Health for All, All for Health
Mr Deputy Speaker, I rise in support of the motion.
2. I want to thank Dr Tan Yia Swam, Dr Shahira and Mr Abdul Samad for tabling this Motion, and pointing out passionately that health is everyone’s concern, and it is only with everyone’s action that we can improve the health of individuals and of our nation.
3. I would also like to thank all the MPs and representatives of Ministries who have, through your speeches, supported the various health-related policies and given suggestions for improvements.
4. This includes Healthier SG – our preventive care strategy –, championing the well-being of our healthcare workers, developing more centralised IT systems, group-buying of drugs with private doctors, ensuring that healthcare remains affordable for everyone, etc.
5. Members have also raised a range of challenges and frustrations of the healthcare system. Indeed, healthcare is probably one of, if not the most, complex systems in our whole public service.
6. It will be unrealistic of me if I were to say we have a solution to every problem that you have raised. Even if we have, theoretically, it is not practical to implement them all. We will need to work within the budget and time resources we have, our management bandwidth to plan and effect change, our people’s appetite to accept changes. We have to improve step by step.
7. What we will do is to prioritise the areas that we can make the most meaningful changes, where there is bang for the buck and focus on them, and this is what we are doing.
8. Hence, we are focusing on expanding our healthcare capacity which includes manpower, rolling out Healthier SG, and building up an effective system for ageing in community. Together, they represent a major transformation of our healthcare system in the medium term.
9. But before I talk about these priorities, let me first address three specific issues on healthcare that were raised by Members – manpower, financing and, as Professor Jamus Lim just raised, healthcare capacity.
Healthcare Manpower
10. At the heart of any healthcare system are the workers. Several MPs such as Dr Tan Yia Swam, Ms Janet Ang, Dr Wan Rizal, Mr Gerald Giam, Mr Abdul Samad, and Mr Raj Joshua Thomas have spoken about the issues confronting them.
11. We have to support healthcare workers as much as we can. The National Trades Union Congress (NTUC) and Healthcare Services Employees’ Union (HSEU) have been fervent supporters for the welfare of healthcare workers. Ms Thanaletchimi, President of HSEU, used to be an NMP in this House and had spoken about it many times.
12. The partnership between the People’s Action Party government and the Labour Movement is a strong institutionalised arrangement, and the Ministry of Health (MOH) looks forward to our continued partnership in advancing the welfare of our healthcare workers.
13. An important part of this work is to regularly review remuneration of healthcare workers, to ensure that we recognise the contributions of the workforce and make sure remuneration is competitive. Mr Leon Perera suggested some benchmarking. We will internally benchmark not just the pay but also taxes, because they vary across countries, and living conditions and rental rates. But I suggest we do this internally, because competition is now so tough, and we do not want to show everyone our benchmark. But certainly, we want to set benchmarks and make sure we are competitive. Right now, rental becomes a problem for foreign nurses coming to Singapore, and out-of-pocket expenses are high. These are some things we need to address to make sure that we are competitive.
14. Of particular urgency now is to actively recruit both local and foreign healthcare workers to boost the workforce, given the rising attrition suffered in the last two years due to the COVID-19 pandemic.
15. For local healthcare workers, we are looking forward to the inflow of the latest batch of polytechnic graduates who have just graduated and will be joining the workforce and our hospitals soon.
16. On Mr Abdul Samad’s feedback about interns not getting paid for their internships, I would like to clarify this: All Institute of Technical Education (ITE) and polytechnic nursing students are given allowances for their internship attachments.
17. However, for certain healthcare-related courses, such as Biomedical Science, allowances are an arrangement left between employers and the school to set, and practices can differ across healthcare institutions.
18. Given feedback, let us look into the specific instances where our public health institutions do not offer internship allowances.
19. As for foreign healthcare workers, it takes time to conduct selection and examinations overseas, and for the shortlisted candidates to move here. They have so far been trickling into Singapore, but we hope in the second half of the year, more of them will start to come onboard.
20. For those who have performed well and are committed to Singapore, we welcome them to apply for Permanent Residency (PR). A few MPs have suggested granting PR status to their dependents as well. We thank the MPs for your suggestions which is worth serious consideration.
21. For everyone in our healthcare workforce, we will need to ensure their well-being. I am glad many MPs spoke up against abuse and harassment of healthcare workers. This is one of the top issues in the minds of our healthcare workers.
22. In general, to be fair, the regard for healthcare workers and their well-being has generally gone up amongst our society post COVID-19. The majority of the public are appreciative and respectful towards our healthcare workers.
23. Those who physically assault, threaten, or hurl vulgar and condescending remarks against healthcare workers are, I think, a small minority. But because their acts are so egregious, their acts feel like a big thing and are a big thing, and we cannot tolerate such behavior. This is unfair to healthcare workers, and unfair to the great majority of the public who respect our healthcare workers.
24. As Members know, MOH has recently announced a zero-tolerance policy against abuse and harassment of healthcare workers. We intend to translate this to procedures and guidelines in all our public healthcare institutions in the second half of this year. I will not elaborate on what it entails as I have spoken about this before.
25. Since the announcement of the policy, I have noticed some reactions. The best is that most members of the public support the policy.
26. A few raised concerns that there were occasions where healthcare workers did not behave appropriately. We acknowledge that. There are always a minority of black sheep, but there are appropriate channels to report such matters, and the hospital management will look into them seriously.
27. Some have said some of the root causes of abuse is the heavy workload at the hospitals and long waiting times, and therefore we should address that first. We are doing what we can to alleviate the situation at the hospitals post COVID-19. It will take time. But heavy workload cannot be an excuse for anyone to physically or verbally abuse our healthcare workers. Mr Raj Thomas mentioned that another reason is that expectations are high, and when they are not met, people get upset. It is alright to have expectations and to demand good service. By all means, do that, but there is no need to abuse healthcare workers should expectations or service delivery fall short, .
28. I should say that notwithstanding the heavy workload, and the occasional abuse and harassment, most healthcare workers I have met remain professional, positive and passionate about their jobs.
29. Ms Koh Fang Qi, for example, was a senior staff nurse in Khoo Teck Puat Hospital since 2015. She has now become a Nurse Manager. Over the years, she had dealt with many abusive patients and next-of-kin, but she had continued to calmly handle each one with empathy and became an expert in this field.
30. Once, she witnessed a junior nurse being abused physically and verbally by the next-of-kin of a patient. So she bravely stood up, managed the situation, escalated the incident for the authorities for follow-up, and remained calm throughout the incident.
31. Despite all these challenges, you can tell she loves her job. She continues to treat patients and their loved ones with care and kindness. She constantly shares her knowledge and experience dealing with abuse cases with her colleagues.
32. The test of the zero-tolerance policy is in the second half of this year, when we have guidelines and empower supervisors to disengage abusive patients or, most likely, their next-of-kin. I do expect some to write to the Ministry to complain about why some supervisors or nurses act this way. We will be very careful. We will make sure that we will effect the consequences only for the most genuine cases and care will always be prioritised. Should I get a complaint, I will back our ground supervisors and healthcare workers.
33. Should they come to this Chamber, because I think some of the residents will complain to their MPs about MOH’s treatment of them, I hope that when the time and the test comes, to have the support of this House. We will be careful and we will do it judiciously if we ever have to disengage abusive patients or next-of-kin, so I seek the support of the whole House.
Healthcare Financing
34. Next, let me move to healthcare financing. Mr Leong Mun Wai made a few points yesterday.
35. I am glad he agreed with our policy to use MediFund to support low-income families. The MediFund disbursed $164 million in FY21, not $100 million as stated by Mr Leong yesterday. Government further topped up MediFund by $1.5 billion in FY23.
36. However, Mr Leong also delivered a political statement yesterday. He declared the Progress Singapore Party’s (PSP) position that Government ought to spend more in healthcare like other Organisation for Economic Co-operation and Development (OECD) countries.
37. Let me make a few points in response.
38. First, it is widely known that spending more on healthcare does not mean better health outcomes. Most health economists will know that. Since Mr Leong is benchmarking ourselves against OECD countries, let us cite two examples, US and UK. They are spending about 17% and 10% of their Gross Domestic Product (GDP) on healthcare, compared to our 4%.
39. Yet, US and UK continue to face high incidence of chronic illnesses, high obesity rates and their expected lifespans are lower than Singapore. It is quite well known that in the US, healthcare is very expensive, despite spending 17% of their GDP. In the UK, the National Health Service (NHS) is crushed by the workload. The waiting time is far longer than in Singapore, despite spending 10% of their GDP on healthcare.
40. We have delivered good health outcomes given what we are spending.
41. Second, for whatever we are spending, we are able to make healthcare affordable for middle- to lower-income groups.
42. Today, about 7 in 10 Singaporeans in subsidised wards do not have to pay any out-of-pocket expenses; 8 in 10 pay less than $100 cash out-of-pocket; 9 in 10 pay less than $500 in cash out-of-pocket.
43. So when Mr Leong asked the Government to spend more to lower out-of-pocket expenses further, he really meant to channel resources to unsubsidised patients – those staying in A class wards or private hospitals. That is where the big bucks and big expenditure are and they will push our healthcare spending to the levels of OECD countries.
44. Third, while Mr Leong asked the Government to spend on healthcare, he failed to mention that government expenditure ultimately has to be raised from the people through taxes. Mr Leong had not made any mention of where PSP will get the funding from.
45. Fourth, the fact is that we are already spending more and more on healthcare. We do not need Mr Leong’s urging. Healthcare spending is going up. In the decade after 2010, our nominal government health expenditure tripled. In the following decade, up to 2030, it is expected to triple again. So it will increase by nine times over 20 years. This is driven by an ageing population, which is also getting sicker. MOH already has the second largest Ministry budget after the Ministry of Defence.
46. In the coming years, our challenge is not to spend more, but to ensure we do not go the way of many OECD countries, with the healthcare fiscal burden spiralling and escalating out of control.
47. Finally, it is therefore much better that we continue with our sensible and practical approach. Have different layers of safety nets – subsidies, MediShield Life, MediSave and MediFund – S+3Ms approach, which has worked quite well.
48. We now combine this with a very important strategy in Healthier SG and our effort to enable ageing in communities, so that we can avoid sickness, and reduce our disease burden even as our population ages.
49. Mr Leong also talked about the seemingly large balances in the Pioneer Generation (PG) and Merdeka Generation (MG) funds, and concluded that more subsidies can therefore be given to PG and MG members.
50. His understanding is misplaced. Both funds were sized based on the projected lifetime cost of the benefits, and accounting for inflation and interest accrued.
51. To illustrate, the oldest and youngest MG member is 73 and 64 years old. PG members will be at least ten years older, with the youngest at 74 years old now. They still have quite a bit of runway ahead of them, and we expect many of them to live until 90 or 100 years old. Their lifetime benefits need to be funded from the two MG and PG funds. The Government will continue to regularly review their adequacies of these two funds.
52. The third issue is healthcare capacity that Professor Jamus Lim just raised. We agree that 80% to 85% occupancy rate is probably ideal. You do not need an engineer to conclude that you must have redundancy in your system; it is not a new concept, it is something I think we all agree to. But why is there a crunch now?
53. First, there will be a crunch during COVID-19. It was an emergency and a crisis of a generation, I do not think any country or any system can plan for that kind of capacity to cater to a crisis.
54. But I think post-crisis, we do have a crunch today. I explained in this House before during the White Paper debate on COVID-19, that the main reason for the crunch is that within a very short span of two years, the average length of stay has gone up significantly. It used to be 6.1 days, now it is 7 days. That is more than a 15% increase, which means that utilisation has gone up by 15% over two years, post-COVID-19.
55. It is a post-COVID-19 phenomenon. I think in time, researchers and clinicians will study why, but there could be a few hypotheses. One is some kind of immunity debt. More seniors are getting infected with viruses and bacteria post-COVID-19. When they do, they fall quite sick and stay in hospitals for quite long, pushing up the average length of stay.
56. Another possible reason is that during COVID-19, too many seniors decided to hide at home, afraid to come out. There were no more community activities, which are so crucial to keep them healthy. With social isolation, their health deteriorated, they get infected, and they stay in the hospital for very long.
57. The 15% increase in utilization alone explains why we have a crunch now. It is happening not just in Singapore, but all over the world. All of us agree we must have redundancy, but are facing a crunch, in OECD countries especially, despite their higher bed to population ratio.
58. What do we need to do? First, catch up on the capacity. Many of our projects have been delayed due to COVID-19. We have to catch up but some things cannot be rushed. We just have to implement them.
59. Sometime this year, the Integrated Care Hub at Novena will open and add a couple hundred beds. The Woodlands Integrated Health Campus, by end of the year, may have one ward open, with more wards hopefully opening next year. We also have the redevelopment of Alexandra Hospital. Regarding the Eastern Regional Hospital that Professor Jamus Lim talked about, we have a redevelopment of the Singapore General Hospital campus that is ongoing. Although it is an existing campus, it is a significant redevelopment with many more beds added.
60. Two, build more Transitional Care Facilities (TCFs). As I explained before, they are very useful. Today there is still quite a number of seniors staying in our hospitals, not because of medical reasons but because of social reasons. TCFs have rehabilitative care and good medical facilities, and we can allow those who are stable to move to TCFs, thus freeing up the acute beds. We are building that up quite actively.
61. Third is recruitment. Although it is very competitive, Singapore continues to be an attractive location for foreign nurses who want to come to Singapore. The healthcare profession continues to be quite attractive to our locals as well. Today, one in 25 students will join nursing. That is not bad at all, considering the number of options they have. I think we are getting our fair share of local talent and we are competitive in hiring foreign nurses. But of course, I hope the House, having raised all these issues, will support the necessary steps that we need to take in order to recruit local as well as foreign nurses.
Everything Did Not Happen, Everything Has Happened
62. Let me come back to the substance of the Motion. It is an important Motion, urging a whole-of-Government approach to support healthcare, even after the COVID-19 crisis has passed.
63. Our public service has a long history of inter-agency collaboration. But COVID-19 was special. It was a period when we witnessed the tremendous potential of inter-agency co-operation, united in a common objective to overcome a national crisis.
64. Our schools kept education going and shifted to home-based learning only for a couple of months. Our economic and social agencies worked together to support businesses and workers. Various agencies got together to set up quarantine, testing and community care facilities.
65. I cannot emphasise enough how much that meant to the hospital system, which would have otherwise bore the full brunt of the pandemic and we would have likely collapsed.
66. Recently, a well-known Chinese infectious disease expert, Dr Zhang Wen Hong, after he observed how life in China has gone back to normal during the May Day Golden Week, he wrote a blog and said, I quote, “it was as if nothing had happened, yet everything has happened.” In Chinese, 一切都没发生，一切都已发生。
67. It was a rather poignant expression of the post-crisis state of mind, which may be relevant in Singapore, and relevant to today’s debate.
68. We do not want to hang on to and relive the crisis. We need to walk out of its shadows, put it behind us and look into the future.
69. Yet, so much has happened. The experience and lessons learned will reshape the way we look at healthcare and inter-agency collaboration. Those cannot be forgotten and cannot go to waste.
70. So I share Members’ hope, that while the crisis may be over and peacetime workload resumed, it cannot be business as usual. We should usher in a new era of even tighter inter-agency collaboration.
Health for All
71. This is especially relevant to healthcare, for two reasons.
72. First, as I have explained, ageing is probably the biggest social transformation for Singapore in the next ten years, as we become a ‘super-aged’ society.
73. This will have implications across multiple policy areas – in employment, economic competitiveness, retirement adequacy, urban planning, education and healthcare. It will draw Ministries together to work in concert.
74. Second, post COVID-19 crisis, we have decided that the conditions and timing are right for us to effect a major healthcare transformation, building upon all the work that was done in previous years.
75. I have explained in this House why and what we are doing in this transformation. Essentially, healthcare needs to go beyond treating sickness in hospitals and clinics but creating health in homes and communities. In other words – health is not just relevant to patients who have fallen sick, Health is for All.
76. That is why we now regard the healthcare system as three inter-linked systems. If I briefly recapitulate:
77. Ms Janet Ang has just explained this earlier. First, the acute care system, which is essential in ensuring that those who are sick get treatment.
78. Second, the population health system, which we are building up through Healthier SG. We are mobilising all our family doctors and GPs, to focus on preventive care that is anchored in the community.
79. The third is the Aged Care System. The default for aged care cannot be nursing homes, or seniors living alone with no social support.
80. In other countries, loneliness and social isolation of seniors have become an epidemic. We also see this happening in Singapore, it is one of the reasons why the length of stay at hospitals has gone up, and especially after COVID-19. I think we can do what Mr Yip Hon Weng suggested, to integrate care across medical and social realms.
81. We need to urgently step up these whole-of-society efforts to enable our seniors to live their golden years in dignity, age actively in their community with their friends and family, involve them in activities, including training programmes like what Mr Mark Chay has suggested. And if they wish, to leave well in a family environment surrounded by their loved ones. This aged care in community is the next major area of work in healthcare.
All for Health
82. To make “Health for All” possible, we need the contribution of every stakeholder, public or private. When healthcare is mostly about treating sickness, it falls mostly under the domain of hospitals. But when healthcare is about creating health and caring for people in their homes and communities, it becomes everyone’s business.
83. Hence, in order to realise “Health for All”, we also need “All for Health”. I think this is really the spirit behind the motion put forward by the Members.
84. In particular, the following stakeholders can make significant contributions to health:
85. First, employers. I thank Dr Tan Yia Swam for speaking on this. Many of us spend a considerable amount of our adult lives at work, and hence the workplace is highly influential in shaping our health habits.
86. I value our existing partnerships with NTUC, Singapore National Employers Federation and the Tripartite Oversight Committee on Workplace Safety & Health (TOC) who have been working with companies to promote good workplace health practices.
87. With Healthier SG, employers can work closely with your panel doctors to join Healthier SG, and continue providing regular and proper screenings for employees, healthier canteen food, physical activity and mental well-being programmes, and better work-life balance.
88. We also urge employers to play their part in making sure those eligible are all part of Healthier SG. By promoting good health, employers will have more productive and happier employees, which is good for businesses.
89. Second, community partners. SPS Eric Chua has shared about the Ministry of Culture, Community, and Youth’s (MCCY) efforts to mobilise the community to foster social cohesion, promote health and develop a strong partnership with family doctors.
90. Dr Tan Yia Swam also suggested the need to have activities that cater to different segments of population and their varied interests.
91. Indeed, when we consulted the public for Healthier SG, we heard from many residents that peer and family influence is a key factor in motivating them to adopt healthier life habits, such as regular exercise and to eat healthily.
92. Under Healthier SG, our healthcare clusters will work with community partners, such as HPB, PA, SportSG, to proliferate physical activities in the community, and encourage strong participation by residents.
93. We welcome other grounds-up initiatives and activities that rally the community.
94. If we take a walk in public parks today, we can spot many of these activities, not organised by any agency. Friends getting together to run, cycle or play football, masters teaching their disciples qigong or tai-chi – all of them are now part of the holistic healthcare system.
95. Third, schools and education institutions. I thank MOS Gan Siow Huang on speaking about the Ministry of Education’s (MOE) efforts in building this health foundation for our young.
96. Indeed, good health starts from our values, habits and choices. Our schools help to build this foundation of health literacy. They introduce our young to sports, help them make friends and form social groups, teach them life skills and knowledge to be useful citizens – all of which are essential building blocks for good health.
97. As mentioned by MOS Gan Siow Huang earlier, through the years, MOE has worked with MOH to thoughtfully infuse health education in its curriculum from early childhood to primary, secondary and tertiary education.
98. Research findings now show that good health habits, such as proper diet and use of devices, inculcated from young – as young as three or four years old – have a profound impact on the cognitive development and well-being of the child later on in life.
99. MOH, MOE and the Ministry of Social and Family Development are studying the linkages between early education and health and developing possible interventions.
100. Fourth, the media. Information and media literacy is our first line of defence against false and viral health myths. We will continue to work with the Ministry of Communications & Information and other media agencies to do this, just as we did during COVID-19 to dispel falsehoods about vaccination.
101. Healthier SG gives us an opportunity to address the problem of health misinformation. This is because we are advocating and trying to build strong patient-doctor relationships. With a trusted relationship, and the family doctor and his care team knowing the health condition and health history of the patient, they become the patient’s trusted source of medical information and advice.
102. In this digital era of information overload, online falsehoods and myths, and artificial intelligence (AI) bots, perhaps what we need in healthcare is stronger human relationships, especially between doctors and patients.
103. We can use technology to strengthen the relationship and improve the quality of care, rather than replace the human relationship. That must ultimately be the mode of co-existence between humans and AI.
104. And finally, our infrastructure and transport planners. Over the years, Ministry of National Development and Ministry of Transport colleagues have expanded green spaces, cycling paths, and fitness corners island-wide to support active living. There are also plans to have more Silver Zones and Green Man+ at pedestrian crossings to allow our seniors to travel more safely and with confidence in their neighourhood.
105. These are many examples of how agencies are coming together to better support health, and we are committed to continue doing so.
The Chamber’s Heart for Health
106. Mr Deputy Speaker, let me conclude.
107. I am mindful that our NMPs are coming to the end of your term. This is perhaps your second last sitting. I know some of you hope to have the assurance that even as you step down, the issues close to your heart continue to receive attention in this Chamber.
108. So I feel honored and privileged that you have chosen to table a Motion on healthcare, just as you have actively been speaking up on healthcare issues during your term.
109. In particular, Dr Tan Yia Swam, who was also the President of the Singapore Medical Association (SMA), has been a strong advocate for various healthcare-related issues.
110. I attended an SMA dinner some time ago, hosted by her. In her speech during that event, she said that she was an angry young doctor, and now she was a less angry middle-aged doctor. The difference was that she learnt how to channel her energy to a greater good and be a better advocate.
111. I say Dr Tan is doing a good job, both in SMA as well as in this House. But I do not think Dr Tan is angry. It is important that we are passionate in our cause and be active in our advocacy.
112. I greatly appreciate this Motion, highlighting the need for MOH to work with other agencies, and for other agencies to support us. Today, we got MOE and MCCY Political Office Holders to deliver their speeches, but we could have gotten many more. Ageing is going to be the big challenge that affects all of us and MOH cannot be alone in this.
113. The passion and activism of our NMPs help uplift the standard of debate in this House, and bode well for the democratic discourse of Singapore.
114. Please rest assured that the issues close to your hearts will continue to be given due attention in this House, even as your term comes to an end. There will be a new batch of NMPs who are passionate and take up the issues that you care about. There will be the MPs who are healthcare professionals, GPC members for health, Labour MPs and NMPs, Members who feel strongly about healthcare, who will carry the torch forward.
115. Most importantly, the MOH Political Office Holders will continue to put forth our agenda and address the concerns of our stakeholders. We are not on different sides. We are all on the same side trying to make the system better for Singaporeans. For our NMPs, after you step down, we hope you will continue to advise and cheer for us at the side.
116. Let us all continue to advocate for a better healthcare system for everyone, so Health is for All, and All is for Health. Thank you.