(Delivered on 5 March 2020)
Progress of War on Diabetes – Chen Show Mao
A year before the Minister of Health declared War on Diabetes four years ago, the International Diabetes Foundation reported that Singapore had the second highest proportion of diabetics among developed nations. Our children and young people were increasingly overweight. One in three Singaporeans had a lifetime risk of developing diabetes, with serious and costly consequences. Following the declaration of war, the Prime Minister spoke of diabetes as one of the three key long term issues for Singapore.
The importance to Singapore of the War on Diabetes cannot be overstated. Could the Minister give us a report of progress from the front? What are the results and lessons? What are our new and continuing efforts and plans? Strategies and tactics?
COVID-19 – Sylvia Lim
I have several residents who are Covid-19 patients, and our thoughts are with all patients for strength and a speedy recovery.
On the treatment front, a resident who was a SARS patient told me that a medical team visited her recently to obtain some blood samples to aid the Covid-19 cases. Some medical experts overseas have opined that using convalescent blood plasma from former SARS patients could assist very sick Covid-19 patients but was unlikely to be deployable on a larger scale. Could Ministry elaborate on the thinking and efforts on this front?
As for containment, the World Health Organisation has opined that it would take 18 months to develop a safe vaccine. As the virus is assessed to be spread by droplets at close range, containing the spread via separation measures like quarantine appears to be appropriate. What are the preliminary assessments of the effectiveness of the government’s strategy so far?
MediFund for Transportation Fee – Muhamad Faisal Abdul Manap
Sir, Medifund scheme is meant to financially assist Singaporeans who have difficulties with their medical expenses for both inpatient and outpatient treatments. It is made available at polyclinics island-wide as well as the restructured hospitals.
I would like to call upon MOH to allow the use of Medifund for reimbursement of transport fare for needy Singaporeans who need to travel by taxi or private-hire car to and fro their medical appointments due to their poor health conditions. A good example is stroke patients.
I have encountered residents who defaulted their medical appointments, especially those who have multiple appointments in a month, as they are too weak to travel by bus or train and they do not have the financial means to take a taxi or private-hire car to ferry them.
Sir, this segment of our fellow Singaporeans are usually those who are unemployed due to their medical conditions and they depend heavily or solely on financial assistance such as ComCare and handouts from relatives and friends, which amount they received is only sufficient and, in some cases, not even enough for their monthly sustenance.
I do know of Voluntary Welfare Organizations (VWOs) that offer subsidies for private ambulance fee to needy individuals, however, this subsidized fee is still too high and unaffordable for some.
Sir, Medifund scheme is to ensure that needy Singaporeans are not being deprived of their rights to medical treatments due to their financial standings. Allowing Medifund Scheme to be used for reimbursement of transport fare will surely ease the financial struggles and, more importantly, it enhances the accessibility of medical treatments for this group.
Mental Health – Daniel Goh Pei Siong
Chairman Sir, the 2016 Singapore Mental Health Study found that one in seven Singaporeans have experienced a mental disorder in their lifetime. Depression is the most common disorder, with around 6.3% of adults suffering from major depressive disorder at some point in their lives.
The good news is that people are now more aware and more willing to seek treatment. Thus, the years of delay in seeking treatment for major depressive disorder have dropped from four in the 2010 Study to one in the 2016 Study. The government’s efforts to ramp up mental wellness promotion are starting to bear fruit. Indeed, the increased prevalence rates in the 2016 Study could be attributed to greater awareness and willingness to seek treatment. But this also means that we are really only catching up to the true extent of mental health disorder and there are a lot more Singaporeans who remain undiagnosed.
Sir, the government and many community initiatives have been doing well in generating awareness about mental well-being. I want to focus instead on three other A’s: availability, accessibility and affordability.
On availability, MOH announced in Budget 2017 that one in two polyclinics will have a mental wellness clinic or a dementia clinic or both by 2021. There were already such clinics in 7 of the 18 polyclinics in 2017. I believe the government should aim higher now and make mental wellness clinics available to Singaporeans in all 18 polyclinics. The other issue is the availability of psychiatrists and psychologists, especially in the public health sector, as the 2016 Study noted the low rate per 100,000 residents here compared to higher income countries. Are there plans to improve on this front?
On accessibility, five of the seven wellness clinics in the polyclinics only see referred patients and the two Community Wellness Clinics run by IMH allow for consultation by appointments. Persons suffering from mental disorders are already finding it hard to come forward for treatment due to social stigma, thus we need to make the clinics as accessible as possible. Would the Ministry make all mental wellness clinics at polyclinic open to consultation by appointment?
Lastly, on affordability, patients can withdraw from Medisave up to $500 a year for outpatient mental health treatments, but estimates for subsidized treatments ranged from $220 to $380 a month. I believe there is a need for the limit to be raised to at least $1,000 a year to make mental health treatments more affordable.
Protecting Our Healthcare Workers – Daniel Goh Pei Siong
Chairman Sir, even as we honour our frontline healthcare workers in this COVID-19 situation, we should make sure that we protect them in three ways: physical health and safety, mental wellness, and social well-being.
On physical health and safety, the most heartbreaking COVID-19 news are those on doctors and nurses getting infected and succumbing to the disease. The Sars outbreak saw about one-fifth of the cases occurring among healthcare workers. A recent article by Dr Gan Wee Hoe and Dr Chia Kee Seng published in the Straits Times gave details on some measures taken to protect the health and safety of our healthcare workers. Would the Minister share the key measures implemented to protect our healthcare workers’ own health and safety?
On mental wellness, again based on the Sars experience, frontline healthcare workers suffered from high levels of burnout and post-traumatic stress. Would the Minister please share whether any mental health resources are made available to our healthcare workers in this crisis, and whether free counselling and mental health resources can be made available to our frontline healthcare workers for the years after this crisis has blown over?
On social well-being, reports of healthcare workers in uniform being ostracized in public bring back ugly memories from the Sars epidemic, where about half of local healthcare workers experienced some form of social stigmatization. I think it is amazing to see how many Singaporeans are fighting back to show appreciation to our frontline workers in concrete ways. Nevertheless, I want to raise two points here. First, are healthcare workers afforded any legal protection from being abused when they are in uniform, whether at work or in public?
Second, in a recent Straits Times report on the ostracization of nurses in uniform, healthcare leaders reassured the public that the uniforms do not pose any risk of infection. After this crisis has blown over, it may be timely to rethink whether uniforms are important for nurses or they should, like doctors, go to work in office attire and change to professional scrubs at work. I am ambivalent about this, as I grew up watching my mum go to work in her nurse uniform and I’m still immensely proud of her. She related to me some of the obstracization she experienced during Sars and how it forced her to change out of her uniform to return home. Thus, I would rather see a change in public attitude. Nevertheless, a public conversation on the uniform will be useful, if anything, to see whether public attitude can be changed.
Long-term Care – Daniel Goh Pei Siong
Chairman Sir, the government has been preparing for the ageing society that is already upon us. Intermediate and long-term care, or ILTC as it is known, will become a critical sector in our healthcare system. This year Singaporeans will see the introduction of CareShield Life and Medisave withdrawals for long-term care. A severely disabled Singaporean, who is unable to perform three or more activities of daily living, will receive a payout of $600 for life, and if the Singaporean’s Medisave balance is $20,000 and above, he or she can withdraw another $200 a month. If we add in the Home Caregiving Grant, there is another $200 in cash assistance to receive. This adds up to a potential $1,000 in cash withdrawals to support the financing of the long-term care needs of a severely disabled Singaporean. If the affected person is from the Pioneer Generation, there is another $100 in cash assistance.
Sir, my concern is with the financing needs of middle-income households, especially those whose wage earners are from the sandwich generation facing the cost of raising school-going children and supporting ageing parents. The latest figure for 2019 from the Department of Statistics for median monthly household income from work per household member is $2,925. This suggests that about half of Singaporean households will not get any subsidies for their elderly household member accessing ILTC non-residential services, since cut off for subsidies is $2,800. A Long Term Care study by Aviva in 2018 suggests that one would need around $2,300 a month on average for care, medical and everyday expenses. Sandwiched middle-income wage earners could be facing the additional financial burden of around $1,300 a month to support an elderly parent needing long-term care.
I believe this burden will become widely felt in the near future, if it is not already being felt today. Already for the Home Caregiving Grant, there is a note on the AIC website that says it will take about 3 months to process applications due to the high volume of applications received. Has the Ministry done any study to ascertain the long-term care financing needs of middle-income households in the next 5-10 years? What more can be done to support the long-term care financing needs of middle-income households who fall outside of the government subsidy threshold? Would opening CareShield Life to additional private insurance enhancements regulated by MOH like the Integrated Shield Plans of MediShield Life, with premiums payable by MediSave within limits be a possible answer?
Enhanced Flexi-Medisave for Seniors – Pritam Singh
Out of pocket expenses for medical care when our seniors enter their 60s can be source of significant insecurity. Sir, I have previously called for the Minister to consider a differentiated ceiling for Medisave withdrawals. In 2018, about 16% of individuals fully utilised their Flexi-Medisave limits. Sir, this percentage appears small but translates to about 136,000 Singaporeans who have fully utilised their yearly $200 limit.
We also know from previous parliamentary replies over the years that elderly patients above 60 years of age with chronic conditions visited polyclinics and Community Health Assist Scheme (CHAS) clinics an average of six times per year, with an average annual bill of about $200 after subsidies. Those without chronic illnesses visited these healthcare facilities an average of about three times a year, with an average annual bill of about $60 after subsidies. I believe there is scope to increase the Flexi-Medisave limits, particularly for those who have larger outpatient bills.
Sir, calls for greater liberalisation of MediSave withdrawals have been made by my colleagues including Mr Faisal Manap. The Workers’ Party acknowledges that higher withdrawal limits based on Medisave balances must be carefully considered as it may result in some Singaporeans having less Medisave savings through retirement. However, each senior Singaporean’s situation is different, particularly in view of differing Medisave balances across seniors in the population.
In addition, Sir, a differentiated ceiling for seniors has been replicated for other Medisave withdrawal schemes. For example, from this year, a differentiated Medisave withdrawal scheme has been introduced for Singaporeans with long-term care needs. Individuals with $20,000 and more in their Medisave account will be allowed to use $200 each month or $2400 per year from Medisave for long-term care. Singaporeans with balances of between $15,000 and above are allowed to use $150 per month and so forth.
Apart from increasing the Flexi-Medisave limits for outpatient treatment, the additional flexibility in the form of a differentiated ceiling should also be considered to allow for in-patient co-payments that have to be paid in cash after Medisave deductions. While Medishield Life and existing Medisave withdrawals can be utilised for inpatient bills, many patients are still required to make out of pocket payments in cash because of existing Medisave limits. Sir, seniors should be not be prevented from relying on their Medisave again to settle the cash component of bills provided their Medisave amounts are healthy.
Just this Monday at my Meet-the-People session, I saw a resident who asked me to write to the authorities to allow his 75-year-old brother, unemployed and living alone, to utilise around $1400 from his Medisave to settle his hospitalisation bills. I asked him how much his brother had in his Medisave account. He showed me his brother’s CPF statement, and the amount stood at in excess of $51,000.
Sir, this is a man in his mid-70s and unemployed. Surely there is scope to further assist our seniors, and reduce their out of pocket expenses for healthcare related expenses. The call is not for additional subsidies that impact the healthcare budget, but a better calibrated Medisave regime, that allow our seniors to better manage their cost of living concerns and to give our seniors in particular, greater peace of mind.
Adult Vaccinations – Leon Perera
Based on the reply to my Parliamentary Question last month, after the launch of the National Adult Immunization Schedule in 2017, the take-up rate for adult vaccination rose but is still way below that of some other developed countries. For example, for flu vaccines among seniors, our take-up rate may be around 24% versus 70% in the UK, US and Australia.
Can we do more to promote adult vaccination? For example, the government works with employers to conduct health screenings. Can those same platforms, events and working relationships be used to offer on-the-spot vaccinations to workers at companies? Can we also do more to nudge GPs to display material in their clinics that prompt patients to ask for vaccinations?
Of course, price is always a consideration, as many would want to conserve their Medisave for other future needs.
I would repeat my call made in Parliament for the level of subsidy given for adult vaccines to take into consideration the downstream fiscal cost savings to the state from fewer diseases as a result of vaccines.
Finally, our child vaccination coverage for measles, for example, is high at around 95%. But in 2019, there were 152 Measles cases, which was the highest number of cases since 1997. MOH figures also show that there were several hundred cases of Mumps every year since 2012.
In response to a PQ about measures to prevent measles outbreaks, the Minister for Health opined that passivity could explain most of the cases of children not being vaccinated.
However, the growth of anti-vaccination beliefs world-wide should not be under-estimated.
I would like to ask for an update on what measures MOH is planning to reduce the numbers for children not receiving these essential vaccinations. Do all childcare centres require vaccination certificates before enrolment? Can we do more, for example working with pre-school centres and private enrichment program centres to flag out cases of non-vaccinated children?
Curbs on High-sugar Products – Leon Perera
The government has introduced mandatory front-of-pack nutrition labels for less healthy pre-packaged sugar sweetened beverage (SSBs) and advertising bans for the least healthy SSBs on local mass media channels.
More than 30 countries have introduced such labels. In Chile, the sales of drinks with the unhealthy labels fell by 25 per cent after 1 1/2 years.
However, with the daily sugar intake of Singaporeans more than double that of the level recommended by the World Health Organization, could we go further?
Could MOH consider reviewing the results of these moves and, if these are not effective, consider adopting, to some degree, and in a tiered and calibrated fashion, the measures that have been adopted for tobacco products, such as more graphic warning labels on packaging? A study by researchers at Harvard in 2018 suggested that graphic warning labels on sugary drinks reduce purchases more than text-based labels.
Research funded by the UK’s Department of Health also suggests that removing products from choice locations within a retail outlet, for example at the check-out counter where impulse buying is common, can reduce sales. While product placement is a negotiated and contractual agreement between the sellers and the retailers, it may be necessary to explore nudging retailers to move in this direction in time, though of course not without industry consultation and piloting.
Industry buy-in for such moves may be facilitated by the fact that many of the firms producing high-sugar F&B products are gradually seeking to shift revenue share to healthier products over time, as they see the writing on the wall globally.
Alternative Medicine Practitioner – Muhamad Faisal Abdul Manap
The use of Complementary and Alternative Medicine (CAM) is widespread in Singapore, with a study showing that as high as 76% of Singaporeans are utilizing at least one form of CAM. This not only includes traditional medicine practices such as Traditional Chinese Medicine, Jamu and Ayurvedic medicine, but also includes practices such as Chiropractic and Homoeopathy.
However, not all types of CAM are treated the same under our existing laws and regulations. Currently, only Traditional Chinese Medicine practitioners are regulated under separate legislation and Chinese Proprietary Medicines are regulated by HSA. However, regulations do not cover the Jamu or Ayurvedic practitioners or the products they sell.
Chiropractic practices, popular amongst office workers, has also seen an increasing number of complaints against practitioners in the field as reported by the Straits Times in 2016. This has led to a call by the chiropractic association calling for government regulation.
This lack of regulation is particularly concerning, for the unregulated use of CAM practices may lead to detrimental outcomes of patients who simultaneously seek western trained doctors alongside CAM practitioners. A 2017 Straits Times article reported that CAM is widely used by patients doing chemotherapy which sometimes increased the side effects of chemotherapy. The same article also reported that the use of CAM also delayed a patient seeking western treatment by an extra six weeks as compared to non-CAM users, exacerbating their conditions3.
With the pitfalls that patients could suffer should CAM be left unregulated, I propose that MOH should consider studying the possibility of a regime that can regulate CAM practitioners in the same way TCM practitioners are being regulated now, which can fall under the ambit of a potential Complementary and Alternative Medicine Act. The Act can help to set regulations that imposes a minimum standard of protection against consumers. Such a regime should consider requiring mandatory registration for all CAM practitioners, mandatory information given to the patient about the underlying risk of using CAM. This should also include the mandatory disclosure of usage of CAM treatment to healthcare medical practitioners when they seek medical treatment.
Such a regime should ensure regulation is in place for both CAM practitioners and patients that otherwise need to seek recourse elsewhere.