Hansard, 2010-03-09

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 (2010) To (2010) Mr S Iswaran 13 Mar 16 Mar 18 Mar 21 Mar 26 Mar 29 Mar Mr Goh Chok Tong 18 Mar 20 Mar Mrs Lim Hwee Hua 20 Mar 21 Mar

ABDULLAH TARMUGI Speaker Parliament of Singapore

Order read for consideration in Committee of Supply [4th Allotted Day].

Head O – Ministry of Health (cont.)

Resumption of Debate on Question [8th March 2010],

"That the total sum to be allocated for Head O of the Estimates be reduced by $100." – [Dr Lam Pin Min].

Question again proposed.

Geriatric medicine

Thank you, Mr Chairman. Before I go on to my cut, I would like to declare my interest as a director on the board of the Agency for Integrated Care. Our ageing population has given rise to a need for a whole spectrum of services in geriatric medicine and healthcare. I can assure you, it is no fun growing old. Your mind does not think it is old but your body starts behaving otherwise. I am going to be 47 very soon and I can attest to that fact. After a while, the mind slows down and a whole range of other challenges pop up. From my interaction with the elderly, it appears that the range of needs is extremely diverse. Medical conditions range from osteoporosis and macular degeneration to senile dementia. Correspondingly, the range of services required is extremely diverse. You need, for example, acute care in hospitals, outpatient treatment for age-related medical conditions in hospitals and polyclinics, step down care in community hospitals, day care centres for the aged, nursing homes for the critically ill. For those who are not so critically ill, you need full-time nursing services at home, day care or part-time nursing at home.

I would like to ask the Minister whether MOH is equipped to deal with this varied and diverse range of healthcare needs for the aged. Also, to what extent geriatric care needs to be handled by the hospitals and to what extent it can be handled by step down care or the community. How MOH can help people better understand and navigate the different types of services, so that we can have a better delivery of healthcare services to those in need.

Ageing

Mr Chairman, Sir, statistics have shown that the aged destitute has the highest number of Public Assistance recipients, consistently amounting to approximately 85%. Statistics have also shown that there is an approximate 1% increase in the total number of residents in old folks’ homes. In view of the rapid ageing population, this rate will definitely increase. There are many pressing questions of the care of the elderly that I would like to ask Minister to address, namely:

How are we to cope with the rapid demands from the ageing population?

Will we be able to build more step down medical and rehabilitation care in the neighbourhood? How many of these step down medical and rehabilitation centres will be planned in relation to population?

What will be the funding like? Are we proceeding with the "many helping hands" approach? Will we do it like the way kidney dialysis centres are located in the heartlands? What is the Ministry's basic funding model if the Ministry proceeds with the "many helping hands" approach?

How are we going to train a pool of medically-trained personnel to take care of the elderly and volunteers who can provide the medical and nursing care for the elderly in the heartland? Presently the elderly homes do not have medical support. To give an example, until recently my family had to take care of our late father-in-law who passed away late last year. We had to fetch him to hospital; once he was dehydrated and got the basic drips, and we brought him back after his condition had stabilised. If there is some basic medical care in the community,

How are we to make outpatient geriatric care more available at the heartlands? Could the services at GP clinics be reviewed to prepare them to take on some of these roles with the co-funding from the Ministry for the cost of geriatric care? Many of the elderly would not be able to walk to the one polyclinic in an estate. The journey is too long and the long waiting time.

How can we manage costs so that the services for nursing, rehabilitation, therapy and medication stay affordable in the years ahead for our elderly?

We need the Minister to show us the masterplan of how his Ministry is going to plan all these rehabilitation and care centres in our living environment to support the elderly.

there is no need to travel to and fro and more efficient use of the hospital care.

Mobile medical services

Mr Chairman, Sir, Singaporeans are ageing rapidly. The Ministerial Committee on Ageing reported in 2007 that by 2030, 20 years from now, one in five will be aged 65 and above, up from one in 12 today. It further projected that by 2050, 40 years from now, Singapore will be the fourth oldest country in the world. Currently there are segments within our population that face difficulties in travelling to the nearest clinic or hospital for treatments. Sometimes, these treatments or checkups can happen more than once in a week. Most patients have chronic illnesses that impede their physical mobility. To keep up with these treatments, patients sometimes find it stressful, a burden to the families and even contemplating suicide. In addition, caregivers of these patients are facing problems, such as time-off from work, job insecurity and higher transportation cost. In anticipation of our

fast growing population, I would like to ask the Minister to seriously consider providing mobile medical services in their respective zones. Using mobile medical services to reach out to people less accessible is not something new. In other countries, it has been done to a large extent. Similarly, in Singapore, some of these mobile services are already provided by private institutions. However, they are not widespread and not affordable to the low-income families. I believe these mobile medical services will enhance workers' productivity and bring comfort and graceful living to the deserving old Singaporeans who have contributed much to the nation-building of Singapore.

Adequacy of healthcare professionals

Sir, my questions for the Minister are focused on the healthcare needs of our ageing population. Given our rapidly ageing population and increase in prevalence of chronic ailments, is there a sufficient number of physicians and nurses to manage the expected increase in demand for geriatric care? How many physicians are currently trained in geriatric care? Will there be incentive to encourage young physicians to specialise in geriatrics, as opposed to, say, cosmetic surgery? How will the expected rise in foreign worker levy affect the supply of nursing care, especially for our nursing homes? One way to keep healthcare cost low is to provide safe options and alternatives to biomedical care. Can the Minister comment on the role traditional Chinese medicine (TCM) plays in eldercare? Are the existing regulatory measures sufficient to raise the professional profile of TCM and level up the alternative healing sector to be effectively complementary to the former healthcare sector? Finally, what measures has MOH taken to avail support services to augment step-down home care for the chronically-ill elderly?

Mental health

Mr Chairman, Sir, as more people are living longer, the incidence of age-related degenerative diseases of the brain, such as Alzheimer's and senile dementia, is expected to rise. Other mental illnesses, such as schizophrenia, depression and addiction are also on the rise. Unfortunately, the stigma attached to mental illness is still very apparent and people tend to shun mental patients due to lack of knowledge and understanding of mental conditions. More should be done to educate the public on mental health and diseases so as to help de-stigmatise this problem. There should also be better support from MOH in the form of mental health promotion and caregivers support. There is also an urgent need for the better integration of the services provided by VWOs and the Government agencies in the areas of social integration and community rehabilitation of patients with mental illness. I will, therefore, like to ask the Minister for an update on MOH's strategy in managing mental health and illness in Singapore.

Sir, mental illness is one of the most maligned and stigmatised illnesses that is least understood but is rising fast. Last year, IMH treated 33,000 patients, an increase of 14% from 2005. After raising this issue over a number of Budget debates, I am happy that there is now greater focus on mental illness. Hence, I urge the Minister to focus on the three areas.

First, cover mental illness under MediShield, as the cost of hospitalisation is increasing and is becoming a burden to families. There appears to be no compelling reason to exclude mental illness, even if there is such a wide range, from the mild to the severe, which is not something insurmountable as the limits can be prescribed. Other countries' healthcare systems already covered

Second, establish more community-based services and provide more funding support to VWOs running shelters in other services for the mentally ill. This would help to reduce the relapse rate which also means less cost for the Government. A big problem for most families is that after a mentally-ill person is discharged from hospital, there is no place for them to go to for help or support, especially during periods of crisis, so they end up sending the patient back to hospital.

Third, provide more workplace support for those who are mentally ill, through educational programmes to raise awareness and reduce the stigma against them, and also help them in better job placement assistance.

mental illness and studies have shown that we will not necessarily increase premiums significantly, especially if coverage enables patients to receive treatments earlier and, therefore, avoid the higher cost involved if their conditions worsen.

(In Mandarin ): [For vernacular speech, please refer to Appendix A *.] Sir, Singapore is seeing a steady increase of people suffering from mental illnesses. In 2006 alone, the Institute of Mental Health treated close to 33,000 patients for mental illnesses. The Government passed the Mental Health Bill in 2008, which mandates the provision of proper care and treatment to the mentally ill. The law also provides for detention of mental patients, both for the sake of the patients and the public. In this regard, since the passing of the law, how many patients have been detained and for how long? Equally important is the Minister’s assurance to this House that no patient has been unnecessarily detained.

A related issue is the projected rise of age-related degenerative diseases, such as Parkinson's, Alzheimer's and senile

dementia. The number of senior citizens aged 65 and above is expected to reach 19% of our population by 2030 and Singapore is expected to have the world’s fourth oldest population by 2050. I would like to seek assurance from the Minister that we have adequate trained psychiatrists and nursing staff to care for senior citizens with mental illnesses. *Cols. 3685-3686.

Mr Chairman, Sir, one of the problems encountered by MPs on the ground is patients with mental health problems who have been released from IMH back into the community, but who do not take their medication, with the result that there is a resurgence of their mental problems. For example, one of my residents is firmly convinced that the neighbour upstairs is doing something to cause water to flood down from the ceiling into her flat. There is, in fact, no such problem. The HDB and Town Council have looked into it. But she is convinced that there is a problem, she comes to see me regularly in great distress and ask for a transfer of the flat. There are others, whose mental conditions lead them to engage in anti-social behaviour and, in some cases, they can be violent. There is less of an issue if they are staying with family members. However, some of them live alone or do not have people to look after them. Very often, the mental conditions are not so serious as to require that they remain in IMH. The mental conditions can be addressed provided that they take their medication. But the problem is that once they are released from IMH and they are staying alone, there is no one to ensure that they do take their medication. I would like to ask the Minister what steps can be taken to address the need for follow-up care of patients with mental health problems and whether this can be addressed by MOH or whether there are plans to address it through other agencies or community networks.

Mr Chairman, the area of mental health and

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Sir, the cost of medication for psychiatric and mental illnesses can be high and many patients have been known to default treatment due to inability to cope with payments.

illness has long been de-emphasised, due to the many stigma and complexities associated with it. Thanks to the Ministry of Health, there has been much more focus on these issues of late. Increase fundings towards this area, including almost double research funding in mental health. The cost of institutionalising these patients are many and varied. Once suitable for ambulatory community care, doctors will discharge them. Can MOH work and coordinate with more VWOs, NGOs, volunteers and community leaders to strategise and coordinate community support groups who can lend a hand and an ear to these people; tasks they can take part, including befriending, advising, social outings, ensuring and supervising taking of medications, giving appropriate feedback to medical personnel and IMH on observed behaviours, etc? This group can be given some simple training to acquire these necessary skills and can include independent and well elderly or retired nurses who can contribute to society.

Since Medisave has been liberalised to be used to fund two chronic mental illnesses, which is schizophrenia and also depression last year, how many people have taken this up and how much costs did this amount to? Will there also be plans to include other chronic mental illness to the list?

Care of mental health patients

Sir, the statistics on suicide make for grim reading. According to a press report, more people in Singapore die from suicides than in road accidents. Between 2000 and

On 20th February this year, one of my residents, a 37-year old IMH outpatient committed suicide by jumping from the HDB block she was living in. Her father, who was also an IMH patient, passed away last year. The deceased has a brother who is institutionalised at IMH. She also has one other brother who is mentally sound but is lowly educated. He is the sole breadwinner of what remains of her family, earning some $500 per month. The family has been assisted by my grassroots and the Southwest CDC for years.

After her father passed away, her mentally sound brother had asked me to appeal to IMH to institutionalise her as he was unable to take care of her. She was then still an inpatient of IMH. IMH subsequently replied that she was assessed to be no longer suicidal and had asked to be discharged everyday. IMH had informed her brother that if their medical social worker could not contact him to explore alternative accommodation, such as a nursing home, for his sister or he was unable to place her in a nursing home, they would have to discharge her once she is assessed to be mentally stable and no longer a danger to herself or others. IMH said that they would then put her under close community supervision and follow-up by members of the Community Mental Health Team (CMHT). Sadly, she committed suicide in February this year.

This incident begs several questions. Should patients be discharged into the community if they lack the necessary family support to continue with their medication and follow-up treatment? Does the IMH have a robust system of

According to Prof. Chong Siow Ann, Vice-Chairman of the IMH’s medical board and Director of Research, an estimated one in two patients drop out of the treatment programmes. They need to be better monitored and engaged by health-care providers.

I fully understand IMH’s approach of not institutionalising all mentally-ill patients but constantly seeking to rehabilitate them in the community instead. To facilitate this, the CMHT programme was started in 2007. The CMHT now have a staff strength of 51, comprising doctors, nurses, medical social workers, occupational therapists and psychologists.

It has been reported that regular house calls have cut re-admission rates by 43% and hospital stays by two-thirds. While this is commendable, one wonders if the CMHT programme’s resources are adequate to handle the estimated more than 30,000 mentally-ill patients known to the IMH who are living in the community under rehabilitation.

Ideally, the family should be the first line of support for these patients. But their families may not know what to do or may not have the means to provide support, such as in the case of my resident. The patients could then become a menace to society and/or themselves. Such patients with little or no family support should receive more attention from IMH or CMHT. Otherwise, IMH should consider institutionalising them.

Voluntary welfare organisations, religious organisations as well as grassroots volunteers could be roped in to work with IMH and the CMHTs to make sure mental outpatients can live and function as

2004, of the more than 1,700 suicides, up to seven in 10 had some form of mental illness. This compares to the 212 fatal accidents in 2003.monitoring mentally-ill patients’ recovery in the community, and intervening if they suffer a relapse? How can IMH better track and care for its outpatients?normally as possible in the community. But the Ministry would have to provide resources to help these volunteers so that they can render appropriate support and assistance.

Mr Sin Boon Ann is not here. Mdm Cynthia Phua.

The mentally challenged

Mr Chairman, Sir, most of us are fortunate not to have to care for a child who is mentally challenged. But for those who face this challenge, I would like to bring up their plight. The stigma that follows the parents of children with mental deficiencies often hold them back from reaching out to their communities for help. The Movement for the Intellectually Disabled of Singapore (MINDS) has been a great source of support for both the child and the caregivers. I truly admire the passion that is driving the people in MINDS. Can we learn from this establishment and provide such establishment for the mentally ill?

Presently, we are doing very little for the mentally ill at home. What can we do for them? Can we have more day care or drop in centres for them to be able to socialise so that we could at least give them some quality of life and to give some reprieve for their caregivers? How about training courses for them to upgrade their skills or hone them into some living skills to enhance their quality of life?

We need more financial assistance for these families too. Many of them are not in the tax paying bracket and do not enjoy the higher tax relief introduced in this Budget.

We need to act more swiftly because as one ages, dementia does set in. To care for the elderly is challenging and to care for the dementia elderly is even more

I would like the Ministry to consider a hotline for the public to call for help when it is obvious that a mentally-ill person needs help. The first sign is when they become a nuisance and do not cause harm yet to themselves. We need a special group to handle these mentally ill or mentally challenged. Many do not open the doors of their flat upon visits and HDB, Town Councils and Police officers are helpless and unable to have access to them as they are not dangerous. And last of all, the other area that we need to address is the caregiver stress, especially for the mentally ill.

strenuous. What is the Ministry doing to prepare for this group of people? Where can the caregivers turn to for help as the normal elderly care centre is unable to cope with the dementia elderly? What is the price for treatment and care giving? Are there sufficient care facilities and manpower? Many of these residents do not and could not explain their medical conditions themselves. Is the Ministry of Health able to share some of this health information with the community care centres to be eventually set up in the heartlands so that proper intervention can be done?

Mr Chairman, Sir, on the first day of Chinese New Year, I received news that Dr Chee Pui Hung had passed away that morning peacefully at home. He was 87. As I wrote in my blog, "I lost a friend, a supporter and a critic" whom I respect. Dr Chee was a legend and was larger than life. Within the medical community, he was widely and affectionately referred to as the "A-gong" of the Medical Alumni, who held together the large community of doctors, dentists and pharmacists. He lived life to the fullest, had a successful medical career, brought up three children well and even dabbled in politics in his early days. I am told that he had even chided a couple of Ministers in public when he disagreed with some of their

Many years ago, my father, too, passed away during the Chinese New Year period. He lived a full life, without any bad habit, kept slim, remained active and socially engaged in retirement. Several days after all the children who lived overseas had returned to their respective homes following several days of New Year reunion with him, he had internal bleeding in his brain one night while watching – and I suppose fallen asleep – in front of the TV. My mother rushed him to the hospital in an ambulance. I took the first flight out to Penang but missed him by an hour. The suddenness was traumatic for the family, but after the emotions had settled, we knew it was a good death and we all quietly wished that when it is our time to go, we could do so just as swiftly. The Japanese call this “pin pin korori”. "Pin pin" means to be healthy, bouncy and dynamic; "korori" means just roll over and die. The expression is so common among Japanese, they even abbreviate it to just PPK. To PPK means to live a long and healthy life without illness and when the time to go, just go swiftly: "Pin pin korori ". And there are pokkuri temples all over the place in Japan, promising the worshippers PPK. Although Japan has been in recession for two decades, pokkuri temples are doing quite well.

I studied the Japanese approach carefully because they have the most experience dealing with ageing. Just how advanced is ageing in the Japanese society? Let me share some observations. In 1963, Japan started giving silver cups to Japanese who turned 100. That year, they gave away 153 cups. There are now 40,000 centenarians and they have just reduced the cup size by 15% to save on silver. Their ageing problem is magnified

As noted by Dr Lam Pin Min and Dr Lily Neo, we have a good healthcare system. As the current and the former Head of GPC for Health, they know what they are talking about. Our system has brought us much success – low mortality, increased longevity, high clinical standards and among the most cost-effective in the world. But ageing of the population will bring new problems.

We hope for PPK, but what if we do not simply "roll over and die"? The Chinese have a saying, jiu bing wu xiao zi: "When you have a prolonged illness, very hard to find filial children". Outsourcing the care of patients is not the solution. The scene in "Money, No Enough 2 " of children dumping their mother outside the gate of a nursing home touched a chord, because that is exactly what we all fear. I know death is a morbid subject and we have just celebrated Chinese New Year. But let me assure Members that this speech is not about gloom and sadness; it is about living well and celebrating life. Yes, we are ageing, but there is much cause for optimism. Today’s seniors are very different from the seniors of the past. I am 58 and my residents often tell me that "You look younger". So, to Ms Indranee who talked about ageing earlier on, ageing can be fun, ageing may not be so bad. When our children become seniors, they will, in turn, be even better than the seniors of today. Where is the

policies. In his unique way, he contributed to Singapore.by their very low birth rate. There are now more adult diapers being sold than children’s diapers. There are 23 million children but 44 million pets! Pet care is big business in Japan. Yesterday, if Members read the Straits Times, they would see a picture of a Japanese man: how he pampered his poodle by carrying it piggy-back on his back, just as he would piggy-back his kid, which he probably does not have. Even pets are ageing, so in the supermarkets they have pet food calibrated by age bands.evidence? More Singaporeans are exercising, jogging, swimming, brisk walking and engaging in all sorts of sports. Here, I must thank Minister Mah Bow Tan, the HDB, the NParks and the PUB for creating an increasingly health promoting environment. In Sembawang, for example, we see our residents regularly jogging away, using the bicycle tracks, the park connectors and the various parks. My GRC MPs, including Dr Lim Wee Kiak, are now working with the NParks to refresh the Sembawang Park so that it keeps up with the needs of modern Singaporeans. But we will ensure that it retains its natural, old world charms. Ms Irene Ng’s observation yesterday that some parks have become too "artificial, plastic", was timely. We would not make that kind of mistake.

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As we discuss this year's Budget and reflect upon our achievements, I agree with Dr Fatimah Lateef that we focus on how we can shape the future to meet our aspirations. I have heard Members' many thoughtful comments. Let me just pick up their key points.

First, the past decade has seen our resident population grow from four million to five million. In the next decade, will we add another million? The Economic Strategies Committee has noted our physical constraints and Singaporeans have also been voicing their concerns. So, I doubt it will be a "6-million people decade". But even a "5.5-million people decade" will mean a substantial increase in demand on healthcare services, as Singaporeans are getting older. In 2000, life expectancy at age 65 was 82 years. Now, it is 84, an increase of two years. With medical advances, this should increase further to 86, I think, in the next decade. This is success. It means that many more Singaporeans can live to their 80s and 90s. With better nutrition and

So we are gearing up for this demographic change. We are adding more beds, more clinics, more staff, more nursing homes, more day care centres. I have shared my expansion plan before but given time constraints, I will not repeat it. Let me just highlight the next big event: the opening of Khoo Teck Puat Hospital (KTPH) in Yishun. Over the next few months, we will open it in stages. Indeed, it will start treating outpatients and conduct day surgeries in three weeks' time. The ambition of the hospital team is to make KTPH a hassle-free hospital, and I look forward to that.

The change in patient profile from younger to older patients will have significant impact on healthcare delivery. The Prime Minister spoke about this during his National Day Rally last year. Young patients recover quickly. They return to status quo soon after discharge. Elderly patients take longer to recover and sometimes full recovery may not even be achievable. They merely change their status from an acute patient to a chronic patient. Many need some transitional care in a community hospital or a nursing home and occasional re-admissions to the acute hospital. That is why it is so important for close collaboration and effective coordination between the acute hospitals and their clinical partners in the community. Done right, this will free up acute beds for patients with more serious conditions and reduce cost for those requiring less intensive care in the community. Dr Lam referred to this as "seamless, integrated care". I code-name it as "hassle-free healthcare system". And one key enabler is the National Electronic Healthcare Records (NEHR), to allow all providers common access to an individual's critical medical information, so that they can develop and coordinate shared care plans. This will reduce unnecessary repeat tests and medication errors, and bring us one step closer to the

I gave the team planning the new Jurong General Hospital (JGH) the project brief to build a hassle-free healthcare system to serve the residents in the West. They accepted the challenge. Being ambitious, they self-imposed an additional target: to make JGH a paperless hospital when it opens. Meanwhile, the hospital team in KTPH, CGH and TTSH are also trying to do the same for their respective regions. They will compete to deliver the best ideas. And I told my Ministry of Health colleagues that this is our priority in the next decade. Indeed, it will take us a decade to complete this assignment.

Second, with more elderly patients requiring care in the community, including those with dementia, we are expanding our long term care sector. This is a point emphasised by several Members – Ms Indranee Rajah, Mdm Cynthia Phua. Many chronic patients can be cared for at home by their family members and their maids. But as Dr Lily Neo and Mdm Cynthia Phua observed, distress among caregivers might arise. I agree that carers need training and support, and we will help them.

All elderly patients want to age at home and many children want to take care of their elderly parents at home. We will build up the home nursing capabilities and we are working with several partners to do so. We must avoid seniors becoming permanent residents in nursing homes.

We are working with the Home Nursing Foundation (HNF) to scale up their operations. They will also extend their services beyond the low-income group to also help the higher-income group access appropriate home nursing care. Many patients do not need subsidies but may

Mr Terry Lee suggested the use of mobile medical services. Some VWOs do run mobile clinics to bring medical care and treatment to the patients at home. SATA is one example. St Andrew's Community Hospital is another. Recently, it launched a new service, what they call "hospital-on-wheels", to "bus" its team of doctors and nurses around Singapore. We are open to all practical ideas.

Third, a minority of elderly patients will unfortunately require long-term care in a nursing home. In Europe, up to 7% of the elderly live in nursing homes. We now have 62 nursing homes, serving 2% of our elderly population. This is not excessive, neither is it grossly inadequate as we are a young society and family bonding is still strong. There is, however, variance in the performance standards of our nursing homes. While some well-run nursing homes are full with a long waiting list, a few others have significant vacancies. We will push the weaker nursing homes to upgrade so that resources are put to optimal use. Still, there is scope for some expansion. That is why we are currently planning three new nursing homes and rebuilding three old ones in larger facilities in better locations within HDB towns.

But we must not make it too easy for irresponsible children to abandon their parents. Abandonment is not a major issue here but we do encounter some from time to time. Last week, Ms Indranee Rajah quoted one case involving

Assoc. Prof. Straughan asked about the impact of the increased foreign worker levy on nursing homes. We have assessed – the direct cost impact actually is small. But, separately, we have just increased our subvention to them by about 7% to help them cope with the higher cost of treating patients with more severe disabilities, what we call category III and category IV patients. The increase will be quite substantial.

Fourth, we will back up the physical expansion with the necessary manpower. In the public sector, we have been adding more doctors, nurses and other healthcare professionals, to improve the staff-to-patient ratio. We launched this in 2007, when we set aside $1.5 billion to recruit 7,700 more healthcare professionals. We are now halfway through this five-year plan. And I am pleased to report to Dr Lily Neo and Assoc. Prof. Straughan that we are on track to achieving the target. Our headcounts have increased by 44%. Our doctor staffing level has gone up from six doctors to eight doctors per 10 beds. Our nurse staffing level has gone up from 20 nurses to 26 nurses per 10 beds. Recently, I met a group of hospital Medical Social Workers where we have been adding numbers. They were "complaining" to me that many of their new recruits do not even have offices and the hospital is rapidly adding workstations to hold them. Equally important is staff retention as Dr Fatimah Lateef emphasised. Although our staff attrition rates have come down from 8% to 6% for doctors and from 10% to 7% for nurses, it is an ongoing challenge. With two new private hospitals coming on-stream, we must expect significant attrition. The only practical way forward is to ramp up training and foreign recruitment.

Last month, in my Sembawang branch, I bade farewell to a young Party activist who left us to start her medical education in a medical school in New South Wales. I asked her about the student intake numbers. She said that she was not sure but more than 300 per year for her batch. But she knew that in her batch, there would be 60 international students. But out of the 60, 40 are Singaporeans. And this is just in one medical school in Australia. I remember blogging about it after hearing this and I made a point that I will figure out a way to "get our kids back" to Singapore. And I will. The restructured hospitals are studying an idea of offering a pre-employment grant to these medical students, to help them with their costs overseas, in return for a bond to serve them when they graduate. It was an idea that Dr Lily Neo planted in my head some years ago and I think it is doable.

We have also been embracing the value proposition of a career in the public sector. We are investing in biomedical research and supporting those with research interest. For the young doctors, we are ramping up training opportunities. This will allow every young doctor to reach his maximum potential in his chosen specialty, including as a family physician. We are setting aside $120 million to strengthen our specialist training programmes over the next five years.

We are also building up geriatric care capabilities. We will encourage GPs to undertake further post-graduate training in geriatric care so that they can better manage their patients in the community. In addition, we will also need more specialist geriatricians. We have 48 now. Over the next three years, we expect to increase it by 30% to 40%. We have incorporated geriatric medicine as a core module of our medical student undergraduate training, and have introduced incentive allowances for geriatric trainees over the more popular specialities. Next to

Among the fresh ideas being considered is to base an institute of geriatrics and gerontology there. It can be a think tank of practical people to help conceptualise and facilitate successful ageing, working closely with Government agencies, NGOs and the community leaders.

We are also upgrading our nurses so that more can take on greater responsibilities and deliver more complex care as Advanced Practice Nurse (APNs). We are targeting 200 new APNs over the next five years.

Another important group of healthcare professionals are the Allied Health Professionals (AHPs). We have started regulating optometrists and opticians. Later this year, I will come back to Parliament with a Bill to regulate the other professions. For this year, we will target the registration of the physiotherapists, occupational therapists and speech therapists. Some 1,300 therapists will be involved.

Fifth, we are enhancing our mental health programme, a topic raised by several Members. We made this commitment in 2007 when we rolled out a National Mental Health Blueprint and we backed it up with $123 million budget. The strategy includes offering a range of treatment options from acute care at IMH to follow-up care in the community. We are making some headway. We now have many more Community Mental Health Teams to facilitate the early detection and treatment of mental health cases within the community. We have developed

However, as noted by Dr Lam and Mdm Halimah, the biggest obstacle to an enhanced mental health programme is stigma and unfounded prejudice. Mental illness makes people fearful. High profile crisis incidents lead people to think that the mentally ill are all dangerous and should all be locked away. The lack of public empathy for the mentally ill arises from misinformation and ignorance. With treatment and support, most mentally-ill patients can recover and can function in the community.

lifestyle, many remain well. But, yes, some will get sick.vision of "One Patient – One Medical Record".not have the knowledge and the contact of how to meet their needs. HNF is working with the TTSH team to ensure a smooth handover for patients newly discharged from the hospital. Once a patient is home, HNF will coordinate with other providers to meet the patient's care needs in the community. We will launch this new initiative within the next couple of months, targeting patients in the Central region.her resident. When it happens, it is a very sad situation. I will talk more about this later.the new KTPH, we are right now planning a community hospital. My project brief to the team is, let us raise the level, ie, create the next generation of community hospital. They are actively thinking about it.programmes for at-risk groups such as caregivers and out-of-school youths. We also have an employers-led alliance that promotes the importance of mental well-being at the workplace.

12.45 pm

Mdm Halimah Yacob, Mr Ong Ah Heng, Ms Indranee Rajah and Dr Amy Khor have asked about the follow-up care for discharged IMH patients and crisis support. I heard with concern Dr Amy Khor's account of a resident who committed suicide last month after discharge from IMH. I do not know the details of this case and whether there are systemic gaps which could have prevented this tragedy. We should try to minimise the suicide rate but, unfortunately, not all suicides are preventable. IMH carefully selects the patients to be discharged. They must have responded positively to treatment, have adequate family or social support and pose minimum danger to themselves or to others. IMH would then teach such patients and their families on the need to comply with medication and regular follow-up to avoid future relapse. Those with higher risk of relapse are followed up closely by their community mental health teams. IMH now runs a 24-hour hotline and provides advice and support to families and patients during periods of crisis. Our follow-up care is getting better but we know there are still gaps. MPs' comments earlier confirm this.

But for this strategy to work we need the support of the community, accommodation and job opportunities so that they can lead normal lives again. Hence, I fully agree with Dr Lam Pin Min, Dr Fatimah Lateef, Mdm Halimah Yacob and Mdm Cynthia Phua that working with employers, community partners and the grassroots is a must. IMH's "job club" has successfully placed more than 380 patients over the last two years with the help of enlightened employers. And I share Mdm Halimah's hope that more such enlightened employers would come forward to offer such job opportunities. IMH will certainly work with VWOs and the community to tap on their resources to help expand IMH's outreach to the discharged patients.

Dr Fatimah asked about the use of Medisave for schizophrenia and severe depression. Five months after implementation, it has benefited 500 patients who withdrew a total of $160,000 for their outpatient treatment.

Mr Chairman, healthcare is a complicated subject. It is also highly emotional and that is why it gets politicised very quickly. Just see what is happening now in Washington. The debate on the Obama health reforms – it is largely politicking. Health systems are, therefore, distorted in all countries, becoming dysfunctional

Second, there is no free healthcare. Every healthcare service is eventually paid for by the patient, either through taxes or reduced wages. Ultimately, patients and their families pay for the bills. Our job is to make sure that the cost of delivery is as low as possible, and this means cutting out abuses and other moral hazards.

Third, specialisation and sub-specialisation have brought about much medical advances and benefiting many acute patients. But as noted by Dr Fatimah Lateef, there is also such a thing as over sub-specialisation. For the elderly with several chronic illnesses, treatment by multiple sub-specialists is often not the best approach.

Fourth, despite medical advances, we are still mortals and we will die one day. Three weeks before Dr Chee Pui Hang passed away, I visited him in his house. We had a good chat for the last time. He had been frail but rejected all attempts by his attending doctors to get him hospitalised. He had the money and the medical network to get the most up-to-date sophisticated medical interventions, but he knew that they would be futile. The interventions might extend his biological life by a few days, or a few weeks, but he knew that the hospitalisation would, in fact, reduce his social interactions and quality time with his loved ones. He wanted every hour of his remaining life to be with his family and friends in the comfort of his home. This is a wise man.

Fifth, when cure is no longer available, care becomes the the most valued by

That was why it was so sad to hear Ms Indranee Rajah speaking about a case of abandonment of parents by one resident. Our hospital nurses have also begun to come across cases of children refusing to take back their parents after discharge. They demand that the parents be sent to a nursing home instead. The numbers are still small but we must not allow this to become a trend. I have told our hospitals to be firm with such irresponsible children.

Three years ago, I spent several days in Kenya's Masai Mara Game Reserve watching wild animals in their natural

Mr Chairman, our population is ageing and living longer. We have a good health care system but past solutions will not work as well for the future. That is why we have been quietly restructuring our

We are not alone. Every country is trying to figure out the best solutions. The efforts are not just happening in the public sector nor are they restricted to the healthcare sector. The industries are seeing an important role for themselves in tackling the ageing problem. In Japan, Toto – the largest toilet producer – makes a toilet that has arms supports to help the old get off the toilet more easily. They were the first to come up with the toilet seat with an integrated bidet. When I first saw it in Japan many years ago, I thought it was because of infection control reasons. They said no. They explained that using water to cleanse rather than paper reduces efforts for the seniors. Zojirushi, an appliance maker, has a kettle that sends a wireless message if granny does not use it by a certain time each morning. It is a clever, non-intrusive way for families to check that things are all right with their elderly. There are many such pockets of excellence and innovations all over the world.

In healthcare, I regularly remind my colleagues that we must challenge ourselves to match the best performer in each class. But the job is not mine alone. My Ministry can only provide a supportive environment. Successful living and successful ageing are personal choices. Dr Chee Pui Hang provided an example,

I am, therefore, adding a further $57 million for mental health initiatives on top of the $123 million already committed. This is a significant $180 million commitment to enhancing our mental health programme. Part of the new budget will be used to increase psychiatric nursing manpower, another will go towards setting up a long-term monitoring and risk assessment system. It will help identify and provide support for patients who default follow-up appointments or treatments, thereby reducing the number who relapse because they do not take their medication. when distortions become extreme. To reduce distortions, we have consciously tried to stick to the basics. And what are they? First, as stressed by Dr Lam, health outcome is largely a personal matter. Doctors and nurses can only point the way forward, the patient must play his part. This is especially so in the case of chronic illnesses. patients, and the highest form of care is underpinned by love and compassion. Last month, I visited the St Joseph's Home in Jurong and watched the saintly Sister Geraldine in action. And she has many wonderful stories to tell, all were inspiring. In her gentle, soft-spoken way, she leads a team of nurses, carers and volunteers, caring the patients with selfless dedication and love. I asked her, "do you have difficult patients or family members?" She said, "yes". She went on to relate one incident where the son of a patient demanded that the nurses should brush his mother's teeth within 15 minutes after every meal. He said that he loved his mother, and such a service level would be in line with the patient-centric mission of the Home and also a demonstration of love and compassion. Sister Geraldine gently but firmly reminded the man that a place in a nursing home is a gift, it is not a right. If every patient imposed such a demand, they will not be able to cope. She went on to add that the nursing staff – whether it is an employee or a volunteer or a Catholic nun and no matter how kind and compassionate – is not the son of the patient. The man got the message. The love of family members cannot be delegated away. habitat. It was the season for their annual long march as some two million wildebeests – a kind of antelope – migrate northwards from Serengeti National Park in Tanzania, in search of water and food. Along the way, many would perish as they got eaten up by crocodiles as they crossed rivers or hunted down by lions and cheetahs in the savannah plain. One late afternoon, we were positioned near the edge of Mara River as a group of wildebeests, numbering tens of thousands attempted a river crossing. There was much hesitation as they could see crocodiles waiting in the river. Almost ritualistically, a leader would eventually emerge, go into the river alone, test the water, and suddenly make a dash across the river. The rest would then rapidly follow in a mass stampede. I prayed for their safety but, inevitably, the weakest could not make it. Most made it and continued their journey northwards. Some, visibly old and frail, dared not even cross and were left behind on the south side of the river. Just as we gathered our cameras and videos to return to camp, we suddenly saw a small group of wildebeests, numbering about 30, which had already made a successful crossing, yet, surprisingly, backtracked. They had already crossed the river but backtracked to presumably rejoin their family members which had failed to make the crossing. Instead of moving on with the rest of the pack, they risked their lives in order to be with their loved ones. It was very moving and very touching. It was an instinctive expression of family bonds, love and sacrifice. I prayed for them even more deeply because the night will bring even more dangers as they were now in a smaller group. These were wild beasts but their behaviour that afternoon was not beastly at all. healthcare delivery system and gearing it up for our future with many more elderly patients. It is a quiet revolution, no fanfare, no sensational headline news. But if we do it well, our efforts will show positive results in 10 years' time. This I promise. I do not know if I will stay so long in the Ministry of Health, though. We have a lot to do. We need to work harder at keeping patients well in the community, avoiding unnecessary hospitalisation, achieving greater integration between hospitals and the community partners and helping patients achieve successful ageing at home. but there are many others. Prof. Chan Heng Leong, a former Head of Medicine in NUS, is another, a brilliant doctor, a dedicated academic and a good family man. He could have earned more in private sector but chose a public career to teach and to treat the poor. In retirement, he continued to contribute in the university and at the hospital. When his time was up, he refused further medical interventions and passed away peacefully at home surrounded by his loved ones.

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The last few days of these wise people are not mournful partings but quiet celebrations of having lived a fulfilling life. Friends and family members drop by to talk about the past and the good times together. Some, I suppose, even karaoke and probably sing Jin Daban - zuihou yi ye: hong deng jiang mie, jiu ye xing, ci ke gai kai xiang ta gao bie ( 金大班 - 最后一夜: “红灯将灭,酒也醒, 此刻该向它告别”). I do not think I need to translate because I am told that this is a very popular karaoke song amongst Members of Parliament. Indeed, Mr Chairman, everyone, rich or poor, will say goodbye one day. And we all want to end well. But to end well, we need to stay well and live a healthy and fulfilling life. We have different starting points but all can live well. Over the weekend, I was so happy to read about Jeremy Lim's achievements at his GCE 'A' level examinations. He was an NKF Ambassador when I first met him several years ago. He was born with a brittle bone disease and told me that even a severe cough could fracture his ribs. He is wheelchair bound but has never allowed the disability to hold him back. As he put it to Zaobao over the weekend, "We cannot determine what life will bring us, but we can determine our life journey". He added, "I cannot walk like other kids, but I can still do many things that other kids can". He told Straits Times this: "I

Life is really a series of successive moments. We cannot change the past moments and we do not know what the next moment will bring. But we can all seize the current moment and live it to the fullest helping others and touching their lives. How?

Lao-tzu's prescription is 2,500 years old but I think it remains relevant today: “上善若水, 水善利万物而不争”. This, I need to translate because it is in classical Chinese and Lao-tzu is not the easiest to fathom. He said: "Water nourishes all life, but itself does not gain anything." What he is trying to tell us is we should all live a life like water. We are here to help others, be kind to everyone else, not to help ourselves. This is a high ideal, but I think we all can strive to be as close as possible to that ideal.

focus on the things that I have, rather than the things that I don't."

Medisave for health screening

Mr Chairman, Sir, over the years, Medisave has been liberalised progressively for payment of medical-related insurances, outpatient treatments and investigations. An example would be the Chronic Diseases Management Programme (CDMP) where Medisave is allowed to be used for the cost of outpatient treatment up to a cap of $300 per Medisave Account per year.

However, we know that early detection and subsequent prompt treatment of diseases can improve the prognosis and outcome. I would like to urge the Minister to consider allowing the use of Medisave for health screening but still subject to similar restriction of capping the maximum withdrawal of $300 per account per year and strict guidelines on the types of screening allowable. This would prevent premature depletion and potential abuse of the Medisave savings of Singaporeans.

Health screening

With developments and research in the medical field, there is now an increased battery of tests available for health screening for a variety of conditions. Some Singaporeans have not been very proactive in coming forward for health screening. Perhaps, they are complacent or, rather, they are confused how to choose and proceed.

Can MOH invest more in educating the public pertaining to health screening? Can MOH also consider allowing Medisave to be used to fend off some cost of health screening? Liberalising too much will open a whole new Pandora's box and we risk having unnecessary tests added to the list. Will MOH be able to come up with a list of approved testing for screening for various groups with some degree of flexibility, of course, and consider allowing a small portion of Medisave to be utilised for this with a fixed cap or ceiling on an annual basis? This would be very much along the lines we have allowed Medisave to be used for part payment for chronic diseases.

Affordable long-term care

Sir, as many Members have pointed out, our healthcare system will come under increasing pressure from an ageing population and other chronic illnesses. Hence, we need to ensure that our system remains robust and affordable and will be affordable for long-term care. I would thus like the Minister to consider the following issues.

First, to provide integrated care so that patients can move easily from acute hospitals to community hospitals to nursing homes or their own homes depending on their needs. So co-location of facilities like the Khoo Teck Puat Hospital, promoting greater synergies amongst the different levels of care and greater sharing of information and records

It is also necessary to ensure that the different subsidy level between acute hospitals and community hospitals does not derail right siting as people would certainly prefer to stay where the subsidy is highest and the cost lowest. MOH should also make it easier for people to take care of their sick family members at home by strengthening home visits by doctors and other healthcare professionals and making these services cheaper as there are limited subsidies now.

The second area is financing of healthcare. The 3M system, together with the 3E system (Eldersave, ElderShield and Elderfund), provides a strong foundation for healthcare financing. I urge the Ministry to constantly review these schemes to ensure their adequacy. At the same time, there is a need to review other policies which have an impact on affordability.

Last year, I asked for more subsidies for some procedures carried out in the C or B2 wards such as the knee replacement surgery. I hope to get an update from the Ministry on the progress of this review.

The other area is the cost of medicine which can be very expensive for treatments such as cancer. The Minister had mentioned that instead of subsidising all expensive medicines, he would consider extending Medifund to middle-income Singaporeans who cannot afford the high cost of medicine. Can the Ministry give an update on this?

Third, in order to help families take care of those who are ill, there has to be stronger community-based care for the elderly or those suffering from severe illnesses such as mental illness. Our community-based care is weak which is the reason why most opt for institutional

amongst them would certainly provide better integration of care.care, thus crowding out our hospitals. I would like to urge for stronger community-based care and, in particular, more subsidies for home-based care.

Affordability of community hospitals

Sir, as the Minister and other Members of this House have noted, the healthcare system is being restructured to meet the challenges of a rapidly ageing population. A key focus would be to build up step-down care facilities to complement the public hospitals.

Acute care hospitals, like TTSH, are seeing a changing profile of patients. They are currently not equipped to handle older patients who are being admitted more frequently, have multiple problems and require longer hospitalisation. This has added to the pressure on hospital beds leading to the recent incident at TTSH where patients were put on movable trolley beds and placed temporarily at the hospital's corridors.

Integrating the whole spectrum of services from acute hospitals to home care would help to optimise scarce resources and remove strains on certain facilities, chief of which are the public hospitals. For this to be successful, we need a mindset change of both the healthcare providers as well as patients and their families. All things being equal, it is generally more expensive to stay in an acute care hospital than a community hospital. Nonetheless, anecdotal evidence on the ground suggests that there tends to be resistance to admission into community hospitals.

There is some public perception that community hospitals are poor cousins of acute hospitals, lacking the full range of medical equipment and specialists. It does not help that many community hospitals are run by charities or religious groups

REACH's Policies Study Work Group on Ageing and Health conducted a study of 800 Singaporeans aged 25 to 64 years and found that 44% of respondents held the misunderstanding that stroke patients can only be discharged from acute hospitals when the patient is completely well and not when the patient is stable and ready for rehabilitation services.

The survey also found that the decision to transfer the stroke patient to step-down care facilities such as community hospitals or day rehabilitation centres is strongly influenced by the out-of-pocket expenses required for these services. All things being equal, even though the total bill size for a stay at an acute hospital is more, the out-of-pocket expenses for the community hospital are generally higher than that for an acute hospital. This is due to the different means-testing systems employed as well as the lower allowable Medisave claims for community hospitals or no claims allowed for day rehabilitation centres and home care services.

I would thus like to ask the Minister to intensify its efforts to educate the public on the value and benefits of rehabilitation and correct the misperception that community hospitals are the poor cousins of acute hospitals. The Ministry should also review the quantum of Medisave that can be claimed for community hospitals and allow the use of Medisave for day rehabilitation centres. This will lead to greater optimisation of different healthcare facilities.

which do not have the financial muscle to match salaries at the public and private hospitals.

Mr Sin Boon Ann is not here. Ms Sylvia Lim.

Medisave for outpatient treatment

Sir, since 2006, Medisave can be used for outpatient treatment for chronic diseases such as hypertension up to a limit of $300 per year. However, it would seem that this has been under-utilised. According to the Ministry's reply to my Parliamentary Question last month, only 15% of chronic disease outpatients paid bills with Medisave in FY2008. Of those who did utilise Medisave for payment, only 30% of claims reached the annual limits on withdrawal of $300.

I recently met an elderly gentleman with hypertension who has Medisave balances but is unable to use them to pay outpatient bills. This is because of the current policy that the outpatient must pay the first $30 of any bill. He showed me that many of his polyclinic bills were below $30. According to MOH's data, the median size of polyclinic bills for chronic diseases is $36 with three months' medication. With the $30 deductible plus an additional 15% of the balance to be paid in cash, Medisave would not be usable or useful for many of such bills.

Sir, there are elderly sick who have little cash and savings. Yet, they are not allowed to draw their own Medisave money for medical treatment but are asked to get family support. This increases the elderly person's dependence on family members. The elderly gentleman I mentioned told me that he would sometimes default on his follow-ups due to finances. This could precipitate a worse inpatient condition which will deplete his Medisave even more rapidly.

The Government may be concerned about Medisave accounts being depleted but safeguards already exist via the annual $300 cap, the requirement to co-pay 15% and the administrative fee of $3.

50. Sir, the Government should consider removing the deductible. There is

anger amongst some elderly sick that even in their poor health condition, they have been denied the use of their own savings for healthcare.

Adequacy of Medisave

Sir, Medisave is one of the biggest pillars of our healthcare system. However, with increasing medical cost, there will be tremendous strains on our Medisave. I would like to ask the Minister the following questions on adequacy.

First, has the Ministry done any projections to assess how much Singaporeans would need to save in their Medisave in order to meet their long-term care needs, say, over a 10- or 20-year timeframe? Second, could the Ministry give an assessment on whether our Medisave at the current level of monthly contribution rate is sufficient to meet our future needs and whether there are any plans to increase the level of monthly contributions? If so, what would be the impact of such a change on other CPF needs of the account holder? Finally, has the Ministry considered whether there is a need to review the Minimum Required Amount (MRA) which was set some years ago to ensure the adequacy of our Medisave?

Earlier, Dr Lam referred to a recent positive commentary on our healthcare system by the Washington Post. It described Singapore as "the only rich nation that boasts universal coverage with health outcomes better than ours [meaning the United States] while spending one-fifth as much per person on health care".

Our system is not perfect. Indeed, we still have many problems to iron out, including the current shortage of hospital beds on certain days. But it is among the most cost-effective in the world, delivering a high clinical standard without

Over the years, many have come to study us. My most recent visitor was a delegation from Armenia, formerly in the communist bloc. Armenia, as Members may know, is a small landlocked country but with talented people. We used to have an Armenian community here in Singapore. They told me that there are still about 100 of them living here. There is an Armenian Church and, of course, our world famous Raffles Hotel was set up by three Armenian brothers a century ago. The delegates who came to study us were serious and bright. They asked critical questions. But for most of the last century, they were bogged down by the communist system of central planning. Twenty years after the fall of the Berlin Wall, they are at a cross-road. They know that their current system of free healthcare and centralised delivery is not sustainable. They read about us and its Health Minister led a team here to probe. I shared with them abundantly, and my parting comment was that health reforms would take decades. And even then, it would always be work-in-progress. Earlier, we discussed our healthcare delivery system. This afternoon, I will discuss how our financing model can be improved further.

inflicting too much financial hardship on patients or taxpayers.

1.15 pm

In the new financial year, our budget to subsidise patients will increase by 10% to $2.2 billion. I am grateful to the Finance Minister for his support. In fact, the increase is more as the Finance Ministry has also topped up Medisave accounts, Medifund and Eldercare Fund by $710 million. These top-ups are, in fact, subsidies as they help Singaporeans pay for their future healthcare needs.

Such Government subsidy for healthcare is the first layer of protection for Singaporeans, which ensures universal access to basic healthcare by all.

After Government subsidies, Medisave forms the second layer of protection. As Mdm Halimah put it, it is a key pillar of our healthcare system. Medisave turns 26 this year. Collectively, we now have more than $45 billion in Medisave. At the individual account level, all salaried employees have healthy Medisave balances for themselves and their dependents. There are many statistics to prove this point, but let me just highlight one. By age 50, the average Medisave balance of all salaried employees would have exceeded $27,000. This is good for 18 hospital admissions if he chooses Class C. And even if he chooses Class A, it can cover six hospital admissions. This assumes he has no insurance coverage. But 90% of all Singaporeans have MediShield coverage, which would reduce the patient's share of the bill substantially. For these Singaporeans, their Medisave balances can cover even more hospital admissions. This is a remarkable achievement. Medisave is one main reason why sophisticated but costly healthcare services are within the reach of all Singaporeans, including the lower-income group. In the current health reforms debate in Washington, serious economists are all advocating what they call "HSA" (health savings account) as a necessary solution for the American healthcare system. Medisave is a HSA – a health savings account; we pioneered it long before economists developed this insight and coined this term.

Recently there was some public discussion on the use of Medisave for health screening. I think Dr Lam Pin Min and Dr Fatimah Lateef have suggested

Because the 3Ms label does not include this item, Government subsidy is often taken for granted. I have been trying to see how we can slip in the "S" (for subsidy) into the 3Ms. But in the end, I still end up with just 3Ms. I suppose the small "s" in the 3Ms could be "subsidy", but in real life our subsidy actually is a big "S" and not a small "s" at all. It is our huge Government subsidy which differentiates our healthcare funding model from that in the US, Japan and many European countries, where hospitals and clinics would charge all their patients at full cost without subsidy. In Singapore, 80% of the patients in our hospitals choose Class B2 or C wards. In these wards, the bulk of the cost is picked up by the Government. For example, a Class C patient going for a hip replacement surgery, which is a major surgery, would cost the hospital, on average, $17,500. Eighty per cent of the cost, or $14,000, is paid by my Ministry through our annual subvention to the hospital. The patient co-pays the remaining 20% or $3,500, which are largely covered by MediShield and his Medisave savings. Mdm Halimah spoke about knee replacement surgery, which she raised last year. We have fixed the problem by revising the claim limits. On average, the cost of treating such a patient in Class C now is about $16,000. My Ministry subsidises about $11,500 with the patient co-paying the remaining $4,500. With Medisave and MediShield, many do not have to pay anything out of pocket, unless they insist on some costly fanciful implants. This is our approach to subsidising care. As medical advances and hospital operating costs go up, we increase our subvention to the hospitals so that patients remain subsidised in accordance with the prescribed subsidy policy. We actually miss the target sometimes. For example, Class B2 subsidy is 65%, with patients co-paying 35% of cost. But, in reality, B2 patients today co-pay 30%, which is five percentage points below target. We will have to close the gap eventually, but let me assure Members that it will be gradual and will not inflict unnecessary hardship on our patients. The idea came from Minister Mentor Lee. Dr Goh Keng Swee sketched out a rough outline. Senior Minister Goh fleshed out the details, persuaded Singaporeans to accept this idea and got it successfully implemented. We have all three to thank for this innovation, which has now become an integral part of Singaporean life. Mdm Halimah asked about the existing Medisave contribution rates. This is tied in with the overall CPF contribution rate and is a factor in employment cost and overall competitiveness. I have no grave concern on the adequacy of the existing Medisave contribution rate. But I must add one caveat on the self-employed who form 12% of CPF members. Many are careful and contribute regularly to their Medisave. They too have an average Medisave balance close to the salaried employees of similar income band. My worry is the 140,000 self-employed members who have an average Medisave balance below $10,000, some just a mere few thousand dollars. Out of this group, only 40% had made some contribution to their Medisave last year. Even then, it is usually just nominally. They would get into problems if they or their dependants fall sick. And it would be worse if they also do not subscribe to MediShield and ElderShield. We must all help to get them into Medisave, MediShield and ElderShield, so that they can enjoy the same protection as the salaried employees. Mdm Halimah asked about the adequacy of the Medisave Minimum Sum. She asked if it is adequate to meet the needs of an ageing population. The current Medisave Minimum Sum is at $32,000 and is not bad for those opting for Class B2 or Class C wards and have MediShield and ElderShield coverage. We will continue to adjust it annually to take into account medical inflation, so as to preserve the purchasing power of the account holders. My concern is that currently, most are not able to achieve the Medisave Minimum Sum by the time they reach 55. The top 40% of income earners are all right, but not those in the lower-income group. That is why we have to be careful in not over-liberalising the use of Medisave for other purposes, which it was not originally designed for. I have the unpleasant task of being the gatekeeper to Medisave. I heard Ms Sylvia Lim. Yes, Medisave is your own money, but if it runs out prematurely, the member will be in trouble. And I am trying to prevent such an outcome. That is why we have stringent Medisave withdrawal rules and limits. This will help to balance current consumption against future needs and ensure that Singaporeans have enough Medisave to look after their medical needs during retirement. Ms Sylvia Lim spoke about the Chronic Disease Management Programme (CDMP) and the deductible of $30 that we put in. She made a couple of observations: one, that the utilisation rate of this scheme seems below expectation, less than 15% of chronically ill have made use of this scheme. It is not a surprise to me because when we estimate the total number of chronically ill, it is based on the disease incidence. Like in all population, probably half of those with chronic illness do not even know they have the disease. And that is why we must step up mass screening. And even among those half who knew they have a chronic disease, not all come forward. Many studies have shown, and again also observed in Singapore, that only half of those who knew they have chronic disease will come forward to see a doctor. And among those who come forward to see a doctor, not all comply; they may decide that changing lifestyle is too troublesome; taking medication is too troublesome, or for whatever reasons. So, when 15% of potential users of this scheme come forward, I thought it was not bad. At first, I thought we cannot even cross 10%. But, yes, we should now aim higher and try to get more people to make use of this scheme. I have spoken to some who are on regular chronic disease management but not using the Medisave. I asked them, they said "why should I", and they gave a couple of reasons. One, some of them are paid for by their employers, so there is no need for them to use their own Medisave. Secondly, some are quite smart, they said that Medisave pays interest rate – I do not know what it is now – 4%-5%. They have enough cash, and they say they will pay cash, which in the bank you cannot even collect 0.5% interest rate today. So, there are all sorts of reasons why we ended up with only 15% utilisation. I do not think we should be discouraged by this figure. The deductible is a problem that can be easily overcome, and I have spoken to GPs and our own polyclinics. And one way they do it – which is quite legitimate and in fact advisable – is they package it up. So, yes, each visit may be only about $30 or $40, as noted by Ms Sylvia Lim. But these are chronic disease management programme, we expect the patients to come forward three or four times a year depending on the risk profile. And, in fact, we want the patients to come forward. We would be very worried if they only come once and disappear. Then compliance would be a problem and their diabetes or high blood pressure will not be managed well. So, many clinics have now offered what is called package deal. They charge per year or even per two years and the whole sum, let us say, $250, will attract the same deductible of $30. The rest can be deducted from their Medisave. So, this is one way to overcome this deductible issue but, more importantly, it secures compliance by the patients.that we consider expanding Medisave for health screening, subject to certain limits and guidelines. I am sympathetic to the call as I believe in prevention. Regular screening and early detection followed by medical intervention and lifestyle changes can avoid future complications and costly medical treatment down the road. There is a case for allowing some Medisave withdrawals for health screening. The question is what kind of health screening? There is a wide range of health screening tests; not all are fully justified or necessary. More screening is not necessarily better. Some accrue benefits more to the provider than the consumer. We must be mindful of such pitfalls. As Dr Fatimah put it, we may be opening a Pandora's Box. A mindless liberalisation of Medisave for health screening may not improve health outcomes, but instead prematurely deplete Medisave balances.

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Let me give one example of health screening which is being promoted in the West: genetic screening to predict the risk of a person getting a particular disease later in life. These are sophisticated tests and, of course, very expensive. The clinics love it because it improves their topline and bottomline. Last month, the Journal of the American Medical Association published a timely research finding on the effectiveness of the current gene markers to help doctors predict which women would develop heart disease. The study found that we still do not yet know enough about genetics for health risk prediction. The article concluded that "instead cholesterol levels, blood pressure and family history remain the better indicators for determining who is at risk for having a heart attack, stroke or dying from heart disease". At the moment, the traditional screening methods are still more reliable and very much cheaper. But they are less

Genetic testing is one example. But there are many other sophisticated screening tests which are also being promoted. All are expensive. The benefits or cost-effectiveness of such tests are often dubious. I call this unethical screening. Health screening is therefore a complex issue and the risks associated with unethical screening are real. We must not fall into the trap of such commercial practices.

As a first step, my Ministry will set up an expert group to review the range of healthcare screening available here and recommend a framework to determine what constitutes appropriate health screening. We will then be in a better position to advise Singaporeans, as suggested by Dr Fatimah, so that they do not get fleeced. She did not use those words, I do. Prof. Lee Hin Peng will chair this expert group. He is a senior public health specialist and has a special interest in cancer screening and prevention. We propose to put this group under the auspices of the Academy of Medicine.

Separately, we will study the financial implications of health screening so that should we decide to open up Medisave for it, we will know how to prescribe the necessary withdrawal limits. This was the approach we took when we opened up Medisave for outpatient chronic disease management. It is a prudent approach to exploit the benefits of Medisave liberalisation, while minimising the downside risks

Another area of Medisave usage is in the intermediate and long-term care (ILTC) sector. Several Members have commented on the need for rational Medisave withdrawal rules to encourage right-siting of patients in the community. And I agree. Today, Medisave can be withdrawn for community hospitals, subject to a daily withdrawal limit of $150, up to an annual cap of $3,500. This is largely adequate for patients undergoing rehabilitation. However, we are stepping up the capabilities of the community hospital so that they can also serve sub-acute patients, for example, those with hip fractures, and elderly with kidney and urinary tract infections. Traditionally, such patients are kept in acute hospitals where their Medisave withdrawal limits are higher, at $450 per day. But it makes sense for the patients to be transferred to a community hospital where the total cost is lower. However, current withdrawal limits may deter such patients from moving to community hospitals because of higher out-of-pocket payments, as Dr Amy Khor pointed out.

To fix this anomaly, we will do two things. First, we will subvent the community hospitals which partner the acute hospitals to provide sub-acute care, more. The daily norm cost for such cases will increase from $271 to $400 per day. So this is quite substantial. Second, we will (a) raise the daily Medisave withdrawal limit for community hospitals from $150 to $250, and (b) raise the annual Medisave withdrawal limit from $3,500 to $5,000. Together with the enhanced nine-tier subsidy framework for community hospitals implemented last year, these adjustments should make it cheaper for sub-acute patients to move from an acute hospital to a community

Medisave can also be used to pay for day rehabilitation services, subject to a daily limit of $20. We will also be raising this limit from $20 to $25.

We are working with the providers to raise the clinical standard of community-based rehabilitation care. We will involve more skilled therapists in the delivery of care and establish individual care plans and improved outcome monitoring to help ensure patients receive the care they need. With better treatment, costs will, however, go up and that is why the increase in Medisave withdrawal limit should benefit the patients.

These changes to Medisave withdrawal limits will be implemented in June, in a couple of months' time.

After Government subsidies and Medisave, health insurance in the form of MediShield, ElderShield and their private supplements, form the third layer of protection. The value of health insurance and the benefits of risk-pooling are well established. Practically all countries have incorporated insurance into their healthcare systems. The Germans under Chancellor Bismarck introduced this innovation a century ago. But we are again unique by insisting on "deductibles and co-payment" in our health insurance framework. We reject comprehensive health insurance based on "first dollar coverage". Many other countries adopt comprehensive health insurance and are now bogged down by abuses, over-consumption, over-servicing and wastages. They are all trying to reform their insurance policies, eg, in the US, by introducing "deductibles and co-payment" but find it politically challenging. Former Health Minister Yeo Cheow Tong incorporated this important feature into

Even the Germans who pioneered health insurance are now trying to reform their national health insurance system as abuses are causing massive deficits. Employers have been shouldering the rising premiums but this has affected their business competitiveness. They are saying "enough is enough" and are demanding that employees should shoulder future premium increases. Last week, an article in a German business weekly, Focus Magazine, discussed this issue. The article was titled "Saving Money With Singapore" and this is an English translation of their German title. I am sure it is more elegant in German. Its sub-headline read: "The Government is looking at an Asian health regime as a model for the reform of the statutory health insurance system". The article said that they "are looking into one health system in particular – that of Singapore". I do not know if our 3Ms is implementable in Germany as our politics are different, but clearly we must be doing something right.

MediShield and ElderShield are not compulsory but, through an opt-out approach, we have achieved good coverage. MediShield coverage has exceeded 93% for all working adults, and the ElderShield per-cohort coverage is about 90%. As noted by Dr Lily Neo, there is room for further expansion, but the current picture is not bad.

I have done several enhancements to MediShield and there is scope to do more, for example, to extend it to cover mental illness and congenital illnesses, when the economic condition is conducive. Mdm Halimah and Ms Denise Phua raised these two ideas several times. I have not forgotten them.

I have also enhanced ElderShield, but I think further enhancement is necessary.

In response to Dr Lily Neo, we are looking to further enhance the basic ElderShield by raising its payout to, say, $800 per month. But this will require some premium adjustment. I am trying to see how we can avoid this and I am studying the alternative of maybe bringing forward the entry age from 40 to, say, 35 or 30, which should mean lower premium adjustments. Effectively, this will allow Singaporeans to spread out their larger premium payments over a longer period of their working life, instead of the current 25 years, in return for higher payouts should they become severely disabled.

The final layer of protection is Medifund. This is the ultimate safety net to catch anyone who falls through the top three layers. We have been building it up since its launch in 1993. With the proposed top up of $200 million, it will reach $2 billion.

Medifund is again unique in Singapore. We consciously set aside budget surpluses during good time, so that our ability to help the vulnerable during bad times is not diminished by the adverse economic climate.

Last year, when we anticipated more patients asking for financial help, we increased the Medifund disbursement to $75 million. It was helpful. While the economy this year should be better, I will nevertheless further raise this year's Medifund budget allocation to institutions

Separately, I have been thinking about how to help lower-income Singaporeans cope with expensive drugs, over and above our current subsidy policy. Last month, I disbursed an additional $8.5 million to Medifund Committees to enable them to help more patients, especially those requiring HIV medications. This year, I will inject a further $10 million from Ministry of Health’s operating budget to help deserving patients cope with seven high cost medications used for diseases such as breast cancer, colorectal cancer, ovarian cancer, COPD and asthma. This should be helpful to many patients suffering from these diseases. We will leverage on the Medifund mechanism to help disburse this additional financial assistance to deserving patients. This includes means-testing and some co-payment by patients as the hospitals deem fit. If the idea proves useful, we can increase the budget allocation to this new Medication Assistance Fund (MAF).

Mr Chairman, our multi-layered protection framework, code-named 3Ms, builds upon and enriches our Government subsidy framework which we inherited from the British. It allows us to combine the best of the British taxation model with the best of the market-based American insurance model. It is not perfect but it has served us quite well. I fully agree with Dr Lily Neo that "we need to continually tweak it so as to cater to the growing needs and expectations of our people". With the support of Members, I will continue to do my best to ensure that all Singaporeans can afford basic healthcare. This is my pledge.

glamorous and bring in less revenue for the clinics. I am sure genetic forecasting will become more useful in future, as their scientific promises are fascinating. But meanwhile, the results are still disappointing. As one International Herald Tribune (IHT) article put it: "If you want to learn your odds of getting different diseases, consult your family history. Or visit a fortune teller. For most traits, genetic testing is little better than consulting the tea leaves."of over-servicing and over-consumption. Meanwhile, I have noted the various suggestions by Members and I will try to incorporate them in due course. hospital. I thank Dr Amy Khor for this suggestion.our health insurance policies and we were wise to have avoided these pitfalls.ElderShield now pays out $400 per month for up to six years. This is just about sufficient for the lower-income group who can qualify for heavy subsidy in nursing homes, but it will not be enough for the higher-income group. They should top up their basic ElderShield with ElderShield supplements. Some do. About 14% of ElderShield policyholders subscribe to ElderShield supplements. It will be a better picture, if another 30% or 40% also join in.to $80 million. This will be funded, as usual, using the interest earned by the endowment fund.

Special needs medical screening

Mr Chairman, children with special needs have an array of different diagnoses – from learning disabilities like dyslexia to profound

Early detection of children with special needs will allow early intervention, leading to better outcome for these children. Currently, there is a lack of awareness amongst parents about these conditions and also a severe shortage of medical screening services for these children. This is aggravated by a shortage of professionals to provide such services.

Does the Ministry have plans to raise awareness of these conditions amongst the public and also to grow this sector to cater to the increasing demand in Singapore?

mental developmental delay; behavioural issues like autism, attention deficit hyperactivity disorder (ADHD) to psychiatric problems.

Health promotion and a healthy nation

Health promotion, as defined by the World Health Organization 2005 Bangkok Charter for Health Promotion in a Globalised World, refers to the process of enabling people to increase control over their health and its determinants, thereby improving their health. The Health Promotion Board has been spearheading health promotion in Singapore.

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Looking at our statistics of chronic and lifestyle diseases, we need a more concerted effort. Thus, increase awareness and education, more proactive health screening, reinforcement at workplaces; where most of our working adults are, and even in institutions of higher learning and schools. Besides the physical, psychological wellness must also be given a greater thrust. Will there be more funds allocated towards this? Are we increasingly investing in innovation towards enhancing health promotion and

will we see more proactive collaborations between MOH and Health Promotion Board with relevant agencies such as MOM for workers' health, MOE for students' health, as we strive towards the goal of more healthy nation?

Workplace health promotion

Sir, with the drive towards longer employment and implementation of the Re-employment Act that will come into effect soon, there is a greater need to keep the workforce healthy. After all, the three key elements in supporting a longer term of employment are; having the skills, having the willingness to work and, more importantly, being physically and mentally fit to work. Employers need to support this drive to help Singaporeans to work as long as they wish.

The tripartite at workplace health promotion helps to improve the health and fitness of workers and to create a healthy working environment by promoting healthy lifestyle for a better life has made a good progress. The programme includes a basic health screening followed by way of empowering Singaporean workers to take personal responsibility for their health. In short, raise their awareness and help them create the drive to take actions to CHEERS – Cease smoking, Healthy Eating, Exercise Regularly and manage Stress.

Offering attractive salaries alone is often not enough to keep staff productive and loyal. It is important for us in making our economy at workforce more future-ready and more competitive. We must strengthen such a holistic workplace health programme for our workers in all workplaces to achieve both physical and mental well-being. I would like to urge the Ministry of Health (MOH) to provide more resources and budget to further support the workplace health promotion to achieve HEALTH – Health and everyone

Apart from physical health, MOH should also provide more support in the area of emotional health. This is an area not to be forgotten of as many seems to regard the workplace as a major source of stress. Workers who have problems dealing with stress arising from personal or work related reasons may inadvertently affect their employees around them as well as their own work productivity; thus affecting the morale of the company.

achieves lifetime health. I hope MOH could give more financial incentives for companies to provide regular basic health screening at work. Health screening is an important means of praising workers' awareness of their own health status and health profile. The basic health screening will also provide the companies with a reference to tailor their health promotion and integration programme so as to help their workers maintain their health and manage their lifestyle habits and reduce all the risks for chronic illnesses.

Workplace health

(In Mandarin ) : [For vernacular speech, please refer to Appendix A*.] Sir, the Health Promotion Board has correctly identified that the workplace is an ideal place to promote health issues. It is estimated that about 65% of our population aged 15 and above are in the workforce. Many of us now spend more time at the workplace than at home.

While basic healthcare coverage is being provided by the majority of companies, there is a disparity in medical benefits provided by large corporations and SMEs. Currently, there are 130,000 SMEs in Singapore. I was told that some small companies do not reimburse their staff if they fall sick and their only entitlement is medical leave with no pay cut.

First, I would like to ask the Health Minister how the Government can

encourage SMEs to provide better medical benefits to their workers. Second, how can the Health Ministry collaborate with the Ministry of Manpower to ensure that more workers will get good healthcare coverage at their workplace? *Cols. 3687-3688.

Banning trans fat

Sir, many cities such as Boston, New York and Philadelphia have banned trans fat, a food ingredient commonly found in french fries, donuts and other fried foods. Trans fat has been linked to heart disease in humans and diabetes in experimental animals. In Singapore, three in 10 Singaporeans have exceeded WHO's recommended daily limit. Will the Ministry of Health (MOH) consider banning this or increasing public education in the harmful effects of trans fat or consider mandatory labeling; similar to what NTUC FairPrice did with the household products?

Sir, this suggestion is not new. Back in December 2006, the Health Promotion Board (HPB announced that it would not ban the use of trans fats in food products. At the time, it gave a long list of reasons mainly based on consumer choice and practical implementations, for example, we consume less fat than Americans. The HPB is hesitant to pass legislation on trans fat as this would result in trade barriers, especially since many food products found here are imported from various countries. About 70% of packaged food products currently do not carry trans fat labelling and will be affected. This would limit the choice of food Singaporeans have. Legislation limiting trans fat to 5% of a product's total fat content would affect 30% of packaged food here.

Since then, HPB in 2007 announced it would allow food products with little or no trans fat to be labelled accordingly, but it had said "no" to Mdm Halimah Yacob's

This was in view of the local studies conducted, which showed that 30% of adults here, particularly those aged 18 to 39, exceeded WHO's recommended daily limit. After three years of deliberation, is it time for us to introduce mandatory or compulsory labelling of trans fat content in food? At the same time, we should keep in mind the possibility of banning such food in the near future.

Sir, while I agree that diet is a matter of personal choice and that we need to take into account practical considerations such as trade barriers, product labelling, and so on, we need also to weigh in such issues as general public health issues and its expenditures and informing the public. Therefore, prevent is better than cure.

Sir, can the Government at least for the moment support initiatives such as labelling efforts by giving local food companies and supermarkets a grant to do so and to increase funding in public education in this area?

suggestion to move towards compulsory labelling and in the same year, NTUC FairPrice then took up the call to voluntarily declare trans fat content on its household products. Last year, 2009, in response to Ms Ellen Lee's query on educating the population on the effects of trans fat, the Ministry said that HPB will step up public education on the harms of excessive consumption of trans fat, and work closely with AVA to review trans fat in food supply.

Myopia

Chairman, Sir, I understand that myopia is the leading eye disease in Singapore. We have among the highest cases of myopia in the world. There is a growing concern that blindness from myopia would become a substantial public health problem in the

It is observed that increasing myopia is related to the heavy amount of reading and near-work that the children are exposed to in school and at home. Such activities are definitely on the rise with advent of the Internet. I would like to know what new initiatives the Ministry of Health (MOH) has embarked on to prevent the onset of myopia on the younger generation and what is the outcome of the vision care programme?

Although laser surgery has been performed to correct myopia in adults in Singapore since 1992, the results have generally been very good. However, SNEC does not believe that it is safe and advisable for children to undergo this surgery currently.

Intense medical research in recent years has led to new discovery on treatment of various diseases. I would like to know whether the National Medical Research Council has committed funds for research related to myopia and if so, whether there is any discovery of new effective treatment or clinically proven method of preventing the onset of myopia.

near future. It was projected that more than 80% of the entire adult population could be myopic within two to three decades. I would like the Minister to share his view on the problem and whether it is indeed a public health concern.

Assessment of special needs of children

Sir, I understand that at KK Women's and Children's Hospital (KKH), it takes about three months for a child to get an appointment for diagnosis of whether or not he has learning disabilities. Waiting times for therapy sessions are even longer. As a mother of a son with dyslexia and Attention Deficit Hyperactive Disorder (ADHD), I can empathise with the anxiety

My son had great difficulties coping with his studies and school life when he was in primary four. On the advice of his form teacher, we brought him for an assessment at the Child Guidance Clinic where he was assessed to have dyslexia and ADHD. This was 10 years ago.

We were then told that if we wanted to enrol him in a Government-supported intervention programme, we would have to wait for months as there was a long queue. Fortunately, we were able to place him in a private centre. Once he was correctly diagnosed and put on an appropriate intervention programme, his condition improved tremendously and he was able to cope with his learning disability. From doing badly in his subjects at Primary Four, he was subsequently able to do relatively well at PSLE. He is a much happier and motivated boy now.

Over the years, the services for special needs children have increased and improved significantly. But there are still remaining gaps that need to be closed. One example is the long queue for medical assessment at KKH. I understand that there is also a shortage of trained manpower such as therapists. This constraint is felt most starkly in the early intervention services. As parents become more enlightened, the demand for such medical assessment would increase.

I would like to ask the Minister if more resources could be deployed to shorten the waiting times for early diagnosis and also intervention programmes.

of parents who desire to send their children for early diagnosis.

Children with special needs

(In Mandarin): [For vernacular speech, please refer to Appendix A*.] Sir, the medical and dental needs of children with disabilities are onerous and deserve our attention. It is

Until recently, parents of children with special needs are at a loss when it comes to dealing with their children's many requirements. The situation is made worse when parents have to cope with heavy medical expenses on their own.

It is the right move for our Government to step in to help the parents by allowing them to use MediShield. I would like to ask the Health Minister two questions. Firstly, what is the current status of MediShield insurance for children with special needs? Secondly, what else can be done to ensure that basic healthcare is available to these children, for instance, are they provided with basic dental care?

difficult to carry out medical procedures on these children. As a result, it places a lot of stress on the child, their parents and medical staff. For example, how do you prevent an autistic child from acting violently when an x-ray examination is being conducted or an injection is being administered? *Cols. 3689-3690.

Traditional Chinese Medicine

(In Mandarin) : [For vernacular speech, please refer to Appendix A *.] With the development of Traditional Chinese Medicine (TCM) particularly in China over the past few decades, and increasing interest in complementary medicine the world over, public interest in TCM has also risen in Singapore. Many of our elderly as well as the young are seeking help from TCM. TCM practice in Singapore is primarily confined to outpatient care. The Traditional Chinese Medicine Practitioners Act was passed on 14th November 2000. Besides registering TCM practitioners, the TCM practitioners Board also accredits TCM schools and courses, and regulates the professional conduct and ethics of registered TCM practitioners.

From my knowledge of TCM, it does not use static anatomy as a starting point for understanding the diseases and does not rely on detection equipments. However, TCM relies upon inspection, listening and smelling, inquiry and pulse-taking to directly observe the dynamic human life function. It is also based on syndrome differentiation to guide the disease treatment. This method can save a lot of examination cost for patients. Western medicine has absolute advantages in medical fields such as surgery, diagnosis of organic diseases, first aid, prevention of spreading of epidemic conditions, and life-sustaining devices where modern science and technology is used. However, Chinese medicine excels in treating chronic inflammation, functional disorders, endocrine disorders, degenerative diseases, senile diseases, general clinical syndromes, sub-health state of the human body, and complex health problem.

In view of the increasing use and recognition of TCM as an alternative medicine, I urge the Government to provide assistance in monetary/non-monetary terms to raise the quality and standard of TCM practitioners and TCM administration so that TCM can indeed be more acceptable and "recognisable" as another source of help for patients.

The registration of TCM practitioners started in 2001 with the registration of acupuncturists. With effect from 1st January 2004, those who wish to practise TCM are required to register with the TCM Practitioners Board and possess valid practising certificates. Our restructured and private hospitals have also set up TCM units/departments in view of the rising demand and awareness of the positive effects of TCM. *Cols. 3691-3692.

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I thank Members for speaking on, among other issues, special needs and health promotion. Speaking of health promotion last month, two UK researchers revealed preliminary findings suggesting that it was possible to be bored to death. Before Members get worried about their own health since all of us get bored from time to time, let me qualify that statement. What the study found was that people who regularly feel bored are more prone to becoming unhappy and unmotivated. This, in turn, can lead them to adopt unhealthy habits, such as smoking, taking drugs or drinking, which increase their chances of dying from conditions such as stroke and heart diseases.

Most Singaporeans I know have the opposite problem – they are so busy they hardly have time to feel bored! We are a time-starved people. We work deadlines, manage family commitments, and run countless errands. Small wonder that we often hear people grumble, "I wish I had more time for the things that matter in life."

Good health is one such thing that matters to all age groups, as Dr Fatimah Lateef has rightly pointed out. The Ministry of Health (MOH) invests heavily in health promotion precisely because it is the crucial first step to good health. It is much better to keep healthy rather than seek treatment when conditions develop. This is why our preventive healthcare budget has increased by 67% over the past decade to $112 million in FY2010. Our aim is to help Singaporeans of all ages – children, adolescents, adults and the elderly – to have the means and ability to lead healthier lifestyles. We want to nip chronic health problems in the bud and reduce the disease burden on our ageing population. I think many Members have alluded to the silver tsunami that is

Unfortunately, when we need to prioritise our time, a healthy lifestyle is often the first to go. Many Singaporeans, stressed from work, often do not eat healthily or exercise regularly. Worse still, they succumb to high-risk habits, such as smoking or heavy drinking, mistakenly viewing all these as a pressure-reliever or a lifestyle choice. They do not realise or may even ignore the fact that it could cause them greater pressure, both financially and emotionally, when health conditions develop down the road.

This is why there is a strong case for healthy lifestyles to be advocated at the workplace. The outreach strategy is sound as two out of three Singaporeans aged 15 years and above are working. I spoke briefly about workplace health in last year’s Budget, and I will spend more time outlining our plans for workplace health promotion this year.

The business case for improving workplace health is simple. Healthier workers mean less absenteeism and lower medical costs for the company. This is the first step to boosting productivity and the bottomlines. Healthy, active employees are also good "walking advertisements" for a company’s work ethos and culture, which helps them in talent recruitment and retention. Healthy and alert employees also contribute to a safer work environment. Indeed, more local companies are recognising the value of good workplace health programmes and have taken steps to implement these.

NatSteel is a good example. I visited NatSteel last month and was impressed by the fruits of their employees' wellness programme. They have wisely banned the sale of cigarettes within their premises

One employee’s effort in keeping himself healthy left a lasting impression on me. Mr Arumugam Kerisnasamy, a security guard, has a family history of chronic diseases. Determined to keep these diseases at bay, he put himself through the Health Promotion Board's "Lose to Win Challenge" and NatSteel’s own "Weight Optimisation Challenge" late last year, losing about eight kilogrammes over a four-month period. Mr Arumugam continues to exercise and watch his diet. He now weighs 96 kilogrammes – about 11 kilogrammes less than when he first started the programme. His fitness level has also improved considerably. During my visit, he shared how grateful he was to NatSteel for their support and encouragement in his weight loss journey. He also told me that he was driven by the strong desire to take charge of his own health so that he can better his work performance and also provide for his loved ones. I think we all have much to learn from Mr Arumugam.

Let me talk about support for Small and Medium Enterprises (SMEs), something which some Members have spoken on. Some SMEs may want to roll out similar measures like NatSteel, but

Today, several industrial and commercial landlords, such as Ascendas Services, CapitaLand Commercial, JTC Corporation, HDB and Mapletree Investments, participate in HPB’s WHP@SMEs’ Doorstep programme. A simple but popular programme, it conducts health screening and health programmes for SME employees at the doorstep of industrial parks and commercial buildings where the SMEs are located. This is how HPB brings the programme to the doorstep of the companies. It has been well received and we intend to roll this out to more locations over time.

I agree with Mr Ong Ah Heng and Mr Yeo Guat Kwang that more can be done. The National Tripartite Committee on Workplace Health, co-chaired by Mr Lucas Chow and Mr Yeo himself, has recommended to MOH a slew of measures to better support our SMEs in workplace health promotion. Let me mention a few that we have implemented or are considering in the coming year.

To help SMEs who face budgetary constraints in starting workplace health programmes, the TriComm and HPB have introduced an enhanced SME Grant since May 2009. The grant now funds up to 90% of the cost of such programmes, capped at $10,000 per application. HPB also recently relaxed the grant guidelines to allow funding for off-site health programmes, such as basic health screening at CDMP-GP clinics and chronic disease intervention programmes. HPB has committed up to $180,000 to 22 SMEs under this enhanced scheme. I encourage more SMEs to sign up for the scheme.

Money alone cannot fully address the situation. SMEs often lack dedicated manpower and protected time to implement workplace health programmes well. To help them, HPB will introduce a workplace health package this month where pre-selected vendors will deliver the packaged health screening and interventions, covering four key areas of healthy lifestyle – physical activity, healthy eating, mental well-being and smoking control. Companies simply have to choose their preferred activities from among the health interventions in these four areas.

Some Members have raised the concern over mental well-being programmes that can be introduced for employees at company level. This is one example in which HPB is trying to reach out to employees, to help the workers manage their health issues through activities, including for mental well-being.

We also know that the work demands of each sector are different. Some sectors, like hospitality, wholesale and retail, and transport and logistics, face greater challenges in implementing workplace health initiatives. For example, in the hospitality sector, it is hard to get service staff who work different shifts to get together to exercise, especially those who work the night shift. To address this, HPB and its partners will be adopting a more customised approach, by tailoring outreach activities and capacity building sessions tailored for specific industries. Industry workgroups, comprising representatives from trade associations, unions and private companies, will be set up to provide feedback on the needs and challenges of their respective industries.

Within Government, HPB has already started working with other agencies to align and streamline our promotional efforts. For example, HPB and the Ministry of Manpower (MOM) have been working closely to integrate workplace

Sir, I know I can count on our unions and trade associations, like NTUC and the Singapore Manufacturers’ Federation (SMa), to step forward and lend us their support. NTUC has already partnered HPB to launch a weight management programme next month to promote healthy living at the workplace. SMa will also hold a kick-off event in May 2010 where some of their SME members will pledge their commitment to implement workplace health programmes. So we have the unions and employers' association to help us in promoting weight management with their members and employees. As we intensify our engagement efforts with SME leaders and associations, I hope more will do the same and motivate their members to improve workplace health.

Let me quickly update Members on smoking control legislation. Singapore is a pioneer in this area on several counts. We were the first Asian country to ban tobacco advertisements in 1971. In 2004, we again led Asia by using graphic warnings on cigarette packs to discourage smokers from lighting up. To date, we are one of the only nine countries in the world recognised by the World Health Organization (WHO) for our nation-wide network of smoking cessation services.

Nevertheless, smoking is an issue that will take years to address and we will persist in it. We already have some successes. Less contraband is being

This is mainly due to an increase in smoking amongst certain population segments, in particular young adults. The smoking rate for young males, aged 18 to 29 years, has increased from 18% in 2004 to 25% in 2007. For young females, the increase was from 7% in 2004 to 9% in 2007. I am concerned about this trend as young adults might not fully appreciate the negative consequences of being hooked on smoking.

Besides stepping up HPB’s public education efforts, we intend to augment the Health Sciences Authority's regulatory arsenal by updating the Smoking (Control of Advertisement and Sale of Tobacco) Act to current operating realities. The Act was last amended in 2003 and the latest proposed amendments are to incorporate more stringent tobacco control measures in response to an increasing trend of smoking among young adults, and the emergence of new tobacco products.

Sir, I will try to cover all grounds before the stipulated guillotine time.coming and asked how we are going to manage it. It is a tall order which requires hard work from all of us, but it is worth doing.and extended the lunch-time break to encourage participation in on-site health programmes. I was told by some workers there that they actively take part in the lunch-time programmes to promote good health of their workers. Employees are also given subsidies and other incentives to participate in healthy lifestyle activities. There have been tangible results – the average days of medical leave taken has fallen from 3.4 days in 2005 to 2.3 days in 2009. With more motivated and healthier staff, the monthly average resignation rate has also fallen from 0.9% in 2005 to 0.7% last year. For comparison, the monthly average for the manufacturing industry is double that, at about 1.6%.they lack the scale, resources and infrastructural support to do so. MOH and HPB recognise the constraints faced by our SMEs and will do more in the coming year to help them.health promotion into the Workplace Safety and Health legislative framework, as well as the Guidelines for Re-employment of Older Workers. They will also be engaging employers, employees, healthcare providers and insurers to pilot a health management framework linking corporate and individual health to appropriate incentive systems. This will be an exciting area for development as we push for greater productivity in our workforce.hawked on the streets, in no small part due to Customs’ vigorous enforcement efforts. Many public places are also going smoke-free, thanks to the National Environment Agency's smoking ban. Over the years, smoking rates dropped from 20% in 1980 to 12.6% in 2004, but the latest figure of 13.6% in 2007 shows a slight rebound. So we still have a lot of work to do.

After extensive public and industry consultation, we are planning to ban misleading labelling, and lower the maximum tar and nicotine limits, among other changes. I look forward to Members' support for the amendment Bill when we table it in this House later.

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Let me now move to detection and prevention of diseases. Mr Khaw earlier spoke about our considerations in making screening more affordable through the use

The Integrated Screening Programme was introduced in June 2008 to facilitate appropriate health screening for Singaporeans aged 40 years and older at CDMP-registered GP clinics. Five conditions are currently covered – diabetes, high blood pressure, lipid disorders and obesity – all these are risk factors for heart attacks and stroke as well as cervical cancer. The programme has served Singaporeans well by lowering the cost of screening through bulk purchases and subsidies for lower income Singaporeans.

We are looking at including colorectal cancer screening under the Integrated Screening Programme. Colorectal cancer is the most common cancer here – 1,500 Singaporeans become afflicted with this disease annually. Over the course of a lifetime, one in every 20 men and one in every 30 women will get colorectal cancer. Last November, we started a pilot in Queenstown, Tiong Bahru, Bishan and Ang Mo Kio where Singaporeans aged 50 years and older were invited to go for colorectal cancer screening at CDMP-GP clinics. To-date, 416 participants have completed the screening, and 39 participants, or 9% of them, were referred for further assessment. We also intend to step up efforts to increase awareness and uptake of colorectal cancer screening among Singaporeans.

Cervical cancer is another noteworthy disease that we are tackling. Pap smear screening is key to detecting this cancer at its early and even pre-cancerous stages, where treatment is most effective. Vaccination against the human papillomavirus (HPV) is an interesting new approach, though not without limitations. For example, it is only effective against 70% of cancer-causing HPV virus, and

Sir, on children's health, I would say that good health boils down to eating enough and eating right. A balanced diet is crucial to improving physical well-being and our resistance against diseases.

But we must guard against too much of a good thing. Chinese New Year is just over and like during the other festivities like Hari Raya or Deepavali, some of you would have suffered from the side effects of over-eating. Imagine the ill effects on our our children of over-eating on a daily basis! Childhood obesity is fast becoming a problem in developed countries. Left unchecked, it would lead to our children developing all sorts of chronic diseases that they would have to live with the rest of their lives. The problem is becoming so severe in America that it has caught the attention of President Barack Obama. He recently set up a taskforce under the First Lady to tackle this growing problem.

In Singapore, we have made obesity the focal point of our National Healthy Lifestyle campaign last year, and this will continue this year. As a lead up to the campaign proper, HPB will launch a weight loss reality TV challenge, similar to the highly popular Lose to Win Challenge in 2009. Community and workplace stakeholders will also be engaged to champion health programmes to provide supportive health promoting environments for optimum weight management.

We know that food advertising to children is a problem, and are working with industry stakeholders to address this. To complement these efforts, HPB is developing guidelines on food marketing to children in schools and will continue health education efforts in the school setting. HPB will also work with MOE to

Mrs Mildred Tan asked specifically if MOH will consider banning trans fat in food sold here due to the increased risk of coming down with cardiovascular diseases from consuming it. I share her concern. Today, three in 10 adult Singaporeans exceed WHO's recommended daily limit of less than two grammes of trans fat a day. Two-thirds of these people are younger adults aged 18 to 39. Our children, especially those who snack frequently, are affected as well. We clearly need to limit the intake of trans fat in Singapore before it gains a foothold in our daily life.

Regulating trans fat, however, is a complex issue. We have adopted a more cautious voluntary approach so as not to create trade barriers, reduce consumer choice and bring about unintended increases in food prices. The concerns that we raised in 2006, as mentioned by Mrs Tan, are still valid, but we are looking at some ways to ensure that people are better informed about healthy choices. After carefully studying the experiences of other countries and taking into account our local situation, we are now prepared to take targeted steps to control the problem.

The experts told me that a total ban is not practical. Many of the catchy headlines we read about trans fat bans in New York and California actually refer to limiting trans fat to a very low level. We will do likewise. We are considering limiting the trans fat content in fats and oils to not more than two grammes of trans fat per 100 grammes of product. This is in line with the practice of developed countries which have implemented trans fat reduction measures.

For other food products besides fats and oils, HPB will continue its approach of

Mr Low Thia Khiang asked about the state of myopia in Singapore. Myopia develops mainly in childhood, but stabilises as we get older. Many of us will recall that one generation ago, fewer children wore spectacles. The proportion of school children in Singapore with myopia is indeed high but has also stabilised over the past five years. Today, about 30% of Primary One school children and two-thirds, or 66%, of Primary Six children have myopia.

The causes of myopia are not well-defined, although studies have identified risk factors like near work mentioned by Mr Low, and protective factors like regular outdoor activity. Local research is ongoing to gain more insights into risk factors and causes of myopia. Our schools have taken the necessary measures to manage the problem but a large part of the solution depends on habits at home. Through the National Myopia Prevention Programme, MOH and HPB help tackle both sides of the equation by educating parents, educators and children themselves on good eye care. Vision screening for pre-school to secondary school students is also provided through the Programme. We must collectively press on our efforts to delay the onset and reduce the progression of myopia in children on these fronts. But we acknowledge that it is challenging.

As these recent cohorts of children age, myopia will inevitably become more prevalent among adults. The concern is that myopia may predispose older adults to other eye problems. HPB will encourage seniors to go for vision screening as part of a broader suite of elderly functional assessments which it will roll out soon. They are also augmenting optometry and optician services nationwide to deal with problems as they emerge.

Fortunately, myopia is a problem easily correctable by spectacles or contact lenses. With affluence, many adults have also gone for the more costly option of laser surgery or LASIK. The technology is evolving. Surgeons are now able to make more precise, three-dimensional measurements of the eye that better guide the reshaping of the cornea. However, as with any surgical procedure, patients have to be carefully assessed for suitability, and LASIK itself carries risk that patients should be aware of. At our public hospitals, the success rate of improving vision in adults via LASIK is more than 98%, though not all will achieve perfect vision. This is comparable to results overseas. Rates of serious complications are low, but side effects such as dry eyes are common, occurring in up to half of all patients.

Let me now talk about special needs children. Besides mainstream school children, I want to highlight another group that we are devoting more resources to – the special needs children. Dr Lam Pin Min and Dr Amy Khor have raised some good questions about our plans to support this group of children. Since 1991, the Child Development Programme has helped identify and treat children with developmental problems in their early childhood. Under this programme, child development experts from KKH, NUH and three community-based clinics work together to provide diagnostic and early

I have seen our healthcare professionals in action. They are doing good work and coping relatively well despite the huge caseload of some 5,200 patients, including 2,000 new cases annually. However, certain support services, like psychological counselling and speech therapy, are stretched as we have only catered for a projected total caseload of 3,200, with 1,200 or so new cases per year. This was the global norm as recently as three years ago.

This rising trend in workload, which experts attribute to increased awareness and better diagnostics, is not unique to Singapore. The situation is exacerbated by a global shortage of trained manpower, which had led to a resultant increase in waiting times worldwide. We acknowledge that parents have to wait before sending their children for screening, but we are managing this by trying to increase the manpower. But I would like to inform Members that this is not just a problem in Singapore but it is also faced by many countries in other parts of the world. This is why we are injecting $46 million into the Child Development Programme, to help us expand capacity and bring down waiting times for these early childhood developmental services. It will cover our needs over the next four years and it is on top of the $16 million already committed from 2007 to 2009. Most of these monies will go towards the training and recruitment of child development manpower, especially psychologists and speech language and physiotherapists. At steady state, we hope to

But let me add that the holistic management of children with special needs is a very complex issue. Multi-agency efforts across the social, educational and healthcare sectors are required for the child to reach his or her full potential, as I am sure Mr Ong Ah Heng is aware. In the majority of children with special needs, such as those with severe mental retardation, autism and cerebral palsy, medical intervention plays only a limited and supportive role compared to the provision of social and educational support measures.

of Medisave. I shall now update the House on clinical developments.there is limited data on the long-term effectiveness. The Expert Committee on Immunisation is reviewing the evidence on HPV vaccination and will report its finding to MOH subsequently. instil a culture of physical activity amongst our young, so as to build lifelong habits for a healthy lifestyle.engaging the food industry and encouraging all of them to voluntarily reduce the trans fat content in their products. Response has been encouraging, especially from larger players in the market. Some companies have voluntarily reduced trans fat in their products, eg, Gardenia, Sunshine, FairPrice, Lam Soon and Nestle. SMEs, like Al Dente Food Pte Ltd, have also come forward to partner us in this effort. I look forward to the support of other industry players on this and other healthy eating initiatives like HPB's Healthier Choice certification.intervention services for special needs children aged 0 to 6, complementing MCYS and MOE's efforts under the wider Enabling Masterplan on Disability. Through these efforts, and the determination of patients and their families, many have risen above their developmental difficulties. Some ex-patients have since secured places in our tertiary institutions and even participated actively in National Service. serve more than 6,000 cases yearly and further bring down waiting time for key services.

These children require early placement in special schools where they can receive appropriate training and education. The child development programme which I have just outlined caters to those with mild to moderate problems. The most appropriate developmental setting for this group is in the mainstream – integrated and inclusive schools where they can receive educational, social and community support as well as therapeutic intervention from healthcare professionals.

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Before I conclude, let me address Ms Ellen Lee's and Assoc. Prof. Paulin Straughan's questions on raising the quality and standard of traditional Chinese medicine (TCM) in Singapore. Today, MOH does this through raising the standards of TCM training courses and continuing professional education of TCM practitioners. Since 2006, MOH has worked with two main local TCM colleges to replace certificates and diploma courses with higher requirement Bachelor courses, jointly conducted with top TCM universities in China. NTU's School of Biological Sciences has also started a double degree biomedical science and Chinese medicine course with the Beijing University of Chinese medicine. Its first

Sir, let me conclude by saying that there is this saying that "health is wealth". It becomes a mantra to many of us, but this is more true in more ways than one. By staying healthy, one need not spend so much on medical bills, so that he can spend on his other pursuits. But besides that, keeping healthy will enable an individual to have a higher quality of life. Most of us want to achieve that but there is always a big question of whether we take that first big step to make sure that our health is well maintained and improved regularly. This is something that no amount of money can buy. I urge all Singaporeans to take the simple first step of taking control of their diets and start exercising so that by 2020 we will be a healthier and wealthier nation.

batch of 59 students will graduate this year. Taken together, these measures have augmented the pool of TCM practitioners with degree level training from 101 in 2006 to 164 last year. In addition, TCM Practitioners' Board has set up a new sub-committee to look into continued professional education for TCM practitioners. We will continue to encourage all registered TCM practitioners to take part in such courses. In 2006, the TCM Practitioners' Board also published an ethical code to guide TCM practitioners in maintaining the quality and standard of their practice.

Mr Chairman, I have three clarifications for the Minister. First and foremost, I would like to ask the Minister while waiting for the new Jurong General Hospital to be ready, what is the plan for the old Alexandra Hospital and whether it can be made fully operational to help relieve the current shortage of beds.

Secondly, I am happy to note that MOH is investing another $57 million for mental health programme. I would like to

Last but, most importantly, the Minister mentioned in his speech just now that although he is 58 years old this year, his residents commented that he looks much younger. Sir, I would like to clarify with the Minister whether he has found an elixir for youthfulness and whether he can share with us his secret recipe for staying young.

ask the Minister what are the deliverables and KPIs to help determine if this money will be well spent.

Mr Chairman, there is no elixir, no secret recipe. Technology does help – I colour my hair. But, no Botox. I think the mind is important, the attitude to life. As I quoted Lao-tzu earlier – what is life all about? It is never about ourselves, it is about others. And if we lead a life in that direction, whatever the physical form, I do not think it matters.

While waiting for Jurong General Hospital, we will retain Alexandra Hospital. The original plan was to close it down immediately when Khoo Teck Puat Hospital is up. But when I reviewed the situation about three years ago, I decided not to close it. I think we cannot afford to close down Alexandra Hospital while waiting for Jurong General Hospital. So, we will keep Alexandra Hospital running as it is; in that way the addition to our bed capacity is really 555 beds, which will come on stream over the next few months. Like IRs, we will open Khoo Teck Puat Hospital in stages – no gambling tables but there will be operating tables.

For the additional $57 million, the emphasis will be on community mental health. We have some KPIs. One will be in terms of additional psychiatric resources (nurses, doctors) that we will be pumping in. I cannot recall the numbers but those are the commitments

that we have made to the Ministry of Finance when we secured the additional money. The second one will be making sure that the community home visit teams will be truly effective. I accompanied those teams on some of their home visits. I visited some of these patients and I can see for myself that, truly, the service is well appreciated. I remember there was this dementia patient who happened to be in Mr Low's constituency. The patient has dementia for several years now. The original SOP would be that each time there is a crisis – and often there will be a crisis – it is a big operation. They have to call the ambulance and that level has no lifts. The lifts are coming but at that moment, there were no lifts. And carrying the patient down was a major operation. So, they were so appreciative when I visited them – the whole extended family was there. Not all the extended family stay there, but those who stay nearby all came to wait for me and expressed how appreciative they were. I think we know now what to do. Our job is to scale it up so that more can benefit.

Mr Chairman, I would like to seek a few clarifications from the Minister. First, the Minister said that he would not consider extending MediShield to cover mental illnesses, but he would when economic times are better. Could the Minister indicate some timeframe, because I had raised it during better economic times and he said that timing was important. So, I think giving us a timeframe would be useful.

Second, the Minister talked about the Medical Assistance Fund (MAF) to be set up to help Singaporeans pay for expensive medicine under Medifund, but he talked about helping the low-income Singaporeans. I think very expensive medicines, like cancer medicines, also affect the middle-income Singaporeans. Will there be flexibility, when this Fund is located under Medifund, to extend assistance also to

Third, I did ask the Minister whether he could consider providing more support for home-based care subsidies. The Minister did not respond to that point. I think more subsidies for home-based care is important if we want to promote right siting. Otherwise, people will crowd the hospitals because they do not have support at home.

Finally, I would like to ask the Minister out of that over $40 million that is now allocated further for mental treatment, whether there would be more of that component be given to the VWOs who are doing a fantastic job to provide support for mental patients, like shelters or other forms of day care services. Would he also extend a portion of that amount to provide support for caregivers, because caregivers of mentally ill patients are also suffering tremendously? Could he extend a portion of that amount to support them in training or other kinds of support for them?

middle-income Singaporeans for them to be able to afford expensive medicines?

Sir, when I said that the MediShield changes to include, for example, the mentally ill will have to await better times, what I meant was that if we want to extend payouts, premiums have to be adjusted. So, it depends on how much the premiums will be. If I am taking so long on this subject, it is because, obviously, the premium increases are not small. If they were small, I would have done it yesterday. But because the impact of the payouts on the premiums is not insignificant, that is why I have been sitting on this for so long. I find it hard to commit to a timeframe because there are still adjustments to be assessed, on how to better bring it about.

And this is the same for the ElderShield reform that Dr Lily Neo raised. We are trying to make some trade-offs, how to extend the benefits so that it is

On MAF, I used the word "lower-income". I did not mean low-income. Lower-income is relative. I do understand that even for lower middle-income group, costly medications can be a problem. And that is why I like the Medifund mechanism because that allows us flexibility. This is a group of wise people who will then help us to determine, case by case, who deserves it, who does not. Because we cannot really translate it into an algorithm which we can just plug into the computer and decide, yes, somebody deserves it, or somebody does not.

Home-care, yes, the intention of scaling up, for example, Home Nursing Foundation (HNF) is to make sure that it is a service that will be useful and meaningful to the patients and their families. And we do subvent HNF and I intend to increase the subvention to them. I accompanied the HNF teams on some of their visits to their patients at home. I observed them. Truly, they are doing very good work. Two months ago, I visited two of their patients who happened to be in Mr Shanmugam's constituency in Chong Pang. These are diabetic patients, one leg already amputated and the second leg will soon be amputated, wheelchair-bound, and with diabetic kidney failure requiring dialysis. Fortunately, there is a NKF Dialysis Centre nearby. But nearby for an able-bodied person is truly nearby, but for a disabled person, even 200 metres is like a mile. And the spouse is the one who has to push the wheelchair

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Under the additional mental health programme, we have funds set aside to work with VWOs, because we know we cannot do this alone, and on the ground, there are many willing VWOs. I have visited some of them in Mdm Cynthia Phua's constituency, they are passionate people. She asked about the Many Helping Hands approach. We could easily say, "All right, we take over, we nationalise it and do everything ourselves as civil servants."

truly meaningful, without incurring too much burden on everybody else. At the end of day, it is about risk-pooling. It is really the rest of the population supporting the small number with mental illness or with severe disabilities. So, these are some of the things that we are looking at, with the help of actuary consultants. Let me assure Mdm Halimah that it is very much at the top of my head because, as she rightly said, she has raised it several times before, and I have not forgotten. all the way to NKF. So, these are the problems that we can see. But we cannot bring dialysis to the home. Of course, we can go with ambulatory dialysis, but in her case it was not suitable, as she has other problems. So the home nurses visiting her have been very useful. They come, check her blood sugar everyday or every other day, and then remind her to comply. I was a bit sad that day when I visited her. They checked her blood sugar, it was high. So, the nurse asked: "Why? You know your diet discipline, you can eat this, but you cannot eat that." And she said, "Yah, I know." That morning she had some unhealthy breakfast, she thought it was just one meal. As I said, we can only point the way forward, but the patients must cooperate with us. Unless they are engaged, it is very hard for us to really bring about true change in health outcome.

But remember the story of Sister Geraldine – no paid employees can deliver that kind of service. So, it is not a matter of we do it without them or they do it without us. I say, let us do it together. Our objectives are the same, which is to help Singaporeans stay well, live well and, hopefully, end well. But the patients have to play their part too.

Sir, I would like the Minister to elaborate on the point that he had just spoken on. I

Everybody seems to be sharing their age today. So, I am 46. My parents are pushing 70 and, thank God, they are mobile. But when they lose their mobility, I will still be working and there are many, many sandwiched families like that. Can the Minister share with us his thoughts on how to free the sandwiched family? Many of these will be dual-income families. How do we free these families so that they can take care of their dependent elderly at home and rise to the challenge that the Minister has posed to Singaporeans – that we must be filial and we must oblige our moral obligation to our parents.

watched "Money No Enough 2" as well and few local movies moved me as much as that movie did, particularly the scene when the elderly mother was moved from one child's home to the other as her health failed. But within the movie, we were also shown the constraints that each of the three sons who clearly loved the mother, I thought, but they were consumed by their own family and work demands. It is easy to trivialise these kinds of barriers in the movie but I think in real life we are going to see a lot more of such families.

Sir, I find that a meaningful commentary. To respond to it with full justice, I think I will need two hours, which I do not have. But, clearly, it is a major issue that all societies are trying to cope. We are lucky in that our population is still young and we have a few years to strengthen the system, which we will. The bottom line is this. I do not think it is whether you are sandwiched or otherwise. There are barriers, yes. Whether you are rich or poor, there are barriers. But if a person is in the middle-income or higher-income group, in fact, he has more personal resources compared to the lower-income group.

I do, as I said, home visits to patients and, most of the time, I visit the lower-

So, at the end of the day, it is attitude. I am not trivialising – the word the Member used – the barriers that people are facing, but they can be overcome once the attitude is right. "Yes, this is my mother (or this is my father) and I am going to go all out with whatever resources I have, topped up by whatever society is able to supplement."

I visited one couple in my house-to-house visit in Sembawang. She is a Malay lady in her early 50s. The husband, heavily diabetic, both legs amputated, on wheelchair when I visited them. She has been looking after the husband for more than 10 years. When I saw them, she explained to me how she coped with great difficulty, but she coped. At the end of the visit, I told her, "You are a good person." She was all right but when I said, "You are a good person", that was when she broke down. She said, "We knew each other since school. I love him for so many years. We have been married now for 20 years. How can I forsake him, desert him?" And that is how people cope. And for people like that, I will go all out to support them and make sure they can deliver.

income group. These are people much less endowed than the sandwiched groups. But what always struck me was how they still manage because the love is there. They have limited resources, yes, but that did not prevent them from going the extra mile. On the other hand, I have come across people who are clearly pretty well endowed, but they just assume that they can delegate and outsource their love and compassion for their parents away.

Dr Lily Neo, Mdm Cynthia Phua and then Ms Sylvia Lim.

Mr Chairman, Sir, first, I would like to commend Minister Khaw Boon Wan on his good deliverance of the first speech earlier in

Sir, I would like to seek the Minister's clarification on the present acute bed shortages in our hospitals and on the reports that many patients and their family members were unhappy for being put up in the hospital corridors while waiting for their hospital beds. My question to the Minister is whether each of the hospital has put up its best problem-solving practices. For example, should there not be better temporary holding areas rather than hospital corridors while waiting for admissions and whether there should be better customer service in allaying patients' fears and placating patients' family members in such situations?

Lastly, the Minister has not replied me on my earlier question on national healthcare expenditure (NHE) – basically, Singaporeans' concern on healthcare costs. How quickly will the NHE rise in such current servicing, how sustainable it is and how would that impact the population since NHE is borne two-third by the people and one-third by the Government, especially on the low-income and middle-income families?

the House. His speech was compassionate, passionate, interesting and explicit, and he also gave appropriate and good personal anecdotal experiences.

I thank Dr Neo for her comments and compliments.

The national health expenditure in our case is less than 4% of GDP. I have discussed this in this House before. Four per cent is not sustainable, because there is a correlation between GDP growth and health expenditures. As we become richer, we are prepared to spend more on healthcare, and that is why the national health spending will grow.

How much will this 4% grow up to? It is hard to say. A lot depends on how well we manage the cost escalation and

On bed shortage, we had a short discussion last month at a parliamentary sitting. I quoted figures to show that, overall, we are not short of beds, but there are mismatches. Of course, when the media played it up, they will play on those days when it is very high in a particular hospital. Even when a particular hospital is short of beds, I have empty beds in other hospitals. So it is not as if there is a complete shortage of beds nationwide, but there are mismatches. Mondays and Tuesdays are bad in certain hospitals and we are trying to cope.

We anticipated this problem three-four years ago. I remember Mr Low Thia Khiang raised this issue on potential bed shortage coming up in Tan Tock Seng Hospital. Somehow he is familiar with Tan Tock Seng Hospital. He had seen some problem there and alerted me to it, which

Hospital construction is lumpy. There is no increase in beds for years, and then suddenly we have a 500-bed hospital. So, what I have done over the last few years is to progressively add in temporary beds in other hospitals while waiting for this Khoo Teck Puat Hospital to open. When it opens, we can then close all those temporary beds. But as we get close to D-Day, that is when the pressure is at the maximum, and that is why we have these temporary shortages of beds on certain days.

But, as I said in this House, clinical care is never compromised and we will never compromise it, but I accept that service level is unsatisfactory. Yes, our staff could be better at communication, but I have some sympathy for our staff. They are really working their guts out when there are so many patients in the last two-three months. The problem is this, and we know this seasonal factor. With the school holidays in December, many surgeries were cancelled, as people went on holiday. In January, we have the return of Singaporeans and hence the return of the elective surgery cases. Then in February, we had two weeks of Chinese New Year, and everybody shied away. And in the last two weeks and now, we see the return of all elective surgeries. That is the reason why we have all this sudden big increase. It should ease once Khoo Teck Puat Hospital is fully opened in a few months' time. But, meanwhile, I plead for some patience.

medical inflation. My own personal target is this. As long as we can keep it to a single digit percentage of GDP, that should be quite an achievement. Many European countries are now at double digits. The US is the worst – 17%, and projecting 20% in a matter of time. And once we go over a tipping point, it is almost uncontrollable. So we must try to keep it single digit – 4% eventually will become 5% and then 6%. Even at the most advanced of ageing, if we can keep it to 8%, I think that would be a huge achievement. How to do it? The key, as I said just now, was to control expenditure. So long as we can keep costs low overall, then who is the one who is responsible for payment is a secondary question. And the way to control healthcare spending is to cut out abuses. The problem in the US and the European system is abuses – what we call "buffet syndrome". The more we can control moral hazards, the more we are able to keep the cost inflation down.I acknowledged. And that is why in the last few years, we have been increasing beds in every hospital. Over the last four years, we have actually added many beds wherever we can. But we are now coming to the tail end of the construction of the new hospital that is coming up.

Mdm Cynthia Phua, keep your intervention brief. We do not have much time.

Yes, Mr Chairman.

I would like to thank the Minister for his care and love for the people of Singapore on healthcare issues. I just want the Minister to elaborate on the mobile care service for the mentally ill. Are they only taking care of the active Institute of Mental Health (IMH) patients or do they allow the residents to call them when mentally-ill residents are identified in their home who need attention? Do they answer to our call for service?

The hotline for IMH is for their ex-patients. There is no problem, because we know the patients on our database. Whether they also respond to new fresh calls, I have got to check. As the hotline is 24 hours, and if somebody calls up and explains what is the problem, I am sure they will be able to, there and then, provide the necessary counsel and advice. But I need to check on this point.

Sir, three clarifications on my cut on Medisave for outpatient treatment for chronic illnesses. First, earlier, the Minister mentioned that he spoke to some elderly who told him that they deliberately chose not to use Medisave for their outpatient treatment. But I wonder whether the Minister is also aware of some feedback being given to him that the deductible has been a problem for some. The man I mentioned earlier hand wrote a letter to the Minister but he received a reply from somebody in the Ministry of Health. So I do not know whether the Minister is actually aware of this feedback that the deductible is causing hardship to some elderly sick.

The second point is, does the Minister agree that with the caps already in place of $300 withdrawal every year plus the co-payment requirement, is there really a need for the deductible to check on over-consumption and to protect the Medisave savings?

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The third point is the Minister earlier mentioned that to get over the deductible some clinics are offering package deals. Could the Minister clarify whether this package deal means that the patient is paying for consultations in advance? Not just the medication, but consultation as well, because patients need to go back every few months. Secondly, whether this option is something that the patient can insist on at the polyclinic.

The beauty of our system is diversity, so I have heard of different packages from different general practitioners (GPs). They package it up – some patients pay in advance or at the end of the year or by instalments or other ways. There are all sorts of packages in town. I will advise the Member to advise whoever who gave her the feedback, to shop around in the neighbourhood. I am sure there are different GPs and they should be able to respond to that.

I want to stress that this packaging is not to get around the deductible. The packaging serves a purpose. A package for chronic disease is no different than our motorcar maintenance package. Many motorcar workshops have maintenance packages for their customers – 5,000 kilometres do this; 10,000 kilometres do that; 20,000 kilometres please come back to check engine. The maintenance of motorcar and of the human body is similar. The package deal serves that purpose and the problem that the Member mentioned can be easily overcome with this package scheme.

As for the person who hand wrote the note on his problem with $30 deductible, I vaguely recall the incident. But as I said, the right solution is to get a suitable package. Chronic disease is not a one-off acute attack. Payment is not just one visit for $30. The patient has to do it for the rest of his life. Very importantly, the

With the capping of $300, the Member asked why there is an additional need for deductible. I have explained that just now. The deductible is a very important part of controlling this morale hazard we talked about. I would advise or suggest that the Member read up on some of the commentaries which are floating around on the Internet in US over their healthcare reforms. Serious economists are all coming to the same conclusion that the only way to tame this beast – ie, runaway healthcare cost – is health savings account coupled with a high deductible insurance scheme. Drop the comprehensive first-dollar coverage and all other means which have been incentivising wrong behaviour.

programme has to be packaged, to ensure compliance.

Mr Chairman, Sir, on behalf of the GPC and Members of the House who have spoken so passionately on various health issues, I would like to thank the Minister and Senior Parliamentary Secretary for their comprehensive, yet emotional, and at times moving responses. There is a Chinese saying, "医者父母心 (Yi zhe fu mu xin )", which basically means, as doctors, we treat patients with the heart and good-intent of a loving parent. Similarly, the Minister and his team shoulder a heavy responsibility of looking after the health needs of four million Singaporeans. This is by no means an easy feat and requires a even bigger heart than that of a parent. I am optimistic and confident that with a big compassionate heart and astute leadership, our healthcare system will undergo this quiet healthcare revolution successfully to remain relevant to the needs of all Singaporeans. On that note, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

The sum of $3,537,809,800 for Head O ordered to stand part of the Main Estimates.

The sum of $643,606,300 for Head O ordered to stand part of the Development Estimates.

Order. I propose we take a 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 at 3.30 pm.

Sitting accordingly suspended at

3.06 pm until 3.30 pm.

Sitting resumed at 3.30 pm

Debate in Committee of Supply resumed.

Head M – Ministry of Finance

High performance Government

Sir, I beg to move,

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

Mr Chairman, Budget 2010 calls for a focus on driving productivity and innovation for sustainable growth and quality service. What is the Government's strategy to take the lead and, as one would say, walk-the-talk, to ensure efficient use of resources and streamlining of processes to improve the effectiveness and the quality of service.

There are five areas that I would like the Minister to clarify. How will the Government ensure that, one, these sources are allocated to areas which

In driving for productivity, what specific measures is the Ministry taking to encourage and leverage on the whole-of-Government approach to ensure more effective citizen services? And what is the Government doing to ensure that regardless of which Ministry or agency that citizens go to for assistance, service or information, that they do receive the appropriate service and not have to manage the complexity of having to deal with multiple agencies to resolve their problems or, as we say, the many silos of services and therefore they have to deal with these silos. So what steps are being taken for the Government to catalyse innovation for productivity growth?

deliver value and service excellence to citizens and businesses. Two, public agencies move towards high-value activities and away from activities and programmes that are no longer relevant. Three, public service staff are developed and trained to understand the principles, techniques and skills related to improving the quality and productivity of Government services as well as in decision-making. Four, improvement and processes are made to enable our public officers to solve citizen issues effectively. And, five, measures are put in place to reinforce and recognise citizen-centric service quality and excellence.

Accountability and budget allocation

Sir, the Budget Book serves as a public document on the proposed Government revenue and expenditure for each financial year. It provides accountability to MPs and members of the public in the usage of Government funds. However, the information provided in the Budget Book seems to be getting lesser with each financial year. For example, there were 728 pages in tbe Budget Book for FY1994/1995 and only 593 pages for FY2000/2001. For this year, the Budget Book has 417 pages. I am not suggesting that the more pages in the

I understand the Ministry of Finance (MOF) has been innovative over the years to allow each Ministry the flexibility to spend public money efficiently. One of the initiatives is to allow each Ministry to have budgetary discretion by block budgeting. While this flexibility may be good for the Ministry, more transparency on expenditure is needed to assure accountability. There should be a balance between flexibility and accountability for the financial resources entrusted to the Ministry. I would like to know how MOF ensure accountability and transparency of Government expenditure to the public.

Budget Book, the better it is, but I find the current Budget Book not useful enough for one to understand the individual programme function and major changes in expenditure, if any, or major items of our Ministries. For instance, in the old Budget Book, under the Ministry of Health, I can see specific subventions given to each restructured hospital. Under hospital Services Programme, I can see some detailed expenditure such as rental, utility, official celebration and mass media expenses, etc, and also under new OOE. But in the current year's Budget Book, under Services Programme of MOH, I see one consolidated amount list like subventions and the breakdown under OOE is rather brief. Some of the expenditure listed are simply classified as running costs without details provided.

Sovereign Wealth Fund management

Sir, I would like to raise some points regarding our Sovereign Wealth Funds (SWF). Firstly, both the Government of Singapore Investment Corporation (GIC) and Temasek are operated as private funds, with larger risk appetites today compared to the past. Both have made losses in recent time and it is timely that the Government gives them a more conservative mandate since their investment outcomes invariably impact the reserves

Sir, last year, I also brought up the need for Temasek to refocus on Singapore and was told that in doing so, we will validate some of the concerns overseas over our SWFs having political objectives. However, if the Government is already setting overall returns objectives, risk thresholds and tolerance limits for our SWFs, then I see little problem in Temasek investing actively in promising locally-based companies. I think we should move away from the mindset that helping local companies would compromise the objectives of Temasek as long as we have a clear mandate, objective and investment philosophy for Temasek, and, in fact, for other funds that we may set up.

I also would like to clarify the rationale for setting up Seatown as a new investment vehicle under Temasek. First, what is the need for this fund and how does its investment philosophy and risk appetite differ from that of Temasek as a whole? I think we need to be clear about the mandate of Seatown and if it is different from Temasek, then how can two investment philosophies come under one company and under one management? Would there be a conflict of interest as such and should we, in fact, set up a third SWF called Seatown rather than putting all of it under Temasek?

Sir, on EXIM bank, I would like to comment on the idea. This was mooted by the ESC. I would also like to remind the House that a similar recommendation was made a few years ago when I was heading the Finance Advisory Committee

There are some very good examples of EXIM banks that have worked in Canada and Japan and we should look into how we can emulate some of their successful strategies and they have done really well. However, I feel strongly that unless we have a focused agency working with companies managing the EXIM bank, we may not succeed. So I hope that we do not farm this out to a private bank because they may not be able to focus on the task at hand. I also think that it is necessary to study our Internationalisation Finance Scheme which was supposed to help our companies internationalise and help them finance their international operations. This has been in place for many years but I understand that it has not been successful in achieving the objectives and too few companies have benefited from the scheme. This is despite the fact that many of us at it, proposed refinements of the scheme and still it did not work. It would be wise for us to learn about the failure there so that when we implement the EXIM bank, we will be successful in achieving our objective.

I hope the Minister will try to understand why the Internationalisation Finance Scheme was not successful so that the EXIM bank can learn and do it right when implemented.

of Singapore and our future. We may want to perhaps learn from China where in today's papers it was reported that their SWF China Investment Corp (CIC) booked US$10 billion unaudited profit for 2009 compared to the losses our SWFs made last year. of SPRING's Board. But the Government's response at that time was not positive. I think it found that there was no need for it. But many developed countries, in fact, have had similar schemes to help their companies, so why not Singapore? I am glad that this has finally become a reality through the ESC's recommendations.

GIC's investment and financial health

Sir, in the last 10 years, compared with other Sovereign Wealth Funds, like Abu Dhabi Investment Authority and the Norwegian SWF – GPF, GIC's portfolio has certainly performed better. With a big portfolio, it

Fund management is risky business. At end March 2009, GIC's portfolio suffered a loss of more than 20% in Sing dollars. These losses were a result of the 2008 global economic downturn. GIC has been releasing its financial report for the past two years but Singaporeans are expecting to know more.

As long as information is market sensitive, GIC, like other fund managers, has a responsibility to ensure that it does not take positions that may lead to speculation and chaos in the market. However, where it warrants a clarification, GIC should be more forthcoming in its disclosures.

Would the Ministry enlighten us on GIC's stake in UBS and the subsequent $9.5 billion paper loss it has suffered? How does GIC intend to ride out the loss? GIC is also helping to underwrite the sale of new shares by Prudential to help pay for its US$35.5 billion purchase of American International Group's (AIG) Asian unit, AIA. What are the implications for GIC?

In January, GIC announced that it had recognised losses on its investment of US$675 million on the Peter Cooper Village and Stuyvesant Township project. Newspaper reports suggest that GIC had written down US$575 million in mezzanine debt. What is the actual amount lost on this project? How are we recouping our loss?

is understandable that GIC may not be as nimble as the smaller fund managers. What is important is that GIC has been able to preserve and guard our national reserves well.

Mdm Ho, your time is up. Mdm Cynthia Phua, your turn, please.

Prime land used for bus interchanges

Mr Chairman, Sir, in limited land resources, there is always

The market cost based on the last tender in Clementi Central is an average of about $1,800 per square foot. That is the average cost for the built-up area that is including the upper levels of the shopping centres. If it is solely on the ground, the average cost is about twice the pricing and that is $3,800 per square foot. If proper costing is not imputed by the Ministry of Finance for the use of public service such as bus parking, the highest and best use of the land will not happen and the bus interchange will get bigger and bigger. And this is already happening as I understand that the LTA has specified bigger area for bus parking for the Bedok North site, ie, more bus bays than the Clementi site.

And with such a requirement, it will occupy the whole ground floor of the future retail complex and all shoppers know ground floor is the best place for any retailer. Can the Ministry let us know the value it imputed for the bus interchanges?

competing use and market price should be allowed to determine the use unless the use is critical. The highest and best use price should be imputed. For bus interchanges, the interchange is essential but the bus parking is not. Here, I would like to declare my interest as the company I work in do tender for the integrated developments at these neighbourhood centres. What is the cost of the space for the Land Transport Authority (LTA) for the use of the prime land for bus parking in a neighbourhood centre?

Property tax on HDB flats

In November 2009, it was reported that IRAS decided to raise taxes on HDB flats. The economy has not recovered. With depressed salary and unemployment, many Singaporeans are still struggling to buy a flat because of high prices. I would

request that the IRAS will not implement the decision to increase the property tax on HDB flats for at least another three years or until the economy picks up. I do not think that the Government is so poor that they have to squeeze every ounce from Singaporeans who are already finding it hard to make out a living in this struggling economy. Seventy percent of Singaporeans comprising the middle and lower income families will be affected.

Diesel car tax

Sir, in Budget 2008, Minister Tharman announced the revision of the special tax for Euro-IV diesel cars. As a result, since July 2008, the annual special tax for a Euro-IV diesel car will be computed based on $1.25 per cubic centimetres of energy capacity, subject to a minimum of $1,250 a year.

This is an improvement compared to what was previously four times of the equivalent road tax for a petrol car. Notwithstanding the revised diesel tax, 99% of the passenger car population in Singapore still runs on petrol, while cars running more efficient engines including diesel IV and V are still a small minority.

Sir, to encourage the use of "greener" vehicles, I would like to propose to the Minister to change the current special diesel tax in favour of taxes to be "charged at the pump" based on volume usage rather than at a flat rate per car per year. This seems to me to be more appropriate because in other words, what we are doing would be to make the tax a variable tax which translates to a variable cost to the driver rather than a fixed cost, just like what we do for petrol taxes.

This would be consistent with the goal of minimising car usage and, more importantly, such taxes "charged at the pump" is also consistent with our goals

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However, if such a scheme is implemented, I would urge the Ministry to also consider the effects that it may have on the incomes of our taxi drivers, most of whom are using diesel vehicles, to ensure that they are not adversely affected by it.

on energy conservation as well as environmental protection.

Road tax

Sir, I would like to ask the Minister if he is proposing to amend the road tax formula in particular for clean diesel vehicles. There are two aspects to my query. First, in relation to the green vehicle rebate, currently, only owners of brand new green vehicles are entitled to green vehicle rebates. To encourage a greater use of low carbon transportation, the scope of the green vehicle rebate scheme would be extended to include imported used green vehicle with effect from 1st July 2010. The definition however of low carbon transportation is currently applicable to CNG petrol biofuel vehicles, petrol electric hybrid vehicles and electric vehicles. If the policy is to promote green vehicles, then why are clean diesel vehicles excluded?

Let me give two examples. First, a Mercedes Benz C Class petrol propelled 1800 cc has a CO2 emission of 216 grams per kilometre. The petrol CNG propelled vehicle is 170 grams per kilometre but the larger capacity CDI vehicle Euro IV compliant is 139 grams per kilometre. So the higher capacity lower emission. A Toyota Prius has a CO2 emission of 104 grams per kilometre but a Volkswagen's Polo Bluemotion, which again is Euro IV compliant vehicle, is only 99 grams per kilometre. What should not be overlooked is that diesel is cheaper and gives far better fuel economy than petrol

The second aspect is the continuing lack of distinction for the tax levied on the different Euro standards for diesel engines. Why do we classify Euro V and VI engines together with lower technology diesel engines for the purpose of the tax when the former are clearly more efficient and environmental friendly? I understand from the last time the Minister spoke in this House on this issue the concern was the amount of particulate emission and the matter was being studied. Could the Minister tell us whether the study has been completed and what the results are?

engines. Less fuel is burnt, less cost incurred and less harmful pollutants are emitted per kilometre driven. So why are clean diesel engines then excluded from the rebate and why are they taxed higher than equivalent petrol vehicles?

Development funds for social concerns

Sir, the revolutionary Indian Aravind non-profit network is famous for its eyecare services and an intralocular lens factory called Aurolab. Since 1976, it has done 3.6 million eye surgeries and laser procedures, treated 29 million patients either for free or a low fee, and yet made $7.9 million on revenues of $20 million in 2009, and all these in US dollars. Through disruptive supply chain innovation, Aurolab manufactures two million lenses in a year sold at between US$2 to US$10, exports to 120 countries, and has a global market share of 7%. Today, it continues to challenge conventional pricing models and supply chain with more products.

Sir, Aravind could have set itself up as a profit maximising "hungry hippo", but the founders decided on the higher value of compassionate capitalism, and turned Aravind into a social enterprise that brought sight to the underpriviledged millions, who would otherwise remain blind. However, in the profit maximising world, the idea of compassionate

Sir, in Singapore, passionate and able social entrepreneurs (SEs) meet with the same challengers as Aravind's founders. We lack the ecosystem and access to financial fuel that can help SEs blossom. There is no incentive for the setting up of social venture fund, SE banks or loans for social good. The 250% tax advantage given to charities with IPC status is attractive, but its mandatory charity status runs contrary to the handup approach taken by SEs. To argue that therefore SEs should be subject to the same rules as private sector is to say that perhaps R&Ds too which are good for the long-term socio-economic growth should also not enjoy any financial incentives or tax advantage.

In UK, social enterprises are supported with Community Interest Companies (CIC) which carries an asset lock and a community interest test. These funds are empowered with a 5% Community Investment Tax Relief (CITR) given to companies who invest in the Community Development Financial Institutions (CDFIs), which in turn invest in community development organisations and projects. CICs are limited by shares, but have the option of issuing shares that pay dividend to investors. In so doing, investors can look forward to financial returns as well as motivate the staff to do well. To protect the asset lock, the dividend to private investors is subject to a cap. In US, low profitability limited liability company (L3C) was introduced in 2008, as a profit generating entity with a social mission as its primary objective. It builds on the Programme Related Investment (PRI) scheme to tap on the

Sir, what do Bill Gates, Warren Buffet, Jack Ma and Andrew Carnegie have in common? They are all believers in social entrepreneurship and strategic philanthropy. If Singapore is to benefit from the rise of Asian wealth and philanthropy and to develop ourselves as a philanthropy hub, the Government would need to play a more proactive role in developing funds for social concerns. Only then, can we build a more inclusive society and have more inclusive growth.

capitalism was considered berserk, so Aravind's founders have to mortgage their homes to raise $55,000 as their seed funding. Fortunately, their persistency paid off and foreign funds in the form of Acumen Fund, Gates Award for Global Health and others came to their rescue as they expanded.potential US$6 trillion going to charities. Both schemes direct good money to high impact, sustainable organisations to solve social concerns and encourage sector growth. Match funding is another concept that is worth exploring as catalyst to fuel philanthropic dollars.

Pro-business Government processes

Mr Chairman, we have been discussing during the Budget debate on the need to deepen skills and encourage innovation of enterprises to raise productivity and enable enterprises to compete and capture new opportunities. As mentioned in the Budget speech, the window of opportunity for Singapore is short and given that other cities, including those in Asia, are developing rapidly and catching up with Singapore.

During the various dialogues that we had with business leaders to get their reactions from the Budget, many highlighted that it is complex to understand the criteria even of existing schemes available as well as time consuming to apply for them. Their feedback was that there are various schemes for Budget 2010 are welcomed, but they would wait and see how easy it is to access these schemes to innovate and to upgrade their businesses. So what measures can the Government take to

I will reiterate that it is not about hand-holding businesses. Being pro-business is critical in attracting businesses with potential to use Singapore as the base for their business as well as to retain Singapore enterprises to locate and operate their businesses from Singapore. The point is about how we will make it easy enough for businesses to begin, run and maintain their operations in Singapore. This will have the right impact on the jobs that will be created or lost and the growth or loss of the cluster of small businesses and those on the supply chain that support and are dependent on these businesses.

I am not referring to just having schemes to incentivise companies to operate in Singapore. We should also assure that Singapore remains pro-business so that enterprises will continue to build the capabilities in Singapore. Government regulations should not be seen as prohibitive, of course inconveniences for business operating in Singapore such that administrative cost of doing business in Singapore is impacted. Singapore must ensure that we remain attractive for enterprises, big or small, local or foreign, to operate and grow their businesses. I would like to ask the Minister to share what measures are being taken to ensure that Singapore stays pro-business.

simplify the processes to enable organisations to access and leverage available initiatives and schemes in a timely manner to enable them to build capability and to compete and grow their businesses? The focus needs to be on simplification and timely access for companies that have potential to leverage the appropriate schemes.

Export-import (EXIM) Bank for SME financing

Mr Chairman, the idea of having

Let me give one example. A local construction and engineering company, WEC Engineers and Constructors Private Limited, set up in 1972, is currently bidding for a multi-million dollar construction project in the Middle East. Part of the bidding process requires WEC Engineers to provide a performance bond and insurance. The company also encounters great difficulty in getting a bank in Singapore to provide project financing required. Despite the fact that WEC Engineers has a history of 28 years, the financial institutions here still require the company to provide high collateral before approving the loan.

To expand overseas or to take part in overseas projects, SMEs need the necessary financial resources. However, financing through traditional banking channels is not forthcoming as SMEs are constrained by their size and lack of collateral. This means that they cannot build up their track records and with no track records and credibility, these SMEs would not be able to expand or secure projects. It is a vicious circle.

The Economic Strategies Committee (ESC) has identified the need to develop a broader and a deeper base of Singapore enterprises of which some can be globally competitive. We fully support this call. Our SMEs must be given the chance to plug into the world markets. If we succeed, we would then be able to truly build an external wing for our economy. Therefore, the proposal of developing a specialised financial institution like the Export-import (EXIM) Bank is a big step in

Countries and regions like China, Japan, South Korea, Germany and Taiwan have set up such financial institutions. A good example is the Small and Medium Enterprise Credit Guarantee Fund (SMEG) set up in Taiwan in 1974. Taiwan's SMEG has assisted in fostering the growth of SMEs with good potential. This may be a useful model for us to study. For the EXIM Bank in Singapore to achieve the intended purpose, it must be easy and convenient for SMEs to obtain quick financing for operations and expansion overseas. Only then can SMEs seize business opportunities in an increasingly competitive and open world market. This EXIM Bank should not just operate purely on commercial returns, but should also assume some risk-taking positions. Otherwise, it would not be different from any other financial institutions. Moreover, such financing facilities should not be limited to just "Made in Singapore" products. We should also take into consideration the key pillars of Singapore's economy that we want to grow. For example, Singapore is an international trading hub with many local companies dealing with import and re-export of goods. We should continue to nurture this sector.

I would also like to propose that the EXIM Bank's facilities be extended to shipping. Shipping is an important contributor to our economy. The direct value added contribution of the maritime sector to Singapore's GDP has grown to about 7%. Today, there are more than 5,000 maritime establishments in Singapore, employing over 100,000 people. A number of foreign shipping companies have chosen Singapore as their headquarters or regional bases. The capital-intensive nature of the industry means that the shipping sector will require financing. An EXIM Bank would be a useful instrument to extend the range of financing solutions available to ship

By extending the EXIM Bank services to these sectors which are traditionally our strengths, we can expect positive multiplier effects which would benefit the economy at large. The business community is keenly awaiting the details of the proposed EXIM Bank!

a bank to support SME has been advocated by the Singapore Chinese Chamber of Commerce and Industry as far back as 2003. In the past few years, local enterprises, both big and small, have been encouraged to expand overseas. However, SMEs face many hurdles in doing so. the right direction. It will bridge the much needed gap in cross border financing.owners and operators with a good track record, and will assist the growth of Singapore as an international maritime centre and a hub for shipping investments.

Development of the accounting sector

Sir, to make Singapore an attractive business and talent hub for Asia, we should focus on the development of the accounting sector as part of our strategy. And to help the accounting sector gain more currency, I would like to propose a body to help set strategic directions for the accounting sector. The body could help establish a strong network between Singapore and the international accounting community. It could foster thought leadership, look into research and development activities for accountancy and related activities. To lend an international voice to its deliberations, we could have representatives from global accountancy related organisations.

Sir, such a body would transform the accounting sector and help it move forward in the local and international context. To create demand and recognition for our accounting staff, specialisation is necessary and the accounting sector should be able to create expertise in areas like internal audit and risk management expertise and valuation expertise. To solidify Singapore's status as an accountancy hub, special attention and effort should also be accorded to the development of Chief Financial Officers.

Sir, what is MOF's strategy with regard to

the strengthening of accounting institutions and nurturing of accounting talents to help our accounting firms compete internationally?

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Mr Zaqy, take your two cuts together, please.

Government co-innovation platform

Mr Chairman, the co-innovation platform is a good means to develop growth companies that have potential to provide innovation and support through Government and international goodwill projects. It is a good approach to identify potential champions within the various sectors. I would like to ask the Minister which are the sectors that the Ministry of Finance (MOF) plans to focus on and what are the indicators of success for this platform to promote research and development. Can the MOF comment on the take up of tax relief incentives for R&D over the last three years? One feedback is that it is generally the large companies that are participating in such initiatives. So, the question is – is this the Ministry's target group and what more could be done to garner more participation from the mid-size and small players in the industry?

The other feedback concerns the issue of IP ownership in such collaborations, so is this something that the Ministry should be looking at and is there something that we can do to promote greater participation to overcome this?

Future direction for e-Government

I have to commend the Government for delivering efficient services to citizens and businesses through the whole-of-Government e-Government initiatives. Some projects have delivered cost savings for the people, businesses and for the Government. I am heartened that the next

What is the MOF's directions for the next e-Government innovation beyond iGov2010? How does the initiatives plan to meet citizens who are becoming more sophisticated, want to be engaged and expect the Government's services to match to those by private sectors and consumer technologies? What is the approach to empower civil servants to work seamlessly and respond faster to the public and establish greater collaboration between the public, private and people sectors? How can we ensure that senior citizens and the needy are not left out of this engagement?

Sir, one feature of the iGov2010 is the implementation of large-scale consolidation projects such as the SOEasy initiative. Can the MOF comment on the progress and measures of success of large-scale initiatives of iGov2010? Have they delivered up to expectations and are there lessons learned that can be applied to future large-scale initiatives? Given the high-risk nature of such projects, has the Ministry also studied the impact of such large-scale projects on the small and medium enterprise sector, given that many have given feedback that they no longer have access to Government contracts that have been consolidated under such initiatives?

wave of e-Government projects plans to put more emphasis on the front face of the Government. Hopefully, this translates to better communication, interaction and participation from businesses and citizens.

Sir, we have witnessed rapid development in the ICT environment over the last decade. Over the years, I understand that the Government had used the ICT to enhance its services and integration process. However, much has changed today. There has been drastic advancement in technologies, Singaporeans' lifestyle and the level of engagement of the different

With the availability of hand held and high-tech handphones and other equipment, this will certainly change the way we live and enhance our integration and engagement via e-services platforms of the Government, private sector and other stakeholders. Therefore, I would like to ask the Minister on the plans laying the future direction for e-Government as we move into the next decade.

stakeholders in our society and with the regard to the ICT. I feel that we need to capitalise on these changes to enhance the way the Government engages its stakeholders, thus, sustaining its relevance today. In the spirit of Budget 2010, I feel that this calls for a great leap and a surge of innovation in using the platform of the e-Government in engaging not only those within its ambits but also the stakeholders outside its organisation. These include linking the services of the Government and the private sector to the people. I feel that the Government should integrate its capabilities via the ICT together with that of the private sector to cater to the needs of the lifestyle of Singaporeans and beyond.

Mr Chairman, Sir, first let me thank hon. Members for their comments and suggestions, and given the constraints of time, I shall endeavour to elaborate on the policy intent and address specific comments wherever possible.

The issues that Members have raised reflect the opportunities and challenges that Singapore faces today and how the Government will ensure that, as an economy, we are well equipped to tap these opportunities. These centre around four broad areas.

Firstly, the need to ensure high Government performance, efficient resource utilisation and accountability. Secondly, suggestions to enhance our tax regime, in particular leveraging on it to

Sir, I will address each of these in turn and, if time permits, to take on the related issues that Members have raised during the Budget debate last week as well.

First, on Government performance resource, utilisation and accountability. Member Jessica Tan asked about the Government's plan to drive productivity and innovation within the public service. Sir, there are many aspects to productivity growth and I quote Deputy Prime Minister Teo who said, "The factors which contribute to productivity include the quality of the systems, the processes, technology, organisation and workforce within enterprises, the attractiveness of their product and services to markets and leadership and management to bring all these factors together." Hence, we know that productivity growth requires everyone to play his part, not just the individual but also the enterprise. The public service, too, has to play its part. Deputy Prime Minister Teo has mentioned that the Head of Civil Service will be overseeing the public service's productivity drive and that the public sector will continue to emphasise training and improvements to processes and to the delivery of quality service to the public.

The Government recognises that the public service can itself be more productive and, as a regulator and a facilitator, the Government can continue to play a role to help businesses enhance their productivity. In the context of this afternoon's debate, however, let me explain how MOF is ensuring effective allocation and use of resources.

Sir, the Ministry of Finance has instituted mechanisms to drive productivity growth through the optimal allocation of resources. Firstly, through the re-investment fund. Every year, a budget is set aside for investment in new areas that support whole-of-Government strategic outcomes, cross-agency collaboration and innovation. This is a mechanism which prioritises and redistributes resources to Ministries with proposals for new and worthwhile projects on a competitive basis. Through the re-investment fund, the Government has provided $1 billion a year over the last three years to fund new Government initiatives. These include, for example, the ABC Waters Programme that is helping to transform our water bodies and parks into aesthetically pleasing and vibrant places that everyone can enjoy.

Secondly, value management. Value management is a process that seeks to achieve better value by scrutinising the specifications of large infrastructure projects upfront at the conceptual design stage. One such example is the Downtown Line 1 where the value management process yielded savings of about $200 million through the use of the most optimal method of constructing tunnels between the Chinatown and Cross Street stations.

Thirdly, the block budget manpower management framework and economy drive mechanisms, which are examples of measures designed to instil discipline over the use of resources by public agencies while according them maximum flexibility and autonomy to derive the best value from these resources. I would elaborate on the block budgeting system later on in my speech.

Further, MOF works closely with the public agencies to achieve higher productivity by pooling resources at the whole-of-Government level. For example, as a consumer, the Government aggregates demand for economies of

Sir, it is important for me to highlight that productivity improvements, in the context of the Government, also includes innovation and this is really at the heart of our productivity drive. MOF introduced a Public Sector Innovation Framework in 2008 to encourage experimentation, test-bedding and capability building within Ministries and statutory boards.

We are also seeking to enable productivity growth in the economy at large via partnerships with the private sector through the Co-Innovation Platform, and e-Government. I will again elaborate on these areas further in my speech.

Sir, let me now move on to Member Low Thia Khiang's question on the amount of information in the Annual Budget Books and how we strike a balance between budgetary autonomy and accountability. The primary purpose of the Budget Book is to provide the annual estimates of revenue and expenditure of the Government as required by the Constitution. In fact, the Constitution does not require the Government to publish programme descriptions in the Budget Book but MOF has chosen to include these, along with key performance indicators (KPIs).

Explanations for material changes in the Ministry's expenditure from the previous year can be found under Section III of the Budget Book entitled "Expenditure Estimates By Heads of Expenditure". The information provided in this section is intended to help readers

Sir, the Budget Book also includes KPIs which provide information on the agencies' achievement of objectives through their programmes. Over time, these indicators have evolved from being just input-based indicators to outcome measurements, wherever possible.

Recognising that the issues facing the public sector are becoming increasingly complex and intertwined, MOF has been working with Ministries to identify key strategic outcomes at the whole-of-Government level. And these will be published in the Singapore Public Sector Performance Report, which will be released some time this year. The report will provide an overview of how well the public service is collectively achieving whole-of-Government (WOG) strategic outcomes.

Furthermore, MOF has a Budget website to reach out to a wider audience. And in this website, you can find a write-up, summarising the spending trends of the year based on the four sectors of Security, Social, Economic and Government Administration. In addition, each Ministry publishes a summary of their spending highlights on this website.

Sir, let me now move on to elaborate how MOF's block budget system ensures

Compared to the line-item method of budgeting we practised in the past, block budgets accord Ministries greater certainty on the funding that they can expect to receive over a three to five year period. Furthermore, Ministries will take responsibility for optimising and re-prioritising their programmes within the allocated block budgets.

Notwithstanding these budgeting flexibilities, sufficient frameworks and checks have been put in place to ensure proper accountability of expenditures. Firstly, MOF reviews and evaluates the strategic expenditure plans for each agency on an annual basis against the desired outcomes set out. Secondly, major development projects require the approval of the Ministerial Development Planning Committee. Thirdly, Ministries are subject to the Manpower Management Framework, which limits the growth of their headcounts by the smoothened Resident Labour Force growth rate and this ensures that growth in public sector manpower does not outstrip that of the economy at large.

Next, the Accountant-General's Department undertakes regular Value-for-Money audits to assess programmes and

achieve social and environmental objectives. Thirdly, measures to aid businesses in their economic expansion and transformation. And, fourthly, preparing for the future through the next wave of e-Government innovation.scale through joint procurements. To illustrate, service-wide demand aggregation of contracts for the supply of fuel and office furniture led to cost savings of 12% and 20% respectively. Likewise, agencies can learn from each other's best practices and enjoy cost savings by coming together to develop shared IT systems and applications.understand how the sums voted to each Head of Expenditure have been appropriated. In addition, should Member Low Thia Khiang and Members wish to know further line item details of spending by Ministries, they can obtain the detailed information from the "Expenditure Control Document", copies of which are found in the Parliament Library. I wish to add that the three volumes totalled more than 1,500 pages. Over time, we have been providing more information, not less, contrary to the MP's assertion. Let me just show Members very quickly the Budget Books [holds up books]. These are two of the volumes, so it is quite a tome.an optimal balance between budgetary flexibility and accountability. At its core, block budgets, which have been the basic foundation of Singapore's budgetary framework for the last ten years, seeks to establish limits to Ministries' expenditure by capping their spending as a pre-determined percentage of GDP. These limits are tied directly to Singapore's economic performance, which is also the key determinant of Government's revenues. By pegging Ministry budgets to the GDP, MOF ensures that the Government, as a whole, spends only as much as it expects to collect in revenues on a sustained basis. projects of Ministries; and finally, the Auditor-General is constitutionally empowered to audit and report on the accounts of the Government and this includes reviews of key financial systems and controls.

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Sir, this House itself plays a role too. Parliament has its own Estimates Committee which scrutinises the Government’s Budget, questions the Government on its Budget estimates and processes for managing expenditure, and suggests improvements. Moreover, the Parliament also has a Public Accounts Committee which examines various accounts of the Government, including the Auditor-General’s Report.

Sir, let me now move on to optimising land assets. Member Cynthia Phua spoke about the need for Government agencies to be aware of the opportunity cost of using prime land for bus interchanges.

Sir, allow me to share some history behind bus interchanges. In the past, bus interchanges were built by HDB as part of its town planning and infrastructure provisions. Many are, therefore, located within the town centres so as to facilitate the transfer of passengers between trunk and feeder bus services.

Today, as part of its efforts to optimise land use, the Land Transport Authority (LTA) works closely with the Urban Redevelopment Authority (URA) and the Housing Development Board (HDB) to redevelop the bus interchange sites from stand-alone developments into integrated developments, for example, commercial development with a bus interchange on the ground floor. Such integration achieves the twin objectives of setting aside prime space within our estates for key infrastructure, while enhancing their value by capitalising on the steady stream of public transport

To determine the appropriate size for a bus interchange, LTA applies a set of space norms for the various components such as driveway and bus park lots. These space norms are reviewed regularly to optimise land take, while ensuring that operational requirements would continue to be met. This is an example of how the Government continuously reviews its land use to unlock the productive yield of our land assets. Every 10 years, URA also conducts the Concept Plan Review to plan ahead for the future so as to optimise land use, taking into consideration inputs from the various stakeholders. The Minister for National Development elaborated on this during the Ministry of National Development’s COS debate.

On MOF’s part, we have put in place measures that encourage the optimisation of land use and the realisation of maximum value. Land cost, at market rate, has been made explicit to Ministries through the application of the Resource Management Framework. Under this framework, public agencies are charged an imputed rent on the land so that they are mindful of the cost of the space of property they use. Should there be development potential beyond the current use – as a bus interchange in this case – Ministry of Finance would certainly review, with the public agency concerned, the possibility from an optimisation perspective. Next, on the management of Government investment companies. Member Inderjit Singh has suggested more conservative mandates for GIC and Temasek as their investment outcomes directly impact the reserves of Singapore.

Sir, in May 2009, in response to a Parliamentary Question, the Minister for

The respective boards of MAS, GIC and Temasek make their own decisions on asset allocation, but the Government regards the whole-of-Government assets from a holistic perspective. The Government regularly monitors and reviews the overall long-term performance and risk profile for the whole-of-Government assets, at various points in a market cycle.

Sir, moving to a more conservative mandate as a knee-jerk reaction to the recent downturn would not be prudent, as this could risk compromising the ability of GIC and Temasek to deliver long-term sustainable returns. And both GIC and Temasek have thus far delivered creditable returns.

It is important for GIC and Temasek as long-term investors to be able to maintain their long-term orientation and ride out market cycles. Nonetheless, the execution of their mandates, through specific investment strategies and approaches will evolve and adapt to structural changes in the investment environment. For example, while Temasek reiterated its focus on long-term value in the updated Temasek

The Government is also assured that the boards of GIC and Temasek have in place risk management frameworks and the proper processes to take risks prudently, while maintaining their long-term orientation.

Sir, Member Ho Geok Choo has requested for an update on GIC and its investments. Let me begin by noting that the recent financial market crisis brought about the sharpest stock market fall since the Great Depression. Investments of GIC as well as other investors worldwide were inevitably affected.

Nevertheless, as noted in the last GIC annual report released in September 2009, the GIC portfolio has recovered more than half of the losses sustained in FY 2008/2009, in line with the broad recovery of global stock markets since the market trough in March 2009. The performance of the portfolio will be updated after the audited full year results are ready. GIC typically releases its annual report in September/October each year.

The Government will continue to assess GIC’s investment performance over the long term, in line with our objective to grow our reserves in a sustainable manner.

As noted previously in this House, the Government does not judge the performance of GIC by individual deals but on its overall portfolio performance. In this regard, it is not the Government’s practice to discuss the performance of GIC’s individual investment deals.

I should add here that GIC takes very seriously every decline in the value of its

While GIC has made losses on some investments, in this case its investment in Stuyvesant Town/Peter Cooper Village, it has made gains on others. The only reasonable way of evaluating GIC’s performance is to look at how the losses and gains stack up and how its overall portfolio performs across market cycles.

Overall, both Temasek and GIC have so far delivered creditable returns on their portfolios over the long term as well as during the six-year cycle between March 2003 and March 2009, which marked the points of the dot-com bust and credit crisis – in other words from trough to trough. Sir, Mr Inderjit Singh has asked how the setting up of Seatown fits into Temasek’s overall investment framework. Seatown is a global investment company that is a wholly-owned subsidiary of Temasek with its own board and management. It is no different from Temasek’s other investment-related subsidiaries, for example, Fullerton Fund Management Company, which was set up in 2003 as an Asia specialist offering investment products and solutions to its clients.

As shareholder, the Government assesses Temasek on the performance of its overall portfolio over the long term. I wish to reiterate again that the Government neither influences nor interferes in Temasek’s investment decisions, which are guided by its own board and management. In this case, the board and management of Temasek have considered and approved the setting up of Seatown as part of its overall investment strategy.

Even if the proposal is for a company to be set up independently of GIC and Temasek, such an approach may not be the best way to nurture local companies. Rather, the Government should identify and bridge market gaps, where they exist, so as to support a thriving ecosystem of locally-based enterprises and leave the private sector to take the lead in identifying worthy investment opportunities. It would be neither sustainable nor appropriate for the Government to step in to finance local enterprises that cannot themselves locate private funding, since our ultimate goal is to nurture globally competitive companies.

Indeed, the Economic Strategies Committee (ESC) considered the matter carefully and sought to identify financing gaps in the market to nurture globally competitive companies. It recommended that the Government create conditions to catalyse, rather than supplant, private financing for SMEs in doing so.

The Government has accepted the recommendation and announced the co-investment programme as part of Budget 2010. Under this programme, the Government will mobilise up to $1.5 billion worth of growth capital by seeding a range of funds over 10 years, for which

First, I would like to provide some clarifications to Mr Chiam See Tong’s comments on property taxes for HDB flats. Sir, property tax is imposed on the ownership of properties in Singapore, including HDB flats and is based on the Annual Value (AV) of each property. Annual Values are determined yearly according to the prevailing market rents that each property can fetch. The property tax for HDB flats in a given year is based on market rentals data from the previous year.

The previous AV revision for HDB flats was carried out on 1st January 2008, based on rentals values in 2007. In 2009, the AVs for HDB flats should have been adjusted upwards because rentals had by then jumped by more than 30% through 2008 over 2007. However, the Government decided to defer the increase in AVs for HDB flats in 2009 in recognition of the weak economic outlook and uncertainties in rental trends at that time. The annual review of AVs for HDB flats resumed in January 2010.

HDB rentals have stabilised after a moderate decline from late 2008 to the middle of 2009, and have since begun to rise. As the current values of HDB rentals are significantly higher than levels observed in 2007, IRAS proceeded to raise the AV this year. Nonetheless, the Government has provided a one-off rebate to help HDB owner-occupiers adjust to the January 2010 AV revision. This was in the form of a 50% property tax rebate, with absolute amounts of between $50

With the new 2010 property tax rebate and the ongoing 1994 rebate, all one- and two-roomers will continue to pay no property tax in 2010. In addition, under the new progressive property tax regime just announced in 2010 which will take effect from January 2011, each HDB owner will enjoy tax savings of up to $240, arising from the exemption of the first $6,000 of AV. All HDB owner-occupiers will thus pay less in taxes. To recap, this new progressive system of property taxes for all owner-occupied homes will cost the Government about $230 million a year.

commuters. The redevelopment also allows LTA the opportunity to right-size the space required for the bus interchanges.Finance had explained to Members that there is a distinction between the investment approaches of Temasek, GIC and the Monetary Authority of Singapore (MAS). Let me just recap. The MAS is at one end of the risk spectrum. As a central bank, it is the most conservative, with significant holdings in liquid, mainly fixed income instruments. GIC is fairly conservative, with a globally diversified portfolio spread across asset classes, mainly in the public markets. Temasek is at the other end of the spectrum. It is largely an equity investor, a value-investor aiming at long-term returns. Temasek is exposed to significantly higher risk than GIC and MAS, but has also delivered higher returns over time as expected. In contrast, MAS will have more stable but lower returns over time.Charter released in 2009, it has increased its exposure in Asia, excluding Singapore, due to its belief in the deep potential of these markets. portfolio and in the value of individual investments. However, it is not realistic to avoid losses on every investment as that would require GIC to be completely risk averse. Next on Temasek II, Mr Inderjit Singh has suggested setting up a Temasek II to invest actively in locally-based companies. For GIC and Temasek, the Government’s position remains that they should continue to operate on a purely commercial basis in order to provide good long-term gains. Requiring Temasek or GIC to invest so as to fulfil other objectives would distract them from their respective mandates. In any case, Temasek is not precluded from making its own decision to invest in local enterprises where there are attractive opportunities and, indeed, it has done so, for example in its investments in Hyflux, Fraser and Neave (F&N) and Olam International.the Government will contribute up to half the capital or $750 million. A key feature of this programme is that it will leverage private equity expertise in evaluation, making and managing investments so as to ensure market discipline. Sir, I would now turn to the taxation issues raised by the various Members.and $120 per flat. This rebate cost the Government $88 million.

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Sir, it is not advisable, as Mr Chiam has suggested, to disrupt the regular revision of AVs as it would lead to a larger than manageable increase when accumulated. Instead, the Government will continue to explore possible forms of transfers, when necessary, to help the needy in a targeted manner.

Next, I would like to assure Members, Mr Cedric Foo and Mr Hri Kumar, that our current vehicle tax structure already serves to encourage the use of more fuel-efficient and environmentally-friendly cars. For example, road taxes, which are levied according to engine capacities, already favour smaller cars which tend to consume less fuel than larger cars.

We also provide the Green Vehicle Rebate (GVR) to encourage the adoption of fuel-efficient vehicles. This rebate is calibrated so that a typical hybrid car, which is greener and more fuel efficient, does not attract higher upfront ownership taxes than the equivalent conventional car – despite the higher Open Market Value (OMVs). The objective of the GVR is to

Currently, we impose a volumetric tax on petrol to discourage the excessive use of vehicles. Ideally, diesel should be taxed on the volume consumed as well. However, we have not introduced a volumetric tax rate on diesel used for vehicles, as diesel is also used for non-transportation purposes such as powering portable electricity generators. Instead, a special tax was introduced for private diesel cars as a proxy. This special tax also took into account the higher particulate matter emissions of diesel cars.

In Budget 2008, in recognition of the improved emission standards of Euro IV diesel cars, the special tax rate for Euro IV diesel cars was revised from four times the road tax to $1.25 per cc with effect from July 2008. And this in effect ensured minimal differences in fuel consumption costs between Euro IV diesel and petrol cars. For a typical 1,600cc Euro IV diesel car, this change translates to a reduction in the annual special tax of about $1,000.

In determining the special tax to be imposed on Euro V diesel cars, the emphasis should be on the desired outcome or performance of the car concerned rather than the technology. Thus, the Government will consider the fuel-efficiency and emissions standards for Euro V diesel cars relative to both Euro IV diesel and petrol cars. Furthermore, as Member Cedric Foo has rightly pointed out, the move should be towards a volumetric basis for charging rather than

Sir, next, let me address Member Penny Low’s suggestion of incentives for social enterprises, which are businesses set up to achieve social objectives, in order to let them flourish and in a bid for Singapore to be a hub for the rising Asia social investment dollar.

Sir, we also recognise and note the important role that the social economy can play. The question is what is the best way for the Government to support social enterprises. Ultimately we want to nurture social enterprises that have sustainable business models because these enterprises would then have the largest impact and the highest chance of succeeding in their social mission.

Giving social enterprises special tax privileges over conventional businesses will not help them to develop as sustainable and competitive businesses. Moreover, our social enterprise sector is still in its nascent stages. Most of our social enterprises are very small outfits and do not have significant amounts of taxable profits. Hence, further tax incentives beyond the generous ones that we already provide to our start-ups and SMEs are unnecessary.

Our focus has been on building up the competencies of our social enterprises to position them for sustainability, while not compromising their businesses’ competitiveness and resilience. Social enterprises can tap on seed funding from the Ministry of Community, Youth and Sports through the ComCare Enterprise Fund to cover start-up costs, including their training needs.

Sir, however, we recognise that there is scope to see how we can do more to help grow this sector. We will study the overseas examples which Miss Penny Low has described to see if there are models of Government support for social enterprises that are suitable for our local context.

Next, let me also address Miss Penny Low’s suggestion to promote greater philanthropy. We agree wholeheartedly with this. That is why, in Budget 2010, we extended the 250% tax deductions for charitable contributions, which means that Government is literally contributing up to 50 cents of every dollar donated to charitable causes. In fact, for the universities, the Government also provides one-for-one direct matching for donations, so that for every dollar received, the Government actually contributes up to 75 cents.

Sir, let me now move on to the pro-business Government initiatives. This year, the Government introduced a number of incentive schemes to spur productivity in businesses. Many Members have expressed similar sentiments to Member Jessica Tan's comment on the importance of keeping the application processes simple so that more businesses can truly benefit from the schemes.

Sir, MOF agrees that the incentive schemes must indeed be simple so that all businesses can benefit from them in an easy and timely manner, while ensuring that the schemes remain relevant to achieving the intended policy outcomes. I would like to assure Ms Tan that we will administer our tax incentives with this objective in mind.

Take, for example, the recently announced Productivity and Innovation Credit, which is an economy-wide initiative to spur all businesses to upgrade themselves and to invest in activities along the innovation value chain. This scheme is kept simple so that all

MOF has also taken the effort to ensure that the qualifying criteria for these deductions are clear, specific and not overly restrictive. This gives businesses more certainty upfront on whether a potential investment can qualify for the scheme.

The scheme also allows some businesses to convert their tax deductions or allowances into a non-taxable cash grant. To apply for this, a business only needs to fill in a declaration form at the point of claim at the end of the financial year. And again, this is done together with its annual tax filing. Upon receiving the form, IRAS will process the claim and credit the cash grant into the business’ account within three months.

Given that the Productivity and Innovation Credit is meant to be a broad-based scheme, the process will be much simpler than the targeted grant schemes, where businesses have to submit an application along with the supporting documents, pass through selection criteria and meet required commitments.

I would therefore like to reassure Member Jessica Tan that the Government has streamlined and will continue to streamline regulations, simplify processes and keep administrative costs low. Even though Singapore has been ranked first in the World Bank’s "Doing Business" Report for four consecutive years from 2007 to 2010, we do not take our ranking lightly

Sir, let me now move on to the cuts on EXIM bank. The Government reviews our policies to support enterprises regularly in response to market trends, new opportunities and gaps. As more of our companies go abroad and the scale of their overseas operations grows rapidly, it becomes imperative to address gaps in cross-border financing. And these are points which both Mr Inderjit Singh and Mr Teo Siong Seng have made pertaining to the Export-Import (EXIM) Bank.

Today, IE Singapore has a suite of financing schemes that support the internationalisation of our companies including the one that Mr Inderjit Singh has highlighted — the Internationalisation Finance Scheme (IFS), which provides support for asset and project financing overseas.

Fundamentally, our schemes today are market-enabled, leveraging on commercial banks to facilitate financing to companies through risk-sharing with the Government. There are, however, structural constraints to this approach, as support from our schemes is limited to the sectors and markets that the commercial banks have appetite for. Therefore, the development of a market-based institution for cross-border financing is one issue that the Government is studying very carefully to facilitate the next wave of growth. The study is expected to be completed in a few months’ time.

Sir, it is the right time to consider this as Mr Teo Siong Seng has noted: The number of Singapore companies internationalising has increased; and besides large companies, SMEs are internationalising more actively than before.

As we evaluate EXIM banks and Export Credit Agencies (ECAs) around the

Adopting a commercial orientation has other benefits besides sustainability. First, a commercially-run institution would be more responsive to the needs of its customers, including SMEs. For example, it would have the commercial incentive to ensure that its products and services meet the needs of its customers, or that the process to obtain financing is not too burdensome.

Second, as the institution develops expertise ranging from trade financing to internationalisation and project financing, it would also naturally want to expand its business to finance both exports and overseas operations and projects, as Mr Teo has suggested.

Third, we would expect a commercial institution to be constantly looking out to roll out new products and services to serve its customers better and to generate more revenues. And in doing so, it will catalyse innovation in the private sector market for cross-border financing. By drawing cross-border financing opportunities to Singapore, the institution will encourage existing players to strengthen their teams here while attracting new market participants.

Sir, next on the accounting sector, I agree with Member Ho Geok Choo that it is important to develop the accountancy sector to solidify Singapore’s position as a leading financial and business services hub in Asia. Having a deep competency in accountancy will enable the growth of our enterprises in and beyond Singapore.

Since 2000, the accountancy sector has generated contribution of about 0.4% of our GDP – similar to the legal sector’s contribution of annual value-add of about $900 million to Singapore. This is poised to increase in tandem with the surge in demand for accountancy services in Singapore and the region. The Asia-Pacific market alone is expected to be worth US$38.3 billion by 2013.

In December 2008, my Ministry established the Committee to Develop the Accountancy Sector (CDAS) to review the accountancy sector. CDAS, which comprised public and private sector representatives and accountancy professionals, plans to transform our accountancy sector into a modern, trusted and high value-adding Global Accountancy Hub over the next 10 years. The Committee’s strategy overlaps with Mdm Ho’s views that Singapore needs to enhance sector-wide professional capabilities and to develop a stronger international outlook.

level the playing field for green vehicles in our system for upfront vehicles taxes, and leave motorists to weigh the additional cost of green cars against their fuel savings in their buying decisions. Clean diesel cars are not much cleaner than petrol cars; although more fuel-efficient, they emit more particulate matter (PM). Moreover, the OMVs are not materially different from petrol cars.the existing fixed special diesel tax. As the Member has also noted, any such move would, however, require careful consideration of the transitional issues, which include not just taxis but also other public transport and commercial vehicles, and other off-road users.businesses, even the smaller ones, can understand and benefit from it. Under the scheme, businesses simply claim the enhanced deductions as part of their normal tax filing process. In general, no application is required. Businesses automatically qualify for these tax deductions so long as they spend on any of the six pre-stated categories of innovation-based activities.and will strive to ensure that we continue to be a favourite place to do business.world, we must, however, avoid replicating the experience of EXIM banks abroad where under-performance or political interference has resulted in long-term subsidies out of the Government’s budget as this is an approach we cannot afford. Instead, we should consider examples in countries like Hong Kong, Sweden and Canada, where EXIM banks or ECAs have clearly-defined mandates to operate commercially and to generate positive returns on capital. These institutions have independent, professional management and use specialist market expertise to assess risks and viability of projects. As a result of their ability to generate commercial returns, they can sustain their operations without Government subsidies. Hence, with such an institution in place, companies that go abroad – both SMEs and large companies – will have better access to financing support than today. While Mr Teo highlights shipping, any sector in which viable Singapore companies have competitive advantages would stand to benefit from this initiative.

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Today, many international professional bodies have established, or are establishing, their presence in Singapore. Within this context, the Committee is

Sir, merger and acquisition (M&A) activities should strictly be market-driven, and the recent announcements in the Budget are designed to help facilitate but not direct such corporate activity. Nonetheless, our accountancy sector can play an enabling role in M&A activities, as transaction advisory, financial due diligence and valuation. This, in turn, could further deepen the expertise here.

The Committee also hopes to develop Singapore into a leading global centre in Asia for accountancy professional development and education and to attract regional talents into Singapore. To help promote Singapore's sector internationally, the Committee is also proposing to anchor practice leaders and Centres of Excellence in Singapore. It would encourage regional and international work to be done from Singapore and to eventually build up a critical demand. CDAS will submit its recommendations to MOF in April 2010.

Sir, the Government will commit $450 million over the next five years to start a Public-Private Co-Innovation Partnership. This initiative is to spur private sector R&D by bringing together Government agencies and companies and co-develop innovation solutions.

Mr Zaqy Mohamad has sought further details on the scope and measures of success. Sir, the Co-Innovation Partnership will focus on innovations that can meet public sector needs, and which can eventually be exported to the region. For a start, we will look at areas such as urban mobility, energy efficiency and environmental sustainability.

We would seek to increase the number of public-private collaborations, and innovative products and services. However, we will not just focus on numbers. The Government recognises that risks are inherent in the innovative process and accepts that not all collaborations may succeed. However, the emphasis should be on creating opportunities for public and private sectors to innovate together.

Last but not least but still on the theme of innovation, Members Zaqy Mohamad and Muhammad Faishal Ibrahim have asked how MOF is responding to the rapidly changing ICT landscape to meet the needs of increasing sophisticated Singaporeans.

Sir, on the iGov2010 masterplan, many of the integrated Government projects are still in progress and will only be completed over the next one to two years. I would just like to highlight that the operative word is not consolidation but integration, where agencies with similar needs come together to jointly leverage on technology to achieve better outcomes. There is a whole range of integrated Government projects and some are smaller scale ones which SMEs can be involved in.

Sir, MOF notes that our citizens are becoming increasingly Internet-savvy. They are used to accessing information and securing services over the Internet. They are comfortable with downloading music and applications using iPhones and other mobile devices. Many are also socialising and sharing resources on

In fact, with emails replacing snail mails as a main mode of communication, some customers expect Government replies and actions to be instantaneous and, moreover, favourable, failing which they will become demanding or even unreasonable.

As much as we would like to, it is not always possible for Government agencies to satisfy all their customers. Also, big statutory boards like LTA and IRAS each receives tens of thousands of correspondences in a month. It would be impossible for their CEOs to reply to each one personally.

Sir, allow me to give you one such example of someone who emailed the LTA repeatedly, to insist that the stretch of road in front of his house be re-surfaced instead of being patched locally. Now, road re-surfacing is expensive and should be undertaken judiciously. LTA explained this to the writer, but he did not accept LTA's explanation. He then replied with phrases like, I quote,

"Mr Yam, I would like you to personally reply to this email of mine and explain to me and the residents why LTA would not want to re-surface such and such a road completely. And please do not hide behind your staff to get them to respond on your behalf."

LTA acknowledged his second last letter and promised to reply soon, but this only met with further unhappiness. Again I quote:

"I would like my resolution letter from LTA to be responded personally by Mr Yam Ah Mee. For your information, I am a CEO of a large financial services company, and I will always take it upon myself to respond and sign off any letters/emails if they require my personal attention."

For the CEO of LTA to personally respond to thousands of mails would be impractical as well as highly inefficient for the organisation. What matters, or should matter, is for the CEO to ensure that there are proper internal processes to give timely, considered responses to citizens.

Sir, please do not get the wrong impression that we have a lot of demanding customers. We have many customers who appreciate the services of our public agencies. Many have in fact written in to express their heartfelt appreciation for our agencies' attention and service standards. Our public officers are encouraged by these letters of commendation and will try even harder to serve their customers better. I have provided this example to illustrate the ever-rising expectations of the public, which has been fuelled by technology.

The Government will always endeavour to improve on its service standards. However, whether it is the public or private sector, we know that good customer behaviour begets good service. Let us work together to develop a culture of good customer behaviour and good service delivery.

With your permission, Sir, I will ask the Clerk of Parliament to distribute the handout. [Handout distributed to Members.]

As I have just mentioned, the Government is committed to improving our public services to delight our customers and to keep up with new technological trends. To support this role, the Government will also evolve from being just a public services provider to a platform provider. It will set and referee the rules in the ecosystem to allow the enterprises or individuals to freely

For example, the Government can facilitate the discovery and use of publicly-available Government data by putting them on a central portal for downloading in machine-readable formats. A common map platform can also be provided to share Government geospatial data.

Sir, we are mindful that this move towards a "Government-with-You" model does not rely on technology alone. On our part, public officers need to embrace a new mindset that some services can be developed and delivered more effectively through collaboration with the public.

Sir, to sum up, MOF has taken a comprehensive approach in addressing the multiple challenges and opportunities ahead of us. On the expenditure side, we have devised programmes and initiatives to make sure that our resources are carefully allocated to worthwhile projects and, second, efficiently used to achieve the intended objectives.

We will also use our tax regime to help promote social and economic objectives. We strive to keep our tax regime competitive to give businesses and individuals incentive for enterprise and effort, and support economic imperatives at different phases of our development. We also keep our overall system of taxes fair, so that everyone pays some tax but the better off pays more.

By adopting a "Government-with-You" approach, MOF seeks to work closely with businesses and citizens to further create new value. We recognise that some of the best ideas are out there in enterprises and the wider community, and

recommending to strengthen the Institute of Certified Public Accountants of Singapore (ICPAS) into a global professional accountancy body; and to develop a post-graduate structured professional accountancy qualification to strengthen and broaden the talent pool of accountants. In addition, to add to the richness of services that Singapore can offer, the Committee intends to develop and build distinctive niches and specialisations such as Chief Financial Officers, internal audit services and valuation.Facebook. Our citizens now expect the same convenience and easy access in their dealings with the Government. And for good measure, he copied his latest email to the Prime Minister.innovate and create value-added services. In other words, the delivery model will change from "Government-to-You" to "Government-with-You".thus would be adopting a collaborative approach to create new services for our people.

I can only take a few interventions because there are a few Members – Mr Low Thia Khiang, Mrs Mildred Tan and Miss Penny Low – in that order, if we have time.

Sir, the Minister referred to the two books that she had. If I am not wrong, one of which is called Budget Highlights. She referred to the annexure. But the figures in the annexure were global figures. What I am asking for are figures which could provide certain depth so that we can understand the expenditure at a certain level. She refers also to the budget control document. Yes, I have seen it. This thick – two volumes and the words are very small, and I think it is too much to chew. I would expect and I hope MOF can provide a budget book which is, at least, with certain depth, rather than superficial information like what the annexure provides. She also said that there is a Public Accounts Committee which would look at the Ministry of Finance's expenditure. I would like to say that, so far, I have not been a Member of the Committee, and I believe that the Committee, most of the time, comprised PAP Members.

Mr Chairman, Sir, I am slightly confused by what Mr Low truly wants in terms of detail because he had asked for more specific line item details to which I have duly pointed out the direction. And then, he goes on to say that those were too many details. Let me just explain that the way we have organised information is really to make it as easy as possible so that in the main Budget Book, one gets a good overall view of all the different Heads. And if one were interested in the line items, one can go on to the two control documents. In addition, the Budget Highlights that he

As regards his comments about the Public Accounts Committee, the Public Accounts Committee is appointed by the Committee of Selection so that is strictly up to the discretion of that Committee.

has referred to really provides also some of the summaries and highlights. If at all, I would think that people will be complaining about overload of information rather than under.

Sir, I thank the Minister for a comprehensive explanation on the Budget and how it works. Can I ask the Minister of Finance about the two points that I had raised earlier during the Budget debate, that of the inclusion of a organisation design for tax deduction and the withholding tax for mega events?

Sir, for process and organisational redesign, indeed, they can be instrumental in many companies to improve enterprise productivity. However, the challenge is in defining what exactly would be classified as process of organisational design for tax deduction purposes. I would go on to add that to implement most of these organisation redesign initiatives, businesses often have to acquire new equipment to automate the new processes, train their employees, to reskill them, and both these activities would qualify anyway. So they should adequately cover what the Member has suggested.

As regards the exemption for mega events of the withholding tax, to attract more international rated acts, performances and so on, the Government has reduced the withholding tax of non-resident public entertainers from 15% to 10% for five years from Budget Day. Our withholding tax rate for royalties is already low by international standards at 10%. And Singapore has a wide network of tax treaties that can actually reduce the rate even further, such as to 5%. In addition, organisers of approved events

can also apply for direct grants from STB under the Tourism Development Assistance Scheme, particularly under the Business Events in Singapore Scheme.

Sir, I want to thank the Minister for distributing this which I think it is a very good example of how the private sector and the public sector can work together. In conjunction with that, I would like to also get her comments on my suggestion during the main Budget speech on the "Wiki Me" idea which is really a seamless collaboration between the public sector and the people sector.

Next, I would also like to seek clarifications from the Minister, first, by thanking her for her support for the SE sector. And I agree with her that many of the SEs are relatively small at this moment. But I wonder if it is a chicken-and-egg question, given that there are a lot of very good, potentially big SEs, that are actually chopped off by the lack of access to finance at the moment. In the past few years, more than 200 SEs have been established in Singapore and more are coming on-stream.

Last but not least, on the IPC's tax incentives that are available for charities, the point here really is that most SEs seek double bottomline which means financial sustainability as well as social returns. And because of that, many of them do not want to establish themselves as charities because charities are inherently a handout approach. They want a hand-up approach.

By asking them to apply for charity status so that they can qualify for the 250% tax incentive, it would actually be a "slap in their faces".

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I wonder if the Minister could consider studying the examples that are given and also think about what could be adapted to suit the local context.

Sir, indeed the Wiki-Me could be a useful initiative to build community self-help and bonding. In fact, we note that today some 8,000 residents in Sengkang are already turning to sengkang.com to get to know their neighbours, organise activities and provide useful information and tips ranging from renovation to neighbourhood safety. And there are many such active digital "kampungs" created by spirited residents. In fact the Straits Times noted that there are at least 10 such "kampungs " serving the various estates.

The Government would be happy to support such initiatives and we welcome suggestions on how we can facilitate the process of getting such active community involvement. For a start, the digital "kampungs " can make use of the common map platform to provide map-based services when the platform is ready. This is indeed a good example of the type of collaboration under the Government-With-You approach that we would like to undertake. As regards the question on Social Enterprises, I would like to confirm that we would continue to study the different forms and to see how best we can promote social entrepreneurship here.

Sir, this is a very short clarification. The Minister has yet to respond to my Budget suggestion on Town Councils asking for the Productivity and Innovation Credit. Can the Minister let us know whether she is agreeable to extending this credit scheme to the Town Councils?

Sir, all tax-paying entities can claim the enhanced deductions on expenses under the Productivity and Innovation Credit Scheme that they incur to produce income. The cash conversion option, however, is only available to companies, partnerships and sole proprietors with at least three local employees. This is because the intention