Committee of Supply – Head O (Ministry of Health)

The Chairman: Head O, Ministry of Health. Dr Tan Wu Meng.

Health and Care – Supporting Our People

Dr Tan Wu Meng (Jurong): Mr Chairman, I beg to move, "That the total sum to be allocated for Head O of the Estimates be reduced by $100". I declare that I am a medical doctor in a public hospital.

Sir, in the Budget debate, I spoke about preparing for the next pandemic. Today, I will speak on delivering healthcare to our fellow Singaporeans and supporting our sisters and brothers working on the healthcare frontline. I will speak on five areas today: (a) seniors' access to care; (b) care coordination; (c) care-givers; (d) IT and design in healthcare; and (e) our healthcare frontliners.

Sir, on seniors' mobility and access to care. In an ageing society, we have more Singaporeans with mobility needs. Some stay in older flats with multiple steps at the doorway, flats where the steps are too high for the usual Enhancement for Active Seniors (EASE) programme organised by HDB.

Has MOH studied whether seniors in such households are more likely to miss medical appointments? Has MOH looked at how to better support such seniors so they can more easily get to the clinic so that chronic diseases can be brought under control better and so that hospital admissions can be reduced by going upstream? Can MOH look into better support for home delivery of medications? Because this too will reduce the need for seniors with limited mobility to make multiple outpatient trips.

Sir, my second point on care coordinators.

On my Clementi home visits, I have met residents who have many, many medical appointments. One old lady told me she has 10 clinic visits in the upcoming, next three months. Each of them will mean her daughter has to take time off from work to accompany her to and from the clinic for the appointment.

With an ageing population and shrinking family sizes, this poses a challenge for many seniors in the community.

In some cases, the son or daughter cannot take leave or has used up all of their annual leave, or the family member may be a low-wage worker, daily-rated, which means time away from work becomes loss of income.

Many patients today are older, with more medical conditions—more complex medical conditions. Sometimes three, four, five – even more – medical teams look after the same patient.

Sir, there is a role for more patient navigators and more care coordinators linking up across different care teams to help coordinate the care better, to help reduce the multiplication of medical appointments, to help make it easier for appointments to be brought onto the same day, where possible. We can look at reimagining our healthcare so as to support this better.

Sir, I am told that IMH has a team of patient care coordinators and, over the years, their experience has been that this reduces the number of patients needing admission. There are lessons we can learn for coordinating care across other medical conditions as well.

Sir, my third point on supporting care-givers.

Some years ago, as a young doctor, I looked after an old lady with advanced cancer. She was very, very sick and not getting better. Her 50-year old son quit his job to look after her. He quit his job to look after his mother. Later, she passed away. Her son's duty was done. But he had a lot of difficulty. He found it so hard getting back into the workforce in his fifties. Yet this man, this filial caring son, had shown dedication and devotion to duty, day and night, looking after his mother who was terminally ill.

Dedication, devotion, duty, but unfortunately, potential employers did not see it that way. They asked, "What is this gap in your CV? Why were you out of the workforce?" They did not see the dedication and devotion to duty.

Sir, I call upon MOH to work with MSF and MOM to look at how we can better support care-givers – both during the journey of care-giving, and especially when a care-giver is trying to get back into the workforce. Together, across the Ministries, together with industry, and with our brothers and sisters in the Unions, we can find ways to build awareness among employers and even go the extra mile to recognise inclusive employers, who hire fellow Singaporeans who are returning to the workforce having spent time as care-givers showing that dedication and devotion to duty.

2.15 pm

Sir, my fourth point on IT and design in healthcare. Chairman, when we empower our healthcare workers, when we look at what is happening on the ground and empower workers on the ground to do their jobs better, it helps patients as well. It improves the quality of care. It improves the patient experience.

Sir, Information Technology, or IT, has transformed healthcare around the world, but we also must continue looking at how IT is implemented and designed. For example, digital ordering of tests today. Is it faster, easier, than ticking boxes and signing a piece of paper? If it is not, we must ask ourselves why and how can it be improved?

Electronic records today. Do they speed things up, so healthcare workers can spend more time, more quality time with patients? Or is there still room for improvement? And if so, why and how can we make it better?

Computer workstations today, the design of workstations today, computers, do they help doctors and nurses maintain eye contact with the patient? Comfort the patients, especially in a world with COVID-19, where everyone is wearing a mask and that eye contact becomes even more important. Does it help that eye contact happen? Or is it sometimes a different experience? And if so why, and how can we make it better?

So, I ask the Ministry, has MOH done any recent studies on the design of healthcare facilities, healthcare IT and the patient experience? Some designers talk about time-movement studies. How much time it takes to get a task done? How much movement is needed to make something happen? Has there been any recent ergonomic research to see what brings more comfort to patients and better performance for healthcare workers?

Sir, these studies may not be easy to do. But what we do not study, what we no not look at, what we do not search for, we do not know. We must seek truth from facts.

Sir, Steve Jobs was co-founder of Apple, and well known for his sense of design and aesthetics. Every iPhone user everyone who uses a modern multi-touch smartphone, sees the impact of his influence and legacy on industrial design. His younger sister Mona wrote in the New York Times shortly after he passed away. She wrote about how Steve Jobs, from his hospital bed, as a patient battling terminal cancer, wanted to make the hospital better. Sketching devices to hold an iPad in a hospital bed, designing new fluid monitors and X-ray equipment, re-drawing the design of a hospital unit.

Not every one of us can be Steve Jobs, but every patient brings an important perspective to the healthcare journey. And when we see better through the eyes of our patients, when we see better through the eyes of our healthcare workers on the ground, we continually see better and better ways to improve our healthcare system.

We can apply the same care and attention and passion to re-imagining the design of healthcare facilities, re-imagining the user experience so healthcare workers can do the job even better, care for patients even better. Whether it is a hospital computer system, the healthcare workplace, or the patient journey. Seeing through the eyes of our people.

Sir, I want to speak about our healthcare frontliners. In particular, I want to salute our nurses and allied health workers. Every doctor knows this instinctively, even before they become a doctor from their days as a medical student. The impact our nurses have, lifting up the lives of our patients making a difference for every patient.

Every patient, every care-giver understands this too. And I say this both as a doctor and as the son of a patient. We see the impact that our nurses have, that care, that dedication, that heart. Nursing is also deeply skilled work, deeply skilled work and essential work.

Last year during the debate on the President's Address, I called upon MOH to look at paying our nurses and allied health workers more and I am glad the Finance Minister has announced better salaries for our sisters and brothers in nursing.

Some years ago, I attended a healthcare conference. One of the speaker was the President and CEO of the Duke University Hospital in the USA. He is a nurse, trained as an Oncology nurse, rose up through the ranks to lead the hospital, to lead an entire healthcare system in the USA. We should continue looking at ways to further empower our nurses in Singapore to create more opportunities for upskilling and advancement, as we all work together to lift up the lives of our patients.

Sir, I also want to speak on another group of healthcare frontliners who are key to keeping us safe. These are some of our outsourced healthcare frontline workers. Our hospital cleaners, our healthcare attendants are an integral part of the health care workforce. They are integral to the hospital. Facing the COVID-19 risks together, serving on the same front line as medical nursing and allied health staff serving together.

Once upon a time all these brothers and sisters were directly hired by the hospitals and not outsourced. Today, a growing number of cleaners and healthcare attendants have been outsourced. But, Sir, the rationale for outsourcing hospital cleaners and hospital attendants is not compelling. It is not compelling. First of all, the demand for hospital cleaners and hospital attendants is the same throughout the year. There is no seasonal component involved. It does not vary much throughout the year. And in a COVID-19 world, it makes sense for team members to stay based within the same healthcare institution rather than moving from place to place amidst a pandemic.

We are already providing outsourced cleaners with protective gear during COVID-19. It recognises that they are part of the same healthcare frontline. And there is something to be said for treating all our hospital cleaners and healthcare attendants as part of the in-house staff, making them feel more fully like part of the team, supporting resourcing, uplifting these workers together accordingly. Because, Sir, when we are fighting on the COVID-19 frontline, we are all in this together. We should think about hospital cleaners, our hospital attendants as part of the whole healthcare team and not as a service to be outsourced.

Furthermore, Sir, direct hiring also makes it easier for hospitals to create additional jobs and job opportunities to hire directly from the community nearby. In my Meet-the-People Sessions in Clementi, I have met older workers who have been retrenched, who are looking for job placements in healthcare institutions nearby. We should look at ways for hospitals to generate employment for residents living nearby as well. I call upon the Ministry to consider this outsourcing issue as one of the issues which COVID-19 is forcing societies around the world to re-think.

Chairman, healthcare is about "health" and "care" supporting our patients, supporting our care-givers, supporting our healthcare workers –our sisters and brothers on the healthcare frontline. It is about keeping all of us safe, keeping all of us safe together. And so, may we continue building a healthier Singapore as we fight this COVID-19 pandemic as we emerge from the COVID-19 pandemic together. [Applause.]

Question proposed.

COVID-19 Vaccination Operations

Mr Yip Hon Weng (Yio Chu Kang): Chairman, achieving herd immunity through COVID-19 vaccinations is important to our economy and livelihoods. Since the first vaccination roll-out in December, what are the latest statistics pertaining to the percentage of eligible recipients who are vaccinated? How many eligible seniors have been vaccinated?

Even with the commencement of the vaccination programme for senior citizens, some of my senior residents shared that they are adopting the wait-and-see approach. I cite some of the most common reasons pertaining to their decision. They are worried about immediate side effects. Moreover, the two approved vaccines in Singapore are based on a novel technology, so the long-term effects are unknown. Some are also questioning the need for vaccination as the community infection rates are low. They may not go for the vaccination if there is no need for a vaccination certificate to travel.

Is outreach also extended to younger Singaporeans pertaining to elderly vaccinations? Some elderly said that their children or grandchildren discouraged them from taking it. This is because their children are worried that the vaccinations have dangerous implications on seniors with health complications. How does MOH plan to encourage more seniors in the community to get vaccinated?

Future Pandemic Preparedness

Mr Ang Wei Neng (West Coast): The National Centre for Infectious Diseases (NCID) was officially opened in September 2019, just a few months before Singapore detected the first confirmed case of COVID-19. Thereafter, NCID played a crucial role in battling COVID-19.

On the whole, Singapore has done relatively well in controlling the number of community cases as compared to our neighbouring countries, Asia and the rest of the world. Certainly, we are not perfect and can do better with the benefit of hindsight. For example, we could have advised Singaporeans to wear reusable masks earlier. Also, the outbreak of COVID-19 at the foreign worker's dormitories caught us by surprise. We could have moved in earlier to improve their living conditions.

Having said that, COVID-19 will not be our last pandemic. We need to document the main learning points of managing COVID-19 and learn from it. Will MOH work with the multi-ministerial task force to conduct a review and release an interim post-mortem report? This would be similar to what the MOF did by releasing the "Interim Assessment of the Impact of Key COVID-19 Budget Measures".

We know that the pandemic is not over yet, but an interim report will be important as what has transpired in the past year is still fresh in our memory. More importantly, we would like to know how MOH and Singapore could be better prepared for the next disease X.

Healthcare Facilities Adequacy

The COVID-19 pandemic has put a strain on healthcare services and facilities. I am concerned with two aspects.

First, COVID-19 has delayed the construction of healthcare facilities in Singapore, but the growth in our ageing population is marching on. What contingency plan does MOH have to deal with the delay in building hospitals, polyclinics and nursing homes?

Second, I am concern about the difficulty in employing domestic helpers to care for the elderly. Many Nanyang residents have approached me to appeal for elder care or nursing home facilities, because of the challenges in bringing in domestic helpers to Singapore. This is probably a nation-wide problem. How can the MOH cope with this sudden surge in demand, especially with the delay in the construction of nursing homes?

Besides the need for nursing homes for elderly that are not able to take care of themselves, there is also a strong interest from the more abled elderly to age in their own homes. Many are interested in Singapore’s first Community Care Apartments in Bukit Batok, which are affordable housing with senior-friendly features. I understand that it is 4.2 times oversubscribed. Since the take-up rate is so strong, will MOH and MND consider offering more of such flats at the next quarter or so?

2.30 pm

Tackling Healthcare Inequality

Mr Leon Perera (Aljunied): Mr Chairman, Sir, from a recent reply to my Parliamentary Question, we now know that residents aged 25 years old with below Secondary education have a life expectancy 5.8 years lower than that with those with post-Secondary education. I thank the Minister for Health for the detailed answer. We also learnt that people with below Secondary education have a greater likelihood of chronic illnesses like diabetes and high cholesterol.

Sir, for many of my lower income constituents, convenient and cheap food options are unhealthy ones, like instant noodles. Research shows poverty often overwhelms one's cognitive ability to make good decisions on health.

I, thus, speak on the urgent need to tackle health inequality. It would seem that the prevalence of conditions like obesity, diabetes, hypertension and high cholesterol has risen over the years. Sir, I would suggest that there is an urgent need to revamp for preventive healthcare efforts, particularly for poorer Singaporeans.

While many efforts have been undertaken, the outcome seems to be moving in the opposite direction. To achieve better outcomes, we need better measurement.

Firstly, could we make public more timely and comprehensive data of chronic diseases by socio-economic groups? Other than the response to my recent Parliamentary Question for what I understand the most recent publicly available data on health risks, behaviours and outcomes by socio-economic class was 2010 National Health Survey. The National Registry of Diseases already collects data on the incidence of cancer and chronic kidney failure. It is an easy next step to include SES indicators like income and education. We must also study the entire life cycle of chronic diseases. Are low-income groups contracting more diseases, more severe diseases or even earlier diseases?

Secondly, can we make more data public and healthcare outcomes for low-income groups? Are they receiving a later diagnosis with poorer outcomes compared to wealthy Singaporeans who can choose top tier private care, for example? I am not suggesting that this is the case but it would be useful to have the data. Some doctors have observed COVID-19-related backlogs and patients transferring from private to public to save money, pressuring the public system and lengthening waiting times for subsidised patients.

Thirdly, could we develop a National Health Equity Index? This could be created by an independent group of academics and include social determinants of health as well as health care accessibility, affordability and outcomes. This will pinpoint areas for targeted action.

Once we have more data, we must act decisively. I note that HPB piloted the Healthy Living Passports Scheme in mid-2020 and aim to reach 15,000 lower income residents over three years. How effective have the incentives been among lower income groups? Other than the number of participants, can we targets in terms of better health outcomes?

The National Health Screening Programme, Screen for Life, heavily subsidies screening for some conditions. What is the take-up rate and outcomes thus far, particularly for those who are less advantaged socio-economically?

Mr Chairman, Sir, we must improve outcomes at the intersection of health inequality and preventive health care. Not only because we have a responsibility to the less fortunate but also because this problem creates spill-over effects that can cause society more if left untreated.

Cost of Public Health Services

Mr Leong Mun Wai (Non-Constituency Member): Chairman, escalating healthcare cost is a major worry for Singaporeans. Since cost is a result of the prices set by the public healthcare institutions, the pricing principles of the public sector is of great interest to us.

Is public health pricing based on average cost or marginal cost?

What are the various cost components incorporated in those costs?

Is the cost-based price checked against the pricing of other countries?

What are the other considerations in determining the final price?

And how does MOH monitor and change the pricing overtime?

Only with this information can we make an informed judgement whether MOH’s services expenditures of about $11 billion which represents about 2.2% of our GDP, is enough or not.

Medical Inflation and Affordability

Lim Wee Kiak (Sembawang): Chairman, it is not uncommon for us to hear senior residents complaining about 可以病，不可以死。可以死，不可以病。Which means that can fall ill but cannot die. Singapore has one of the best healthcare systems in the world but it does not come cheap. This is evident from the effectiveness of our COVID-19 response and is further reinforced by the fact that Singaporeans enjoy one of the highest life expectancies in the world – that is 83.8 years for 2021.

But with rapid medical technological and pharmaceutical advances, costs of healthcare delivery have increased exponentially. In 2018, medical inflation was at 10%,10 times more than the general inflation rate in Singapore. But this appears to be a global situation. The average global medical inflation rate was observed at 9.7% that year. As the population ages, more spending on healthcare will be required and the rate of medical inflation will need to be checked.

How is MOH keeping track of the medical inflation trend and looking into its impact on Singaporeans? The average Singaporean household expenses on healthcare costs in 2017 and 2018 were found to have increased by 4.5 to 5.5 percentage point as from five years ago. The actual increase differs slightly across different income groups, and it is somewhat concerning that the below income group, the lowest 20% bracket saw their healthcare costs forming the largest portion which is 7.8% of their household expenses. How much does the average Singaporean household spend on healthcare? And how does it compare to other developed countries? Are our current MediSave contributions keeping pace with the medical inflation?

Our "3M" framework public financing healthcare plays a crucial role to keep quality of health care affordable for all.

The Deputy Prime Minister has announced that there will higher remuneration for our nurses and healthcare support staff, which I fully concur with. So, we must now also examine how to fund the inevitable increases in healthcare expenses.

With our ageing population, our elderly will be saddled with more healthcare costs pertaining to illness. Last year, I voiced my concerns for senior citizens who had to pay upfront cash for age-related medical treatments. I would like to suggest that medical usage limits be tiered according to age to ensure our elderly residents' growing healthcare needs are met.

Naturally, we must ensure MediSave contributions would commensurate with the higher medical expenses. When is our last review of our MediSave contributions? Will the Ministry do a review on our current "3M" health financing strategy to ensure all Singaporeans will be adequately covered and keep up with medical inflation?

Expand MediSave Usage

Ms Hazel Poa (Non-Constituency Member): Mr Chairman, MediSave limits are a major concern for the elderly and it is the issue I have been asked most frequently to raise. Many feel that the annual limits of $200 or $500 are inadequate for their needs, given current healthcare costs.

In November last year, Senior Minister of State said that MediSave limits are being reviewed. Can the Minister provide an update on the status of the review?

At the moment, MediSave can be used mainly for hospitalisation and in-patient treatment with limited outpatient treatments allowed. Limiting MediSave to mainly in-patient treatment skews demand towards hospitalisation. Outpatient treatment is cheaper and can manage disease before they worsen and become more costly to treat. If we can allow MediSave to be used more widely on out-patient treatments, we can shift demand towards the lower cost outpatient treatments and help control healthcare costs.

Can the Minister consider expanding the range of outpatient treatments allowed to use MediSave?

MediSave Use for Outpatient Treatment

Mr Gerald Giam Yean Song (Aljunied): Many seniors suffer from chronic conditions which require extended care and that can be very expensive. Most outpatient treatment is not covered by MediShield Life and access to MediFund is only available to the very low income. The use of MediSave is subject to annual withdrawal caps. This can have an undesirable effect of discouraging seniors from seeking early treatment.

Can MOH allow MediSave withdrawals for the treatment of all chronic conditions, not just those under the Chronic Disease Management Programme list to ensure that no one is excluded just because they suffer from a less common chronic condition? And can MOH remove annual withdrawal limits on the use of MediSave of patients over 60 years old, who have a balance of at least $5,000 in their MediSave accounts? This can be rolled out at polyclinics, restructured hospitals and CHAS clinics where tight procedures are already in place to ensure that only medically necessary treatment is prescribed.

Value-based Healthcare

Ms Ng Ling Ling (Ang Mo Kio): Chairman, the Government has responded decisively in deploying resources to combat the COVID-19 pandemic with healthcare expenditures increased significantly to provide for our public health management measures. However, even without the pandemic, we know that the healthcare expenditure has been rising globally. Globally, we are also seeing similar trends in developed countries due to increasing medical attention, medication, procedures and longer hospital stays from an ageing population.

In Singapore, the Government has been working on making our health care accessible and affordable through investing in medical infrastructure, establishing "P" benchmarks, providing various subsidies, as well as working with Singaporeans to encourage a healthy lifestyle. This has worked well for Singaporeans thus far. But we cannot ignore the rising healthcare costs that Singaporeans may face. How can we continue to provide higher value in healthcare in the face of rising healthcare costs and ageing population and advances in medical procedures?

Sir, I hope that the Government can consider value-based healthcare as another lever to help manage overall costs of healthcare for Singaporeans. Value in healthcare is generated by delivering better health outcomes for the same or a lower cost. While our healthcare costs have been rising each year, we currently do not have a very clear grasp if healthcare outcomes of major or common diseases, such as diabetes or asthma have been improving.

Healthcare providers have typically been paid on a fee-for-service model with subvention given mainly by volume. The objective of health, value-based healthcare, is to create financial incentive to encourage providers to improve the health value given to patients.

One example is from Sweden's National Health System where they piloted a bundled payment model for cataract and hip replacement procedure. The bundle sets a single base price that covers the entire care delivery chain from diagnostic surgery to follow-up visits. Providers are paid based on whether they met pre-defined health outcomes to the patient. This has helped in the pilot years for complications to decrease by 18% re-operations to fall by 23%.

I acknowledge that there are no silver bullets to address the rising healthcare costs. Nonetheless. I hope that the Government will consider value-based healthcare incentive approach as an important part of the short and long-term strategy to achieve better healthcare value for Singaporeans.

MedShield Life Premiums

Mr Gerald Giam Yean Song: Between 2016 and 2019, $7.5 billion in premiums for MediShield Life were collected and $3.5 billion in claims were paid out, while a further $3 billion was set aside for future premium rebates.

Many Singaporeans are concerned about the impending premium hikes of up to 35% to MediShield Life. More transparency on the data and assumptions used will help to better to explain these premium hikes.

Last November, in response to my request for the release of the full MediShield Life actuarial report, Senior Minister of State Koh Poh Koon, said that MOH may engage different consultants to challenge the assumptions and do another calculation and publish some of this data in an academic way. Will the full MediShield Life actuarial report be provided to these consultants and academics for further analysis? And if so, when will this be done?

Lastly, I note that the new MediShield Life premiums have kicked in on 1 of March. Can MOH consider postponing the increased premiums until our economy recovers?

Portable Health Insurance

Ms Hazel Poa: Mr Chairman, the issue of portable health insurance was raised by Health Correspondent Salma Khalik in December last year.

Currently, many Singaporeans have integrated plans. As a person gets older, it becomes difficult to move from one insurer to another. This is because people develop medical problems as they grow older. When they tried to switch insurers, they generally face the prospect of these pre-existing conditions being excluded from cover. As a result, beyond a certain age, it becomes practically impossible for people to switch to another insurer even if there is a big difference in premiums paid.

Theoretically, insurers can entice younger people with much lower premiums and later hike the premiums significantly when they are older and unable to switch insurers due to their pre-existing conditions.

Will the Minister consider ensuring that IPs are fully portable by making it a condition for IP providers to allow policy holders to switch providers without imposing additional conditions?

2.45 pm

Integrated Shield Plan Providers

Dr Tan Yia Swam (Nominated Member): Mr Chairman, Sir, I need to first declare conflict of interest as a general surgeon in private practice, with an interest in breast surgery; and my role as the elected President of Singapore Medical Association.

Escalating healthcare costs is a concern for many governments. In Singapore, this has gained much attention recently with questions raised by the public on private insurance agents. In truth, managing healthcare costs is a complex problem.

Learned economists have studied it, and there is no simple answer. I see a need for everyone to be part of the solution. I list five key factors: (a) advances in technology leading to better quality of care; (b) healthcare facilities costs, (c) doctors' fees; (d) patient health-seeking behaviour; and (e) insurers.

As research and experimental trials become validated, the advances will be accepted in mainstream clinical practice. One simple example in my field – 30 years ago, most breast cancer patients had to accept a mastectomy, and the resulting change in appearance was unacceptable to some. Now, patients can opt for nipple-sparing mastectomy and immediate reconstruction which allow the patient to regain a physical appearance which is similar to her normal. This means a better outcome for some patients, but clearly, increase costs.

Who monitors the costs of the private healthcare facilities? As a patient, when I receive the itemised bill, how do I know which of these items are reasonably charged, and which are not? Doctors' fees have often been blamed as the main source of increased costs. How true is this? Historically, SMA had a guideline of fees since 1987, which had to be removed in 2007, as it was deemed anti-competitive. MOH announced in end 2017 that fee benchmarks will be implemented. Since then, the benchmarks serve as a guide on how doctors charge.

Patient health-seeking behaviour also affects costs. When people fall sick, how do they choose their care? Just take a panadol and rest? See a General Practitioner? See a TCM physician? Do they go to a polyclinic, the emergency department or straight to a specialist?

Finally, how are insurers involved? Patients factor in financial costs when they need to see a doctor. Some will go only to their company doctors based on their corporate insurances with no need to pay out of pocket. When they need to have hospital admissions, day surgery or major operations, that is when their Integrated Shield Plans will come in useful.

In my Budget debate speech, I highlighted the importance of shared decision making in healthcare.

We are in the age of patient empowerment. This has been so for quite a few years with an increasingly better educated population. The Judiciary has acknowledged this trend when they introduced the Modified Montgomery Test and the understanding was reinforced by this Government when the Civil Law Act was amended last year.

Patients must be adequately informed before they make a choice on the medical care that they want to receive. I am all for this and medical practitioners here have been making adjustments in the way they practise, in order that patients are better informed and empowered.

Likewise, insurers need to share more information and allow their clients to make informed decisions. From time to time, I get asked by friends and relatives about health insurance, especially Integrated Shield Plans or IPs in short. These questions include – which IP provider is better, and which IP plan provided by the provider is more suited to my needs?

I must admit I am ill-equipped to answer these questions. I myself am insured with an IP, but I must confess that when I bought it many years ago, I did not make a detailed comparison of the various IP providers' offerings, but trusted my financial advisor's recommendation.

Close to 70% of Singapore Residents buy IPs. So, IPs affect the majority of us living here. It is therefore important that Singaporeans are adequately informed upfront by the various IP insurers before they make a decision to buy an IP, or before they make a decision to switch IP providers, since IPs are bought annually.

I ask myself, what would I like to know before I made a decision to buy a certain IP or not. These are the most important questions that will make me choose one IP provider over another. One, what are the premiums for me now and when I get older? Two, what are the benefits and claim limits of each plan offered? Three, what percentage of private sector specialists are empanelled by a certain IP provider? Four, does the IP provider allow me to go to any private hospital in Singapore? Five, are all restructured hospital specialists automatically empanelled? Six, how does the IP provider pay specialists; does it follow MOH fee benchmarks?

I realised that other than the first two questions, information was difficult or impossible to obtain for me to make an informed decision on which IP to purchase. Questions about empanelling are important because ultimately, it is about choice. The IP provider that offers more choices is more attractive to a potential IP customer.

The last question about how IP insurers pay specialists is important in an indirect way. A system that reimburses private sector specialists adequately is more sustainable and better for me as a policyholder, in the long run. More specialists will want to be empanelled with this IP provider and I will have a wider choice. If my IP insurer does not pay the specialist fairly or adequately, how would the doctor feel?

We can use the MOH fee benchmarks as a good guide for this. How does each IP provider pay specialists for procedures? Does a certain IP insurer pay up to the higher limit of the benchmarks, or the lower limit, or up to the mid-point? Or does this IP insurer reimburse at rates that are even lower than the lower limit of MOH fee benchmarks?

It should be a warning sign to policyholders when an IP provider pays doctors below or only at the lower limit of the MOH benchmarks. I think the regulators of IPs, which are MAS and MOH, can obtain the answers to these six questions from IP insurers and present them in a tabulated and easily digestible form that members of the public can refer to when they make their decisions on which IP to buy. This will advance the cause of patient education and empowerment.

A more difficult but important policy question to ask is what proportion of Singapore Residents should buy IP. The combined market share of private hospitals and A class and B1 class beds in Restructured Hospitals is estimated to be in the range of 30% to 35%. Yet the proportion of Singapore Residents buying an IP is nearing 70%.

This is an unusual phenomenon in the running of a health insurance system. In the normal scheme of things, healthy insurance policyholders subsidise policyholders who fall sick and make claims. But in our IP environment, the business of IP is cross-subsidised not just by those who do not fall sick, but by those who fall sick and yet choose to be treated at subsidised B2 and C classes in restructured hospitals when they are entitled to more under their IPs.

At the superficial level, it would appear that there is nothing wrong with this because it is the patient's choice and it is good to be prudent. However, there is an externality cost, when IP holders choose subsidised wards in the restructured hospitals when they fall sick. The consumption of these Government subsidies are indirectly subsidising the insurers' IP businesses and depriving patients-in-need of more subsidies, since MOH's budget is a finite thing.

These Government subsidies would not have been consumed had the patients chose what they were entitled to, to be treated in the private hospitals or in A or B1 class wards. Another important corollary of this unusual phenomenon is that it further lengthens the waiting times for subsidised services in restructured hospitals.

I think it is important that we study this "voluntary downgrading" phenomenon so that we can ensure that the IP environment today is functioning faithfully to the original policy intent of IPs. Also, what is the desired proportion of Singapore residents who should buy IPs. Is it the current 65% to 70%? Or below or above this range? I do not know the correct figure, but with a private sector market share of only 30% to 35%, including B1 and A class beds in restructured hospitals, the corresponding figure of 70% of the population having IPs sounds rather high.

Can the private sector support the needs of this 70% if all of them who fell ill chose the unsubsidised services they are entitled to under their IPs? I have a few patients who themselves are insurance agents, and they realise they do not quite know what they are covered for. Are all insurance agents well trained and up-to-date about the products they are selling? Are the medical underwriters also keeping their medical knowledge up to date?

I raise one specific and very common example in my field: a healthy lady in her 20s with no family history is offered a free health screening when she signs up for an IP, including ultrasound of the breasts. This picks up a 3-mm nodule, too small to categorise. This lady is then informed that she will be excluded from breast cancer coverage. Thereafter, there is a cycle of her agent asking her to see a doctor, the doctor telling her it is likely benign and can observe. The agent may then ask for a memo to state that she does not have cancer. I have met patients where they state that the agent has asked them to pay for the surgery themselves to remove the lump, and then appeal to be covered. As a breast surgeon, I do not know how to help this group of affected women. There are no good medical indications for any of these.

In summary, escalating healthcare costs is a complex problem, and the medical professional bodies are ready to be part of the solution through honest, open discussion. I call for increased transparency and accountability of insurance companies and their agents. MOH and the SMC scrutinise doctors. Who is scrutinising the other players in the healthcare costs equation?

Raise IVF MediSave Withdrawal Limits

Mr Louis Ng Kok Kwang (Nee Soon): Sir, in 2013, the Government started allowing the use of MediSave for IVF, subject to a withdrawal limit per cycle and per patient. Recently, many couples have called for an increase in these limits to better meet IVF costs.

MOH has said, "Couples who find themselves unable to cope with unexpectedly large bills, for instance, as a result of complications, even after co-funding, may appeal to use MediSave beyond the current limits" on a case-by-case basis. It has been over seven years since we reviewed these withdrawal limits. I hope we can conduct a review and consider increasing the limits on the use of MediSave for IVF and not just on a case-by-case basis. IVF is a costly procedure. It would be a pity for couples who are unable to afford it but have funds in their MediSave, to be denied the gift of parenthood.

Use MediSave for IVF TCM Treatments

In the dialogues I have organised on IVF, many couples told me that they have achieved better results from supplementing their IVF treatments with TCM. Some doctors recommend TCM treatment for certain patients as it may optimise results. TCM treatments such as acupuncture can act as a supplementary method for patients to increase their chances of success.

My wife also, upon the advice of our doctor, did TCM during our IVF treatments. Some might say that TCM does not work, while others say it does, but we can all agree that it does help provide an ease of mind, that we have tried everything we can do to have a successful IVF cycle.

TCM can be expensive. Couples I have spoken to end up spending around $500 to $1,000 a month, on top of already mounting IVF costs. Can we allow couples to use their MediSave which they are allowed to use for IVF and subject to the current withdrawal limits, for TCM treatments associated with IVF?

Rollover Excess IVF Co-funding

Last month, I proposed extending co-funding to the seventh and eighth IVF cycles to support couples who need more cycles to conceive successfully. MOH responded that, "We also need to balance the need to meaningfully and responsibly allocate public funds on this."

In this case, rather than provide additional funding after the sixth cycle, will MOH allow co-funding leftover from the first six subsidised IVF cycles to be rolled over into the seventh and eighth cycle? Can it also allow any co-funding leftover from the three subsidised fresh cycles to be used for the subsidised frozen cycles?

These are funds the Government has already budgeted for. It is win-win solution as it allows couples to complete additional cycles using subsidies that we have already budgeted for without additional allocation needed.

Maternal and Children Health

Ms Ng Ling Ling: Chairman, as we dedicate 2021 as the year of celebrating SG women and as a mother myself, I would like to dedicate this cut to bring attention to the health of pregnant women and how it can affect our children. Both overseas and local research have pointed to the impact of maternal health on the health of our children. One of such findings is from a homegrown Growing Up in Singapore Towards healthy Outcomes or GUSTO study conducted by researchers in the National University Health System, KK Women's and Children's Hospital and A*STAR Singapore Institute for Clinical Sciences over the last 10 years.

The study found that one in five mothers-to-be develop gestational diabetes and this heightened the risk of their children developing obesity Type 2 diabetes, heart disease and even neurodevelopmental disorder later in their lives. Another concern pointed out by the study is the mental health of pregnant women. Mental well-being of mothers-to-be will also affect children, who are likely to develop neuro-developmental disorders such as anxiety, depression or disruptive behaviour disorders.

We know that causes for these diseases can be multi-faceted and complex, including the pregnant mothers' own health and her social economic environment. Pregnant mothers and disadvantaged circumstances are at even higher risk.

I would like to ask if the Government will consider a more concerted upstream support at maternal stage for women, including looking after both their social and healthcare needs.

Secondly, would the Government consider piloting more care services for maternal and child health such as the new Temasek Foundation Integrated Maternal and Child Wellness Hub at SingHealth Polyclinic at Punggol, to better understand what kind of intervention can improve the outcomes of maternal and children health.

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Lastly, how can the Government enable evidence-based information to be disseminated more effectively to more pregnant women to increase awareness and encourage self-care for the well-being of their children?

The Chairman: Order. I propose to take a break now.

Thereupon Mr Speaker left the Chair of the Committee and took the Chair of the House.

Mr Speaker: Order. I suspend the Sitting and will take the Chair at 3.25 pm.

Sitting accordingly suspended

at 3.01 pm until 3.25 pm.

Sitting resumed at 3.25 pm.

[Mr Speaker in the Chair]

Debate in Committee of Supply resumed.

[Mr Speaker in the Chair]

Head O (cont) –

The Chairman: Minister Gan.

The Minister for Health (Mr Gan Kim Yong): Mr Chairman, I would like to thank Members for their speeches and their remarks. Mr Yip Hon Weng and Mr Ang Wei Neng asked about the COVID-19 situation. Let me provide a brief overview.

Globally, the number of new cases and deaths continue to trend down, although there was a spike in the last week of February. So, we need to watch. Within Singapore, the COVID-19 situation has stabilised, with one or two new community cases on some days. Imported cases are isolated on arrival and the risk of transmission to the community is low. However, the World Health Organization has just warned that we need to stay vigilant as the pandemic is not likely to be over within this year.

I want to thank everyone – Singaporeans, healthcare workers, businessmen, businesses, enterprises, Government agencies – for playing your part this past year. Your sacrifices have helped Singapore weather this storm.

Mr Ang Wei Neng asked about the impact of COVID-19 on our infrastructure projects. As I have informed the House earlier, the pandemic has delayed many of our healthcare infrastructure projects by up to a year or so. Construction works have since been ramping up progressively and we are working on contingency measures to ensure we are able to meet the needs of our people.

We are making steady progress in our vaccination programme. As of 4 March, more than 350,000 Singapore Residents have received their first dose, including some 80% of our healthcare workforce, and 215,000 have received their second doses.

We have started with our seniors, too. I would like to thank our community volunteers from the People’s Association and Silver Generation Ambassadors who have worked hard in reaching out to our seniors and helping them to make their appointments. Over 40,000 seniors aged 70 and above have received their first dose. We will soon begin the vaccination of seniors aged 60 and above. Mr Chairman, allow me to say a few words in Mandarin please.

(In Mandarin): [Please refer to Vernacular Speech.] Seniors are most at risk of severe outcomes if they are infected with COVID-19. Therefore, we have prioritised seniors in our vaccination programme. The vaccines approved for use in Singapore must meet stringent safety and efficacy standards. I urge Singaporeans to get vaccinated.

Some Singaporeans with chronic diseases are worried about being vaccinated. Do not worry, because we will arrange for healthcare professionals on site to assess if you can be vaccinated safely. In fact, most people can be vaccinated safely, including those with diabetes, hypertension, high cholesterol, asthma, chronic lung disease, heart disease and cancer patients in remission. Hence, I encourage Singaporeans with these conditions to register for vaccination as soon as they are invited.

(In English): Let me emphasise that only COVID-19 vaccines that meet strict standards of safety and effectiveness will be used in Singapore for our Singapore Residents.

We will monitor the development of the COVID-19 pandemic and adjust our measures accordingly. We will also continue to strengthen our defences for future health system crises, such as Disease X. Senior Minister of State Janil Puthucheary will share more.

Even as we mobilise the nation to fight COVID-19, we have to remain focused on long-term issues.

Members may recall our Three Beyonds to meet our challenges in the future. Beyond Hospital to Community, to provide better care closer to home; Beyond Quality to Value, to help Singaporeans stretch their dollar; and Beyond Healthcare to Health, to help Singaporeans stay healthy.

We will continue to anchor care in the community by strengthening primary care. We will be building 12 new polyclinics, bringing the total to 32 by 2030. The Community Health Assist Scheme (CHAS) has been expanded recently to allow more Singaporeans to receive subsidised care from private GPs, who are our key partners in primary care.

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We are also expanding community care, especially for our seniors. We have expanded the Community Nursing teams to cover 29 regions across Singapore since September 2020, with a total of 185 Community Nursing Posts to make care more accessible to our seniors. We will add new Community Nursing Posts where needed.

Our second thrust is to stretch your health dollar. Dr Lim Wee Kiak and Mr Leong Mun Wai asked about how we manage healthcare costs. We keep care affordable and sustainable through a multi-pronged approach.

First, we leverage risk pooling. Insurance plays a useful role in helping us stretch our resources through pooling, so that those who are ill can tap into the pool to pay for the healthcare services they need. That is why we introduced MediShield Life. But insurance has an inherent risk of over-consumption. This is because of OPM syndrome. What is OPM? Other People's Money. Because through insurance, we are pooling resources and we are tapping on other people’s money in the pool to pay for our healthcare services. So, we need safeguards to encourage prudence when deciding on healthcare services.

Dr Tan Yia Swam asked about Integrated Shield Plans (IPs), and I agree with Dr Tan that we can all benefit from more information-sharing and a better understanding of insurance products. Towards this objective, MOH has facilitated several engagement sessions with insurance providers and professional bodies to foster a better understanding of the parties’ concerns.

Dr Tan herself was present at these sessions and we benefited significantly from her contributions. We have resolved some issues – not all – but discussions are still on-going. An important progress we have achieved is the establishment of a multilateral platform comprising Life Insurance Association, Academy of Medicine, Singapore and the Singapore Medical Association. This platform will allow discussions to resolve issues of common concern.

We are also setting up a claims management mechanism to facilitate resolution of claims-related matters. Our common objective is to ensure patient care is not compromised and allow patients adequate choice, while ensuring that fees and claims remain reasonable. I am confident that with this common understanding, we can find workable solutions that will benefit all parties, insurers, doctors, as well as patients.

Ms Hazel Poa asked about whether IPs can be made fully portable. As IPs are commercial products, their features and pricing are ultimately determined by private insurers. But what is important is that all Singaporeans are covered under MediShield Life, regardless of their medical conditions.

Second, we will continue to improve the healthcare system’s cost effectiveness and efficiency. As Minister Lawrence Wong mentioned, the Agency for Care Effectiveness has enabled us to save $300 million since 2016 and benefited over 375,000 patients. The Agency for Logistics Procurement and Supply, or ALPS for short, has also achieved cost savings of about $180 million in two years by driving economies of scale through group procurement.

Even with our best efforts, we will still be spending more on healthcare over time, given an ageing population and increasing consumption of healthcare services. The Government continues to bear a significant and growing share of the National Health Expenditure, from 40% in 2013 to 46% in 2018.

We want all Singaporeans to be healthy and have access to good and affordable care. We pay particular attention to lower income households, as Mr Leon Perera highlighted, and provide them with additional support to ensure healthcare, including preventive health, remains affordable and accessible to them, and they can improve their health outcomes.

Health outcomes are influenced by multiple factors, including social, biological, cultural preferences and environmental factors, in addition to Social Economic Status, or SES.

Local studies showed that adults with lower SES do have differences in chronic disease prevalence. We have been publishing health data regularly. More data has been collected in the last two years including breakdown by education level as a proxy for SES, and this data will be published later this year. We will continue to refine the data we publish.

From local studies, we also know that adults with lower SES do have good access to care and are able to control their health conditions well. Again, using educational attainment as a proxy for SES, among persons diagnosed with diabetes, hypertension and high blood cholesterol, over 90% of those with below Secondary school education had visited their doctor for their condition at least once in the preceding year. Further, the proportions of those with acceptable control of their medical conditions are close to the national averages. Nonetheless, we must continue to support them to improve health outcomes and we will need to start from young, which I will talk about in a short while.

Through enhancing our healthcare financing system over the years, we have kept healthcare affordable, especially for the lower income patients. In fact, the lowest income quintile’s share of total subsidies was 37% in 2018, the highest across all income quintiles. Our healthcare financing framework is a progressive one, overall. Further, the amount of subsidies received per household for the lowest income quintile has increased by over 70% from 2013 to 2018.

Overall, government spending on healthcare has grown year after year and is likely to continue to increase. But as Dr Tan Yia Swam mentioned, and I quote, "government subsidy is a finite thing". That is why we have to be prudent in how we allocate limited resources, to ensure that the support we provide is more targeted to benefit those with greater need.

This is our third effort – to better target subsidies, such that those with less will receive more, healthcare is kept affordable for all, and patients can be cared for at the most appropriate facilities.

We have recently enhanced the subsidies for low-income patients at the public Specialist Outpatient Clinics or SOCs. We will further adjust subsidies at the SOCs by introducing two new tiers of 30% and 40% subsidy for higher income patients. This will enable more subsidies to be channelled to those in greater need.

With more targeted subsidies at the SOCs, we can now allow private patients discharged from our acute hospitals to choose subsidised follow-up care at the SOCs. Currently, they are treated as private patients at the SOCs.

Next, we will align the means-testing basis in the acute hospitals to per capita household income which is more reflective of patients’ means, similar to the basis used for most healthcare schemes, rather than rely on personal income of the patient today.

Lastly, we will also enhance subsidies at community hospitals, to keep them more affordable and facilitate the flow of patients from acute hospitals.

Taken together, these moves will ensure more targeted use of our healthcare resources, stretch our healthcare dollars, and encourage appropriate care. Senior Minister of State Koh Poh Koon will go into greater detail in his speech.

In the longer term, the best way to manage healthcare costs is through our third thrust – staying healthy. We encourage all Singaporeans, young and old, to partner us on this journey: attend your recommended health screenings regularly, go for vaccination, and adopt healthy living habits.

I encourage all to also continue the good fight to win our on-going War on Diabetes and keep chronic conditions at bay. Parliamentary Secretary Rahayu will share more on this, as well as our other health promotion efforts.

Earlier I talked about the three key thrusts, better care, stretching your dollar, and staying healthy. These are not isolated initiatives. All our policy and measures work together to take care of the health of every Singaporean, starting from birth and throughout their life journey, keeping them as healthy as possible, for as long as possible.

The best place to start is right at the beginning. Minister Masagos will share our thinking on improving Child and Maternal Health, how to better support our children and their families, and to bring agencies together to co-deliver services and solutions for better outcomes.

Our care transformation journey will continue. As we plan for our future health system, we will study how we can develop a longitudinal system of care services and programmes, to journey with you and design programmes with a life-course approach, taking care of each Singaporean from birth and throughout their life. The National Healthcare Group has, in fact, developed a River of Life framework to test this approach.

As staying well often involves not just health but also social and other factors, we will also explore how we can pull in resources across agencies and service providers to support your overall well-being. SingHealth, for example, has started trials to prescribe not just drugs but also social programmes, such as diet, exercise and social activities. Dr Tan Wu Meng will be happy to know that they too have care coordinators to help guide their senior patients.

Finally, the built environment also plays a key role in nudging our choices. Therefore, the built environment should be designed to promote healthy living and digital tools can also be used. NUHS, the National University Health System, is working on this with the various agencies. We will share more on these efforts at a later stage.

Anchoring all these transformation efforts are our healthcare staff who will continue to play a central role in our future health system, much like how they have been at the forefront line in our battle against COVID-19. We are blessed with a very dedicated, driven and professional team. They are our most precious resource, and we will continue to provide them with better progression, more training opportunities, and greater recognition of the work and risks they undertake. Senior Minister of State Koh Poh Koon will elaborate on this.

To conclude, as Prime Minister Lee said, it has been a year of uncertainty, anxiety, and fear. Many of us would have emerged slightly different from how we first entered. A little more tired, more stretched, perhaps a little tougher and, I hope, a little wiser.

Partner with us as we journey forward and as we transform our healthcare system to be future-ready. Let us work together and help all Singaporeans to stay healthy, and live well, every day of your life. [Applause.]

The Chairman: Mr Yip Hon Weng.

Mr Yip Hon Weng: Chairman, permission to take my three cuts together.

The Chairman: Yes, please.

Action Plan for Successful Ageing

Mr Yip Hon Weng: Chairman, active ageing has always been an important part of successful ageing. In the past years, HPB introduced many community programmes to encourage seniors to participate in healthy activities like group exercises and to create an avenue for neighbours to socialise. All these have a positive impact on the resident's well-being.

With the COVID-19, the good work has been disrupted. Seniors are advised to stay home to reduce their exposure to the virus, as they are vulnerable. But this has affected their physical and emotional well-being. Without the in-person group exercises and the opportunity to meet their friends, they have less motivation to exercise. The online programmes are useful. But they are simply not quite the same. Our Action Plans to encourage active ageing must evolve with the pandemic. What is the progress on these? How else can we meet the evolving needs of our future seniors?

Last year, MOH announced various measures to better support seniors to age in place. What is the progress of these measures, especially on the Eldercare Centres? Future generations of seniors will have different lifestyle preferences and aspirations. How are we meeting the evolving needs of our seniors? What are the measures of success and timelines for the plans?

Seniors' Mobility and Enabling Fund

Many seniors have benefited from the Seniors' Mobility and Enabling Fund (SMF). But there is still some room for improvement. Will the Ministry review the policy of the once-in-a-lifetime eligibility?

Some seniors may require a replacement device after their first device has worn out from many years of use. Another problem is that they cannot apply for aids under the same category. So, if one applies for a walking stick now and gets progressively weaker over time, he might need a quad stick or walking frame but he would not be eligible. While there are other schemes like the Assistive Technology Fund under SG Enable, the multiple schemes make things more complex than necessary for the elderly.

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The lack of support for the repair of devices is another handicap. Batteries in motorised wheelchairs running out is a common problem and sometimes, these devices are perfectly usable after replacement of parts and repairs. But SMF does not provide such support, so we have to tap on other schemes.

SMF also only covers consumables for applications made through a healthcare service provider like a nursing home. If the senior is cared for at his own home, he is not eligible. This runs contrary to our policies of encouraging ageing in place.

I would also like to suggest that SMF extends its coverage to elderly-friendly safety features in non-HDB estates, such as ramps and grab bars, especially for the lower value private units. I hope that the Ministry can better refine the SMF to help those in need.

Support for Care-givers

COVID-19 presents new challenges for care-givers. The temporary suspension of certain care-giving services as well as the suspension of house visits during the circuit breaker period meant that many care-givers were on their own. Some of them had to cope with heightened feelings of anxiety, loneliness and depression. And with foreign domestic help being more costly and hard to come by in the midst of the pandemic, it is timely to review the Caregiver Support Action Plan that was launched in 2019.

How has the plan benefited care-givers since its launch? How can we better support care-givers, particular those who are looking after individuals with mental health conditions?

Can the Ministry look into availing more flexible homecare services to meet care-givers' needs? There are many instances I can think of whereby care-givers need a break but they are unable to find a care institution to provide short-term care within a short notice.

For example, Mrs Koh, a resident in Yio Chu Kang, is a care-giver to her husband who has advanced dementia. Her domestic helper is going back to her home country and there is a transition period while waiting for the new helper to arrive, given Stay-Home Notice (SHN) rules. As such, there needs to be more respite care options available to help care-givers. We need to give more care to our care-givers.

Support for Care-givers

Ms Yeo Wan Ling (Pasir Ris-Punggol): Mr Chairman, Sir, I declare that I am a director of a social enterprise that provides care-giving services. Care-giving is one of the most noble yet taxing responsibilities a person can take on. In fact, many Singaporeans are called upon to become care-givers at crucial stages of their lives when their careers are developing or at a very abrupt notice when illnesses strike or accidents occur.

Be it senior loved ones, children, the infirmed or fragile, those called on to become care-givers are up to a hefty task, often having to do this on a very long-term basis and often at the expense of their careers, time with their family and, sometimes, their own mental health.

During my Budget speech, I spoke about my frazzled resident who needs 45 minutes a week to restore and refresh her spirits. Many other family care-givers I speak with also tell me that while they have made adjustments to their lives in the long-term care of their loved ones – some have resigned from their jobs, others have taken on full work-from-home arrangements, some have hired foreign domestic workers (FDWs) – the problem comes with the availability and affordability of short-term respite care.

Besides self-care, care-givers need short breaks from care-giving to run errands like going to the post office, picking up groceries, or even going for a much needed haircut. Respite care typically lasts between 45 minutes and about three hours.

To help our family care-givers balance their care-giving duties with the other responsibilities they are carrying in life, support systems like short-term respite care must be made available; and this must be affordable and accessible at very short notice.

The Caregiver Support Action Plan developed by MOH and partner agencies addresses many care-giving related issues. However, I think that there is room to develop more support for respite care options beyond centre-based and nursing home respite care. Could MOH consider expanding their support to care-givers who need home-based short-term respite care through financial support and the availing of local care-giving resources such as creating a repository of local micro-jobbers who have care-giving experience?

Safeguarding Our Healthcare Workers

Dr Wan Rizal (Jalan Besar): Mr Chairman, I was asked recently, why am I asking for a cut for MOH when they should be getting an increment for their outstanding work in this pandemic, on top of the good work that they have been doing all this while. So, a big thank you to the Minister, his team from MOH and, of course, our healthcare workers.

Unfortunately, we have read reports of healthcare workers being abused physically and mentally while carrying out their duties. Their sacrifice and courage were met by behaviours unacceptable in any circumstances. When the pandemic started to unfold, we hear of healthcare workers being sprayed disinfectant by neighbours, denied boarding private vehicles and many other instances on social media. The number of abuse and harassment cases increased from 1,080 in 2018 to 1,300 last year.

How does MOH plan to further protect our healthcare workers' physical and mental well-being, considering the injustices made against them?

Abuse aside, we are also aware that our healthcare workers work long hours and have overnight schedules. We must provide them with the best work-life balance to maintain healthy, mental well-being. How does the Ministry plan to support our healthcare workers in this aspect?

Ms Mariam Jaafar (Sembawang): Mr Chairman, may I have permission to take both cuts together?

The Chairman: Yes, please.

Healthcare Manpower

Ms Mariam Jaafar: As the daughter of a former nurse, I literally applauded at my seat when the Deputy Prime Minister announced the increase in healthcare workers' salaries. It is long overdue.

Besides being a welcomed signal of the increasing recognition of the need to recognise the value of healthcare workers and the work that they do, one hopes that this will go some way to addressing the shortage of nurses and other healthcare workers today as our population ages.

I would like to know if the Government has any expectations or targets for how much we can close the gap in demand with this move to increase compensation and, if a gap yet remains, what more we can do to meet the demand for healthcare workers and where the biggest obstacles are – from the life cycle of recruitment, to advancement, to retention.

On recruitment, I would like to ask about the adequacy of spaces in our nursing programmes in our tertiary institutions as well as any data on leakage of students in nursing programmes who do not go on to become nurses, and why? I would also like to know the success rate at hiring people from other backgrounds into nursing – we heard some of that, I think, earlier in the debate – as well as the success rate of getting back former nurses and other women returning to work after some time off.

On advancement, I would like to know what is being done to enhance the career paths for healthcare workers.

On retention, I would like to know the top reasons why healthcare workers quit and what is being done to address each of these drivers, including a review of shift structures – both working and off-work schedules because a lot of research shows that the impact of shifts is more about off-work schedules and not actually the working schedules – and the support resources available to nurses. My next cut.

Private Sector Partnerships

The COVID-19 pandemic showed the necessity of a whole system approach in addressing a national crisis. Many doctors and nurses in private practice stepped forward as volunteers and private hospitals took in recovering COVID-19 patients at subsidised rates to free up capacity in public facilities.

Such partnerships between public and private facilities also exist outside of a crisis environment. I have had residents who are public patients telling me they were referred to Raffles Hospital for their x-rays and much to my relief at whether they were making the right decision, I learned that they were going to be offered a subsidised rate. As a result, they were able to get their x-rays done earlier than the queues at the public hospital would otherwise have allowed.

Mr Chairman, the private hospital sector is an important part of the healthcare eco-system. As the pandemic plays out, we may see some shifts in demand, for example, with more private sector patients opting to public care if they lose their jobs and their insurance and, of course, if there are changes to their Integrated Shield Plan (IP).

I would like to ask the Ministry if there is opportunity to optimise the current balance of healthcare in public versus private facilities and better leverage private sector partnerships to provide care for public sector patients, in particular, our subsidised patients, which of course would require the right incentives across the delivery chain.

Similarly, our private general practitioners (GPs), who play a critical role in MOH's thrust to shift healthcare beyond hospital to community as part of the goal to provide accessible, affordable and best care for all, I am heartened that we continue to build primary care capacity and strengthen primary care networks, including for mental health.

But, of course, it is not just about expanding capacity, alignment of interests, incentives and processes is also key. Having GPs and community nurses with special interests and training, giving GPs and nurses direct access to specialist advice and closer teaming and better communication with doctors, which I know some private doctors do really effectively over email and WhatsApp, giving GPs and nurses access to a broader range of diagnostic tests are proven levers to transfer care to the community and, at the same time, reducing overall demand through direct demand management at the GP level and continued education efforts to make informed patients.

The Chairman: Can the Member wrap up, please?

Ms Mariam Jaafar: I would like to ask the Ministry what is being done to enable and empower our GPs and nurses to further deliver care in the community.

The Chairman: Minister Masagos Zulkifli B M M.

The Second Minister for Health (Mr Masagos Zulkifli B M M): Mr Chairman, since Independence, Singapore has charted through several crises, adapted to the changing world while strengthening our social compact to keep our society strong.

Many Members of this House have shared how COVID-19 has accelerated change and uncertainties. As we recover, we must continue to renew our social compact, enabling our people to be resilient in overcoming future challenges.

Our healthcare system is a critical part of our social compact. We will continue to transform it to become a proactive and inclusive care system for all Singaporeans, enabling them to attain good health and live well. We will build resilience in every individual throughout life, designing our care system to address Singaporeans' health needs and risks across their life course.

Today, I will highlight how we are doing this at two ends of the spectrum: first, starting well in life; and second, ageing well.

For our young, we need to help them start well and achieve their fullest potential. International research shows that the early years of life are a critical window for development, with lasting impact on later life outcomes. This extends to even before the child is born, during the antenatal stage. Locally, the Growing Up in Singapore Towards healthy Outcomes, or GUSTO, found evidence that a mother's health can directly influence a child's development, which Ms Ng Ling Ling spoke about. These findings underscore the importance of intervening early in life to prevent disadvantages from snowballing, and that parents play a key role to a child's long-term development.

Mr Leon Perera will be happy to know that it was to this end that the Government launched and is scaling up KidSTART to give children from low-income families a good start in life through upstream support. We equip KidSTART parents with skills and knowledge to support their child's development and physical and socio-emotional well-being.

At our hospitals, the National University Hospital started an intervention programme called Promoting Parental Emotional Health to Enhance Child Learning (ProPEL). It supports mothers and mothers-to-be from low-income families through pregnancy into motherhood to enhance the child's development and learning.

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Ms Nurdiana joined the programme during the early stages of her pregnancy. She struggled with anxiety after being diagnosed with an auto-immune disease and had lost her job. The ProPEL team provided psychological interventions – helping her work through her fears and anxiety on health, pregnancy and motherhood. With the support, Ms Nurdiana developed skills to better manage her stress and anxiety. She is now more confident to start her journey as a mother.

The National Healthcare Group is partnering with a few Primary schools on the Living Well@School pilot. It aims to build awareness and motivation in choosing healthier food options for the young. Children are coached on healthier eating choices, while parents and teachers are equipped with resources to scaffold the child’s journey to embrace healthy living.

While we have made good strides in promoting the health and well-being of children and their families upstream, we will continue to invest even more, so that we can have a healthier next generation. We must do so in a coordinated manner, across social, health and education boundaries.

Therefore, I am pleased to announce that MOH will develop a Child and Maternal Health and Well-being Strategy to provide comprehensive support to women and their children. We will drive the Strategy and Action Plan through an inter-agency taskforce, over a five-year period. Its scope will span from pre-conception to adolescents aged 18 years old – many critical developmental milestones occur then. These are part of our larger efforts to improve the population’s health by addressing individual health needs and modifiable risk factors beyond the healthcare domain.

The Taskforce will focus on cross-cutting issues that require multiple agencies to collaborate and address decisively, to achieve a common goal of better health, social and education outcomes for our young. We will review our service delivery processes to integrate our services better, across the domains.

Our plans will be anchored on what matters most to mothers and their children. Since early this year, the Taskforce has already started engaging various groups of parents and stakeholders, to better understand their challenges in fostering a healthy lifestyle in their children and in accessing services. We found their feedback very insightful and will continue to facilitate more conversations throughout the year.

Next, on the second group – our seniors.

While COVID-19 has posed many challenges, it also presents us with new opportunities to further transform our support for them.

In this spirit, we have embarked on a refresh of the Action Plan for Successful Ageing. Since its launch in 2015, we have made significant progress on many fronts. We have raised the retirement age, provided seniors with opportunities to learn and volunteer, and rolled out the Pioneer and Merdeka Generation Packages.

Nevertheless, our plans must continue to evolve to meet the needs and aspirations of current and future generations. Achieving these aspirations is only possible through a whole-of-society, citizen-centric effort that brings together everyone to “turn silver into gold”. In my previous job, I was turning "waste into wealth"; this time, I am trying to turn "silver into gold".

I am glad to share with Mr Yip Hon Weng that we have started engagement sessions since last October to partner citizens on the Refreshed Action Plan. I encourage everyone to join this meaningful national SGTogether effort!

Having participated in some sessions myself, I am deeply encouraged by the diverse discussions and participants’ aspirations to age well.

Beyond this, Mr Tan Wu Meng and other Members have also asked about our on-going efforts to enhance support for seniors. I would like to share about three areas – first, our care landscape; second, care-giver support; and third, developing the community care sector.

Our care landscape. In our care landscape, we launched the new Community Care Apartments in Bukit Batok last month – a novel public housing-cum-care concept. The flats integrate senior-friendly housing features with care services and community building through social interaction and communal spaces.

When I visited the exhibition at HDB Hub, a senior told me that she had been long awaiting this! Others said they appreciated the communal spirit that it brings, greater assurance to age independently and the range of programmes to keep them active.

The flats were over-subscribed, with more than four seniors applying for each flat. We will continue to work with MND on planning for additional sites.

Last December, we announced a new Eldercare Centre service to serve all seniors nationwide. These centres would be key nodes in our social support and care landscape, and the first batch of centres will start from 1 May 2021. MOH will set aside about $180 million to complete the rollout of over 200 centres by 2024.

Each will provide a common suite of “ABC” services – A for Active ageing programmes, B for Befriending, and C – connecting to Care services. Seniors can participate in wellness activities or have their queries about care services and support schemes answered. Befrienders will reach out to those with little support.

To better reflect the new model, centres that provide the suite of “ABC” services will be named “Active Ageing Centres”. Today, some centres provide care services, such as day care and community rehabilitation. They will be called “Active Ageing Care Hubs” once they come on board to provide the new “ABC” services on top of their existing regular care services.

Next, on care-givers – they play a key role in supporting seniors to age well in the community. To support them better, MOH launched the Caregiver Support Action Plan (CSAP) two years ago. In response to Ms Yeo Wan Ling and Mr Yip Hon Weng, I am pleased to share that MOH, AIC and various community partners have rolled out all the initiatives under the CSAP. I will share a couple of examples.

First, we launched the Home Caregiving Grant two years ago, providing a cash grant to help with care-giving costs. More than 29,000 care-givers have since benefited.

To Mr Yip Hon Weng's query, we are also reviewing the Seniors’ Mobility and Enabling Fund to further defray costs of care-giving.

Second, we set up touchpoints within the community to support seniors and their care-givers. For example, the Silver Generation Office refers frail and homebound seniors to the Medical Escort and Transport service to assist them in getting to their medical appointments.

Third, we also have various care-giver respite services. We introduced the home-based respite care pilot in September 2019 for palliative cancer patients and expanded this in 2021 to all patients receiving home palliative care, regardless of diagnosis.

[Deputy Speaker (Mr Christopher de Souza) in the Chair]

Fourth, we will be launching a new grant, a new grant call this year on the Caregiving Ecosystem, under the National Innovation Challenge on Active and Confident Ageing, to support research on innovative solutions to sustainable care-giving.

Fifth, we have worked with community partners to set up four care-giver community outreach teams to better support care-givers at risk of burn-out or developing mental health needs. We will increase this to six teams by year-end. We have also established seven care-giver support networks in Dementia-Friendly Communities, enabling peer support among care-givers.

In addition, we will pilot a structured support system for care-givers of loved ones first diagnosed with dementia. We will proactively support and equip these persons with dementia and their care-givers with information upon the first diagnosis. I will also share more on the support measures we have for care-givers of Persons with Disabilities in my MSF COS speech.

Finally, developing our community care sector. To better serve seniors’ needs, we have expanded the capacity of community care services. Since 2015, we have added 4,600 day care places, as well as 3,100 home care places for home-bound seniors. We have also added 4,000 nursing home beds to cater to frail seniors with less family support.

We share Mr Ang Wei Neng’s concern about the impact of COVID-19 on the construction of nursing homes. To mitigate this, we are working with providers to open up currently non-operational beds. AIC also helps seniors and care-givers with alternative care arrangements while awaiting nursing home placement, such as the Interim Caregiver Service for short-term home-based custodial care, and the Integrated Home and Day Care programme. Seniors or care-givers who need help can approach AIC for further assistance.

Before I conclude, let me summarise my speech in Malay.

(In Malay): [Please refer to Vernacular Speech.] The healthcare system is critical in building a cohesive social support system.

We will continue to transform it to provide proactive and inclusive healthcare for all Singaporeans.

We will develop a Child and Maternal Health and Well-being Strategy over a five-year period.

This plan will provide comprehensive support to mothers and their young children during the critical phases of life to produce better health, social and education developmental outcomes for future generations.

For seniors, we will work with the agencies and individuals from various backgrounds to co-own and implement new initiatives through the revamped Action Plan for Successful Ageing.

(In English): Chairman, we are in good stead to address the future's challenges by identifying points of intervention upstream and strengthening support in the community. These are part of our continuous efforts to renew our social compact to safeguard our future as a strong, resilient and caring society. [Applause.]

The Chairman: Senior Minister of State Dr Koh Poh Koon.

The Senior Minister of State for Health (Dr Koh Poh Koon): Mr Chairman, even as we continue the fight against COVID-19, MOH’s key priority continues to be a healthcare system that provides good quality, affordable and sustainable healthcare for all Singaporeans. I will speak on how deepening our partnerships with the private sector, strengthening our healthcare financing system, driving greater value in healthcare delivery, and uplifting our healthcare workforce can help us to achieve these aims.

Our strong partnerships with the private sector over the years have allowed us to mount a robust and coordinated national response to the COVID-19 pandemic. For example, we have partnered private hospitals to provide subsidised care to patients, such as Raffles Hospital for non-life-threatening emergency cases, an example referenced by Ms Mariam Jafaar, as well as Parkway Hospital, Mt Alvenia and Farrer Park Hospitals for other conditions, including dengue.

At the peak of COVID-19, up to 400 beds across seven private hospitals were used to manage recovering COVID-19 patients. Private providers also supported our Community Care Facilities, clinics in worker dormitories, roving medical or swabbing teams, and many much more.

Our partnerships with private GPs have also matured over the years. CHAS subsidies have expanded since 2012. Today, over two million Singaporeans can access subsidised primary care at CHAS GP clinics. In FY19 alone, we disbursed more than $180 million in CHAS subsidies. GP clinics in Primary Care Networks (PCNs) anchored care in the community, deriving economies of scale for ancillary services, and serving 130,000 patients with chronic conditions last year. Over 970 private GP clinics serve as Public Health Preparedness Clinics (PHPCs), screening all patients with acute respiratory infections and conducted more than 250,000 swabs for early detection and containment of community COVID-19 cases.

In the long-term care sector, private nursing homes receive funding to provide subsidised services. Both private and not-for-profit organisations also operate many Government-built nursing homes and eldercare centres, under a Build-Own-Lease arrangement. In the pandemic, they actively stepped up safe management measures and supported COVID-19 testing and vaccinations to keep our seniors safe.

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To mount a strong pandemic response, MOH also tapped on expertise and resources from private laboratories for PCR testing capacity, vendors and distributors of medical supplies, cleaning companies that disinfected our medical facilities, and security companies, facility managers and transport companies that supported our quarantine and other operations.

There are too many to list comprehensively, but each one helped make our robust national response to COVID-19 possible. On behalf of all Singaporeans, I thank our many private-sector partners for protecting Singaporeans from the scourge of COVID-19.

I, therefore, agree with Ms Mariam Jaafar that the Government should continue to renew and deepen our partnership with private healthcare providers.

First, we will uplift capabilities of our GPs through continuing professional education. For example, the Agency for Care Effectiveness (ACE)’s Clinical Update Service (CUES) assists GPs in navigating areas of uncertainty and challenges specific to their area of practice through personalised, evidence-based discussions. We will also train and equip GPs to care for persons with mental health needs. My colleague, Senior Minister of State Janil Puthucheary, will share more on this later.

Second, strengthening regulatory frameworks, such as the Healthcare Services Act (HCSA) passed in January last year, will help us to better regulate newer, non-premises-based, models of care, such as telemedicine, through a services-based licensing framework.

Fee benchmarks, an area which Dr Tan Yia Swam mentioned earlier, was introduced in 2018. This gave patients seeking care at private sector providers more confidence that charges are fair and reasonable. Early data showed that doctors have been taking reference from the benchmarks, with more than 80% of charges in 2019 within the upper limit of the benchmarks, and this is about 4% higher than in 2018. Therefore, together with the Fee Benchmarks Advisory Committee, we introduced new benchmarks for anaesthetist and inpatient attendance charges in December 2020 and will continue to review and develop new areas of fee benchmarking.

I will now move on to our healthcare financing system which is anchored on Government subsidies and the 3Ms: MediShield Life, MediSave and MediFund.

Today, the Government provides significant subsidies, covering up to 80% of treatment costs. In FY19, Government spending on healthcare subsidies amounted to approximately $5.7 billion, or about 60% of MOH's total operating budget that year. This is projected to grow to S$6.5 billion in FY20, an increase of 13.6%.

As a society, we widely accept the need to be progressive and to target subsidies to those with greater needs. When formulating subsidy levels across the various healthcare settings, we should also encourage right-siting of care. We will, therefore, introduce a set of changes to the subsidy frameworks for inpatient care at the acute hospitals, specialist outpatient clinics (SOCs) and community hospitals. Let me go through each in turn.

First, the acute hospitals. For inpatient admissions to acute hospitals, we currently use individual income as the basis for means-testing. I have seen in my clinical practice and also met people during my Meet-The-People sessions, how a sole breadwinner may earn a high individual income, but shoulders the full responsibility for his or her household needs alone. For such individuals, healthcare costs can become a significant strain, and I have great sympathy for them.

Per Capita Household Income (PCHI), which is already widely used in our healthcare system, is, therefore, a better measure of means, as it also considers the amount of household support available, and the number of household members that this individual supports. MOH will thus align means-testing for inpatient admissions to acute hospitals from individual income to PCHI.

Another observation over the years is that the physical differences between B2 and C wards are no longer so obvious, following infrastructural improvements to raise patient safety and infection control standards. However, we still have a legacy system of using choice of wards as a proxy of financial means to differentiate subsidy levels.

Currently, B2 wards are subsidised at 50% to 65% and C-class wards at 65% to 80%. With better means-testing through PCHI, there is, therefore, less need to rely on ward choice. Therefore, we will unify B2 and C subsidies into a common framework, maintaining the same minimum and maximum range at 50% to 80%. This acute inpatient subsidy framework will also be applied to day surgeries which are currently subsidised at 65%. Effectively, this will increase subsidies for 70% of day surgery bills and encourage day surgeries instead of inpatient admissions when appropriate.

Overall, with MediShield Life and MediSave, we expect that most patients will not see a change in out-of-pocket payments, or OOP payments, with about 30% seeing lower OOP and about 15% seeing higher OOP.

Let me go to the SOC setting. While we raised SOC subsidies for the lower income up to 70% in 2014, higher income patients and median-income patients currently receive the same 50% subsidy support, despite both having quite different financial means.

To bring about greater progressivity and allow resources to be better directed, MOH will introduce two new subsidy tiers in the SOC setting for patients with higher PCHI: (a) 40% for PCHI more than $3,300 and (b) 30% for PCHI more than $6,500. For a family of four, these PCHI levels correspond to household incomes of $13,200 and $26,000 respectively. Nonetheless, these higher income households may continue to tap on MediSave up to the applicable withdrawal limits to help pay for healthcare bills.

With the introduction of the CHAS Green tier in 2019, higher PCHI patients with chronic conditions also have access to subsidised chronic care at CHAS GP clinics as an alternative. Complex chronic patients who are not suitable for management at primary care will also be able to utilise their MediSave through higher limits that are going to be introduced. I will speak more about this later.

Sir, having been in clinical practice for more than 20 years, I have also seen subsidised patients in the surgical SOCs who have, at times, preferred an A or B1 ward for specific procedures. Some preferred air-conditioning and others wanted more privacy in the private wards. But the cost of a potentially long tail of SOC consultations upon discharge worries them. For this reason, some patients have sometimes had to forgo their preference and request for a subsidised ward instead. These particular groups are those that Dr Tan Yia Swam shared earlier.

With better targeted subsidies at the SOCs, we will now allow private patients in the Inpatient setting to opt for either subsidised or private SOC for their discharge follow up. If subsidised SOC is chosen, the patient will no longer be able to pick their specialist, as is the current practice.

Overall, the SOC subsidy changes will affect about 30% of subsidised SOC patients, who are from higher PCHI households. Of these, seven in 10 will see an increase of less than $100 in total co-payment for their cumulative annual bills. This can be further offset by MediSave or MediShield Life, or for those who have private insurance coverage.

For elderly patients, any increase in co-payment will also be partially offset by Pioneer Generation and Merdeka Generation subsidies.

This brings me to community hospitals (CHs). Having worked in an acute surgical ward, I have occasionally encountered patients who have recovered significantly to be well enough for discharge to a community hospital for sub-acute or rehabilitative care, but who were reluctant to do so, due to the differences in the subsidy levels between acute and community hospitals.

We will, therefore, enhance subsidies available in our community hospitals to support patients in utilising appropriate care, and facilitate the smooth flow of patients from acute hospitals to community hospitals. This allows acute hospital resources to be available for patients who require more intensive acute care. We will raise the maximum subsidy of community hospitals to 80%, aligned with that of acute inpatient care, and further increase the minimum subsidy from 20% to 30%.

Together with increased MediShield Life claim limits for community hospitals sub-acute care from 1 March 2021, this should make community hospitals even more affordable, especially when compared to a prolonged acute hospital stay. Almost all, about 95% of all community hospitals patients will see an increase in subsidies.

Mr Chairman, subsidies are the bedrock of our healthcare financing system. Healthcare costs will continue to rise in the years ahead, and Government spending on healthcare subsidies will commensurately increase even after all these changes. The changes outlined will make healthcare subsidies more progressive and help facilitate care at appropriate settings. We expect to implement these changes over the course of 2022.

In addition to these changes, MOH will also review the financing landscape in the Long-Term Care, or LTC, sector. Last year, we launched CareShield Life and Medisave Care, improving affordability. However, as we uplift standards and draw in more Singaporeans to work in the LTC sector, cost pressures may potentially impact affordability. So, in anticipation of these challenges, we will once again review the financing situation for the LTC sector to see if further changes are needed.

Next, I will speak on the enhancements to MediShield Life and MediSave.

First, MediShield Life covers Singaporeans for large hospitalisation bills and selected costly outpatient treatments. Following the recent MediShield Life 2020 review, various benefit changes have been made to ensure that the scheme continues to provide adequate and meaningful protection to Singaporeans. These include raising the policy year claim limit from $100,000 to $150,000. Premiums will also be adjusted to keep the scheme solvent and sustainable.

The Government will provide up to $2.2 billion in premium subsidies and support over the next three years. Net premium increases for all Singapore citizens will be kept to no more than about 10% in the first year. Premium payment will also be deferred till the end 2021 for those who have insufficient MediSave balances and are unable to pay their premiums due to the economic impact from COVID-19.

As noted by Mr Gerald Giam, the benefit changes and premium adjustments will take effect on or after 1 March 2021, which is the Monday that just passed. On premium pricing, I wish to assure Mr Gerald Giam that the pricing assumptions are assessed by independent actuarial experts. We are studying how technically complex actuarial reports can be shared in a meaningful way, and will provide an update when ready.

Second, MediSave helps Singaporeans set aside some income towards their future healthcare needs, such as co-payments for large bills and for health insurance premiums. I would like to assure Dr Lim Wee Kiak that the MediSave contribution rates and Basic Healthcare Sum are reviewed regularly, in conjunction with other key healthcare financing levers, such as Government subsidies and MediShield Life.

Ms Hazel Poa and Mr Gerald Giam asked how MediSave coverage can be expanded in the outpatient setting. We certainly recognise that seniors tend to have higher healthcare expenses, especially if they have chronic conditions.

From the start of this year, we raised annual MediSave limits from $500 to $700 for patients with complex chronic conditions under the Chronic Disease Management Programme, or CDMP. The list of CDMP conditions will be reviewed regularly.

To support elderly patients in seeking outpatient treatment, we also introduced Flexi-MediSave in 2015, and lowered the age eligibility from 65 to 60 in 2018, allowing more patients to benefit. From 1 June 2021, we will further raise the Flexi-MediSave annual limit from $200 to $300. We will continue to review the MediSave withdrawal limits regularly, to ensure that they remain relevant and adequate for Singaporeans.

Beyond healthcare financing, as Dr Lim Wee Kiak has pointed out, we must also control upstream growth in medical costs to ensure affordability in the long run.

First, we should tap on technology to deliver care more effectively while optimising our limited manpower resource. Since the circuit breaker period, polyclinics, SOCs and community nursing teams have used teleconsultation to reach their patients at home, allowing continued consultation and advice for these patients during the circuit breaker period. I understand from feedback that patients are comfortable with teleconsultation.

Further, when ready, the National Central Fill Pharmacy will consolidate medications across multiple providers in a central location, enabling the delivery of medications directly to patient's homes, secured post boxes or other convenient locations. This will improve the access to pharmacy services, including for seniors with mobility needs, as Dr Tan Wu Meng mentioned, and support new care models, such as telemedicine.

We also agree with Dr Tan Wu Meng that patient navigators can improve patient convenience, and our public healthcare institutions have increased the number of staff trained in such roles by 3% annually between 2018 and 2020. But beyond this, we have also improved scheduling services and offer telehealth follow-ups for suitable patients, helping to reduce the need for multiple hospital visits.

Second, innovative care models have been introduced to improve right-siting of care in the community. Examples include the Urgent Care Centre (UCC) pilot concept and the GPFirst Pilot Programme which support patients with non-emergency conditions, helping them avoid unnecessary emergency department visits.

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MOH will review the performance of such technology-enabled services and innovative care models, and explore how we can scale up the promising ones. We also strive for greater value and better services in our healthcare system.

The Agency for Care Effectiveness (ACE) helps us to ensure that the prices we pay for subsidised treatments and vaccines are fair and commensurate with the healthcare outcomes they confer. This is done through health technology assessments and value-based pricing (VBP) negotiations. ACE will continue to ensure that subsidised medicines and medical technologies are both clinically and cost-effective.

We also established ALPS in 2018 to aggregate demand and achieve economies of scale in procurement and supply chain management. In 2019, ALPS’s Central Warehouse Distribution (CWD) pilot for polyclinics saved an estimated $1.7 million through advanced warehouse and logistics technology. ALPS will study how this CWD concept can be expanded to the whole of public healthcare boosting efficiency, resilience, and value in our healthcare supply chain.

We also agree with Ms Ng Ling Ling that funding mechanisms can drive greater value through influencing providers’ behaviour. We, in fact, implemented some of the ideas that she has shared.

One financing innovation which MOH has started to adopt is bundled payments, where funding is based on a patient’s entire care episode, even across multiple healthcare settings or attendances. This gives providers the opportunity to optimise care, reduce costs, and pass on savings to patients.

MOH has also implemented a Pay For Performance (P4P) framework which financially incentivises clusters to perform well in key priority areas and the Value-Driven Care (VDC) Programme which tracks clinical performance and cost of care for medical conditions.

We will expand these positive efforts and study other financing solutions and innovations that encourage healthcare providers to optimise care and improve outcomes.

Beyond technology and care models, healthcare is ultimately a high touch and people-centric sector. Healthcare professionals are key in improving patient care and outcomes.

COVID-19 has shown us the importance of maintaining a resilient core of healthcare workers. Following the launch of the SG Healthcare Corps (SHC) in April last year, over 5,000 workers and volunteers have been trained, and provided support in areas such as the care of elderly in nursing homes, swab operations, laboratory testing and vaccination operations.

Going forward, we plan to develop the Corps into a platform for citizen engagement and volunteerism in healthcare during peacetime, and serve as a reserve pool in times of crisis.

COVID-19 has been a trying time for all our healthcare staff and volunteers. I know many staff in our public healthcare institutions suspended their annual leave to meet the surge in manpower demands during the height of the COVID-19 crisis.

Many have played a critical role in the battle against COVID-19 and I would like to express our heartfelt thanks to all of them for their dedication and contributions, and their families for supporting them through this very tough period.

We also recognise and appreciate the contributions of our outsourced workers in the healthcare sector. We agree with Dr Tan Wu Meng that their work is intrinsic to the hospital as many of them, such as cleaners and health attendants, work alongside our healthcare staff in the wards. The intent of outsourcing is to leverage economies of scale and enable our public healthcare institutions to focus on the core mission of delivery of healthcare services. While our public healthcare institutions are not their direct employers, they have also extended support and tokens of appreciation to these outsourced workers. We will continue to work closely with the outsourced companies to improve the work conditions of their staff.

To strengthen our healthcare workforce, I agree with Ms Mariam Jaafar that we need to attract more talent to healthcare and to build a strong local core.

First, we have strengthened our pipeline of fresh graduates. Since 2012, we have increased intakes and retained a strong local core of doctors, dentists, pharmacists and therapists. We have also strengthened the attractiveness of nursing, increasing intakes by about 45%, from about 1,500 in 2014 to about 2,200 in 2020. At steady state, we will be training about 3,300 students annually in our Institutes of Higher Learning to become healthcare professionals.

Second, we have built pathways for progression, and continue to expand mid-career conversion pipelines.

We introduced new pathways for Enrolled Nurses to move from Nitec to Diploma-level qualifications within a shorter time and progress as a Registered Nurse.

In line with the recommendations of the Future Nursing Career Review Committee (FNCRC), we enhanced nursing career tracks and job scopes. Nurses can now perform a wider breadth of care tasks and make clinical decisions.

We are seeing increased interest in our Professional Conversion Programmes (PCPs). Between 2018 and 2020, an average of 160 mid-career locals enrolled each year, about double our average annual PCP intake in the preceding three years. This year, Ngee Ann Polytechnic (NP) will join Nanyang Polytechnic (NYP) in offering the two-year accelerated PCP for diploma-level registered nurses. We will also explore more pathways for mid-career entrants to complete their training in a shorter time. The Singapore Institute of Technology (SIT) is introducing an accelerated PCP in Occupational Therapy for those who have already got a degree in a science-related field. They can complete their training in slightly under three years instead of four years.

Third, we actively partner healthcare employers in re-designing jobs for staff working in healthcare support and operations support roles. For example, the Care Support Associate (CSA) role in SGH, and AIC’s sectoral job redesign project relook processes and blend clinical support, administrative and operations responsibilities into new roles. These initiatives encourage cross-deployment and multi-skilling of staff, create new career pathways, and provide interesting development opportunities for them.

Finally, we are cognisant that salaries play a key role in the attraction and retention of staff. Our healthcare workforce is the lifeblood of our healthcare system and the work that they do is critical in protecting the health and safety of our society. We must maintain the salary competitiveness of healthcare staff against the overall market to attract and retain quality talent.

For doctors and dentists, we recently updated the salaries for junior House Officers, Medical and Dental Officers, Consultant Family Physicians and newly-promoted Associate Consultants within our public healthcare institutions in 2019.

So, I am pleased to announce that nurses in the public healthcare sector can look forward to an increase of 5 to 14% in their monthly base salaries, phased over the next two years. Allied health professionals, pharmacists, and administrative and ancillary staff, including support care staff, in the public healthcare sector can also look forward to an increase of 3% to 7% in their monthly base salaries this year.

We will also increase funding support to publicly-funded community care organisations to ensure that salaries of their staff also remain competitive. The changes to both sectors will be implemented from July this year.

MOH will regularly monitor the salary competitiveness of our public healthcare workforce. Aside from salaries, we will also work with healthcare providers and union partners to make healthcare a progressive and fulfilling career.

Sir, COVID-19 has posed a major challenge to our healthcare system, but we have learned valuable lessons and we will emerge stronger. With deeper partnerships with our private sector providers, innovative, value-based healthcare delivery, a strong healthcare financing framework, and a resilient healthcare workforce, we will be better placed to provide all Singaporeans with good quality, affordable, and accessible healthcare. [Applause.]

The Chairman: Dr Wan Rizal.

Mental Health

Dr Wan Rizal: Chairman, in my recent speeches, I spoke about the importance of mental health and the need to destigmatise mental health issues. Now, its frequency has reached to a point where my students have given me hashtag DWR4MH, which means "Do what's right for mental health." Chairman, we need to change the negative perception and treat mental health issues like any other health conditions. Additionally, it is crucial for those who need assistance are able to get them quickly and properly.

Some time ago, I was approached by a family who has a teenage son who was depressed and suicidal. They did not seek professional help and I quote them, "malu" which means "embarrassing". "The incident was indeed embarrassing and brought shame to the family." And when they were convinced to seek help finally, they found it daunting to go to the polyclinics, let alone IMH.

The longer we delay the assistance rendered, the shorter the window period to undo this damage. We need a more comprehensive framework to address the issues of stigmatisation and, of course, accessibility.

Last year, the Ministry announced that it would be expanding mental health services under the Community Mental Health Masterplan to enhance the reach and provide support for youths and their families. May the Minister, please, provide an update on this?

The Chairman: Dr Tan, if you like to take both your cuts together, please do.

Mental Health and Wellness

Dr Tan Yia Swam: Yes, Sir. Mr Chairman, Sir, the COVID-19 Mental Wellness Taskforce convened by the MOH and the IMH in October 2020, with representatives from various Ministries has done great work in promoting mental health literacy. Yet, I hear of anecdotal cases of discrimination against people who have mental illnesses. I will speak on three main groups: one, the general population and working adults; two, the young; three, other vulnerable groups.

For the general public, how do we react when we see someone behaving “oddly” – such as talking to themselves, removing all their clothing in public, becoming violent for no apparent reason, or wailing inconsolably? Do we take a video and post the incident online? Call the Police? Walk away? Or will we step forward to offer some kind of help? I suspect many people want to, but we do not feel able to.

For working adults, I understand when colleagues and bosses see only the underperformance of the affected employee. For example, frequent absenteeism, missing work deadlines, or simply being very unsociable at work. Physical illnesses such as high blood pressure and diabetes, have a measurable scale of normality. Mental illnesses are harder to pick up. Is someone just having a bad day? Is it triggered by something specific and situational which will resolve itself after the event is over? Or could these bad moods be symptoms of a mental illness such as depression, anxiety disorder or even schizophrenia?

We need to have more schemes in place for the general population to recognise early signs of mental illnesses and learn how to assist as a first responder.

Regarding the youth, the world is changing fast. I am only a few years past the official definition of "youth", but there are times when I feel very distant from them! Exploring one’s sense of identity as a growing teenager has never been easy. Being in a more connected world now, they are perhaps subject to more pressures.

As a doctor, I have received ground feedback that there is a mental health crisis in our youths – child psychiatrists observe that youth suicide is at its highest rate in the past couple of years. Contributing factors may be increased parental conflicts and divorces, academic stresses, COVID-19, social media and bullying.

How do we recognise and stop bullying of any kind – physical, emotional, verbal? In my Budget speech, I brought up the modern phenomenon of cyberbullying and the amplification effect of social media. A short video clip gets shared, liked and goes viral. Shaming gets weaponised. When I was a child, any once-off silly act gets forgotten, and maybe brought up only at annual family gatherings during Chinese New Year. But now, the Internet never forgets.

Suicide is a painful and difficult subject, as there is a taboo around this. But this is exactly why healthcare has to educate and teach about the mental health issues that contribute to this tragedy.

Let us guide our people to be more caring, and inclusive. How do we approach those who are different? Mental resilience, sleep hygiene, and the safe use of the Internet should be taught in schools, and to adults as well; to be given as much importance as physical exercise! I thank other Members, as well as MOE for addressing this, and welcome the changes to CCE.

However, after we succeed in early detection, are there enough healthcare providers to render help? We will need enough psychiatrists, psychologists, nurses, pharmacists, medical social workers, case managers, family therapists and so on. For many of the patients with mental illnesses, it is a lifelong disease, and some of the triggers may be related to socio-economic stressors.

Young patients with mental health may just be the tip of the iceberg, and further investigation may uncover more members of the family with mental health issues. They will all need to have adequate treatment. Community support has to come in hand in hand with doctors in the hospital to provide integrated care. The network of support is essential to minimise the episodes and severity of relapses. Focus cannot be just on the acute admissions, but in discharge back to the community, gainful employment and meaningful living.

Finally, vulnerable groups such as singles, single families and elderly staying alone may be at higher risk due to social isolation and lack of access to resources. Does the Ministry have plans in place to help these groups?

In summary, the global COVID-19 pandemic has caused increased stress in multiple areas – retrenchment, change in jobs, lifestyles, education. This has a far-reaching impact on interpersonal relationships, physical and mental health. I urge MOH to further develop programmes on mental wellness and building resilience as a routine part of daily life.

Staying Healthy in the New Norm

Many people are now working from home due to COVID-19. Other speakers have shared on the challenges that parents with young children face working from home. While some adults have managed to incorporate daily exercise into their new routine, many others are struggling to balance work, daily chores and the demands of family care.

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For many busy working parents, the daily commute to work and back home might be the only exercise they get. For example, walking 10 minutes to the MRT station and another 10 minutes to the workplace. This makes up a total of 40 minutes' walking time and one may clock 8,000 to 10,000 steps, hopefully. The lack of commute while working from home means a reduction in mobility. Some of us snack more. For those of us who like to chat over coffee or lunch at the office, working from home also results in less social engagement, which may lead to chronic health issues such as obesity, depression and anxiety.

What are the Ministry's plans to support Singaporeans to pursue healthy habits in this new norm?

The Chairman: Dr Lim Wee Kiak, if you would like to take both your cuts together, please do.

Partnering Singaporeans for Good Health

Dr Lim Wee Kiak: Mr Chairman, nowadays, we see everyone wearing a healthcare device to monitor our steps, our heartrate, our stress level, oxygen saturation and how well we slept last night. Some of the more advanced ones perform electrocardiogram (ECG) and even measure your blood sugar levels now as well as blood pressure.

On our home front, I am encouraged to read about the Health Promotion Board and Fitbit – headquartered in San Francisco, California – tap on technology to help Singaporeans to live healthier using its devices. I must commend the Ministry for mobilising technology to boost Singaporeans' interest in fitness and healthcare.

Sir, I think Singaporeans are ready to use digital technology to take charge and take responsibility of their own health. Let Singaporeans have accessibility to their own health data when the National Electronic Health Record (NEHR) is ready.

I envisage in the near future, I will have access to my own medical as well as health record, just like the details of my COVID-19 vaccinations on HealthHub app now. In the near future, I will receive a reminder from MOH for my annual health checks, blood tests, annual immunisation, and my once-in-five-years colonoscopy screening. Once completed, there could be an artificial intelligence (AI) system in MOH that will review my health records, and then they will send me an advice to take active steps to improve my health through lifestyle adjustments. They may recalculate and lower my annual MediShield insurance premium, if my health is good.

That will encourage more Singaporeans to come on board and to take responsibility of their own health.

I feel we can go a step further now to get Singaporeans to do more exercises, to manage their stress, maintain mental wellbeing and manage their sleep better. Another area would be to manage good nutritional diet daily and influence them to have good eating habits. Singaporeans already have one of the longest lifespans in the world but we spend the last decade of our lives in poor health.

What we want is not just a long lifespan but a healthier lifespan.

I urge MOH to take advantage of all the advances in digital healthcare devices now to set up a national health management system and to step up the partnership with Singaporeans to achieve good health for life.

National Immunisation Programme

Sir, the popular adage goes, "prevention is better than cure", and in modern healthcare, immunisation against infectious diseases and potentially fatal diseases is the key factor to a long, healthy lifespan.

One of the things that comes out from this COVID-19 pandemic is the heightened public awareness about the role of immunisation in our healthcare measures. Immunisation is one of the key advances in medicine that has extended the lifespan of humans globally. Apart from the immunisations that we received during our childhood, many Singaporeans do not get regular immunisations unless they need to travel or for work. How many Singaporeans would regularly go for their annual flu vaccinations or pneumococcal vaccinations? Even new vaccines such as the human papillomavirus (HPV) vaccine will reduce the risk of cervical cancer.

Although we have a comprehensive vaccination programme for our children, do we have a more comprehensive programme for adults and the elderly?

We are constantly reminded to take our COVID-19 vaccination to protect our loved ones, especially those immuno-compromised and the elderly around us. Likewise, we should do the same for influenza.

Perhaps not immediately but in the months ahead as we advance in our COVID-19 vaccination, I would urge MOH to take advantage of this opportune time to review and enhance our national immunisation programme, implement measures to promote public awareness and facilitate and improve accessibility and affordability of immunisation for all Singaporeans for their good health.

The Chairman: Senior Minister of State for Health Dr Janil Puthucheary.

The Senior Minister of State for Health (Dr Janil Puthucheary): Mr Chairman, Singapore is fortunate to have a workforce in the healthcare family driven by professionalism and dedication. Our people answered the call of duty, they have carried us far in this fight against COVID-19 and have contributed to keeping Singapore safe during the pandemic.

Our infectious diseases experts and staff at the National Centre for Infectious Diseases (NCID) and other public healthcare institutions have worked to provide clinical guidance to and support for public health operations. Laboratory specialists at the National Public Health Laboratory provided guidance for COVID-19 tests and conducted genomic analysis to support cluster investigations and surveillance for variants. The staff at the public and private healthcare institutions do their duty, putting themselves in harm's way. They undertake healthcare operations in high-risk locations like the foreign workers' dormitories, emergency departments, hospital wards and intensive care units across our healthcare system.

I echo the sentiments of many in the House to express our deep appreciation for colleagues in many, many different roles.

The work continues and Members will know that we started our national vaccination operations at NCID on 30 December 2020.

NCID was one of several initiatives and projects that came out of the lessons we learned from SARS. In the test of that crisis, we identified vulnerabilities and in our response, developed capabilities and institutions that exist to this day, like NCID, helping us with COVID-19.

In this crisis, we are learning new lessons and responding to different vulnerabilities. We need to institutionalise the capabilities that we are developing. We have needed to deal with the pandemic and continue the usual clinical services and, now, stand up a massive national vaccination exercise. Many of these skills, tools, processes and systems we have developed are distributed across our healthcare network and the care providers.

But centrally, at MOH, we have had to also develop and improve our organisational capability to manage the response to this crisis and, hopefully, be better prepared for the next.

At MOH, we have set up a new Crisis Strategy and Operations Group. They have worked hard, in collaboration with other Ministries and other agencies, to coordinate COVID-19-related operations. This is a capability and a team that we will need in order to be better prepared for the next pandemic.

We are heartened by the appreciation demonstrated by the public for our healthcare workers. However, today, there are still cases of harassment and abuse against staff. This has affected their well-being and their safety.

To Dr Wan Rizal's question, we take abuse and harassment against our healthcare workers very seriously and will not hesitate to take appropriate action when necessary.

The enhancements to the Protection from Harassment Act in November 2014 gave additional protection against harassment to Public sector healthcare professionals and support care staff. Public healthcare institutions also have policies in place to handle abuse cases. The institutions conduct training for healthcare staff, including on de-escalation measures during potential conflict and abuse.

In addition, we will work with the clusters and the Healthcare Services Employees' Union (HSEU) on a tripartite effort to strengthen messages against abuse and harassment of public healthcare staff.

During the Budget debate, Mr Darryl David asked about staff benefits. Dr Wan Rizal also asked about this just recently. Our public healthcare institutions do pay close attention to staff leave and make time for sufficient rest. These are planned to ensure sufficient staffing for patient safety. There are also rostered breaks and staff rotations to ensure sufficient rest during and between shifts.

To better support our healthcare staff, a cross-cluster Staff Wellbeing Committee, with representatives from our public healthcare institutions and MOH, has been set up. The committee will share best practices and provide feedback to MOH on possible enhancements to improve staff wellbeing.

Besides healthcare workers, our HealthTech – health technology – engineers have also played an important role. They have rapidly developed systems to support new operational demands, including the on-going vaccination operations.

These are also important capabilities that we need within our system. Thus, to grow our health technology workforce, we work closely with the Integrated Health Information Systems (IHiS) to redesign jobs and actively recruit people into new roles, including software engineers, systems analysts and cybersecurity professionals. To facilitate mid-career switches into HealthTech, IHiS, Infocomm Media Development Authority (IMDA) and SkillsFuture have curated specific training programmes.

One such example of a mid-career switch is a gentleman by the name of Mr Daniel Ong, whom I spoke to recently. He was a copywriter and his formal education was in English Literature. He could not write code before joining IMDA's Tech Immersion and Placement Programme, which is part of our TechSkills Accelerator. In March last year, Daniel began work at IHiS as a front-end developer. He has contributed to two IT projects supporting the fight against COVID-19. Now, he is developing the user-facing components of the system supporting the One-Rehab framework, which I will speak a little bit more about later.

We hope that more people will see opportunities in this HealthTech space and embrace the possibility that with some training, they can join the healthcare family, not necessarily as a clinician but contributing to the success of our public healthcare eco-system.

As Mr Ang Wei Neng pointed out, we can and should learn many things from our fight against COVID-19.

For example, our early, comprehensive and persistent contact tracing and quarantine efforts have played a key role in our COVID-19 response. Besides the vigilance and skill of our healthcare workforce, our digital tools such as SafeEntry and TraceTogether continue to be central to the speed and efficiency of our contact tracing. Coupled with our aggressive testing strategies, these measures have contributed to our success in keeping the number of our community cases under control, for now.

To swiftly identify COVID-19 cases and contain the outbreak, we have built up our testing capacity and our community testing operations. Through targeted operations as well as routine surveillance testing, such as the testing of our hawker centre workers, we have so far been able to detect cases and quickly prevent spread.

As a repository of patient records, the National Electronic Health Records (NEHR) has also been a key enabler in facilitating this provision of care during the pandemic. Healthcare professionals can access NEHR for their patients' COVID-19 test results and their existing medical conditions before the vaccination. The NEHR has also been enhanced this year to meet the requirements for COVID-19 vaccinations, displaying alerts and reporting problems.

As we do this, data security remains a key priority. We have been taking steps to improve the security of our NEHR through technical and process enhancements, in response to the security reviews that we conducted in 2018. We expect to complete most of this within the year and onboard more healthcare institutions to contribute to NEHR more securely.

Beyond COVID-19, we must be ready to respond to future public health crises by having the right systems and capabilities. We will do so in four ways.

First, we will enhance our surveillance and response capabilities through the use of new technologies to enable us to more effectively consolidate, analyse and generate insights from large amounts of data.

Second, we will augment our human capabilities to prepare Singapore against future threats. Skilled clinical teams will always play an important role in detecting and managing new diseases and outbreaks, and we also need other experts such as epidemiologists, data scientists, statisticians and software engineers like Daniel. We need teams to investigate and perform advance analytics, for example, to determine the likelihood of spread and inform our response to an outbreak.

Third, while we remain in DORSCON Orange for now – DORSCON stands for Disease Outbreak Response System Condition – we will look into strengthening our DORSCON framework, incorporating lessons learnt from the pandemic so that we can better communicate public health risk and to help us more effectively respond as a whole society when "Disease X" strikes, the next serious pandemic crisis.

Finally, we will develop a national R&D Programme for Research in Epidemic Preparedness And Response – and the acronym is appropriately called PREPARE to strengthen our R&D capabilities to prevent, prepare for and respond to future public health crises.

It will include (a) strengthening infectious disease collaboration networks locally and regionally; (b) strengthening capabilities for the accelerated development of diagnostics, therapeutics and vaccines; and (c) establishing a national infectious disease repository and database for research and data analysis.

To further address Mr Ang’s question, MOH regularly reviews our national response and is conducting an interim review. It will include other Ministries and Agencies. We will share details when completed.

5.00 pm

Beyond pandemics, we must ensure that the healthcare needs of our general population are met. The work continues.

Our polyclinics are a vital element in our Public Health primary response. Built in 1980, Clementi Polyclinic is one of our oldest and smaller polyclinics. Its central location has served residents well, with about 850 patients seen per day. We will be redeveloping the polyclinic by 2027 to better serve residents in the region.

Dr Tan Wu Meng asked whether we have considered patient’s comfort and staff’s performance in our design of healthcare facilities. The answer is yes. When designing new healthcare facilities, the design team will engage stakeholders including the care team, patients and carers, and the facilities management team.

The redeveloped Clementi Polyclinic will undergo the same process. It will be more spacious with more elderly-friendly and accessibility features. Residents can also look forward to a comprehensive range of primary care services, including medical treatment for acute conditions, chronic disease management, women’s and children’s health services, as well as radiological, laboratory and pharmacy services.

Another example of the on-going work to improve routine clinical care services despite the pandemic is to ensure our population has timely access to the right level of rehabilitation care. We have developed the National One-Rehab framework. Under this framework, patients will have improved access to community-based rehabilitation and benefit from expanded capacity and capability in the care providers.

Our hospitals, polyclinics and community care providers will embark on a multi-year pilot to validate this new care model. Our hope for patients with stable musculoskeletal conditions such as lower back pain who do not require surgery or complex interventions to receive this rehabilitation care in the community, instead of only at specialist clinics or hospitals.

During last week’s Budget debate, we heard Dr Shahira Abdullah, Ms Carrie Tan, Dr Wan Rizal, Ms Mariam Jaafar and Mr Eric Chua speak about mental health. Since the launch of the Community Mental Health Masterplan in 2012, and its enhancement in 2017, we have increased the capacity of community mental health services. We are on track to meeting our targets by end 2021.

In primary care, we have over 220 GP partners and 14 polyclinics providing mental health and/or dementia services.

We have set up 50 community outreach teams and reached out to over 350,000 persons with mental health or dementia needs. In addition, 21 community intervention teams were established to provide mental health interventions such as psycho-social therapeutic interventions and counselling. We have met our targets of 50 community outreach teams and 18 community intervention teams ahead of our end 2021 timeline.

To Dr Wan Rizal’s question on support for youth and their families, we have piloted the Integrated Youth Service (IYS) within the Agency for Integrated Care (AIC), the Institute of Mental Health (IMH) and Care Corner, which is one of our community partners in the North.

Since April 2020, Care Corner has begun community outreach using online platforms, and has reached out to over 2,600 users. In November 2020, the Care Corner team moved into the new Woods Square Community Space, to provide face-to-face mental health screening and basic emotional support sessions for persons with mental health challenges, and to conduct experiential resilience or mental well-being events.

MOH and AIC have also worked with other community partners to set up youth community outreach teams to reach out to young people in mental distress to provide basic emotional support and resources. The team would also engage the family to understand the stressors and the home environment. Links to social and health services would also be provided.

Through the Youth Mental Well-being Network, we have heard from the youth, mental health and social sector professionals, patients and caregivers, on how we could improve the mental well-being of our young people.

Minister of State Sun Xueling earlier shared on how the Network has initiated ideas for over 30 potential ground-up projects. Parliamentary Secretary Eric Chua will also be sharing about an initiative to provide positive peer support during his MSF speech. The three of us are working together, just as MOE, MSF and MSH are working together on this important area.

To look into the psycho-social impact of the COVID-19 pandemic on the population, we set up the COVID-19 Mental Wellness Taskforce in October 2020. The Taskforce has reviewed and recommended three areas to work on, namely, to develop a national mental health and well-being strategy; secondly, a national mental health resources webpage; and a national mental health competency training framework.

Beyond COVID-19, we will evolve the Taskforce into an inter-agency platform on mental health and well-being, by mid 2021. The platform will oversee mental health and well-being efforts, focusing on cross-cutting issues that require multi- and inter-agency collaborations. We are working out the details of the platform and will share more when ready.

Dr Tan Yia Swam asked about the support for other vulnerable groups such as our seniors and building a more inclusive society. The Government recognises that those who suffer from mental health conditions may face discrimination. We have been working with partners to roll out initiatives to address this issue. It will take a whole-of-society approach to tackle this issue effectively.

The National Council of Social Service launched the “Beyond the Label” movement in 2018 to fight the stigma of mental health conditions and encourage social inclusion, positive attitudes and support towards persons living with mental health conditions. The movement also provides a platform for more conversations about mental health and promotes greater awareness and the acceptance of mental health conditions among the public.

To reach out to persons with or at-risk of mental health conditions or dementia, including seniors, community teams also reach out to residents and their caregivers to provide mental health or dementia information, basic emotional support and links to appropriate services, health or social, as necessary.

For seniors at risk of social isolation, the AACs, Silver Generation Office and local grassroots organisations connect them to befrienders who will reach out to them on a regular basis, providing companionship and encourage them to participate in social activities, keeping active and keeping connected with the local community.

Seniors can also sign up with CareLine, which is a 24/7 social support hotline that provides tele-befriending services as well as emergency response to seniors in distress.

While we do all this to build up the capabilities in our community partners, we will make sure that our main psychiatric sector, IMH, is updated. Since 2018, IMH has been undergoing refurbishment and improvement works to facilitate the care and improve operational efficiency and safety for patients and staff. And these works are expected to be completed by the end of 2022.

Mr Chairman, to fight COVID-19 we have had to rely on the skill, dedication and professionalism of our people. We have had to develop and deploy technology and we have had to scale up clinical services, all the while looking after the many healthcare issues that are unrelated to the pandemic, but essential to our health. We have had to be agile, steadfast and determined.

We are all a bit tired and fatigued, but also hopeful and confident that we can find our way forward. Our ability to get this far was the result of many years of investing in our people, our facilities, systems, research and capabilities. We must learn the lessons from this experience. The preparations for the next crisis, whatever it is, are underway and require that we keep ourselves and our healthcare system in good health. Prevention is best, preparation is also necessary.

The Chairman: Parliament Secretary Ms Rahayu Mahzam.

The Parliamentary Secretary to the Minister for Health (Ms Rahayu Mahzam): Mr Chairman, we remain committed to our long-term priorities even as we focus on containing the pandemic. We continue to transform from Beyond Healthcare to Health, to support Singaporeans to lead healthier lifestyles and stay healthy in the “new normal”.

It is important to take stock of our state of health. I am happy to report that Singapore ranked first globally for life expectancy at birth and healthy life expectancy at birth in the Global Burden of Diseases 2019 study.

However, based on our National Population Health Survey 2020, there are still areas for improvement.

While our smoking prevalence rates decreased to 10.1%, down from 13.9% in 2010, compared to 2017, the proportion of Singaporeans with sufficient total physical activity has dropped. The proportion of Singaporeans that are obese or overweight has increased. In 2019 and 2020, about two out of five are overweight. And the age-standardised prevalence of the three common chronic diseases, high blood pressure and high blood cholesterol have risen and the prevalence of diabetes have not decreased.

There is a need to better understand the current situation among different groups. Additionally, COVID-19 and the various measures and socio-economic challenges have impacted our lifestyles and our health. Dr Tan Yia Swam has also asked about supporting healthy living in this new norm. I will therefore share our plans to innovate health promotion efforts for Singaporeans to remain healthy in the “new normal” and how to better prepare Singaporeans to lead healthy lives for the future.

Indeed, in the past year, Singaporeans faced challenges pursuing healthier habits in ways they were used to. With safe distancing concerns, we were unable to hold our usual health promotion programmes such as mass exercises. As working from home became the norm, we also observed a drop in physical activity time, likely from reduced commuting. This drop is also demonstrated in the daily average step count data from the Health Promotion Board’s (HPB) National Steps Challenge.

We quickly pivoted to delivering our programmes virtually, in line with the safe management measures, or SMMs.

We shifted physical activity programmes online, and produced exercise routines on YouTube and an edutainment series on free-to-air TV channels to help Singaporeans keep active. We understand that some seniors have found it challenging to adapt from physical to virtual modes of exercise. To help seniors navigate around these platforms, we worked with partners such as People’s Association to organise workshops to provide assistance, and equip them with basic IT skills.

I am heartened to hear that our regular participants have benefitted. For example, for the senior-centric virtual Community Physical Activity Programmes, over 5,000 participated across more than 190 sessions from July to December 2020. To benefit as many as possible given the current guidelines, we will be scaling up our virtual programmes progressively this year.

We understand that some still prefer physical interaction for health programmes. To reach out to more Singaporeans, we have gradually resumed physical sessions both in the community, such as our popular Sundays at the Park, and at the workplaces with the appropriate SMMs.

Like physical health, mental wellbeing is also important for one’s health. I echo Senior Minister of State Janil on creating a supportive environment to empower Singaporeans to take care of their mental well-being.

In August last year, we launched the “Brave the New” campaign with MCCY to build psychological resilience of individuals. The campaign provided tips for self-care, and information to support their peers and loved ones. It reached 2.1 million Singaporeans and three-quarters of those surveyed reported being more motivated to self-help or help others in their mental well-being.

To complement this, the “Hi!JustCheckingIn” movement started in January this year to equip targeted segments of the population with the appropriate skills to help them identify and reach out to those who may need support. Building a supportive community is important, to encourage Singaporeans to seek help if they are unable to cope.

Through our community partners, we included seniors in our mental well-being efforts. We understand that many seniors are mentally and physically affected during this pandemic, especially during the circuit breaker. Last year, we trialled the virtual “Balik Kampung” programme to link up 100 seniors over 22 Senior Activity Centres over activities to stay mentally stimulated. With good feedback on how it has helped seniors stay socially connected, we will ramp up these efforts.

We will continue to promote holistic well-being. The HPB’s National Steps Challenge saw over 900,000 participants in its fifth season. The sixth season will start in the third quarter of this year and will augment the traditional Steps Challenge with a different dimension of well-being – sleep, via the first pilot Sleep Challenge.

Having good sleep habits is key to good health and well-being. Through the Healthy365 application and a wearable, there will be nudges to achieve the recommended sleep duration, and tips on good sleep habits. Interested participants can look out for more details on Healthy365 and HealthHub.

We will continue to work on avenues for Singaporeans to keep healthy while staying safe.

5.15 pm

We recognise that at different life stages, Singaporeans face different health needs, challenges and risks. Going forward, we will add a person-centric approach to address these across our population segments.

Dr Tan Yia Swam has highlighted health literacy in her Budget debate speech and Dr Lim Wee Kiak has also suggested boosting our efforts with technology. We have embarked on initiatives similar to Dr Lim's vision. I am happy to update that the first digital version of My Health Booklet is ready on HealthHub, developed based on ground insights. This version provides an overview of your health screening records drawn from national health databases and smoking cessation messages for those motivated to quit smoking. We will add more features and health topics such as stress management and the nationally recommended vaccinations starting from July this year.

Another example is LumiHealth, a free, two-year personalised health programme designed by HPB, in partnership with Apple, using the Apple Watch. Under this programme, participants will embark on customised health journeys and earn rewards as they complete health-related challenges. They will also receive personalised reminders, to encourage them to meet their goals. Since its launch in end-October 2020, we have seen more than 100,000 downloads.

We must also not forget our efforts to keep chronic conditions at bay, like our on-going War on Diabetes. MOH developed the Patient Empowerment for Self-Care Framework to empower patients to co-own their care journeys and achieve better care outcomes with support from their healthcare team, family and friends. Under this framework, we developed the first tranche of the National Diabetes Reference Materials that provides fundamental information and hosted it online on HealthHub.

We are now working on the next tranche of materials with more in-depth information to help patients, their family and friends, better understand and manage diabetes. This resource is being co-created by the people for the people – about 700 citizens highlighted additional topics and content that would be useful, and suggested design features for a more user-friendly online experience. These materials will be ready from 2022.

Beyond our broad plans for our Singaporeans, I will elaborate on targeted efforts. Mr Leon Perera has highlighted the lower income groups. Minister Gan has shared how we ensure they have good access to affordable care. While our health promotion efforts remain inclusive to all, there are also efforts targeted to address their health needs, and we work across agencies to provide holistic support.

One example is the Healthy Living Passport programme, which Mr Perera referred to. The programme is designed to improve health literacy and promote healthy lifestyles. It is customised based on the lifestyle needs of lower income families, with tailored messaging and education. This is a multi-agency effort, and will commence after the SMMs are reviewed.

We aim to benefit 15,000 residents over three years. We intend to track changes in our participants' health literacy as well as their behavourial improvements. This would allow us to evaluate the impact of our programmes as we generally do with our efforts.

We see significant disparities in health behaviours and outcomes across ethnicities and will be ramping up efforts in this area. For chronic diseases, in 2020, 14.4% of Malays and 14.2% of Indians have diabetes, compared to 8.2% for Chinese. Thirty-seven point five percent of Malays and 36.1% of Chinese have higher blood pressure, compared to 29.5% for Indians. For cancers, the Chinese consistently have the highest age-standardised cancer incidence rates, but the proportion of Malays among all cases of cancer has gradually increased over the decades.

Looking upstream at other modifiable lifestyle risk factors, the Malays have the highest obesity rates and Indians have the highest prevalence of being overweight. The prevalence of daily smokers are more than twice as high amongst the Malays as compared to the Chinese and Indians.

Research has shown, poor health behaviours can affect life expectancy. Therefore, our community needs to take stronger action, and support one another against poor health habits. Cultural preferences may influence health behaviours and we recognise the importance of engagement and collaboration with the different ethnic minority groups to design culturally relevant programmes. Some of our earlier efforts have seen good progress.

For the Malay community, we have built our partnerships under HPB's Jaga Kesihatan, Jaga Ummah from 23 in 2018 to 32 mosque partners, and 18 other partners such as the Malay Executive Activity Committees (MAEC) and MENDAKI. With their support, we were able to provide a range of healthy living programmes for their congregants.

Our Indian community partners such as Hindu Endowment Board, Sikh Welfare Council, SINDA and places of worship have provided strong support in engagement efforts with their networks. For example, NARPANI Pearavai provides Indian Activity Executive Committees funding to co-create health activities for their residents. Between 2018 and 2020, close to 15,000 Singapore Indian residents have participated in the various health promotion programmes.

We will build on early successes to improve our work, to make healthy living a sustainable achievement. Moving forward, we will expand community partnerships and harness ground-up efforts to multiply our impact and and ensure that our programmes are culturally relevant through customisation.

We will engage key community leaders through significant platforms to garner commitment towards health. For example, at a forum in end-March 2021, leaders from the Hindu Endowment Board, SINDA, NARPANI, Sikh Welfare Council and HPB will discuss the state of health amongst Indians and co-develop culturally relevant efforts to facilitate healthier lifestyles among Singaporean Indians. We look forward to an invigorating discussion and a year of fun, healthier activities for all Singapore Indian residents.

Let me share further for the Malay community. Mr Chairman, allow me to say a few words in Malay, please.

(In Malay): [Please refer to Vernacular Speech.] To bolster health-related efforts for the Malay community, we will form a new working group. I will be chairing this group together with Dr Wan Rizal and Ms Mariam Jaafar, as well as community bodies, such as M3 and the Muslim Healthcare Professionals Association (MPHA).

We will continue to collaborate with the "Jaga Kesihatan, Jaga Ummah" (JKJU) network and community leaders to develop and implement health programmes throughout the year to foster good health habits.

We will produce simple tips to remind the Malay community about the important steps to take care of their health. To sustain this effort on health, we will have Health Ambassadors and continue to enlarge this network of volunteers.

Mdm Rahimah is one of our most committed Health Ambassadors since 2012. As a member of the Macpherson MAEC, she plans motivational health lectures for the Malay community. She also spends time teaching our seniors to surf the Internet. Mdm Rahimah’s efforts should be emulated. I would like to encourage all Singaporeans to follow her lead and contribute to the community.

(In English): Beyond ethnic minorities, I echo what Minister Masagos said on the importance of supporting our children and women to lead healthy lives for a healthier next generation. It is key to support couples who wish to start their own families.

Mr Louis Ng asked about supporting couples undergoing IVF. Today, eligible Singaporean couples undergoing Assisted Conception Procedures, or ACP, in public Assisted Reproduction centres can receive co-funding support for the different procedures.

The co-funding applies to each Assisted Reproduction Technology (ART) cycle, and the patient would either receive the co-funding of 75% of the cost or the capped co-funding amount, whichever is lower. As such, there is no remaining balance to be rolled over. However, MOH regularly reviews the clinical evidence around the number of cycles to co-fund. At present, on average, women undergo two ART cycles before achieving pregnancy successfully. Evidence shows that the success rate of ART decreases with maternal age, as each successful cycle progresses. It is not just about Government funding, but the strain of couples to keep trying. Hence, we must continue to encourage couples to marry and start families early, to maximise the chances of conception.

After co-funding, the current MediSave per-cycle limits are generally sufficient to cover the cost of a ACP cycle at public Assisted Reproduction Centres. As not all couples go through multiple cycles, we have allowed a higher MediSave withdrawal limit for the first two cycles so that more of the lifetime limit can be used. MediSave can be used to pay for all standard procedures for each method of treatment, such as the priming of the uterus, egg recovery and fertilisation processes. However, as Traditional Chinese Medicine treatments associated with IVF are not part of mainstream evidence-based treatment, there are no plans to allow MediSave for their use currently.

MOH remains committed towards supporting Singaporean couples in their parenting journeys, and will continue to review the MediSave withdrawal limits to ensure they remain relevant and adequate for Singaporeans, as we balance immediate expenses with retaining sufficient savings for basic healthcare needs in old age.

Apart from supporting couples, we enabled early intervention and enhanced subsidies for vaccinations under the National Childhood Immunisation Schedule, or NCIS, for all Singaporean children at polyclinics, and extended them to CHAS GP clinics across Singapore in November 2020. We have also added vaccines against chicken pox, influenza and pneumococcal disease to the NCIS.

For Singaporean children up to the age of six, we have extended full subsidies for childhood developmental screenings at CHAS GP clinics, to allow for early detection and timely intervention for any developmental delays. There is also support for their families. From last November, subsidies have been extended to vaccinations under the National Adult Immunisation Schedule, or NAIS, at CHAS GP clinics and polyclinics for all eligible Singaporean adults.

Dr Lim Wee Kiak asked about the progress of our national immunisation efforts. Based on the National Population Health Survey 2020, the take-up rate is estimated to be 23% for influenza vaccination, and 14% for pneumococcal vaccination in persons aged 65 to 79 years of age.

I am happy to update that three months after the enhancements, a total of 158,000 and 121,000 doses of the NAIS and NCIS vaccinations respectively have been administered nationally. In particular, for pneumococcal and influenza vaccinations that are recommended for the elderly aged 65 years or older, the uptake has been encouraging with more than 38,000 and 62,000 doses received respectively.

One of the families that benefited is the Chiam family. The three-generational family has been regularly consulting Dr Lim Hong Shen from A Medical Clinic, under the NUHS Primary Care Network. With Dr Lim's strong support, their two children, aged two and four years old, have undergone their childhood developmental screenings and received subsidised vaccinations for influenza, as well as measles, mumps and rubella. The grandfather, aged 69 years old, has also received both the pneumococcal and influenza vaccinations.

We hope that this improved accessibility and affordability will encourage Singaporeans to protect themselves and their families against vaccine-preventable diseases by getting vaccinated as recommended, and support children in starting off well and healthy. MOH is committed to increase the uptake of nationally recommended vaccinations, and will encourage eligible Singaporeans to be vaccinated.

Together, we can encourage one another to take greater ownership of our health and lead healthier lives, for a better future.

The Chairman: We have some time for clarifications. Dr Tan Wu Meng.

Dr Tan Wu Meng: Thank you, Mr Chairman. By way of clarifications, I have one observation and one question. First, regarding the Senior Minister of State, Dr Janil's observation that relooking healthcare needs to be through the lens of longer term issues in a COVID-19 world and looking at the larger social eco-system. I agree with this approach. It is essential in our approach to society and healthcare.

I have a follow-up question for the Senior Minister of State, Dr Koh, regarding the earlier point in my speech on the approach to outsourcing hospital cleaners and hospital attendants. I do not expect an immediate resolution to this question, but I will urge a longer term rethink once the COVID-19 crisis is over.

After all, COVID-19 has raised many questions of countries around the world. If it is supply chains, countries are looking, "at just in time" as compared to "just in case". And may I suggest that on issues of workforce, we also may want to look at economies of efficiency, but juxtaposing this and considering as well the resilience of solidarity across the entire healthcare team. And I hope MOH will consider this as part of a longer term review for the COVID-19 world, and what comes next.

Dr Koh Poh Koon: Mr Chairman, I thank Dr Tan for his clarification. I would agree with him that as needs evolve over time, and certainly COVID-19 is a very challenging time, for us to also take stock post-COVID-19, what kind of healthcare model will we have, and in that case, to build resilience within maybe certain critical parts of our healthcare system; do we need to review the current structure in which we engage with outsourcing of our staff?

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So, I do not think we are ideological here but we will take an open-minded approach to review the needs and maybe talk to our healthcare institutions as well to see during this period, whether they have made useful insights and observations to warrant a change in the current approach.

But I also must caution that in insourcing back certain levels of staff within the system, we need to make sure that there is still a meaningful career progression and prospects for them as well. Because if they are a small number, for which there is little career progression, we need to also bear that in mind to balance out the needs of the organisation versus the aspirations of the person.

The Chairman: Dr Lim Wee Kiak.

Dr Lim Wee Kiak: Thank you, Chairman. I have two clarifications.

First, for the Parliamentary Secretary. Regarding the vaccination programme, I am happy to hear that a huge percentage of our seniors has been vaccinated for flu as well as for pneumococcal. The issue now is, of course, the outreach to the rest. There is currently now no specific outreach programme to reach out to seniors that have not been vaccinated. So, I hope that MOH can review this and then take a look.

When I take a look at the HealthHub apps, there is immunisation charge based on age, but the age stops at 26 years old. Beyond that, there is nothing. So, can MOH take a look at it to see how to expand that further.

My second clarification goes to the Senior Minister of State Janil. I would like to ask the Senior Minister of State on a hypothetical question: if COVID-19 outbreak were to happen in Singapore, in the sense, let us say it happened in November 2019, could our current system or our NCID have picked up the unusual presentation of pneumonia, and could we have the capability to diagnose such a novel virus? Looking back, do we have the ability to do so?

Ms Rahayu Mahzam: I thank the Member for the clarification question. Thank you for highlighting the issue with regard to the HealthHub age cut-off. We are, indeed, still developing the platform and we will be adding more information. So, I will bring this back and then we will develop it further.

In response to the query on the outreach for vaccination, especially the seniors, actually HPB has recently launched a public education campaign to encourage eligible individuals to get vaccinated, and getting them to increase their awareness. The key thing about vaccination is getting them to be aware of it. So, we did try to roll out a public education campaign and this is something that we can build on. The other thing is to work with the General Practitioners (GPs), with the doctors, to get them to routinely advise their patients on vaccination needs, especially every time they come to visit, we would ask them to inform their patients, so that this will also increase awareness and their interest and uptake for vaccination.

The Chairman: Senior Minister of State Janil.

Dr Janil Puthucheary: Thank you, Mr Chairman. If I understand the Member's questions correctly, if an outbreak had occurred now? With the capability we had then or the capability we have now?

Dr Lim Wee Kiak: In October 2019.

Dr Janil Puthucheary: So, with the capability that we had in October 2019, would we have picked up COVID-19 outbreak in October 2019?

The short answer is yes. We pick up outbreaks of disease on a regular basis. Our level of paranoia, anxiety, concern about this increased after SARS, as a result of which clinical teams across the healthcare network have to report any number of either confirmed or suspected infectious diseases. And we have surveillance systems.

So, the real answer is not really whether we would have picked it up, but how quickly would we have picked it up and how quickly would we have responded and put in place many of these strategies that we now see as normal for containing disease outbreak. Whether it is the testing, the tracing, speed of that, the ability to quarantine individuals, the ability to do the sequencing and stand up therapeutics. So, certainly, our capabilities have improved and increased quite significantly since the first outbreak.

So, the short answer to the Member's question is yes but we can do it much better today.

One of the reasons why we can do it much better today is because this is not SARS. We have learned the lessons from SARS, we have learned the lessons from COVID-19, and we have to prepare that Disease X, the next pandemic and the next crisis, will be like neither. And we need that institutional agility and institutional capability to deal with the unknown, which is one of the more difficult things that we have to do. I hope that answers the Member's question.

The Chairman: Mr Leong Mun Wai, please.

Mr Leong Mun Wai: Thank you, Chairman. I have two clarifications.

One is I think the Ministers and the Senior Ministers of State did not answer my query on how the public health services are being priced, whether it is based on marginal cost or average cost. Maybe I add a bit more information on that, specifically about whether it is based on amortisation of assets, land cost, rental cost, all these – I hope to be clarified.

Second question is on MediShield Life insurance scheme. I am actually still very puzzled why our healthcare insurance schemes are left open-ended. Because as one gets older, as Singaporeans get older, they will find it more and more unaffordable.

I have also spoken in my speech that when Singaporeans get older like 80 years old or 90 years old, the premium will become very high. For example, under two scenarios, when you keep the premium —

The Chairman: Mr Leong, can we not have a speech? Just ask your clarifications borne out of the responses of the Political Office Holders (POHs). So, please get to the point of your clarification.

Mr Leong Mun Wai: Okay. I would like to ask for clarifications that the MediShield Life Scheme indeed is unaffordable, as one gets older, and there is a drain on the CPF resources on the Singaporean And that is a very high number, up to $110,000 for a family. So, those are the questions I would like further clarification on. Because these are very important; has to be answered.

Dr Koh Poh Koon: Mr Chairman, I will attempt to explain the MediShield Life premium issue. I have actually done an extensive explanation when I gave an update to this House late last year. I think the answer still applies. Mr Leong should check the Hansard. I think his point that the MediShield Life premium is unaffordable, the older the Singaporean gets, is not correct. Because if he checks my speech in the Hansard, he would have understood the fact that, for the Pioneer Generation, who are the older Singaporeans in Singapore, they get MediSave top-ups to pay for their premiums. In fact, for many of the oldest in the Pioneer Generation, they get virtually free MediShield Life because they virtually pay no premium at all.

So, I do not think he understood what was said in the House last year and I urge him to read my speech all over again in Hansard.

The Chairman: Ms Carrie Tan.

Ms Carrie Tan (Nee Soon): Thank you, Chairman. My question is related to mental health. I thank the Senior Minister of State Dr Janil for sharing with us about the tremendous progress made in the Mental Health Master Plan, and to know that there is so much more infrastructure and community care facilities set up and that we are already ahead of targets.

But my question really is whether MOH has a view or is it currently embarking on any kind of study or upstream prevention campaigns, in the likes of when we identified diabetes to be a big healthcare crisis for Singapore, then we went on a very national campaign and we looked into reducing sugar and salt in our food in the hawker centre and so on. I remember when I was a child in Primary School, I was also in the Trim and Fit (TAF) Club to address obesity.

The Chairman: Ms Tan, if you could kindly ask your clarification.

Ms Carrie Tan: Yes. My question is: does MOH have a view or intention to study how we can embark on a prevention strategy to avoid this continuing trend of high incidence of mental health or mental illness amongst our population in the long run?

Dr Janil Puthucheary: Mr Chairman, the answer is yes. It is not just MOH that is interested in this. This is an area where the academics and the professionals working with people with mental health issues are very interested in looking at. This is not going to be an area that we can have complete prevention. We also have to research into areas about how we can help people cope and mitigate the mental health issues that they come across.

It is not going to be easy to pinpoint a single factor, just like diabetes. While we can concentrate our efforts on sugar or weight loss activity, we will have a variety of things to direct attention and the efforts of the individual in the family. But the reality is it is a wide space with many different causes and many different paths through it, and it will be something that requires effort from a multi-disciplinary team and, indeed, the whole of society. But the short answer is yes, we are very interested in this.

The Chairman: Mr Gerald Giam. Minister, my apologies, I did not see your hand.

Mr Gan Kim Yong: Thank you, Mr Chairman. Let me just add on to what Senior Minister of State Janil has explained. Mental wellness is quite a complex issue. And, very often, is not just a medical issue. Therefore, very often, when we want to address challenges of mental well-being, it will have to go beyond MOH. That is why we are forming a multi-agency platform to allow the various agencies including MSF, and including MOM to look at the workplace mental well-being; and including MOE to start from young.

So, it is a multi-pronged approach and it requires a whole-of-society involvement in this, particularly in preventive mental health. Because it requires a lot of support in the community to work with us, work with various Ministries and agencies, so that, together, we can better address the challenges of mental well-being and help our Singaporeans, particularly, the young, to be better prepared for the challenges that they are going to see, so that we can strengthen their resilience against mental challenges.

The Chairman: Yes, Mr Giam.

Mr Gerald Giam Yean Song: Sir, I have some clarifications for Senior Minister of State Koh.

First, can I confirm the Ministry's definition of PCHI is based on family members living under the same roof?

Second, what is the Ministry's main concern about allowing greater use of MediSave in polyclinics, SOCs and restructured hospitals? I know MOH is worried about premature depletion of the MediSave accounts. However, MediSave can only be used for medically necessary treatments, and the risk of doctors in these public institutions over-treating is minimal. And patients there also have little discretion to demand unnecessary treatment.

On the flip side, patients do retain their discretion to skip treatment to reduce out-of-pocket payments. This will impact the success of their treatment that may cause both the patient and the Government more in the long term.

Can MOH reconsider how prudent it still is to restrict the use of MediSave in these public healthcare institutions?

Dr Koh Poh Koon: Mr Chairman, I thank the Member for asking the clarifications. Yes, indeed, for PCHI, it is based on residents with the same household address, so that we know that they are staying in close proximity and they can mutually support each other.

In terms of MediSave usage for mutual support, in fact, you can designate a next-of-kin, for example, You can have your spouse or even the children, who may not necessarily be staying at the same address, can also add support with their MediSave to contribute to the care of their aged parents, who may not reside in the same address but they can use the MediSave from their children, and vice versa.

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In terms of liberalising MediSave usage, we have through the years, allowed more and more uses for MediSave. You will remember that when we first started with the Chronic Disease Management (CDMP), there were only a few conditions that were in it. In the last few years, more and more conditions were added with considerations such as disease prevalence, whether they are effective treatment and whether there is clear treatment protocol, that can translate to a good outcome.

We are open to review the list of diseases that will be added on overtime as the science and the medical understanding develops as well, and in consultation with a panel of medical experts who can advise us on what they feel is useful to include in the CDMP list. We are always opening further opportunity to use MediSave, and as the Member pointed out, they could well be situations in which we could liberalise some more and we will continue to do so.

The Chairman: We have got time for just two more clarifications, so could I invite Members to keep them short? Mr Yip Hon Weng.

Mr Yip Hon Weng: Thank you, Chairman. I am glad to hear from Minister Masagoes that the Ministry is reviewing the Senior Mobility and Enabling Fund. Can the Ministry provide more details about the focus area of review and when will the review be completed?

Mr Masagos Zulkifli B M M: I thank the Member for clarification. We will begin the review this year. Hopefully, by the second half but we do not know yet the scope nor the time that this will complete.

The Chairman: Last clarification, Mr Louis Ng.

Mr Louis Ng Kok Kwang: Thank you, Sir. I thank the Parliamentary Secretary on the reply on the IVF policies. There is quite a fair bit of good suggestions out there on IVF and that is why I filed so many cuts, Parliamentary Questions and Adjournment Motion. Could I ask whether MOH can consider setting up a citizen workgroup to really deep dive into this issue of IVF here in Singapore?

Ms Rahayu Mahzam: I thank Member for the suggestion. I am sure that this is something we can consider and I will follow up with the Member after the Budget and Committee of Supply debates are over.

Mr Leong Mun Wai: Chairman, excuse me, Chairman. My clarification on the pricing of the public health services has not been answered.

The Chairman: I am afraid Mr Leong, it is 5.50 pm, which is the guillotine time for this Head. So, Dr Tan Wu Meng, if would like to withdraw your amendment. Yes, Minister.

Mr Gan Kim Yong: Perhaps I can just give a very quick answer. First, we take into account all the costs that healthcare institutions incurred, because someone has to pay for these costs – whether it is the Government, whether it is the patient, whether it is the institution. So, we have to cost them fully.

Having costed them fully, the Government then provides subvention to cover the bulk of the cost of operation and the cost of investment in the building of the infrastructure. On top of that, we provide subvention for the patients when they go and see the doctors or they receive treatment at these healthcare institutions.

So, yes, we account for the cost of the building and the delivery of services. But at the same time, we provide subvention and subsidies for the patients and for the institutions' operations.

The Chairman: Dr Tan Wu Meng.

Dr Tan Wu Meng: Mr Chairman, I thank all Members for their cuts and I thank our Ministers, Senior Ministers of State, Parliamentary Secretary at MOH for their responses and sharing. The COVID-19 virus does not sleep. It does not rest and so are our healthcare frontliners, our agencies, our MOH officials have also had many sleepless nights because of this COVID-19 pandemic. Presumably, with implications for sleep health as Parliamentary Secretary shared earlier.

So, a big thank you to all who keep us safe, and in doing so, keep Singapore going. I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The sum of $17,355,401,300 for Head O ordered to stand part of the Main Estimates.

The sum of $1,489,629,300 for Head O ordered to stand part of the Development Estimates.