and coordinate them. It is not done by the Ministry of Health because there are two clusters and they coordinate. There is a central procurement unit which calls tenders on behalf of both clusters. And, as I have said, it applies to both generic as well as non-generic drugs. In fact, the savings are a lot more in the case of non-generic drugs because generic drugs, by nature, are low cost. So whether you call bulk tenders or you call smaller tenders, the price will be low anyway. But even then, the benefits ought to be exploited.replicate what others are doing and unwittingly push up healthcare cost.

Sir, I would like to ask the Minister whether he has updated himself with the latest copy of the Workers' Party's manifesto because, in this manifesto, we are proposing a compulsory basic hospitalisation insurance. He says it is a comprehensive insurance scheme.

Secondly, I would like to ask him whether he purposely distorted the Workers' Party's manifesto for political purpose to hoodwink the voters. Sir, what he has said was not what we published in the 1994 manifesto. We highlighted the inadequacy of Medisave, but we did not say that we want to abolish it. We believe more on risk-pooling of insurance schemes rather than the method of direct payment through Medisave, because you never know how much you need to save. That was the basis on which the Workers' Party felt that insurance would be a better solution.

I would like the Minister to clarify why there is a need for him, when he became Minister for Health, to look at the MediShield insurance scheme and to revamp it. That is exactly the same concept which the Workers' Party's manifesto has enshrined in 1994. It is not true when the Minister accused me like what the papers described as Chen Sui-bian as "pulling the people into a hole". I would say that, Sir, without the revamp of an insurance scheme, it will probably be the Ministry of Health that will have a bigger hole for the people to fall inside, and the hole is something which the Minister created for political purpose to pull me in.

Mr Chairman, I do not like to read the Workers' Party's manifesto but, unfortunately, it is my duty, as Health Minister, to also see it because I read all suggestions on healthcare, and I take a personal interest. So I read them. He asked whether I have updated myself. Yes, I have. In fact, I went to great length. I read their latest manifesto and also the previous one. So when I quote, I am a careful person, as you would know by now. When the Member used the words and claimed that I lied - although he did not want to use those words - it was in his Party's own manifesto when he talked about abolition of Medisave and a comprehensive public health insurance.

In our business, maybe he is not familiar, "comprehensive" has a very special meaning in health insurance. "Comprehensive" means comprehensive - everything, first dollar coverage. That is the meaning of comprehensive. He cannot say, as he tried to explain just now, that "comprehensive" means that there is still co-payment. Once you have co-payment, it is no longer comprehensive. So I read it in that light. I take it at face value. That was in their earlier document when they talked about abolishing Medisave and going into comprehensive medical insurance.

So I must object to his use of words that I am trying to hoodwink Singaporeans. Singaporeans would have seen me by now. I have been in public service for many years. I did not enter politics to score political points. I entered politics because I thought that is one way to do some good for Singaporeans, and that is the way I carry my task seriously. I am not one who hoodwinks people.

Healthcare Infrastructure

Mr Chairman, Sir, it is essential that our medical services have the technology and the technical know-how

In the past, doctors wanting to know whether a patient's heart is functioning well may resort to angiography, a procedure in which a thin tube is snaked up the heart arteries through a blood vessel in the groin. Now, an alternative is available. Modern technology has made possible for scanning machines to perform a cardiac CT-scan which will show detailed images of the heart in just a few seconds, all these without the expense and risk of any invasive coronary angiography.

As patients demand for more accurate and quicker diagnosis of their illnesses, be it cancer or a stiff neck that lasts for days, doctors will turn to such technologies as a useful tool for their answers. Are we seeing such trends in the medical sector and, if so, what are the plans the Ministry has in mind for such heavy investments? Will MOH be looking at the advent of such technologies and its uses nationally and, if necessary, provide guidelines on its usage so that a uniformed approach will aid patients in making an informed decision before paying for these services?

To have an economical approach to this scenario, pooling of resources may be necessary to lower individual commitments to such investments and, subsequently, spread out the cost to the paying public who are the users. In cases where it is too expensive for the private sector to invest in such machines for some reason or other, will MOH be looking at buying them and allowing the private practitioners to use them on a pay-as-you-use scheme?

Adequacy of Hospital Services

In 2004, there were 405,306 admissions. If we average that figure over a period of 12 months, this would work out to be about 33,775 admissions a month. Given the overwhelming statistics, it is clear more admissions are to be expected and the need for more healthcare in hospitals should be anticipated.

Is MOH planning to build new hospitals or extensions to hospitals to cater for expected or projected increases in the demand for hospitalisation? Are there plans to increase the number of doctors and hospital beds to cater for possible increase in demand from an aging population?

Nurses form an important part in providing an excellent medical service and their numbers are always lacking. Training new nurses will not only help to fill in the gaps in the shortage of nurses, but will also contribute to having more adequate hospital services. What are the plans by MOH to ensure that there are enough doctors and nurses to cater to and treat the high-level of patients visiting the hospitals?

While increasing the number of intakes for the medical faculty, and in training nurses at technical and degree levels, is there any dependency level that we have for foreign doctors and nurses? Our aging population will certainly put heavy pressure on the demand for hospital services.

to properly diagnose diseases and illnesses as quickly and accurately as possible.

Sir, I want to pose a question to the Minister with regard to my cut.

But he has already answered the question.

I put up my hand but I did not catch your eye.

All right. I will give you two minutes.

Thank you. I accepted the Minister's reply on the different pricing in the outpatient polyclinics and the hospitals. My point is that the patient's problem has still not been solved. Whenever a doctor refers a patient from a hospital to an outpatient clinic, he still has to pay more. That is the question I am asking the Minister: how is he going to solve that problem?

My advice to Dr Tan, so that he can in turn help his patients, is to look at the total bill. Do not just look at one single item and say that you want the cheapest of everything possible, like drugs, X-rays, and so on. But you have to look at it on a total basis, ie, is your total bill in a polyclinic cheaper than your total bill in a hospital? At the end of the day, that is what counts to the patient, how much he has to pay. If he goes to SGH, how much will he have to pay, and if he goes to Toa Payoh polyclinic, how much will it cost? At the principle level, I agree with Dr Tan that we should not distort the pricing so that it becomes silly for patients, who want to downgrade, to have difficulties.

2.45 pm

Since I am on the floor, let me just take one minute to explain this. Actually, I know the reason for the discrepancy. Years ago, I helped to formulate the pricing policy for polyclinics. Those of you, like Dr Chong, who had read the Lianhe Zaobao's interview of me, would know that I believe in the Robin Hood's principle in healthcare, because healthcare is so expensive that the only way to ensure healthcare is affordable is you must play Robin Hood. How? One, the rich subsidises the poor

through taxation. Two, the healthy subsidises the

But, a few years ago, I do not know when, somehow the hospitals decided to go more precise. So they removed this policy and they just said, "Well, let's look at the drug, if it is 20 cents charge 20 cents, 50 cents charge 50 cents and $2 charge $2, and whatever". So you can argue which is the more correct system. I believe in the Robin Hood's principle. I feel that the $1.40 per week, regardless of medication, is a better way for the patients. Maybe I should persuade the hospitals to move back to the polyclinic system.

unhealthy, who is more sickly, through insurance. There is no other way. And, therefore, when I looked at the pricing of drugs at that time in the polyclinics, I suggested to them - which is still the policy today - "Charge patients $1.40 for drugs". The last time it was lesser, maybe $1; now it is $1.40 per week of medication. In other words, regardless of the medication, cheap or expensive, you pay $1.

40. In that way, patients who have minor ailments and, therefore, drugs are simpler, they may be actually paying above cost to the polyclinic, but it is still $1.

40. Let us say, if one is unlucky and very sick, the drug may cost $20 per week of prescription, but you still pay $1.

40. So, in that way, patients who have cheaper drugs subsidise those who have more expensive drugs. Until today, I will defend that policy. I think that is the correct policy.

Primary Healthcare

Sir, it has been shown time and time again that the most cost-efficient way of managing healthcare costs is to move care away from the hospital setting to the primary healthcare setting, where health promotion and disease prevention take place and where the primary healthcare physician acts as a gatekeeper to the hospital services. To realise this, many governments have shifted consumption of public healthcare from the hospital to the primary

Can the Ministry of Health inform us how much of MOH's operating expenditure is devoted to primary healthcare and how does this percentage compare with other countries, such as Australia, the United Kingdom, New Zealand and Canada?

I am not asking for the overall MOH operating budget to be increased, but rather to consider shifting more of the operating budget from hospital services to primary healthcare where we can achieve a bigger bang for the buck, especially if you are found to be relatively under-funding primary healthcare when compared to other developed countries due to insufficient apportionment.

healthcare setting through apportioning of more financial resources to primary healthcare providers as well as health promotion and prevention efforts.

Institutions of Public Character

Sir, the Government has, in recent months, moved to ensure better corporate governance of the voluntary welfare organisations. This, I hope, will stop any future NKF-form of misusing and misrepresenting its activities to the public.

I noted that while the Ministry of Health has made every effort to explain to the public its position on NKF, it has yet to clarify the issues surrounding the Ministry of Health's award of Institution of Public Character (IPC) status to the then NKF. In the interest of greater transparency on the part of MOH, I would like to ask the Minister, under sections 37 and 107 of the Income Tax Act, who was the final approving authority for NKF's IPC status at MOH? In particular, Sir, I would like to know whether the said approving authority was aware of the concerns of the National Council of Social Services

and why the concerns of NCSS were overwritten by MOH? I would also like to know what is the procedure for application and approval of the IPC status by MOH and whether the decision is subject to review by a higher authority, or the Minister himself is the final approving authority.

Hospitals

I want to ask the Minister for Health where exactly is the Northern General Hospital to be sited, when is construction work commencing and when can we expect it to start operation.

Patient Care

Sir, with block funding already in place for the clusters, there exists the possibility that each cluster is incentivised to see as few subsidised patients as possible, especially at the hospital level where the lion's share of the block funding is consumed, by shifting workload to the other cluster through more referrals.

Can the Minister reassure the House that there is no gaming within the clusters and cross-cluster referral rates have remained relatively constant over the recent years?

Can the Minister also inform the House what percentage of NHG polyclinic and A&E patients is referred to SingHealth hospitals for further care and vice-versa, for each of the years from 2001 to 2005, omitting 2003 due to SARS outbreak?

Pathology Services

During the 2003 SARS outbreak, our pathology, especially our virology diagnostic capabilities and capacities were put under severe strain. The need to boost our capacities and capabilities was clearly felt. It is thus a disappointment to

If my memory serves me correct, when SGH was redeveloped in the 1970s, the Pathology Department buildings were omitted. Thus, the buildings are at least 40 years old, if not older. We all know that most HDB flats at 40 years of age have been given extensive upgrades or redeveloped, what more our SGH's Pathology which actually forms the backbone of our nation's pathology and virology services? The small, crammed and old rooms at the SGH's Pathology Department are also not coping with automation, which saves manpower, and it is also where laboratory medicine is heading towards currently.

The redevelopment of SGH's Pathology Department is especially far more pressing now with an H5 Avian flu pandemic, and probably a human flu pandemic, looming over the horizon. Can the Minister explain why the redevelopment of the SGH's Pathology Department, which is the backbone of our nation's virology diagnostic services, has been delayed, and what steps are taken to expedite its redevelopment?

note in the Ministry of Health's budget estimates that plan to redevelop the Singapore General Hospital's Pathology Department building has been delayed.

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 3.15 pm.

Sitting accordingly suspended

at 2.51 pm until 3.15 pm.

Sitting resumed at 3.15 pm

Debate in Committee of Supply resumed.

Head O - Ministry of Health (cont.)

Sir, Mr Andy Gan asked whether the supply of our healthcare services is adequate. Frankly speaking, supply of healthcare services will never be fully adequate. This is because in healthcare, supply does create its own demand, particularly if that demand is heavily subsidised.

Among health economists, there is a well-known observation called "Roemer's Law", which states that "a built (hospital) bed is a filled bed". It is, therefore, wise to keep public hospitals slightly under-supplied and run it at high occupancy rates. That is why, last year, I resisted tackling the overcrowding in Tan Tock Seng Hospital by simply allowing them to expand. By forcing the hospital to understand its sources of overcrowding, we then discovered outdated policies, like free treatment for foreign workers infected with chickenpox and cumbersome discharge procedures which kept patients unnecessarily in hospital.

But we cannot sit on the cap forever. Periodically, we need to expand our facilities to meet real rising demand. That is why we are building a general hospital in Yishun. Mr Steve Chia asked for some details. The site has been finalised. It is a good site, near to Yishun MRT and bus interchange. Planning of the hospital has started. In fact, a design competition is ongoing, and I understand that Prof. Ho Peng Kee will soon organise an exhibition of the design proposals that we have received for this hospital, so that we can get some public consultations and opinions on them. We expect to ground-break before the next Chinese New Year

Dr Tan Sze Wee asked me about the building of the Pathology Department at SGH. The project was a little bit a victim of the Asian financial crisis in 1997. Actually, the project was approved and funds were allocated. But after the Asian financial crisis, there was a review of all the capital expenditure projects in the public sector, and this was one of the projects that was decided to be delayed. In any case, those years are over, and we will get the project going again. We are going to rebuild it on a new site within the SGH campus. Planning has begun and we hope to open the new facility around 2010. In fact, if Members check the Budget book, they will see an entry on this particular project.

Besides buildings, we will continue to invest in new equipment. Mr Andy Gan has noted a rise in high-tech diagnostic machines. It has been so for many years and, in fact, it is a factor which contributes to rising healthcare cost. But we will pace it appropriately, balancing between inevitable cost increases and enhanced healthcare standards. As a principle, I prefer the public hospitals to be slightly behind the curve, but not too much behind. For example, the current interest in high-tech scanning equipment - the 64-slice CT scanner, which costs a few million dollars. The first unit was brought into Singapore in 2004 by the private sector. But soon after that, others also bought such scanners, including public hospitals.

By being slightly behind the curve, we allow ourselves some time to evaluate each new machine and establish its cost-effectiveness. Ultimately, it is not investment in technology for its own sake, but, really, investment in patient outcomes that matters. Given the high

Mr Andy Gan also asked about the adequacy of nurses to serve our patients. For nurses, we will continue to both train locals and recruit foreigners from abroad, and there has been a progressive increase in the nursing population in Singapore. Just last week, NUS announced the launch of Singapore's first local nursing degree course in NUS, for year of admission 2006. This is a milestone event for our nurses. The programme is designed to meet international standards, and the first batch of nurses will graduate in 2009.

Dr Tan Sze Wee is worried that our cluster polyclinics may game on their block budget, and refer subsidised patients from polyclinics to hospital A&E Departments of the other cluster, so as to save on cost. Let us look at the data. First of all, very few percentage of polyclinic patients get referred to hospital A&E Departments - less than 2% each year. The vast majority of such referrals were within each cluster. So this so-called cross-cluster referral is tiny. As far as I can see, there is no evidence for such gaming going on. I am pleased to say that our doctors are largely ethical, and we should be proud of them.

Let me now spend some time on chronic diseases, which Dr Lily Neo raised earlier and was also mentioned by Mdm Halimah and the other Members as well. This is a very big topic, because it affects a large number of patients, and most of them tend to be elderly, and it consumes a large amount of resources. No country has managed it well. There is much scope for transformation and improvement.

It is my personal goal to see how we can cause the transformation of the care

To achieve this goal, family physicians play a critical role. Recently, I visited one in Toa Payoh and I am impressed with her practice. She has a base of regular clientele - many elderly with chronic diseases. She knows them well, including their family members, and that is really what a good family physician ought to be. When one of her patients suffered a fracture and could not walk, she arranged for a physiotherapist to provide home therapy twice a week, instead of simply referring the patient to the hospital. The patient had so much pain that walking was not possible. After a month of home therapy, the patient was able to walk. In this way, unnecessary hospitalisation and operations were avoided, and the money saved from inpatient charges was used to engage the therapist.

When another patient was diagnosed with terminal cancer, she personally arranged a shared-care programme with the hospital oncologist - cancer specialist. This way, she was able to continue the patient's intravenous antibiotics at home. That was also the patient's strong preference, to spend his last few months in the company of his loved ones, rather than wasting precious time waiting in the queue in hospital clinics. The patient eventually passed away peacefully at home, avoiding unnecessary hospitalisation which would not have made any difference. His family got to spend quality time with him at home. When death came, this family physician was there to sign the death certificate.

This is what good family physicians can do to bring about better care at lower cost and less hassle for their patients, instead of simply referring them to hospital specialists. There are many such good family physicians in Singapore. But we should grow their numbers and profile them to the public, so that such care

I asked our hospitals and polyclinics to help facilitate this transformation. The hospitals have an interest to see this succeed. Many of their patients in the specialist clinics can be competently treated by family physicians, at lower cost. They are keen to partner with willing family physicians through shared-care programmes at the community level.

Let us take diabetes as an example of how this can be done. We already know quite a lot about diabetes. It is a common chronic disease, and affects one in 11 Singaporeans. So it is a large number. Diabetes occurs when the body loses its ability to control the blood sugar level. When poorly controlled, doctors can almost predict what will happen to the patient at different stages over the next 20-30 years. Compared to others, diabetic patients have a higher chance of getting heart attacks, stroke, blindness, loss of limbs and kidney failure. In early stages, there are no symptoms, and many patients are unaware. Left untreated, the condition will just deteriorate over the years. Many suffer greatly from multiple organ failures towards the end.

Many diabetic patients start treatment late, ending up going to multiple specialists for treatment of their many problems as and when each problem surfaces. It is not unusual for a diabetic patient to consult a cardiologist for his heart problem, an orthopaedic surgeon for his leg problem, an eye specialist for his eye problem, and a neurologist for his loss of sensation. The suffering, the time spent at each hospital clinic and the cost of treatment can be unbearable.

Yet, that need not be and should not be the case, if their diabetic condition is detected early and managed well. The simple trick is to help the patients control their blood sugar, look out for early signs of complications and treat the

Today, many diabetic patients are middle-aged and are better educated than their parents. They have the ability and motivation to help themselves. We should really re-orientate our healthcare to work with the patients and enable them to lead a long and healthy life. We actually have many success stories right here in Singapore, at helping diabetic patients live a long and healthy life.

For example, SGH and Alexandra Hospital, and likewise other hospitals as well as Kandang Kerbau and NUH, have diabetes centres to run structured disease management programmes for the patients. Their staff work with the community and employers to screen the population. Those with mild diabetes are referred to their family physicians for follow-up.

For those with more severe diabetes, the specialists assess the patients thoroughly at the beginning of the programme, draw up individualised treatment plans. Non-specialists and other team members then take over and work with the patients to control their blood sugar and to screen for complications, at appropriate intervals, under the supervision of specialists. Once the conditions have stabilised, they are referred back to their family physicians for routine follow-up.

The key is to make patients and their family members the main carers of their diabetic condition. Patients are taught individually and in groups, to enable them to help themselves. They adopt healthier eating habits with the help of dieticians. They exercise more and they reduce their weight. Many are even able to adjust their insulin dosage with help from nurses.

The outcome has been very satisfying. Patients' blood sugar level is better controlled. Complications are detected earlier and treatment to prevent deterioration initiated earlier. Their experience suggests that one of the most feared complications of diabetes, namely, progressive kidney failure, can be stabilised with good management.

We should expand such success stories widely, to benefit many more patients and also others with other chronic diseases, such as high blood pressure and asthma. Both hospital clusters are spearheading a few structured disease management programmes for their chronic patients and they already have good results to show. For example, patients under the NHG cluster's asthma programme are less likely to end up with emergency asthma attacks. The programme must have saved many lives and avoided unnecessary deaths due to asthma.

Another disease management programme is for heart failure patients - patients who have survived a heart attack. Results are also very encouraging.

3.30 pm

I am very cheered by these innovations and their success stories.

and, eventually, open the hospital in phases from the year 2009. cost of such equipment investment, I agree that wherever it is possible to share it with the private sector, public hospitals should do so. But sharing has to be done at the right price, and certainly not at the expense of public patients.of chronic diseases, so that patients with chronic diseases can enjoy better care at lower cost and with less hassle. would become standard best practices here. complications before they become a big problem. Many of the complications of diabetes can be avoided totally or, at least, delayed for many years.

Quietly and unglamorously, our polyclinic family physicians, working jointly with the hospital specialists, are helping our chronically-ill live longer and healthier lives.

Let us help push these programmes nationwide. To succeed at the national level, many things will have to happen. Time does not permit me to elaborate, but they include successful implementation of concepts like right-siting of care - a topic that Dr Tan Cheng Bock mentioned just now. In other words, you should be treated at the right place, not in the wrong place, higher cost, more hassle and

This is a tall order, and that is why no country has so far done it well. I am counting on our being small and compact and better organised. I think it can be done. I have been in healthcare for many years now and for the rest of my term as Health Minister, I want to focus on this subject. If we can make a significant difference to the way we handle the management of chronically ill, I think we can then make a major contribution to the health of Singaporeans. It is unglamorous, it will not attract headlines, media attention, but it will make the most crucial difference to our health status. We are building a Health Centre at Jurong West to be one focal point to deliver this transformed service for the residents there. If it succeeds, I will replicate it elsewhere. It will be a one-stop health hub, providing a range of services from, say, outpatient specialist, diagnostic and day surgery services to chronic disease management for common chronic illnesses. It will also be a place for health screening and health promotion. If we can tear down barriers between public and private, GPs and specialists, hospitals and step-down care homes, and leverage on technology, I see an opportunity for a transformation of the way we traditionally manage chronic diseases.

Earlier, I said that we are studying how Medisave can be liberalised to pay for costly outpatient care. I therefore see an opportunity to leverage on this initiative to help nudge the profession and patients towards this direction.

Dr Tan Sze Wee asked for data on Government spending on primary healthcare. More than 60% of the Government's subsidies goes towards hospital care, 7% is spent on primary healthcare. This is much lower compared to the various countries he mentioned - Canada, UK and New Zealand - where they spend up to 30% of their health budget on primary care. But I must caution here that the figures are not comparable because, in their case, the primary healthcare is 100% public, whereas in our case, 80% of primary healthcare is in the private sector by GPs. So the spending is not captured. Our 6% is only on public healthcare.

Finally, let me respond to Mr Low Thia Khiang's point about NKF and IPC. I remember I had a full discussion with Mr Steve Chia - unfortunately he has left - not too long ago, maybe last month. Perhaps, Mr Low was not in the Chamber, and it fully addressed what are the NCSS' concerns. I clarified them and these concerns were properly addressed. Time does not permit me to go into it. Perhaps, I think Mr Low may want to just read up the Hansard so that we do not waste

unnecessary "one Singaporean, one family physician": every Singaporean, if you do not have a good family physician, start looking for one and make sure find one that is good, and build up that long-term relationship. One Singaporean, one electronic medical record - this can be done if we fully exploit IT. And we need IT so that electronic medical records can be shared with all the partners in healthcare so that we can then collectively, as a partner, look after these patients as the centrepiece. It also requires effective partnership between GPs and specialists, opportunistic health screening, cooperation and compliance by patients, and many more such concepts. If we do it right, year by year, we will see improvements, not only in service standard, but also in the health status of the patients. Let us start with a couple of the most common chronic diseases, say, diabetes, perhaps hypertension, where there are established clinical guidelines on how such diseases should be managed over time, and let us get more GPs, specialists and patients to join the programme and embrace the new approach.everybody's time here. He did ask a point about who is the final authority on charities. There is a Commissioner of Charities who currently is also the Commissioner of Income Tax. But if you read the consultation paper, which is now in circulation, and MCYS will make a formal response to it in a few days' time, their intent now is to separate the two roles so that there will be a new Commissioner of Charities and he will be supported by the various deputies, because there are so many charities in Singapore, a few thousands of them - some in sports, arts and healthcare. I suppose, in the case of healthcare IPC, there will be a person identified and he will be the Deputy to the Commissioner of Charities.

Sir, at the point in time, MOH was the approving authority for IPC. My question was: who in MOH approved the IPC status and whether or not NCSS had some reservations about that and how did it miss the person's approval?

Please read the Hansard when this was debated with Mr Steve Chia. The concerns were fully addressed. Let us not get the impression as if NCSS was aware that there was hanky-panky going on in all those things that are now discovered by KPMG. There was none of that kind. The concerns raised were totally different and, frankly speaking, minor in nature, and they were addressed. MOH studied it, analysed it and since there were no reasons to reject the IPC, of course, they approved the IPC. It is easy on hindsight to say, "Hey, why didn't you do this? Why didn't you do that?" But, as I explained at that sitting to Mr Steve Chia, when a CEO, helped by a group of people, in this case, the Board of Directors or at least some of them, went all out to mislead the public, they

I also made a critical point which was that while KPMG came up with this thick report but only about a year ago, when KPMG was actually commissioned by the Ministry of Health to look into NKF, they discovered some minor things which were all fixed, but they did not uncover the problem that we now read in the report. So let us put this thing in perspective. On hindsight, it is easy to say, "Why didn't we do this? Why didn't we do that?" In many ways, as I told Mr Steve Chia at that time, the former CEO misled all of us, including Mr Steve Chia, myself and Mr Low Thia Khiang, because he was also in this Chamber for several years and, if he had known about all this, he could have raised it too. But I am quite sure he was not aware, we were not aware, all of us were misled. But never mind, now the problem has been uncovered, let us progressively fix them, and we are fixing them.

will be discovered but it does take some time.

Dr Chong Weng Chiew, you have two cuts. Six minutes.

Mobile Healthcare Services

Sir, I am definitely happy and glad to hear the Minister's description of the Ministry's interest and views on the chronic sick's illnesses. My two cuts actually involve the following up of the chronic sick's illnesses as well.

First, let me declare my interest as I am involved in a couple of VWOs that provide non-institutional clinical services to needy senior citizens - one runs a mobile clinic and the other provides domiciliary homecare services for the elderly. Today, I will be emphasising about mobile clinics.

As our population ages, more and more senior citizens will face mobility

The mobile clinic concept offers an easier option for the elderly with chronic illnesses. They encourage them to get their illnesses examined and monitored. In fact, the work of the mobile clinics complements the services of our established polyclinics as well as general practitioners. If there is a way these two services can work together, they should, in the sharing of patient information, updating of patient conditions, treatments, and so forth. I am glad that the Minister's earlier description on IT has addressed these concerns.

Currently, these mobile clinics operate independently and their services are not subsidised by the Government. They are only able to subsidise patients with funds from donors. As a result, they can only cater to a small number of elderly. If the Government would consider subsidising their services or, more importantly, share patient information with respect to patient confidentiality for the elderly poor, such monetary as well as logistic support will help many VWOs to expand its capacity to service more poor chronic sick elderly in more estates. It would also go a long way to help ensure that the service will continue to be provided to needy, senior citizens at very affordable rates. I hope the Minister would consider this suggestion favourably.

Home Therapy

Next, I will move on to my next cut on home therapy. Likewise, the Minister has mentioned examples on home therapy earlier on and I am sure the Minister is fully supportive of the fact that home

My cut on home therapy would actually be particularly angled for the chronically sick, poor and those living alone. As much as we are able to, we should also do our best to help the elderly sick alleviate their sufferings, particularly in the area of therapy. As I have mentioned earlier in my speech on mobile healthcare services, many senior citizens have difficulties travelling even to nearby polyclinics or community rehabilitation centres for subsidised follow-up treatments. The case as mentioned by the Minister earlier on, to a great extent, is a good example of such a case where the patient would have problem travelling to specific centres for treatment.

Hence, I would like to request the Ministry to consider extending Government subsidies to home therapy sessions for the elderly poor. Many of these live alone, with an elderly spouse or as "latch key" grandparents. Mobility is a big problem for them and many cannot afford to pay for unsubsidised home therapy sessions or domestic help and taxi fares to bring them for follow-up appointments. More often than not, they miss their follow-up therapy sessions and their conditions will start deteriorating from there. Then what happens, ironically, is that they will reach such a bad stage that they have to be admitted into an acute hospital where their medical fees would then be subsidised. But does this not lead to higher treatment costs, more given subsidies and greater suffering, all quite unnecessary since it is preventable in the first place?

Sir, I understand that such one-to-one home therapy sessions come at higher costs because they do not enjoy economies of scale, unlike sessions conducted at community rehabilitation facilities. However, I hope that the Ministry would be able to approve a system whereby selected cases, genuine

problems. Although the Government has started working on making our neighbourhood estates barrier-free, this process will take a few years. Meanwhile, a growing number of elderly, especially the chronic sick, face challenges going to nearby polyclinics, or even their GPs, for their follow-up treatments.therapy does provide lots of benefits for patients.cases, with severe problems gaining access to community services, can be given the benefit of subsidies for using home therapy sessions.

Financial Assistance

(In Mandarin): Sir, in recent years, the Government has reformed its healthcare policies to the benefit of many Singaporeans, particularly patients in the middle and lower-income groups. However, very often, when the senior citizens went for treatment in the hospitals, they were not aware of the many financial assistance schemes provided by the Government to help them pay for their hospital bills. Some of them came to see me at my meet-the-people sessions and asked me to write to the hospitals to ask for assistance in the payment of their medical expenses.

As a matter of fact, many are eligible for the assistance schemes provided by the Government. At the time when they sought treatment at the hospital, they could have applied and be granted the assistance on the spot, without having to wait until the hefty hospital bill comes before rushing to their Member of Parliament for help. Perhaps, it was because they are not well-educated, hence are ignorant of how to apply for such assistance.

I hope that the Ministry would set up an effective system whereby a team of designated officers or department would offer the required assistance to these senior citizens on the spot. This is also a way to reward the elderly for their past contribution to our nation building.

3.45 pm

Gerontological Education

Mr Chairman, Sir, in 1984, the Howe Yoon Chong

I think the Howe Yoon Chong Report is actually a very good report. The only problem was that it got hijacked by the issue of the withdrawal of CPF monies at age 55, which spoiled the whole report. But there are many, many good aspects in this report. Let me just quote what he said:

"Ageing is not only a physical process but also a state of mind. Today, large sections of society still deem the elderly to be a group of persons who should be classified with the sick and the disabled who are no longer fit for employment or capable of being retrained or re-educated to fit into the new jobs."

This is a very important statement. And this is what he suggested, ie, that this particular education should be established to encourage the academic staff, scholars and students of the NUS to do research, studies and investigations into the field of gerontology, to include gerontology in the curriculum of sociology or social science students, and to incorporate geriatric medicine as part of the medical curriculum, and also to encourage research, investigations, studies and regular surveys to monitor the social, economic and other changes that affect the aged.

This report, therefore, called for a new look at ageing by calling for the studying of ageing through properly structured courses to better understand this subject. As I said, we have not done much. We must not be captured by our old style of

There are two aspects of gerontological education. The one that Members are most familiar with is geriatrics. But it is the other aspect, the social aspect, which has not been well studied. And many of us assume we know a lot. But we will be surprised that we really do not know that much. Therefore, I am asking the Government to have a good look at this subject and incorporate it perhaps as a subject or course in the university and, also, maybe in the polytechnic.

Report on Ageing was debated in the House, and I remember the report suggested that there should be an education called Gerontological Education, ie, studies on ageing. He said that Singaporeans must be better prepared for the impending ageing population. Now, 20 years have passed and I do not see that this particular education has been supported. I think it is time that we studied this particular subject again.managing the old. The new old, as I said before, are better educated and travelled, and are very knowledgeable. So we must quickly explore new ways and methods to meet the expectations of the new old. The setting up of the Gerontological Unit should not be delayed further. It could be in the universities or polytechnics. I think it is up to the Government to decide. It would provide courses for the care-givers and also policymakers so that they can better understand the subject.

Mr Chairman, Sir, together with Dr Tan before me, I would also like to ask the Minister for Health regarding the promotion of gerontological education in Singapore.

Our Government has addressed the ageing population issue for more than 20 years. During this time, it has focused properly on the healthcare needs of older persons. The health issues of older persons are addressed by medical gerontology or geriatrics. Non-medical issues are addressed by social gerontology. By this, we mean the study of the reciprocal relationship between the older person and health, family, community and society, as well as policymakers in Government whose decisions affect him or her.

Society needs to ensure the following:

There will be sufficient healthcare for our ageing population; and

This can only be ensured through gerontological education. It is concerned not only with the provision of healthcare for older persons but also with their development, so that they can continue to contribute to society or to find fulfillment and meaning in later life. It includes the promotion of knowledge and understanding about ageing and older persons.

Therefore, may I ask the Minister, in view of the rapidly ageing population, what are the Ministry's plans for the promotion of gerontological education in Singapore?

There will be policies, practices and understanding to meet the social and economic challenges posed by that population.

Mr Chairman, Sir, I thank Dr Chong Weng Chiew, Mr Ang Mong Seng, Dr Tan Cheng Bock and Dr Tan Sze Wee for their questions and comments.

As they have pointed out, we are an ageing population. There are about 300,000 senior citizens in Singapore. They form 9% of our citizens. Singaporeans are living longer and healthier lives than ever before. These improvements in life expectancy and freedom from disease for most of an average person's life are an achievement that our healthcare system can be proud of.

But this has created new challenges. A good proportion of the elderly will develop a chronic illness in the last phase of their lives. 85% of the elderly will have one or more chronic illnesses that require lifelong treatment. Some will develop disabilities that require daily assistance. At any one time, 5%-10% of the elderly population will need help with

The historical focus of healthcare systems, which is to manage episodes of acute illness with intensive treatment, is not well-suited to manage the medical problems of the elderly. The elderly usually need continuous low intensity medical or nursing care to manage their chronic illness and to enable them to live good quality lives even if they have an age-related disability. If this can be provided in an efficient manner away from hospitals and nursing homes, they can enjoy a higher quality of life. So we must focus our health services to bring care as close to the home setting as possible. This needs a mindset change on the part of everyone, ie, healthcare providers, patients and their families.

The Committee on Ageing Issues, in its report, has recommended that the Government adopt a holistic family practitioner approach towards managing the healthcare needs of senior citizens. Over the next decade, our healthcare system will evolve in this direction.

Dr Chong Weng Chiew has quite clearly pointed out the benefits of providing home therapy and mobile healthcare to the elderly, and he has asked for subsidies for mobile healthcare and home therapy. We should consider this. Subsidies that channel the elderly to the hospital should be re-channelled to keep the elderly chronic sick at home, especially if this is a more efficient way of looking after the elderly sick. We have channelled subsidies before from inpatient to outpatient, eg, HIV treatment and chemotherapy for cancer. So we need to look at this again and, if we can provide more efficient care closer to the home, we should do so. Dr Lily Neo also suggested subsidised home therapy for the needy elderly.

This is a start. We will study our experience with the PCPS scheme and expand the programme gradually to manage chronic illness in the elderly. This will be in line with the recommendations of the Committee on Ageing Issues.

To bring therapy and care closer to home, MOH, together with MCYS, intends to partner the private and people sectors to develop a range of community-based nursing services and personal care services. In addition, we will enhance case management services in the community through tighter integration between the acute and step-down care facilities.

Mr Ang Mong Seng related cases where patients come to see him at the MPS to ask for financial help with their medical bills. I, too, have seen such patients in my MPS, and I asked them if they had seen the Medical Social Worker (MSW). Very often, they have not. And this is because the bill often comes after they are discharged, or they look at it only after they are discharged. One reason this happens is that our hospitals look after patients, regardless of whether the patient can afford to pay the bill, because they know that there are Medisave, Medifund and other assistance schemes to help the patient. So they treat the patient first, get the patient well, send the patient home, and then only after he is well, the patient looks at the bill. Very often, when they see the bill, instead of seeing the MSW, they come down to see us at our MPS

All our public sector hospitals, national centres and polyclinics have medical social workers. An estimated total of 140 MSWs help look after the social and financial needs of patients. They help administer Medifund, the Government's safety net to help those Singaporeans who, despite Government subsidies, MediShield and Medisave coverage, are still unable to pay the balance of their bills.

Besides Medifund, the MSWs work with the people sector and help administer a whole wide range of non-Government assistance. Our MSWs are highly-committed and passionate individuals who do their best to assist needy patients. Since they administer all the systems, they are really one-stop centres. The application process is kept simple to keep the administration cost down.

Dr Tan Cheng Bock and Dr Tan Sze Wee also spoke on the promotion of gerontological education in Singapore. Recently, the Singapore Action Group of Elders (SAGE) also came up with an open letter proposing the promotion of gerontological education. Dr Tan Cheng Bock referred to the Howe Yoon Chong Report which talked about gerontological education and the elderly. Twenty years ago, the problem of looking after the elderly was the tip of the iceberg. Today, the iceberg is upon us.

So I would go one step further. With an ageing population, it may not be appropriate to consider gerontology as a specialised area for a select group of healthcare and welfare workers with a specialised institution to train a few people. Today, the elderly population are

Sir, I was quite happy to note that there were three university professors who were in the SAGE initiative to promote gerontology. But they were writing in their private capacity, which is a shame. I encourage these professors to don their university caps and, in their professional capacity as professors in the university responsible for the education of our future doctors and social workers, promote gerontology as part of the mainstream university core curriculum in their respective faculties.

MOH, for its part, will be doing more to promote gerontological education. Most geriatricians currently work in acute care hospitals. But if the elderly are to be looked after in the community, then geriatric skills must reside in the doctors looking after patients in the community. That means family practitioners must practise community geriatrics. MOH will facilitate Continuing Medical Education (CME) courses that will equip GPs with the knowledge skills needed to function as community geriatricians.

Ageing issues are complex and must be tackled through an integrated and holistic approach involving Government, community agencies and the private sector. Much progress has been made in the last several years, though more remains to be done. Going forth, the collective will and efforts of all sectors, ie, the public, private and people sectors, will

their personal care and the activities of daily living. The Ministry of Health has tried out such schemes and launched the Primary Care Partnership Scheme (PCPS) in 2000, to help bring affordable healthcare to the doorstep of the needy elderly. Instead of having needy elderly patients travel to polyclinics, the scheme engages neighbourhood GPs to provide common outpatient treatment conveniently at polyclinic prices. But it was only for acute medical conditions. and we write the letters to the hospital, and then the MSW sees them. But, in fact, they can approach the MSW directly in the hospital. the major consumers of medical and welfare services. In some developed countries, more than 50% of government healthcare expenditure is directed towards the elderly. With care for the elderly becoming such a major part of medical and welfare services, gerontology, or the holistic study of the elderly, has to be part of the core curriculum and education of a doctor, nurse, social worker or anyone else in the medical and social services field of study.contribute towards achieving "Successful Ageing for Singapore".

4.00 pm

Flu Pandemic

Sir, concerns over a potential bird flu pandemic remain strong, globally as well as in the region. With these concerns in mind, could the Minister please update this House on the measures taken to prepare Singapore for a bird flu pandemic. How prepared are our hospitals to treat bird flu victims? What are we doing to prepare Singaporeans for such a pandemic?

One way of preparing Singaporeans for the possibility of a bird flu outbreak is through drills. Will the Ministry be conducting such a drill? In Parliament, the Minister had mentioned that the Ministry is actively looking at how Singapore can produce our own vaccine as there is a worldwide shortage of such a vaccine. What is the progress of this and do we have enough stockpile of the vaccine?

Sir, in fighting bird flu, maintaining cross-border cooperation is important, particularly, amongst close neighbours. Several Asian countries have reported cases of the H5N1 virus infecting birds. In a few countries, the virus has spread to humans and had caused death. Could the Minister update this House on the status of the pilot project that it is conducting in Indonesia to help our neighbours fight bird flu?

Mr Chairman, Sir, it is alarming that the Avian flu in the form of H5N1 strain has spread across from Asia to Europe. It is, however, heartening to know that MOH has set up a comprehensive influenza pandemic readiness and response plan and influenza pandemic contingency plan. These plans

In the influenza pandemic readiness and response plan, it was hypothesised that if a conservative percentage of 25% of Singaporeans fall victim to influenza, most likely, 11,240 people are expected to be hospitalised. I would like to know whether MOH will be receiving sufficient funds to ensure that implementation of the influenza pandemic readiness and response plan be carried out effectively. And if so, what is the expected budget for doing so?

If there is a pandemic, will our quarantine facilities be adequate with sufficient manpower to cope with? Are there further plans to strengthen our protection against bird flu coming to our shores? There now appears, in some countries affected by Avian flu, to be human-to-human transmission of H5N1 virus and with Singapore, being an open society, infected persons may unknowingly bring the virus here and how are we going to cope with such a possibility. If an outbreak occurs, in spite of these measures, will it have the same effect on the country as in SARS?

aim to reduce the impact of an outbreak on our social and economic lives to reduce the spread of Avian flu.

Genetic Counselling

With regard to my cut on genetic counselling, I would like to suggest that the Ministry work with the Registry of Marriages to encourage all couples registering for marriage to go for medical screening and genetic counselling.

Potential couples have the right to know about each other's health status. If they plan to have children, this information will be even more important. For the majority, there will be nothing to worry about, but for the minority, this information could be critical. They could present an opportunity to seek medical

Every child is precious, especially in baby-scarce Singapore. Pre-marital health screening and genetic counselling will help to maximise the potential of each child in our small nation.

advice and treatment. Preventive measures could help to reduce potential health risk to the unborn children and avoid unnecessary suffering.

Anti-smoking Policy

Sir, since the inception of a comprehensive anti-smoking campaign in 1986, I have seen the Government undertake a myriad of approaches to curb the prevalence of smoking in Singapore.

Sir, we have tried many things, from banning advertising by tobacco companies, raising duties and tax payable for cigarettes, including health warning on cigarette packaging and have even restricted the places where one can have a smoke. We have made it illegal to sell cigarettes to those below 18 years old. In effect, we have made cigarettes a forbidden fruit and the consequence is that the groups which we are trying to dissuade from smoking are the ones who clamour all the more for it.

I think most smokers, about 90%, according to a survey by HPB on "Youth Attitudes on Smoking" in 2000, know that smoking can have an adverse effect on their health. But, by restricting it so thoroughly, we may have made some groups all the more determined to try it for themselves. While the prevalence of smoking is down to 12.6% as of middle of last year, down from 13.8% in 2001 for some groups, it is on an uptrend, particularly for youths between the ages 16 and 24 and for females between the ages of 18 and 24.

Sir, in Thailand, cigarettes are cheaply and freely available, even though it has a bit less stringent preventive legislation like

Sir, perhaps, our public awareness campaign or anti-smoking communications directed at youths may take the tack that smoking is not cool or something along that line. For the image concerned youths today, this alternative tack may bear fruit rather than just making cigarettes a forbidden fruit. This approach may leave a more lasting impression on the youth and young female smokers for which there is an uptrend. This group will, in time, stretch our health dollar that will already be stretched by our greying population and the healthcare needs.

Can the Minister tell us what is in store to combat the uptrend of youth smokers?

Singapore in place. Yet, while overall youth smoking trends are rising, the group that most resembles the Singapore youth, and that is the average urban school-going middle-class youth, is not clamouring more for cigarettes. In fact, studies showed that youths in Thailand associate smoking with those who drop out of the mainstream education or move into the labour market early. So this mindset has developed despite cigarettes being so readily available.

National Blood Programme

Sir, with regard to my cut on national blood programme, I am very concerned with the recurring shortage in our blood bank, particularly during our year-end festive seasons.

In December 2005 and January 2006, our supply dropped to such low levels at one point that we have only enough to last 24 hours. With only 1.5% of our population donating blood, we have one of the lowest rates amongst developed nations. An adequate supply of blood is crucial. Imagine what could have happened if we had a crisis during that period? Incidents, such as 911 in the US,

How we boost our blood bank is no longer just an health issue. It is also a national security issue. I would like to ask the Ministry if we could re-examine our blood donation programme and identify areas for improvement. As we try to increase supply, we should also try to reduce demand. One way is to get suitable patients to use autologous blood. Patients going for elective surgeries, in particular, could be encouraged to do so. Elective surgeries account for one-third of total blood usage but only around 4.5% of such procedures use autologous blood.

Perhaps, we can look at the experience of other countries. An article in the Philadelphia Inquiry on 27th January this year described the success of blood donation drive in the US. Teenagers over the age of 16 are now the fastest growing group of blood donors, contributing up to 16% of the blood supply in some places. I quote: "Blood banks, including the Red Cross, have aggressively marketed to teens through web pages, MTV commercials. Research by the Ad Council shows teens are more willing to engage in community service than many adults."

Teens under the age of 18 have to get permission from their parents and many end up persuading their parents to donate too. Their contribution comes at a time when demand is growing due to the aging American population. I am not suggesting that we focus on getting blood only from our teenagers but, rather, this development in the US could be instructive. There may be elements that we could adopt. We certainly do not want to make the parents of our teenagers nervous.

Due to cultural differences, our attitude towards blood donation needs

showed how vulnerable any country can be despite security measures. time to change but, sadly, we cannot afford to wait too long. We too have an aging population. The onus for blood donation remains on the adult population.

Sir, I thank Mdm Halimah, Mr Andy Gan, Dr Chong Weng Chiew and Mr Arthur Fong for their questions and comments. Many of the medical issues brought up have been with us for a long time but one problem is new - bird flu. Hardly a day goes by without a news report in the media on developments related to bird flu.

Mdm Halimah and Mr Andy Gan have asked about aspects of our bird flu pandemic preparations. We must be prepared to manage three types of bird flu spread: one, bird to bird spread; two, bird to human spread; and three, human to human spread.

I will begin with bird to bird spread. It appears that the H5N1 virus has established itself in wild birds. It has spread relentlessly from Asia to Europe and Africa. Fortunately, our poultry population is limited and is located in farms with good bio-security. You have heard earlier in the House all the measures that AVA and ENV have taken to ensure that there is no bird to bird spread in Singapore. So far, no H5N1 influenza virus has been detected in Singapore.

Next, there are sporadic cases of bird to human spread. This has occurred in our neighbouring countries when humans have had close contact with sick birds. We have advised Singaporeans to avoid chicken farms when travelling to other countries. We have also put our doctors on alert against possible human cases of Avian flu coming into Singapore.

Finally, we should be prepared for a pandemic in case the virus mutates and starts spreading from human to human. Will a pandemic occur? We do not know. Experts differ in their opinion. Looking

Managing a pandemic is a national exercise in science-based risk management. Success depends on three factors: a strong effective political leadership, a cooperative public who follows health advisories during the pandemic, and a healthcare system that is well prepared to deal with public health challenges. This is what we learnt from our SARS experience. In Singapore, we have both, an effective leadership and a cooperative public. I want to assure the House that the third factor, the healthcare system, is well-prepared.

We currently have some 700,000 courses of Tamiflu and are on track to build up our national stockpile by the end of the year. We have an assured supply of pandemic vaccine if we think it is necessary to vaccinate the population. Public healthcare institutions have put in place plans to manage the expected surge in outpatients and in-patients in a pandemic.

We have also worked with other Government agencies to ensure that essential services will continue to operate during a pandemic so that there is minimal disruption to the economy and society. Through our outreach, we have given talks to MNCs, SMEs, private organisations and grassroots leaders to help them understand the nature of pandemics and the measures that they can take to be prepared.

We will conduct exercises in the next few months to test our pandemic preparedness. In the first stage, we will focus on all public and private acute hospitals to ensure that they are ready. The second stage will be a wider system-level exercise and will also involve other agencies such as CAAS and ICA, as well as the public.

As the risk of a bird flu pandemic is a global one, we are working with WHO and the international community to do our part in containing this threat. In January 2006, Singapore pledged $1 million at the International Pledging Conference in Beijing to fight bird flu. This will go towards our laboratory collaboration and capacity building efforts in Indonesia. In addition to this, together with the United States, we are also working with our Indonesian counterparts on a pilot project in Avian flu surveillance and control

back at the last century provides conflicting examples. In 1978, there was concern about a swine flu pandemic occurring and 24% of the population in the United States was vaccinated. The pandemic never occurred and no one died of swine fever. But the vaccination caused 500 complications and 25 deaths. On the other hand, in 1918, the Spanish flu pandemic spread across the world and caused 25 million deaths.

at the Tangerang Municipality just outside Jakarta. This is an area with a population of about one and a half million people. The project is expected to commence in April 2006. Singapore will be contributing both funds and technical expertise towards this project.

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