Rethinking Preventive Health to Generate Better Outcomes

ADJOURNMENT MOTION

The Leader of the House (Ms Indranee Rajah): Mr Deputy Speaker, I beg to move, "That Parliament do now adjourn."

Question proposed.

Mr Deputy Speaker: Mr Leon Perera.

Rethinking Preventive Health to Generate Better Outcomes

5.05 pm

Mr Leon Perera (Aljunied): Mr Deputy Speaker, my Adjournment Motion today focuses on transforming our preventive health efforts. In the view of some Singaporeans and healthcare workers I have spoken to, these efforts are not yet fighting-fit to take on some of the big health challenges of the near future and are already not delivering the health outcomes that we could be achieving for a well-developed nation.

By preventive health efforts here, I mean our policies and programmes for reducing the incidence of chronic disease conditions like diabetes, hypertension and so on, as well as our policies to move Singaporeans towards better health outcomes in general.

In this speech, I will detail proposals fitting into three overall thrusts.

One, we should adopt an outcomes-focused approach that is long term but given tough regular reviews. Two, we should reward the good health choices of individuals, especially at-risk groups. And three, we should use highly targeted strategies that nudge healthcare providers and leverage data towards better health outcomes.

But, first, let us take stock of our preventive health efforts and the huge health problems that we face.

Sir, the Health Promotion Board (HPB) was founded in 2001. Our spending on preventive healthcare efforts last year was about 5% of total non-COVID-19 MOH spending, with about $330 million allocated to HPB.

There are many worthy programmes that have been undertaken. For example, in public discussions of what the Government does to nudge Singapore towards living healthier lifestyles, the National Steps Challenge is often mentioned. However, what is the picture that emerges when we look at indicators of chronic conditions? We find that the incidence of certain dangerous chronic conditions has increased steadily in recent decades. Are we in danger of racking up an "A" grade for effort but a "C" grade for outcomes?

It is true that our mortality rates for cancer, stroke and heart disease have improved, perhaps owing to technological and economic factors. But as the Singapore Public Sector Outcomes Review does soberingly acknowledge, about one in three residents aged 40 to 69 has hypertension and two in five have high cholesterol.

Based on the last like-for-like comparison I could find, our 2015 diabetes prevalence among those aged 20 to 79 at about 11% is much higher than the OECD average of 7%.

In 2015, Singapore was number two in the world in diabetes prevalence. In fact, one in four Singaporeans aged 40 and above has at least one chronic disease. The proportion of older adults with three or more chronic diseases nearly doubled from 2009 to 2017. A 2017 MOH study showed that Singaporeans may have a longer life expectancy today but do not necessarily enjoy a better quality of health. Singaporeans born in 2017 are expected to spend on average 1.5 more years in poor health compared to those born in 1990 and this refers to the years spent on average in poor health, alive but in poor health.

Sir, these trends are likely to worsen if transformative intervention is not done. In 2017, an HPB expert noted that if obesity is not effectively curbed, Singapore could hit obesity rates of 15% in just seven years. That was the point at which obesity increased rapidly in the United States where it is now considered an epidemic.

According to a report by The Economist, cardiovascular diseases contribute to approximately one in three deaths in Singapore and levy about US$11 billion in costs on individuals, their households and the public finances. Modifiable risk factors for CVD, such as smoking and cholesterol levels, account for 60% of these costs.

In short, Mr Deputy Speaker, Sir, we have a very big problem that needs to be tackled now with new thinking.

I would like to make some policy recommendations to reverse these worrying chronic condition trends and get tough on preventive health.

My first recommendation is that the Government should focus more clearly on outputs and outcomes. We should set clear goals for outputs like the proportion of persons exercising regularly, for example. We should also state clear short- and medium-term targets for lowering chronic disease incidence.

We cannot succeed if we do not define what success looks like. Meeting such targets is, of course, dependent on a range of factors and not only Government policies. This is clear and I do not disagree with this. We cannot, ultimately, micro-manage personal behaviour but we should know what are the short- and medium-term targets for outputs and outcomes that we are aiming at, so that we know when we are away from goodness.

It is useful to refer to participation rates for programmes and events, the number of app downloads and so on and so forth, but these, Sir, are effort indicators. We must not over-emphasise effort indicators in our public communications. Doing well on effort indicators can lull us into a false sense of security and self-congratulation. Rather, we should prioritise outputs and outcomes. These determine whether we have won or lost the battle. For instance, although it has been five years since Singapore declared war on diabetes, MOH said at the Committee of Supply last year that "the prevalence of diabetes has not decreased" from 2017 to 2020.

Furthermore, during this time, the prevalence of obesity, high blood pressure and high blood cholesterol had risen.

Some types of efforts may not yield good outcomes. One example, HPB's "1 Million kg Challenge" in 2014 set a clear target of a collective weight loss of one million kilogrammes, from at least 300,000 participants over three years. The CEO of HPB has publicly acknowledged that they only managed to lose a few tens of thousands of kilogrammes. It is important to draw lessons from such experiences.

As an international example for comparison, I will cite the Nordic Plan of Action which sets specific ambitious targets for reducing obesity rates and improving physical activity levels and healthy diets, with a regular monitoring system every two years. While recent results in that part of the world have not been very good, at least there is a robust, transparent system, with targets and monitoring to drive towards the right outcomes.

Sir, let me go on to make some very specific policy recommendations.

Firstly, I would speak on rewarding good health choices. It is time to provide serious financial nudges to citizens to encourage healthy behaviours. First, we should provide some cash incentives or subsidies for MediShield premiums to those who demonstrate a commitment to healthier behaviours, such as regular screenings or regular exercise, as verified by way of attendance records or wearable technology, for example.

We have tried such schemes before, such as Lumihealth, the Apple watch tie-up, but we must put our money where our mouth is to ensure these schemes reach more people, in particular, those who are not yet exercising, eating well or going for their screenings. We can use various touch-points, like family doctors in whom many trust deeply, to spread the word.

There are examples of health insurers in other countries that provide premium discounts based on the adoption of behaviours that tend to make payouts for medical treatment less likely. For example, the US insurance provider Vitality provides premium discounts for members alongside freebies.

I realise that this is a significant departure from the current approach. Further study should be done before adopting this as a general policy. The approach of testing a major policy through randomised controlled trials was also something I argued for when calling for smaller form class sizes in schools in an Adjournment Motion in 2017 and I have argued for this year as well.

Next, let me turn to vaccines. In its GE 2020 manifesto, the Workers' Party called for making COVID-19 vaccines free, long before they had been successfully launched. This is something that most governments in the world have done, including Singapore's Government, and rightly so.

But the principle of making vaccines free can be extended. Other things being equal, higher vaccination rates have the potential to minimise disease incidence and, hence, reduce public and private expense in healthcare treatment for those diseases.

Sir, in the past, I have argued for making HPV free and added to the compulsory immunisation schedule for children. I also called for a bigger role for free vaccines in the public health system, rather than simply allowing MediSave to be used for vaccines. MediSave is, after all, our own money. Many Singaporeans are reluctant to touch it for something less tangible like a vaccine, fearing that they would need all the MediSave that they can get later in life for actual medical treatment. Vaccines have huge public benefits, as we have seen during COVID-19, so the Government should pay for them.

In 2020, the Government announced some improvements to subsidy levels for vaccines. I remember having an exchange in this House with then Senior Parliamentary Secretary Mr Amrin Amin, asking him if the subsidies for vaccines can be pegged to the amount of money the state would save from higher vaccination rates. He replied, saying they were crafting this package and would announce the details in time. I would like to repeat this call.

There is much more that can be done to improve vaccine take-up rates. Our take-up rate for flu vaccines, for example, is much lower than it should be, compared to some other developed countries. In a reply to my earlier Parliamentary Question, the Government acknowledged that our take-up rate for flu vaccinations of 24% among Singaporeans aged 65 and above is significantly lower than the equivalent rate of about 70% in Australia, the UK and the US.

According to one widely-cited figure, about 4,000 people in Singapore die from pneumonia and influenza every year. There is a great deal of suffering and costs involved in treating flu patients who become ill. Let us start with making flu vaccines free and thus easy to get for key groups like pregnant women, those with chronic health conditions and older folk over 65. Again, GPs can play a big role in promoting adult vaccination. This reasoning can also be applied to the pneumococcal vaccine.

Sir, even setting aside the toll in human suffering, which should be reason enough, if we calculate the cost, it could benefit the state to make such vaccines completely free, as this would save downstream fiscal expenditure like hospital subsidies. A healthier population is always worth investing in.

Sir, next, I would like to talk about health screening. Screen for Life (SFL) is a well-intentioned policy, but low take-up rates leave much to improve on. According to MOH's response to a Parliamentary Question I filed, 100,000 out of 1.8 million of eligible Singaporeans, or 5.6%, have benefited from SFL subsidies. By comparison, take-up rates of national health screening programmes are 22% in Japan and 30% in Taiwan, versus our 5.6%. Take-up is notably skewed towards the Chinese community, compared to other ethnic groups. Sir, I do acknowledge the Government's efforts to reach out to community groups to raise health screening take-up, including among minority communities. These are worthy efforts, but, clearly, the results still leave room for improvement.

HPB should conduct studies into the reasons for low take-up rates despite heavy subsidies for health screening under SFL. Anecdotally, lower-income constituents I have met will occasionally share that they do not wish to go for health screening as they are daunted by the high cost of treatment, or what they perceive to be the high cost of treatment, if disease is detected. If those who are most at risk of chronic diseases are not getting screened, this will not only incur greater downstream costs to the individual and the society, but also raise deeper questions about access to basic healthcare for the most vulnerable among us.

But, for now, I would like to offer some policy suggestions here on raising health screening take-up rates.

Firstly, as mentioned earlier, the Government could provide subsidies for MediShield Life premiums for those who regularly undertake health screenings. Some insurers, like NTUC Income, reward policyholders who have good health screening results with shopping vouchers. Sir, many studies prove that it is far cheaper to screen and to catch a disease early and slow down its progression.

In Singapore, one in three diabetics, one in four people with hypertension and almost half of those with high cholesterol levels do not know that they have these conditions. Those who do not know that they have these diseases will push up costs for everyone. I have called in a past Parliamentary Question for inclusion of waist circumference measurement in national health screenings. This metric is important in defining obesity risk, rather than over-relying on the Body Mass Index (BMI). I am glad that MOH is moving to implement this and I look forward to seeing more evidence-based inclusions in health screening.

Next, in nudging individuals towards healthier choices, I think it is important to place special attention on especially vulnerable groups, like the lower-income. Many lower-income Singaporeans lack the means to purchase and cook healthier foods. When I say this, of course, I do not mean that all healthy foods are costly, but many healthy food decisions are more expensive, complicated or time-consuming.

In providing aid to lower-income families, can some of our aid be provided in the form of highly frictionless digital currency earmarked for the purchase of healthier food products with, for example, less saturated fat and sugar? It could also focus on unprocessed foods like raw meat. A digital currency would be easily programmable and could be updated monthly to reflect inflation. With RFID technology in supermarkets and grocery chains, this should not be too difficult to do.

In the past, we have tried vouchers and other similar programmes, but if we could have a regular provision of frictionless aid, this would act as a much stronger nudge to eat healthily at home.

Sir, I also want to make a more philosophical point about helping the poor on health. Our preventive health programmes tend to place personal responsibility on individuals to take charge of their health and lead healthy lifestyles. However, we have a collective responsibility to ensure the less privileged among us also have access to healthy lifestyle habits and are supported in that direction. Health is a critical dimension in improving lives and livelihoods for poorer Singaporeans.

In reply to my earlier Parliamentary Question in 2020, MOH revealed that the life expectancy gap between those with post-Secondary and above education versus those with below Secondary education was 5.8 years, basically, six years. This is a shocking figure. Though it should be said that similar statistics can be found in other developed countries, at the 2021 Committee of Supply, then Health Minister Gan Kim Yong, remarked that MOH paid special attention to lower-income households, including their preventive health needs. This is a welcome assurance.

How effective, though, are the existing preventive health care programmes targeted at low-income groups such as Healthy Living Passport, KidSTART and Propel? Can we release more data on chronic disease prevalence and other health outcomes by gender, by socio-economic status? With more data, we can devise better programmes to nudge those on lower-incomes towards better health outcomes.

Next, I would like to talk about incentives for healthcare providers. Can we think of alternative models where there is a degree of incentivisation based on the success of the healthcare provider in nudging patients towards better health outcomes? In other words, instead of paying providers just for treating the sick, can we pay them in part, at least, for encouraging their patients not to get sick in the first place?

The notion is not as utopian as it seems. A few healthcare systems in the world are inching towards that. For example, Kaiser Permanente in California is well-regarded as a provider of high-quality, efficient and affordable integrated care. It is three separate entities: a health plan that bears insurance risk, medical groups of physicians and the hospital system. The financial incentive there is to provide a high-quality continuum of care and maximise population health, rather than profiting from a high volume of compensable services.

Can we thus remodel our system of healthcare providers to incorporate incentives for effective preventive health work with patients, rather than just rely on compensation to the healthcare provider being linked only to the performance of treatments and tests?

One other specific example would be to empower healthcare providers with inter-operable IT systems that can flag out if a patient has not got a mammogram or a blood screening recently and direct the patient to get that done while they are visiting for something else entirely. This would be the medical equivalent of a no-wrong-door approach.

Moving towards such an alternative system of compensation for healthcare providers is, indeed, a very big, some would say, radical idea. As always, piloting randomised controlled trials are all advisable. But the time to act is now.

Lastly, Sir, I would argue that we should make health data available more quickly and in more granular detail regarding chronic conditions.

Much of the data on disease incidence is not published so frequently and after a significant time lag from data collection. COVID-19 has shown that we can publish data on healthcare metrics practically in real time when the political will is there. It would help us to have public data on diabetes, say, quarterly, to ensure not only better public debate on healthcare policy, but also better alignment of outcomes and incentives to providers.

And on this note, I would like to ask if all Members of Parliament can be given data on chronic disease patterns and also other relevant indicators at the precinct level in their wards. It will help Members to know where there are concentrations of particular health issues, with a purpose of raising relevant talking points when we meet constituents and perhaps organising relevant ground events such as talks.

Can we conclusively move towards a system where a comprehensive data on a patient is easily and always available to healthcare providers, assuming permissions are given, of course? In fact, can we nudge patients to provide permission for data-sharing across healthcare providers? This would enable medical professionals to reduce duplication of tests and get a more holistic picture of every patient's health situation at any time.

Right now, data is available from the National Electronic Health Record (NEHR), but feedback is that the process of accessing it is not easy and not streamlined.

I would also suggest that the Government invest more in workforce automation of sorts for doctors, such that the IT system prompts them towards possible conditions the patient may have or alternative theories based on data analytics and AI.

The US NPO Kaiser Permanente, again, is widely recognised as having pioneered some world-class IT systems that help doctors do just that, suggesting to doctors that patients may have a certain condition in some cases, in the same way that Amazon prompts buyers by saying those who bought this book also liked this other book.

Mr Deputy Speaker, in conclusion, we are not faring well on many chronic disease indicators and this could portend worse to come. That would mean more human suffering and more pressure on our fiscal resources. When the costs of failing are socialised, as it is in this preventive health war, stronger action is justified.

The challenges we face in preventive healthcare are large, complex and defy any one magic bullet, but there are good ideas for change on the table, ideas that have been researched and put to the test academically and in the experience of other countries. The rewards for early, bold, decisive action can be tremendous. Our children and grandchildren will thank us for taking those actions today. So, let us do this today.

Mr Deputy Speaker: Senior Minister of State Koh Poh Koon.

5.24 pm

The Senior Minister of State for Health (Dr Koh Poh Koon): Mr Deputy Speaker, Sir, Mr Leon Perera spoke about rethinking preventive health. I thank him for the suggestions that he has made. These are useful improvements that MOH will consider, but I would not describe them as a rethink of preventive health. In fact, improving preventive health has been on the agenda of MOH for many years now.

In 2016, MOH put forth the Action Plan for Primary Care 2.0, to anchor the role of GPs in chronic disease management, a point which Mr Leon Perera has made, to make GPs the anchor. This, in fact, set the stage for the formation of Primary Care Networks (PCN) to strengthen the doctor-patient relationship in the management of chronic diseases. The Community Health Assist Scheme (CHAS) was also enhanced to support the financing.

In 2017, MOH announced our "three Beyonds" strategy: Beyond healthcare to health; Beyond hospital to community; and Beyond quality to value. Minister Gan Kim Yong, in his Committee of Supply 2017 speech, emphasised the importance of focusing on early interventions and healthy lifestyle choices to go "Beyond Healthcare to Health". And he further gave the example of how one front of the war on diabetes would be fought via healthy living and prevention, encouraging the population to stay active and eat healthy to reduce the risk of diabetes.

At the MOH Workplan Seminar last year – which was his first public speech as Minister for Health – Minister Ong Ye Kung focused his speech on preventive care, emphasising how interventions should move and have moved upstream to tackle lifestyle risk factors for chronic diseases. In comments made during the Ministerial panel on Primary Care at the session of the WHO Regional Committee for the Western Pacific held in October 2021, Minister Ong also shared that MOH was looking to change the system focus from acute hospital care back to preventive care provided in the community and primary care settings, which would result in a very good quality system that is also sustainable.

Since then, we have been engaged in dialogues and in-depth discussions with our GP leaders and many in our Healthcare Cluster leadership. One of the things we discussed is on the possibility of a capitation model, to transform our primary care providers' way of engaging with our patients. So, MOH's big push to revamp preventive care in recent months is really no big secret. And we thank Mr Leon Perera for weighing in, and supporting this move, including providing some useful suggestions.

Over the weekend, in fact, at the topping-out ceremony of the Woodlands Health Campus, Minister Ong Ye Kung said that he would be announcing a national programme focusing on preventive care at the coming Committee of Supply. So, I hope Mr Leon Perera and the Workers' Party Members will give it their full support at the Committee of Supply.

Mr Leon Perera suggested more subsidies and incentives to promote screening. His underlying assumption is that if we make things cheaper, in fact, make it free, the take-up rate will improve. But actually, having sat across the table with many patients, advising them on health screening, in preventive health, the hardest hurdle to overcome is the mindset and health beliefs of the individual. We all know what is good for us, health-wise. Every doctor counsels and wants his patients to go and do the right things for his own health. But, alas, in real life, changing mindset and health-seeking beliefs is not something that policy or clinical protocols alone can change.

For example, the national Screen for Life (SFL) programme was introduced across more than 1,100 CHAS GP clinics to provide easy access to affordable and appropriate screening for eligible persons for cardiovascular disease risk factors, such as diabetes, high blood pressure and high blood cholesterol, and also certain cancers, like cancers of the breast, cervix and colon/rectum. Eligible individuals pay no more than $5 for screening under SFL and MediSave can be used for approved screenings, including colonoscopy screening for colon cancer.

In fact, based on the National Population Health Survey (NPHS) done in 2020, despite efforts to make screening accessible and affordable for all, cancer screening uptake rates remained between only 40% and 50% for each of these three cancers: cervical, breast and colorectal. This illustrates the point that despite efforts to reduce the cost barrier to screening, more still needs to be done to address the individual’s perceptions, their barriers, their fears, to undergo screening. We have to do more to nudge them to undertake screening.

Vaccination is an important component of preventive health interventions, a point that Mr Leon Perera also made. In fact, all recommended vaccinations under the National Childhood Immunisation Schedule (NCIS) are free for Singaporean children at polyclinics and CHAS GP clinics under the Vaccination and Child Development Screening Subsidies (VCDSS) as part of the Government's efforts to support marriage and parenthood and to encourage vaccinations on a cohort basis. So, Mr Leon Perera's call for free vaccination is already, in effect, being done.

All adult Singaporeans are eligible for means-tested subsidies at both CHAS GP clinics and polyclinics for recommended vaccinations under the the National Adult Immunisation Schedule (NAIS). MediSave can also be used for any approved NAIS vaccinations, which means that co-payment could, in fact, be zero. And this includes influenza vaccination for our elderly.

MOH also uses other touchpoints to increase adoption of these important vaccinations. For example, the Human Papillomavirus (HPV) vaccine that Mr Leon Perera talked about was actually introduced as a part of the school health programme in 2019 – a few years ago now. And all cohorts of Secondary 1 female students are offered the fully subsidised HPV vaccine in their respective schools. Fully subsidised means it is free. This is in addition to fully subsidised vaccinations provided as part of the immunisation schedule delivered in schools via HPB's School Health Service.

MOH has also been working with our primary care partners to increase vaccination uptake, especially among seniors, for influenza and pneumococcal vaccinations. Seniors are also able to learn more about the importance of vaccinations through interactive health workshops conducted within the community and through online platforms.

Tackling preventive health requires an "integrated" as well as a "life-course" approach.

Over the years, we have built a strong foundation in various key domains across different agencies: health promotion under HPB, health screening and chronic disease management by our GP clinics and polyclinics as well as our Healthcare Clusters, promoting sports and active lifestyle by Active SG and encouraging citizens to remain active in our Community Clubs and interest groups

Having built up all these key pieces, we now move to enhance the delivery of evidence-based preventive health to the population by integrating them together.

For example, the "Health Up!" initiative in Tampines, an initiative led by SingHealth polyclinics, in partnership with agencies, such as HPB, Changi General Hospital, Tampines GRC and SportSG, is a very good example of how the different stakeholders have come together to provide a holistic and structured health journey for residents by increasing awareness of healthy lifestyle habits and promoting appropriate screening for disease.

With this integrative approach, a resident who undergoes health screening by the GP to determine the health parameters that needed improvement – could be his BMI, could be his blood control targets – can be subsequently assessed by a fitness coach under Active SG to customise a fitness regime targeting these particular goals. A structured exercise regime which also connects the resident with the Community Sports Club builds a network of peer support, friendships, peer groups, that eventually enables a sustained active lifestyle. Dietary counselling is also provided where needed. In fact, a Care Coordinator from Changi General Hospital serves as an "account manager" to help coordinate the health journey of the participant and helps transmit data, helps to coordinate the programme between the GP, the coach and the dietician.

This entire process will be data-driven such that the GPs and the coaches have a shared view of the progress, participation and target goals that the individual has achieved. Suitable incentives and gamification can eventually be built into this process to further encourage and ingrain healthier habits.

The "Health Up!" integrated approach aims to build an ecosystem within the community and centre around the individual so that this, hopefully, provides stronger support to encourage more upstream preventive health.

MOH is also moving upstream to promote healthy lifestyle by adopting a life-course approach. Healthy habits start young – prevention is better than cure. HPB works with MOE and the Early Childhood Development Agency (ECDA) to provide school health promotion initiatives and healthier food options for students in preschools and our schools. For the general adult population, our health promotion efforts include public education to increase health literacy and awareness of modifiable lifestyle risk factors for chronic diseases with health messages.

Together with MOM and other partners, HPB also aims to improve the health of working adults by transforming workplace clusters into Healthy Workplace Ecosystems (HWEs) through partnering developers and key industry partners to deliver customised programmes to mature workers in seven priority sectors and the gig economy workers. Programmes are also offered directly to companies, including SMEs and mid- to large-sized companies and organisations. As of end December 2021, HPB has reached more than 1.24 million workers, with more than 213,000 workers participating in both virtual and face-to-face programme sessions.

Today, doctors are supported by the National Electronic Health Records to access their patients' records for patient management. Singaporeans have access to own consolidated health records and eligibility for screening subsidies through Health Hub to empower self-management. We will also certainly leverage on technology and analytics to transform citizens' experience in health promotion programmes, moving from a "one-size-fits-all" approach to a more precise and personalised approach.

LumiHealth, an example that the Member has quoted, was launched in 2020, is one such intervention that has empowered individuals to take charge of their health through precise and personalised insights and recommendations. The programme has encouraged participants to be more active, with their daily exercise minutes increased by over 39% when compared to the month before they started on the programme.

Sir, MOH conducts regular population health surveys and is able to examine health behaviours and outcomes of the different population segments. These reports are actually publicly available via the MOH website.

While we have made progress over the years, the latest National Population Health Survey 2020 saw an increase in the prevalence of hypertension and hyperlipidemia and a reduction in the prevalence of Singaporeans with sufficient total physical activity and screening participation, partly due to the COVID-19 disruptions. There is a need to double up the preventive health efforts as we seek to regain the momentum and improvements that were lost due to the impact of COVID-19. There is an urgent need for the population to take action and participate in improving their health as we emerge from COVID-19.

Sir, I urge all Singaporeans to play an active role in their own health journey by making sensible lifestyle choices and informed decisions. MOH, together with relevant stakeholders, will also continually refine our approach to preventive health to bring about a healthier Singapore.

Mr Deputy Speaker: Order. The time allowed for the proceedings has expired.

The Question having been proposed at 5.05 pm and the Debate having continued for half an hour, Mr Deputy Speaker adjourned the House without Question put, pursuant to the Standing Order.

Adjourned accordingly at 5.36 pm.