1.  Mdm Halimah Yacob asked the Prime Minister and Minister for Finance (a) if he will provide an update on the efforts to promote the re-employment of officers above the age of 62 in the civil service and statutory boards; and (b) what percentage of those who reached the age of 62 were re-employed last year and what were the terms and conditions of their employment.

     The Minister for Defence (Mr Teo Chee Hean) (for the Prime Minister and Minister for Finance):  Mr Speaker, Sir, the civil service and the statutory boards recognise that as a large employer, the public sector has a role to play in improving employment opportunities and employability of older workers.  One key area we have moved on is the re-employment of officers who have retired upon reaching the age of 62.

     In September last year, the public sector refined its re-employment policy to make it easier for agencies to re-employ their retired officers.  Agencies were encouraged to actively consider offering re-employment to retiring officers, particularly those who have contributed well and who can continue to add value to the organisation.  Procedures were changed such that agencies need no longer conduct an open recruitment exercise if it re-employs its retired officer within six months from his retirement.  The public sector also aligned its guidelines on the remuneration package for re-employed officers with the “Tripartite Guidelines on the Employment of Older Workers Above 62 Years Old”.  Re-employed officers are paid based on the scope of work and responsibility that they are given when they are re-employed.  Re-employed officers need not be limited to doing their previous jobs at their previous pay.  Those who are given a smaller job scope and responsibility will be paid a salary that is commensurate with the size of the new job.  Re-employed officers can be employed on various flexible work arrangements, including on a full-time, part-time, or on a project basis.

     In 2006, about 1,110 officers retired from the civil service.  A total of 207 officers aged 62 years and above were re-employed. This represents about 19% of the total number of retired officers in 2006.   But this percentage does not include those who may have been re-employed, say, on contract for service or on a casual basis, because we do not capture these data.  Those re-employed included education officers, clerical officers and immigration officers.  Some performed new roles, for example, teachers who were re-trained for school counsellor positions while others continued in similar roles upon re-employment. For the statutory boards, as a whole, about a total of 370 officers retired in 2006.  The number of re-employed officers was 361, representing more than 90% of retired officers.  The majority of those re-employed in the statutory boards were daily-rated employees and Assistant Technicians.

     The civil service has also recently started an older worker database where retiring and retired civil servants can sign up to be on the programme if they wish to be considered for job assignments in the public sector after their retirement.  This programme will eventually be extended to include statutory board employees.

     Mdm Halimah Yacob (Jurong):  Sir, the 19% of people re-employed in the civil service appears to be a very small number compared to the total number who retired last year.  I would like to ask the Minister whether there is any target set in the civil service as to what is the percentage of people it wants to re-employ, taking into account the need to look at performance, skills, relevance, and requirements for the job.  But, at the least, it would be useful for the civil servants to know that there is some target set for re-employment of older workers after the age of 62.

     Mr Teo Chee Hean:  Mr Speaker, Sir, I would not want to set a target because that sets expectations which may not fit in with the employment requirements either of the civil service or the individual officer himself.  I think what is more important is to follow the principles that we have outlined in accordance with the Tripartite Guidelines on the Employment of Older Workers Above 62 Years Old, which I enumerated just now.  When we re-employ an officer, it should be based on the value that he can add, which is the scope of work and responsibility.  The re-employed officers need not be limited to doing their previous jobs at their previous pay and we also provide for flexible work arrangements.

     The 19% that I mentioned just now does not include persons who may have been employed, say, on contract of the Government and who may be providing services to the Government.  Some of these retired civil servants actually join such firms and seek re-employment that way.  Also, some officers are re-employed on a casual basis, and those numbers are not in the 19%.

     2. Mr Zaqy Mohamad asked the Minister for National Development if the Ministry will consider redefining asset enhancement to allow the second subsidised HDB housing loan to be based on housing valuation and not on the number of rooms a flat has, as it can be considered to be a housing upgrade if an owner of a flat in a suburban area purchases another flat in a better location closer to town.

     The Parliamentary Secretary to the Minister for National Development (Dr Mohamad Maliki Bin Osman) (for the Minister for National Development):  Mr Speaker, Sir, HDB provides a maximum of two concessionary loans for each eligible citizen family to assist them to buy HDB flats.  The first loan can be used to purchase any type of flat according to the family's needs and affordability.  The objective of the second concessionary loan is to help facilitate social mobility among HDB lessees, especially those with larger households and, hence, need to upgrade to a bigger flat type. 

     It would not be appropriate to use the market value of a flat to determine a family’s eligibility for a second concessionary loan.  Such a move would not serve the social objectives being promoted by the existing policy.  Moreover, this would subject flat owners to much uncertainty about whether they qualify for a second concessionary loan, as the value of the flat is not static and may fluctuate according to changing market conditions and other factors. 

     Mr Zaqy Mohamad (Hong Kah):  Sir, the term "asset enhancement" may be outdated because someone with a larger flat which is 15 or 20 years' old in the suburban area has a lesser chance of asset enhancement than, say, a second flat bought in an urban area which has a larger potential to enhance its return of assets.

     Dr Mohamad Maliki Bin Osman:  Sir, I think the policy of giving the second concessionary loan is not specifically about asset enhancement.  It is really about social mobility, to encourage lessees to upgrade to a bigger flat.  If we define social mobility as the size of the flat, I think people will generally accept that a 3-room flat moving up to a 4-room flat is an indication of social mobility.  The value of a flat varies.  Mr Zaqy has rightly pointed out that the location determines the value of the property.

    For us, by definition today, we see social mobility as defined by the size of the flat.  I have encouraged lessees to upgrade to a bigger flat to facilitate social mobility, so that they can have a bigger flat when their children grow up and need bigger and more space within the flat.

     3.  Dr Lily Neo asked the Minister for Education whether he will adopt the recommendations by the International Academic Advisory Panel convened here recently and, if so, what are the recommendations.

     The Minister of State for Education (Mr Gan Kim Yong) (for the Minister for Education):  Mr Speaker, Sir, the IAAP’s recommendations focused on three main areas - developing research and teaching excellence in our universities, increasing diversity in Singapore’s tertiary education sector and investing in lifelong learning.

     In its deliberations, the IAAP strongly endorsed the development of the three autonomous universities into research-intensive universities renowned also for their excellence in teaching.  This is in line with MOE’s view that teaching and research excellence are equally important for our three universities.  As our universities have traditionally had a strong teaching role, more recent developments have focused on supporting them to develop research excellence.  Funding for R&D in the universities has been increased through MOE’s enhanced Academic Research Fund (AcRF).  Starting from the next financial year, MOE will be funding the indirect cost of research in the universities to ensure that resources are not inadvertently diverted from teaching to research.  The universities can also bid for additional research funding from A*STAR and the National Research Foundation.

     The IAAP recognised and supported the Government’s ongoing efforts to widen opportunities and provide more choices for Singaporeans to obtain a tertiary education in Singapore.  These include, for example, the establishment of links between our polytechnics and foreign specialised institutions (FSIs) to offer a wider range of degree programmes here.  Ngee Ann Polytechnic’s collaboration with Wheelock College and NTUC Childcare Regional Training and Resource Centre to offer a degree programme in early childhood studies was the first of such tie-ups under this initiative.  Going forward, MOE will continue to encourage more Poly-FSI tie-ups.  MOE will also be studying the feasibility and options for establishing a quality liberal arts college in Singapore, as suggested by the IAAP.  If established, the college would provide a distinctive educational experience for our students and further boost the reputation of Singapore’s university sector.

     As the economy becomes more complex and knowledge-based, the IAAP felt that Singaporeans will require more years of education and will need to take full advantage of opportunities for lifelong learning. 
At the post-secondary level, the Government already provides substantial subsidies to our educational institutions to keep fees affordable. To encourage Singaporeans to acquire more years of education in the form of quality post-secondary programmes, the Government is establishing post-secondary education accounts, which can be used to pay for tuition fees at publicly-funded post-secondary institutions, UniSIM and WDA-accredited lead training providers. 

     In line with the IAAP’s recommendations, we will also do more to encourage Singaporeans to participate in lifelong learning, including increased funding for adult worker training institutions, implementation of more Place and Train programmes for workers and increased subsidies for adult learners taking up post-diploma courses in the polytechnics.  Going forward, the Government will continue to study how best we can provide continuous learning opportunities to every Singaporean, and encourage them to see this as a way of life.

     Dr Lily Neo (Jalan Besar): May I ask MOS whether he agrees with Prof. Brown, the IAAP member, who said that the IAAP panel believed that Singapore could become an international centre for R&D on par with the best around the world?  How would this add value to the future of the Singapore's economy and how does MOE plan to achieve this vision?

     Mr Gan Kim Yong:   From Singapore's point of view, indeed, we can have the opportunity to become an international centre for R&D.  In fact, we have already moved ahead in this direction.  The Government, as I have mentioned earlier, has invested in the R&D efforts, both at the university as well as the research institution levels.  Moving forward, we will continue to do so in a very targeted way to develop the R&D capability in Singapore.  And how does this contribute to our economy?  As we move forward towards a knowledge-based, innovation-driven economy, I think R&D will play a very important part to generate economic activities at the higher level and to also attract talents to Singapore.

     Mr Speaker:  Last question, Dr Neo.

     Dr Lily Neo:  Thank you, Mr Speaker.  May I ask MOS how does he plan to increase the take-up rate of Singaporeans pursuing the Ph.D and Masters courses since only 10% of those doing such courses in NUS and NTU are Singaporeans?  Could he elaborate on this?

     Mr Gan Kim Yong:  I think the universities will have to continue to make their research programmes more attractive.  Through Government funding, we will also provide opportunities for Singaporeans who are interested in pursuing R&D to have opportunities to pursue their interests in Singapore.  It is a long-term effort. We would not be able to see results overnight, but with sustained effort from the universities and the Government, we would be able to achieve our objectives.

ESTIMATES OF EXPENDITURE FOR THE

FINANCIAL YEAR 1ST APRIL, 2007 TO 31ST MARCH, 2008

(Paper Cmd. 2 of 2007)

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

[Mr Speaker in the Chair]

     Head L - Ministry of the Environment and Water Resources

    The Chairman: Head L - Ministry of the Environment and Water Resources. Mr Charles Chong.

Clean and Sustainable Environment

     Mr Charles Chong (Pasir Ris-Punggol): Sir, I beg to move,

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

     Sir, we have already heard that Singapore aspires to be closer to the top among First World nations. In the years ahead, we plan to support a significantly larger population and increase industrial activities for economic growth.  However, much needs to be done to ensure that we always have a clean and sustainable environment that will enhance our quality of life.  Could the Minister tell us where Singapore now stands compared to First World countries, in terms of environmental performance?  What are the benchmark and timeframe he has set for his Ministry to achieve our objectives of being among the top of the First World countries?

      One of the most important factors in our survival is the availability of clean water at affordable prices.  Could the Minister tell us what plans are there to ensure that we will always have sufficient water for our people, industries, businesses and recreation even when our population approaches 6.5 million people?

      In addition to water sufficiency, we need to ensure good air quality, despite increasing industrial activities and more vehicles on our roads.  Could the Minister tell us what has been done to ensure good air quality in Singapore and the promotion of the use of environmentally-friendly vehicles on our roads? However, good air quality is not dependent solely on domestic measures.

     Despite our best efforts, our air quality may be affected by transboundary haze. And I think it may be a bit more difficult for Indonesia to enforce a ban on the export of its haze compared to the enforcement of the ban on its sand exports.  But I will talk more about the haze in the later cut.

     Sir, economic growth and population increase are often accompanied by increased waste generation.  How fast are our landfills filling up and how is Singapore addressing our waste problems?  What is the percentage on waste recycling compared to other developed countries and what measures are being taken to raise the percentage of recycling in Singapore?

     Sir, being a top First World country is more than just infrastructure development and providing world-class amenities.  Our people must develop social responsibility and social graces that are associated and even expected of a top First World nation. A visit to some of our housing estates and parks will reveal that public behaviour and attitudes towards the care of public property and amenities still leave much room for improvement.  Without the thousands of efficient cleaners cleaning up for us every day, many of our estates may not even be near First World standards.

      Achieving a clean and sustainable environment would require more than just Government action.  The support and commitment of all parties involved are of vital importance if we are to succeed.  Could the Minister tell us what measures his Ministry has taken and will take to enhance public education and enforcement action, if necessary, in order to ensure that our social behaviour keeps pace with our drive to become a top First World country?  Could the Minister also tell us how successful has its engagement efforts seen with its three "P" partners - people, private and public sector partners - been so far and what more would be done to enhance this partnership?

     Mr Edwin Khew Teck Fook (Nominated Member): Sir, Singapore has invested heavily in technology and R&D in the environment of water sector over the last 40 years to ensure we have a clean and sustainable environment.  I do applaud MEWR and the Government for this long-sighted initiative.

     We will be spending even more in R&D in this sector over the next five years.  And I believe the National Research Foundation has allocated $330 million this year for research on environment and water technology.  May I ask the Minister whether there is a masterplan drawn up for R&D and technology development in this sector, and whether an Environment Water Ministry Technology Task Force was set up and whether the private sector was consulted to develop this masterplan?  If there is such a masterplan, can the Minister share this with the industry?

     There are many sub-sectors in this large area of environment and water and Singapore cannot be taking the lead in all sub-sectors.  It would therefore be good if Singapore, as a whole, both Government and private sector decide on what sectors should Singapore focus on, particularly because of our special constraints of limited space and high population density.  Many technologies in developed economies like Europe and the US had been developed and become leaders worldwide because of government regulations in environmental laws.  For example, Photo Voltage, or PV, for solar cells, Germany introduced feed-in tariff laws for renewables in year 2000.  It is now the biggest market for PV in the world, making 25% to 30% of the world's markets for PV, creating 38,000 jobs in manufacturing and systems supply and over 1,000 jobs in R&D.

     Sir, if Singapore wants to be a leader in the EWI sector, we need to plan, strategise and take bold initiatives and decisions.  Only then can we attract major global players in this industry to come to Singapore and, more importantly, to develop our own Singapore based EWI SMEs, and therefore to be a leader in sustainable development.

Haze

     Mr Charles Chong: Sir, could the Minister update the House on the measures taken to prevent the recurrence of the haze situation experienced in Singapore last year and in previous years.  I understand that Singapore and other countries have agreed to work with the Indonesians to eliminate slash and burn land clearance methods and, ultimately, eliminate the annual occurrence of haze over the entire region.  Could the Minister tell us what is the level of Singapore's commitment to assist Indonesia eliminate this domestic and transborder environmental hazard faced by Indonesia and the regional countries, including Singapore, for many years already?

    Sir, no amount of effort would succeed without effective monitoring and enforcement action on the ground by the Indonesian authorities.  However, I remain optimistic that good progress will be achieved as Indonesia has recently demonstrated its ability to take drastic action to protect the environment.

     Finally, Sir, is the Minister aware of any Singapore-owned companies involved in agricultural activities in Indonesia that generate haze?  And, if so, what action does he plan to take against such companies?

Dust Pollution

     Dr Lim Wee Kiak (Sembawang): Mr Chairman, Sir, Singapore has been consistently ranked high on good ambient air quality by PERC (Political and Economic Risk Consultancy) as well as the ECA International. The Pollutant Standard Index (PSI) was reported to be in the good range for more than 85% of the year for the last three years. For that, I applaud the efforts of the Ministry.  The period affected was mainly due to transboundary haze as a result of forest fires in our neighboring countries.

     I am also heartened to hear that the Ministry will work in achieving a good PM2.5 air quality. This can be achieved by further control of fuel pollutants released by the motor diesel vehicles on our roads by the introduction of Euro IV emission standards for diesel vehicles from October 2006 last year. While we are on the way to achieving good results in these areas and maintaining good air ambient quality for PSI, we still have some way to go for the control of dust particles that are of much larger in size. These dust particles are generated by heavy industries, such as sand blasting activities by the shipyards and some other heavy industries.

     Residential areas in the vicinity of these heavy industries, that is, within one kilometre, bear the brunt of the dust assault annually with the seasonal change of monsoon winds. This problem is particularly acute in some parts of Sembawang Town and has been reported in an article in Lianhe Zaobao dated 5th January this year.  My question is: what are the planning guidelines when we sited residential areas near to an industrial area?  Perhaps, there should be a light industry buffer area to buffer the residential area.  This probably is a question to be answered better by MND, but perhaps the Minister could enlighten us a little bit.

      Sembawang Shipyard has, over the past two years, invested significantly on indoor blasting facilities and also introduced many measures, such as netting at source, to control the dust pollution.  National Parks (NParks) had also planted 500 trees during the Clean and Green Week last year upon our request to create a green belt between the shipyard and the residential areas. Although these dust particles, as claimed by the health officials, are inert and may not result in significant respiratory and other health problems, they are still a source of concern for the residents who have to clean the black dust from their floors, windows and table tops daily.

      I would like to ask the Minister what measures are currently in place to mitigate the dust pollution and what are the future plans of the Ministry to further reduce the dust pollution.

Littering

     The Senior Parliamentary Secretary to the Minister for Education (Mr Masagos Zulkifli B M M): Sir, I will not belabour the House much more on the littering problems, as I have already stated them in my Budget speech. Therefore, I will only ask the following questions of the Ministry and perhaps just reiterate the relevant points.  I am sure that there must be no lack of programmes and engagement with the community to keep Singapore litter free.  However, the doubling of offenders in 2006 to 7,000 seems to hint at fatigue by the public with the campaign or show that the message is not heeded by a sizeable group of the public.

Anecdotally, our HDB estates suffer more littering than ever. 

12.30 pm

     Therefore, what other initiatives will the Ministry embark on to inculcate ownership and care for the environment other than stronger enforcement of the law?  Would the Ministry consider alternative programmes that would instead provide incentives to the public who participate and contribute to a more cost-effective way to keep our surroundings clean and litter free?

     Mr Liang Eng Hwa (Holland-Bukit Timah): Sir, we can do more to reduce littering.  Anecdotal evidence seems to suggest that public cleanliness in crowded parts of Singapore is deteriorating as a result of littering. 

     A clean environment in Singapore is of utmost importance because we are a densely populated country.  Litter can also spoil the image of our cityscape and clog up our waterways.  The Keep Singapore Clean campaign goes all the way back to 1968.  Over the years, we have numerous initiatives at the national and local levels to keep Singapore litter free.  Despite these campaigns and initiatives, I do not think we would have this current state of cleanliness, if not for the efforts of our cleaners. 

     One effective way to drive home the anti-littering message is to have an annual national No Sweep Day so that the public can have a sense of the extent of littering if the cleaners are not there to sweep the floors and the streets.  It will also give us a good sense of whether our litter-free habit has taken root and it will enable us to track progress and calibrate new approaches to tackle the littering problem.  I understand that some constituencies already have such No Sweep Days in some form.  But I believe a national level No Sweep Day would be better able to drive home the point to all Singaporeans.

     I would also like to suggest to the Ministry to be more targeted in anti-littering enforcement by focusing, firstly, on the most littered areas, such as hawker centres and bus interchanges.  Secondly, it is always the recalcitrant minority that are the habitual litterbugs.  Hence, I would like to suggest different penalties for repeat or habitual offenders, which include also a mandatory education programme for those repeat offenders to learn why we need to keep the environment clean. 

     Littering in the HDB heartlands has also not improved.  Often, the common dirty spots are those behind the blocks where socially irresponsible residents just throw their rubbish out of their kitchen windows.  This should also be another targeted area of enforcement by NEA and the Town Councils.  However, in the HDB communities, I think a more sustainable approach to keep the estate clean is to build a stronger sense of community ownership.  If our residents feel a strong sense of ownership to their community, keeping their estate clean will come naturally for them.  But to build this community ownership, a by-the-people-for-the-people approach would be more effective, rather than a top-down approach.  I hope NEA and HDB can be given even more resources to work with the grassroots communities to strengthen ownership and spread this message of keeping their home environment clean.

Public Cleanliness

     Mrs Josephine Teo (Bishan-Toa Payoh): Sir, in many public places, we still see the "Singapore OK" sign, but a casual survey conveys something different, especially around the restrooms.  They do not look OK, neither do they smell OK.  Personal hygiene and habits certainly do play a part, but there are two other contributing factors. 

     First, the restrooms are often thoughtlessly designed.  They are tucked away in narrow corners which are poorly lit, and restrooms near cinemas and foodcourts are often too small.  This leads to long queues.  Towel dispensers are placed a distance away from washbasins, contributing to wet and slippery floors.  Besides these, cleaners are often not given the right tools to do their jobs.  Many of them do not seem to have had the proper training.  As a result, the poorly-designed restrooms are poorly maintained.  As for the  poor restroom user, good luck to him or her.

     To turn this vicious cycle around, we must have well-designed restrooms which will make it easier for well-trained cleaners to do their jobs and motivate users to keep them clean.  To be a first-class city with first-class social habits, we should also have first-class restrooms with first-class cleaners.  Can the Ministry take steps towards this goal?

     The Minister for the Environment and Water Resources (Assoc. Prof. Dr Yaacob Ibrahim): Mr Chairman, Sir, I would like to first thank Mr Charles Chong, the Chairman of the GPC for National Development and the Environment, and other Members for their questions and suggestions.  Both Dr Amy Khor and myself will endeavour to answer them to the best of our abilities and we promise not to sweep anything under the carpet.

     Sir, we have every reason to be proud of the environment that we have today.  Through careful planning and sound policies, we now enjoy a clean and healthy living environment that is internationally recognised.  We have been ranked first in cleanliness for four consecutive years from 2003 to 2006 in the Condé Nast Traveller’s Readers’ Travel Awards.  Singapore has also been consistently rated best for the overall quality of our environment among Asian countries for the past six years in the surveys conducted by the Political and Economic Risk Consultancy (PERC).  For 2006, however, PERC's latest report on “Comparative Country Risk” has indicated that Singapore is not spared from transboundary challenges. But the PERC report also notes that "the Government has benefited from an aggressive campaign to do what it can within its own powers to pursue green policies.”  We should, therefore, continue to actively pursue our own environmental objectives, while working closely with our neighbours to tackle the transboundary issues.

     By keeping our air, water and land clean, our quality of life has improved over the years.  Our excellent living environment has become our competitive advantage in rooting residents and attracting investments and talents.  According to the 2006 Quality of Living Survey done by Mercer Human Resource Consulting among executives worldwide, Singapore has the best quality of life in Asia.

     Sir, Mr Chong and Mr Edwin Khew have asked about our domestic efforts to maintain good air quality and to promote the use of environmentally-friendly vehicles on our roads.  I will update the House on our efforts to promote green vehicles in response to the cut on hybrid vehicles later.  But, first, on the air quality.

     Singapore’s ambient air quality compares favourably with major cities of the world.  As our industry base expands and vehicle population increases, we have ensured that the sources of air pollution are kept in check and the quality of our ambient air remains good.

     The National Environment Agency (NEA) has put in place a system of planning control, enforcement and monitoring to ensure that our industries meet the emission standards.  Industries are required to install pollution control equipment or take pollution abatement measures to reduce air impurities and dust from their operations.  NEA carries out regular checks to ensure that industries comply with the requirements. Motor vehicles are also required to comply with the vehicular emission standards.

     In Singapore, our key air pollutants are well within the USEPA standards, except for very fine particulate matter less than 2.5 microns in diameter or it is called PM2.5.  This is of particular concern to us, as PM2.5 has been linked by many studies to respiratory diseases, such as bronchitis and asthma, and to heart disease, which may result in increased hospitalisations and premature deaths.  Our current ambient level of PM2.5 for year 2006 is 23ug/m3, which is above the USEPA standard of 15ug/m3.

     As diesel vehicles are a major emitter of PM2.5, it is important for us to implement measures to reduce PM2.5 emissions from this source.  As noted by a Member, from October 2006, we have introduced the more stringent Euro IV standards for new diesel vehicles.  Over time, older diesel vehicles will be replaced by the cleaner Euro IV vehicles, and ambient levels of PM2.5 will fall.

     Sir, from January this year, diesel vehicles are also required to undergo the more rigorous chassis dynamometer smoke test (CDST) during their mandatory periodic inspections.  This smoke test has replaced the former free-acceleration smoke test, and will help ensure that diesel vehicles are maintained properly to reduce their pollutant emissions.

     With these measures, we target to achieve the USEPA standard for PM2.5 by 2014. 

     Sir, let me now turn to the cut by Dr Lim Wee Kiak who has asked about pollution caused by dust particles.  Dust pollution from industries is generally not a problem in Singapore.  However, it may arise from certain premises, as noted by Dr Lim, like shipyards, due to their work processes.  For instance, some residents living in Sembawang New Town in the vicinity of Admiralty Link have experienced the deposition of black dust in their flats.  The black dust is caused by grit blasting of ships at Sembawang Shipyard and carried towards the HDB flats by wind during the north-east monsoon from November to March.  The black dust comprises mainly iron and copper particles and is no more harmful than other particles in the air, if present in small quantities.  The NEA has monitored the dust level at the HDB estate in Admiralty Link and found it to be within the USEPA standard for PM10, which is the standard.  The black dust, therefore, does not pose a health risk to the residents.  But, as rightly noted by Dr Lim, the black dust is a nuisance to his residents.

     Hence, NEA has been working with Sembawang Shipyard and the grassroots to mitigate the problem.  Sembawang Shipyard has taken various measures to minimise the dust emissions from its operations, such as using a water curtain system, to wash down the dust emissions and using a fine net covering around the ships to contain the dust.  Grassroots leaders at a dialogue session in December last year told us the situation had improved compared to two or three years ago.  And I would like to assure Dr Lim that the NEA will continue to be vigilant in the regulation of air pollution to ensure that the ambient air in Singapore is kept within the USEPA standards.  Dr Lim has also asked about the internal guidelines, in terms of having residential places together with industries.  There are buffer zones that separate industries from residential premises.

     Sir, let me now turn to the issue of haze.  Notwithstanding our efforts to mitigate air pollution within Singapore, our air quality is also affected by external factors that, unfortunately, are not directly within our control.  Singapore experienced severe transboundary haze episodes last year and in 1997, with the PSI going above 100 into the “unhealthy” range on three days.

     Singapore will work closely with the regional countries in tackling the transboundary haze problem, so that it would not undermine our efforts to maintain good air quality in Singapore.  On 14th November last year, I updated the House on the actions taken by Singapore, together with Indonesia, Malaysia, Brunei and Thailand, to address our concerns over the serious haze episodes in October last year.  I reported on the Sub-Regional Ministerial Meeting (SRMM) held among the five countries in Pekanbaru on 13th October last year.  The SRMM was an idea mooted by our Prime Minister who had written to Indonesian President Susilo Bambang Yudhoyono on 10th October 2006 to register our concern and disappointment at the recurring haze from forest fires in Indonesia.

     At the SRMM, the Sub-Regional Ministerial Steering Committee (MSC) on Transboundary Haze Pollution was set up at Singapore’s suggestion.  It was agreed that the MSC would meet frequently to focus attention on the haze problem.  I also reported that at the First Meeting of the MSC on 9th November last year in Cebu, the Philippines, Indonesia presented its National Plan of Action (PoA) to deal with land and forest fires in Indonesia.  Under its PoA, Indonesia identified 35 fire-prone areas in eight provinces, including Jambi, Riau, South Sumatra and Central Kalimantan, to deal with the fires there. Singapore offered to work with a regency in Jambi Province to enhance its capacity to prevent and mitigate land and forest fires.

     Sir, I have just returned from the Second MSC Meeting on 28th February this year in Brunei Darussalam.  Allow me to update the House on the developments.

     Sir, Indonesia had committed to reduce the number of hotspots by 50% in 2007 as compared to 2006.  This is indeed commendable.  Indonesia had also budgeted Rp 700 billion (S$110 million) a year to implement its PoA to tackle land and forest fires.  I see Mr Chong nodding.  You will recall that Singapore had at the First MSC Meeting pledged an amount of US$50,000 to the ASEAN Haze Fund. Indonesia had likewise pledged a similar amount.  At the Second MSC Meeting, both Brunei and Malaysia had also pledged that they would each contribute US$50,000 to the ASEAN Haze Fund.  ASEAN has set an initial target of US$500,000 for the Haze Fund, and I hope that our pledges would spur other ASEAN member countries as well as international and regional organisations to do likewise.

     In the past, the approach in tackling land and forest fires was through the national government.  But this top-down approach alone is insufficient.  It needs to be complemented by a bottom-up approach, if the source of the problem is to be effectively tackled.  This bottom-up approach has now been addressed under Indonesia’s PoA.  The focus is now on fire prevention and mitigation at the local government level.  In response to the call from Indonesia for ASEAN member countries to collaborate with a fireprone province, Singapore had offered to work with a regency in the Jambi Province to enhance its capacity to prevent and mitigate land and forest fires.  Indonesia had welcomed our offer.

     Since then, the NEA has sent a team of officers to Jambi on a fact-finding mission on 8th to 10th January this year.  The objective is to have a better understanding and appreciation of the ground conditions, existing resources available, and other local dynamics.  I am pleased to note that the Jambi Governor, Pak Zulkifli, is himself personally involved in this project.  We have since worked closely with the Indonesian Ministry of Environment (KLH) and the Jambi Provincial Government, and developed a Framework for a Master Plan to prevent and mitigate land and forest fires in the Muaro Jambi Regency.

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     Based on the Framework, Jambi, KLH and my officers will jointly develop a Master Plan for Muaro Jambi Regency in Singapore this month. The Master Plan will comprise the following five elements, namely, fire prevention; fire suppression; legislation and enforcement; early warning and  monitoring; and, finally, regional and international collaboration. Projects and programmes will be developed for each of the five elements. But the key focus is on fire prevention.

     Sir, the Master Plan for Muaro Jambi Regency will be aligned with Indonesia’s national PoA. More importantly, the Jambi Provincial Government will own the Master Plan. If successfully implemented in Jambi, the Master Plan can serve as a model for other fire-prone districts in Indonesia.

    At the 2nd MSC Meeting, Malaysia indicated that it would be assisting in the implementation of Indonesia’s PoA by undertaking a number of projects, including working with plantation companies to implement zero burning practices and other preventive measures. Malaysia also liked the Jambi-Singapore collaboration model and wanted to know more about it. Hence, I have invited Malaysian officials to join my officers when we develop the Master Plan jointly with Jambi and KLH officials.

     Besides available expertise and resources in dealing with fire prevention and mitigation within ASEAN, there are expertise and resources outside this region. These could come from international and regional organisations, NGOs, civil societies and ASEAN dialogue partners. We should not be shy to tap these expertise and resources and we will do so for the Jambi-Singapore collaboration.

      The inaugural MSC Meeting in Cebu agreed that Indonesia would organise an International Conference to request for assistance and funding support.  Indonesia did so with the High-Level International Conference on Haze held in Jakarta on 22nd February this year.

     Several international and regional organisations and NGOs supported Indonesia's PoA at the Conference. They also pledged to provide technical and financial assistance to Indonesia in the implementation of the PoA. Jambi and ourselves also presented the Jambi-Singapore collaboration project at the Conference. The Asian Development Bank (ADB), in particular, announced its readiness to provide technical expertise and funding for some projects under the Jambi Master Plan.

     Sir, I would like to inform the House that the regional smoke haze problem can only be effectively addressed by sustained efforts and strong political will from Indonesia. We hope that Indonesia will heed the calls of ASEAN member countries for Indonesia to ratify the ASEAN Haze Agreement as soon as possible. On our part, Singapore will continue to render assistance to Indonesia to implement its PoA. We hope that other ASEAN countries, international and regional organisations, and NGOs will also play a role to help Indonesia on this regional issue which has global implications.

     At the 2nd MSC Meeting in Brunei, Indonesia informed that their Ministers of Environment, Forestry and Agriculture are scheduled to meet again with timber processing estate, logging and plantation companies to develop a comprehensive strategy, and also seek their cooperation in preventing and suppressing fires in the next dry season. This is a positive development and should be continued to ensure that sustainable plantation practices are conducted on the ground.  Mr Chong has asked whether we know of any Singaporean company involved. We do not know, Sir, but we have always told our Indonesian colleagues that if they are caught, they should be dealt with according to the law of the land.

     Sir, the land and forest fires will not go away immediately, nor will the haze affecting Singapore and the region. Indonesia will need to sustain the momentum generated and follow through with concrete action programmes on the ground. We should be prepared for a long-haul and this would require political determination, resources and collaboration with other stakeholders. But, Sir, I am confident that we are on the right track towards ameliorating the haze problem in the region.

    The other issues raised by other Members on resource conservation, the 3P engagement efforts, cuts on water, waste management and environmental responsibility - I will deal with them later.  Now, allow my colleague, Dr Amy Khor to update the House on our efforts to tackle the littering problem. 

     The Senior Parliamentary Secretary to the Minister for the Environment and Water Resources (Dr Amy Khor Lean Suan): Sir, our first anti-littering campaign was the "Keep Singapore Clean" public education campaign in 1968. Since then, we have come a long way to achieve high standards of public health and a quality living environment. But littering remains a key challenge today, especially in the heartlands, as noted by Members, Mr Liang Eng Hwa, Mr Charles Chong and Mr Masagos.  If left unchecked, the littering problem will seriously tarnish Singapore’s reputation as a clean city and degrade our quality of life.

    We have recently completed a survey on littering behaviour. The survey showed that those who litter tend to be males below 30 years of age. Commonly littered items include cigarette butts, tissue papers and plastic wrappers. I see some smiles on my female fellow parliamentary colleagues.  The survey results also showed that only a small minority, about 5% of the people, think that littering is a socially acceptable behaviour.

      The way to keep our environment "litter-free", however, should not be to employ an ever-increasing army of cleaners to clean up after the people who litter, as has been alluded again by Mr Chong, Mr Masagos Zulkifli and Mr Liang Eng Hwa.  Instead, Singaporeans, in particular our youths, need to have a greater sense of ownership and care of the environment and refrain from littering.  My Ministry believes that environmental ownership can be strengthened further. NEA has therefore been working closely with the community to encourage residents, young people in particular, to participate in initiatives towards a cleaner and healthier environment.

    For instance, NEA has worked with the Central CDC on an initiative for students called "Youth Environmental Guardians".  Under the initiative, members are to undertake projects such as "Adopt-a-Neighbourhood" to improve the public health standards of the estate they choose to adopt. Another initiative, supported by NEA, is that by the North-East CDC termed "SCAN" -  Schools and Community Anti-littering Network, which encourages schools and Residents’ Committees to adopt and improve cleanliness of littered areas within the GRC.

      To address the littering problem involving youths, which include those aged 35 and below, we have also recently formed a Committee on Youths for Clean and Sustainable Environment.  This consists of representatives from the Ministry of Education, Ministry of Community Development, Youth and Sports, People’s Association Youth Movement, Singapore Environment Council, National Youth Council and educational institutions, to jointly develop strategies and educational programmes targeted at our youths.

     At the same time, NEA has intensified enforcement action against litterbugs by carrying out more inspections at public places which are frequently littered. NEA will also continue to enforce the Corrective Work Order (CWO) against recalcitrant litterbugs and those who commit serious littering offences.

     Students below the age of 18 who are caught littering will continue to be referred to their schools for counselling, to give them a chance to mend their ways. We hope that the various measures would bring about positive changes in mindset and behaviour among the litterbugs, while we continue to ensure a balance between educational efforts and enforcement.

     As Ms Indranee Rajah has mentioned in this House, in order to have a "first-class" living environment, Singaporeans must cultivate "first-class" habits to match, and creating "waterworks" in lifts is definitely not. As responsible members of our society, we should maintain the cleanliness of public places as we do for our homes.  I could not agree more with Mrs Josephine Teo that we should take active steps to improve on the cleanliness and hygiene of public facilities, such as public toilets so that they look and smell okay.

     Many would agree that we have come a long way from having night soil collectors - I wonder how many know about this or remember this - to having themed toilets like those in large shopping malls and our parks.

    However, having better hardware only forms part of the equation.  It is just as important to focus on the "software" aspects of keeping public toilets clean. NEA therefore actively engages the community to promote good toilet behaviour through various community campaigns and projects. Such projects include the "My Coffeeshop Shines Programme @ South West" and the "Clean, Dry & Sparkling Toilets @ Yuhua" in which the grassroots and the community work with coffeeshop operators and cleaners to improve the hygiene and cleanliness of coffeeshop toilets.

     Cleaners also play an important role in the upkeeping and maintenance of public toilets. We therefore encourage toilet cleaners to undertake training and skills upgrading under the National Skills Recognition Scheme (NSRS), so that they can perform their tasks more efficiently and effectively. Outstanding toilet cleaners who show a high level of service performance and dedication to their jobs are also recognised through awards presented at the annual "Clean and Green" Week.

     NEA also partners the Restroom Association of Singapore (RAS) in implementing the Happy Toilet Programme to recognise the efforts put in by owners of public toilets in improving their cleanliness standards.  Participation in this rating programme is voluntary and we are very happy to see that some 400 toilets from commercial buildings, schools, hawker centres and petrol kiosks have participated in this programme which includes the design of toilets and not just the cleaning aspect, since its implementation in 2003.

     I would like to assure Members of the House that my Ministry is committed to sustaining a high standard of public cleanliness for the benefit of all. However, we need the cooperation of the community to do their part to keep our public areas clean as well, and not take clean public places and cleaners for granted. And I do agree with Mrs Josephine Teo that for a first-class city, you need not just have first-class cleaners but also, I would like to add, a first-class community with first-class toilet habits.

Dengue Prevention

     Dr Teo Ho Pin (Bukit Panjang): Sir, I would like the Ministry to continue to partner and co-fund the dedicated mosquito control programme with all Town Councils to prevent dengue outbreak.  Sir, dengue outbreak is a public health problem.  It is under the responsibility of the Ministry of the Environment and Water Resources.

    In 2005, there was a dengue outbreak in Singapore, and dengue fever cases went up to 14,209 cases.  In that year, NEA called for an all out war against the Aedes mosquitoes which cause dengue fever.  As such, NEA approached the Town Councils for help to fight the dengue outbreak.

  Sir, as responsible corporate citizens, the 14 PAP Town Councils agreed to allocate more resources to partner NEA in its fight against dengue. A series of dengue prevention and elimination efforts were implemented jointly by the NEA and 14 PAP Town Councils. These included carpet combing of more than 8,000 blocks of HDB flats, stepping up routine maintenance inspections and chemical control, appointment of pest control operators for the dedicated mosquito control programme, and the appointment of estate environmental officers.  The joint programme which amounted to $6.7 million was co-funded by the 14 PAP Town Councils and NEA.  

     Sir, the dengue prevention efforts of the 14 PAP Town Councils and NEA have brought the dengue situation under control.  In 2006, the number of cases dropped from 14,209 to 3,126.   Sir, although the dengue prevention programme is effective, the implementation of a dedicated mosquito control programme is costly, and imposes financial constraints on the Town Councils.  In 2006, the NEA decided not to co-fund this programme and, instead, set up an enforcement regime to penalise Town Councils if mosquito breeding grounds were found. 

   Sir, I feel that the NEA is unfair to the Town Councils, ie, to its partners. First, dengue outbreak is a public health issue which NEA must take responsibility to address.  Second, many mosquito breeding grounds are due to littering of receptacles by the general public.  Sir, littering comes under the purview of the NEA.  If NEA has been effective in educating the public and its enforcement action, there will be no litter for mosquitoes to breed.  Maybe NEA should organise a "Big Sweep Day" and better understand littering problem.  Third, the PAP Town Councils have acted in good faith of the partnership, and have already awarded the contract to the pest control operators amounting to $7.7 million.

   Sir, dengue prevention is a big task.  I hope the Ministry will not give the 14 PAP Town Councils a small mosquito fund to perform the task. The cost of the programme is $7.7 million.

     Mdm Cynthia Phua (Aljunied): Mr Chairman, Sir, I strongly support Dr Teo Ho Pin's call for dengue prevention and the share of the cost of Town Councils.  I would like to urge the Ministry to look into the cost as, presently, it is as high as $1 for one residential unit per month. And this is just to add 20 inspectors to comb through the Aljunied Estate within the cycle of seven days.

In addition, bolder efforts to make the community aware of the status of dengue outbreak cases and the call for community help are critical.

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     I give an example.  Just before the Lunar New Year, there was an outbreak of dengue cases in Defu Industrial Estate.  As advisor, I was informed and, together with merchant association members as well as our grassroots leaders, inspections were made.  However, we found that most of the drains were inside the premises.  The only way to inform the community at the industrial estate, ie, the workers, the tenants and the owners, is through big banners.  We flooded the estate with about 20 big 12 feet by 12 feet red banners stating, "Dengue Fever Red Alert" at minor and major road junctions, calling for cooperation to inspect their own premises.

     I am pleased to note that for the past 10 days, I have not received any SMS on any fresh dengue fever case.  For the reduction in dengue fever cases, the many-hands approach must be sought, and the community must readily be informed of the status of the dengue cases if there is an outbreak.

     The Aljunied Town Council will adopt the colour coded banners  -  white, orange and red  -  to indicate the level of dengue cases in our estates.  I would urge the NEA to do so rather than a small white banner that NEA officers are putting up.  In addition, can the Ministry let us know its key strategies in keeping the dengue fever at bay in Singapore?  Is the Ministry expecting a spike in dengue cases, as what had happened in 2005, over the next few years?  Is it a cycle or just a one-off situation?

Dengue Vector Control

     Dr Lim Wee Kiak: Mr Chairman, Sir, you can rest assured that I am not asking for more money for the Town Council, but I am asking for more money to support research in terms of dengue.

    Dengue will remain endemic in South East Asia for many years to come.  Much as we hope that it will go away, I do not think it will.  In 2005, we witnessed one of the largest outbreaks we had with over 14,000 cases.  Thanks to the efforts of all the agencies, including NEA, CDCs, Town Councils, grassroots volunteers, we overcame the problem and dengue cases decreased to 3,126 cases in 2006.

     However, we remain susceptible to dengue epidemics. There is a group of unsung heroes that I must say we have to acknowledge in this House.  These are the men and women who work in the Environmental Health Institute (EHI).  The EHI actually does research on vector as well as dengue virus, and maintains a very strict surveillance on mosquito population controls in various parts of the island.

     The EHI embarks on research on mosquito breeding habits as well as on the effectiveness of commercial insecticides or pesticides for mosquito control.  As a result, they actually recommend to the Town Council's pest control what are the insecticides or pesticides to use.

     We understand that for dengue, it is a cyclical thing.  In the 1980s, dengue actually hit Singapore once in a six-year cycle.  And there are various serotypes in terms of dengue.  There are four serotypes.  In 1992, it was serotype 3; in 1998, it was serotype 2; and in the recent 2005, it was serotype 1.  As a result, monitoring of serotype subtypes as well as monitoring of the shift itself may actually predict the risk of an epidemic early.

     I would like to compliment the efforts of the staff there who are working very hard as well as their dedication in our fight against dengue fever.  However, their efforts cannot be alone.  It is more useful for the EHI to work in collaboration with centres in our neighbouring countries now and provide us with a radar screen of the dengue subtypes, serotype shifts as well as the vector distribution in South East Asia, and that will provide us with an advance warning system of the change in viral serotypes before it actually hits our shores.

     I would like to ask the Minister what form of regional collaboration efforts have the EHI established and whether a cooperative agreement with our immediate neighbours is in the pipeline, so that we can actually better protect ourselves rather than just giving funds to Town Councils to help them.

Dengue

     Dr Lam Pin Min (Ang Mo Kio): Sir, the global burden of dengue has increased dramatically in  recent decades and is currently classified as a re-emerging infectious disease by the WHO.  Dengue is known to be endemic in approximately 100 countries with more than 2.5 billion people at risk.  The major disease burden is found in South East Asia and the Western Pacific with increasing reporting of the dengue infection in the Americas.

     Annually, it is estimated that about 50 to 100 million dengue infections occur world wide.  The number of cases reported in Singapore has recorded an all time high in 2005.  It was to be the worst dengue epidemic ever experienced in Singapore's history that eventually claimed 19 lives and resulted in over 12,000 cases by the time it tapered off in October 2005.

     The number of mortality and the prolonged down time from the illness may pose significant strain on the healthcare system, as evidenced by the postponement of many elective surgeries due to shortages of hospital beds during its peak in 2005.  Thus, it appears reasonable and paramount that dengue vaccine research and development should be a national as well as a global health priority.

     I would like to ask the Minister for the potential economic cost of this disease annually, as well as an update on his effort in tackling dengue infection in Singapore, and whether there are any plans to develop a dengue vaccine and to eradicate this disease from Singapore totally, just like we had eradicated malaria and poliomyelitis.

Smoking Ban

     Mr Charles Chong: Sir, the smoking ban was extended to coffee shops and hawker centres last year.  However, such establishment can still have designated smoking areas.  Could the Minister provide an update on the enforcement of this new regulation?  Are there sufficient officers deployed to enforce the ban?  Are all the designated smoking areas suitable locations, such that non-smokers are not required to inhale second-hand smoke?

     The Parliamentary Secretary to the Minister for National Development (Dr Mohamad Maliki Bin Osman): Sir, the effects of smoking, whether one is an active or passive smoker, have been well documented and articulated.  We have taken very proactive measures in protecting the non-smoking public who are often at risk as passive smokers.

     The ban on smoking in public places has been in place for several months now.  However, since the ban took effect, we have seen reports or public complaints that the ban has not been well enforced, especially at coffee shop spaces in public housing estates.  I would like to ask the Minister on his assessment of how well the ban has been enforced, and what further measures the Ministry will take to ensure that the intent of the ban is achieved.

     MEWR has also announced that the ban will be extended to pubs with effect from 1st July 2007.  This comes as a surprise to many clubbers who see smoking as synonymous to pubs and nightlife.  I would like to ask the Minister what is the effectiveness of the current programme of banning smoking in public places.  Are we seeing a reduction in the number of smokers, especially new smokers?

     Sir, I would also like to ask the Minister whether his Ministry conducts systematic evaluation research on the profile of smokers who are not adhering to the smoking ban in such public places, to enable a more targeted approach at reaching out to these smokers.

     In relation to the new ban in pubs, I would like to ask the Minister whether this move would affect the nightlife scene as well as Singapore as a tourist destination.  How does Singapore compare with other major cities in the world with regard to such ban?  Can the Minister also elaborate on what are the key performance indicators of the smoking ban initiative?  Does his Ministry have a target on the proportion of smoke-free space that we would like to see Singapore have and, if so, to be reached by when?

     Lastly, we have seen gory pictures of the effects of smoking on cigarette packets for smokers.  Can we have a public education campaign on the effects of passive smoking?  Because I think only then will the public be more appreciative of the need for such smoking ban in public places.

     Mr Liang Eng Hwa: Sir, the smoking ban in entertainment outlets will soon come into effect on 1st July this year.  I support this ban and applaud the Ministry for stepping on with the tough measures to protect the well-being of non-smokers.  I would like to ask the Ministry how it intends to enforce the ban  -  whether it is going to be the same light approach that we have seen so far for the smoking ban in public areas.  Are the entertainment outlets ready and prepared for this ban, and would there be any impact on our tourism business?

     Secondly, may I suggest to the Ministry to consider extending smoking ban to public areas that are near facilities used by children such as kindergartens and playgrounds?

     Thirdly, I see a disturbing trend of increasing numbers of young smokers seen in public areas along Orchard Road, in our neighbourhood shopping malls and so on.  Does the Ministry have an estimated number of smokers by the various age group and the profile of a typical offender caught for smoking in non-smoking areas?

     I would like to suggest that the Ministry be more targeted in the enforcement of the ban with higher emphasis in locations more frequented by the young, eg, near campuses, recreational areas and sports facilities.

     Lastly, would the Ministry consider banning smoking in all public areas, like what Hong Kong and France have done?

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, I will update first on the smoking ban.  Mr Charles Chong, Mr Liang Eng Hwa and Dr Maliki have asked about the effectiveness of the smoking ban.  To protect the general public against the harmful effects of second-hand tobacco smoke, we extended the smoking ban to coffee shops and hawker centres in July last year and, as rightly noted, we will be extending it to entertainment outlets on 1st July this year.

     We are happy to see that most of the food shop operators and smokers abide by the ban.  There, however, remains a small minority of smokers who flout the ban, and some operators who fail to enforce the ban within their premises.  We take a serious
view of such violations.  Since the implementation of the ban in July last year, 1,057 smokers and 205 food shop operators have been fined for infringing the rules under the smoking ban.

     NEA will continue to carry out enforcement action through its environmental health officers and through a private operator whom it has engaged to supplement its enforcement efforts.

     For the impending smoking ban on entertainment outlets this year, operators have a lead time of two years to prepare for the ban.  So it is not a surprise, as noted by Dr Maliki.  NEA has also been liaising closely with the operators to help prepare them for smooth implementation of the ban. We do not think that the smoking ban in entertainment outlets will impede Singapore’s effort to become a tourist destination.

     Indeed, Singapore was one of the first few countries to ban smoking in public places.  Many countries and cities have since recognised that second-hand smoke is a serious health hazard, and are moving quickly towards becoming smoke-free societies,
banning smoking in pubs, bars, restaurants and other workplaces.  Even the French are moving in that direction.

     Over the years, we have successfully extended the smoking ban to cover more than 30 types of premises and public places. This is achieved through cooperation from businesses and members of the public, especially from the premises owners and trade operators. The smoking ban regime gives due consideration to the need to balance the interests of non-smokers, smokers and
businesses.

     Sir, over the years, the ban has also helped bring down the proportion of smokers in the population.  The prevalence of daily
cigarette smoking among adults declined from 18% in 1992 to 15% in 1998, and further dropped to less than 13% in 2004.

     Dr Maliki asked whether we have a target.  Yes, we wish all Singaporeans to be non-smokers.  But let us be realistic.  I think we will have to continue to find ways to provide places for people who want to smoke without compromising the health of non-smokers.

     We will continue to monitor the effectiveness of the smoking ban before we decide whether to further tighten the ban and to
extend it to more public areas.  The Government will continue to do what is necessary to protect the public from the harmful effect of second-hand tobacco smoke.

     Sir, Mr Liang Eng Hwa has asked for some details on the data.  I do not have it with me here, but I will be more than happy to provide this after the debate.

     I will now leave it to my colleague, Dr Amy Khor, to take the more biting cuts on dengue.

     Dr Amy Khor Lean Suan: Sir, through the combined efforts of grassroots, volunteers, residents, Town Councils, CDCs and other stakeholders, we have succeeded in keeping dengue fever under control.  Here, I would like to reiterate again - if it is still not clear from Dr Teo Ho Pin's earlier comments - the good work of the Town Councils in helping us in the fight against dengue.

     In 2006, there were slightly more than 3,000 dengue cases in Singapore, significantly lower than the 14,209 cases for 2005, or about one-fifth of the cases for 2005, and the lowest since 2002.  This is despite a continued rise and spread of dengue cases in the region.  WHO has also reported an increasing trend in dengue incidence worldwide, from about 293,000 per year in 1980-1989, to about 780,000 per year in 2000-2005.

     Currently, there is no vaccine against the virus.  So it would be difficult for us to totally eradicate dengue from Singapore or the region.  What we have done is to put in place a rigorous dengue control regime to maintain a low incidence of dengue and to minimise the likelihood and impact of dengue outbreaks.  We do this through a four-pronged approach of surveillance checks, public outreach, enforcement and research.

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     Since the dengue outbreak in 2005, NEA has doubled the number of vector control officers to 500.  These officers carry out regular surveillance checks islandwide to systematically uncover and destroy mosquito breeding habitats - search and destroy.  Through an Inter-Agency Dengue Task Force, NEA also leads other Government agencies to similarly enhance their mosquito control programmes so as to remove all possible mosquito breeding sites.

    On top of regular surveillance checks, NEA and the other land agencies carry out additional combing checks or "intensive source reduction exercises" (ISREs) to further suppress the mosquito population ahead of anticipated warm months.  Two successful ISREs were carried out in April to May and in July to September last year.  They pre-empted the increase in dengue cases that traditionally happened during the warmer months of June to September.  NEA will be carrying out similar exercises this year.  My Ministry greatly appreciates the commitment and ownership shown by the various land agencies towards this collective effort.

     As more than 80% of our population stay in HDB flats, strict mosquito control in HDB estates is very important.  Town Councils, which are responsible for the general upkeep and maintenance of the HDB housing estates, have the responsibility to keep mosquito breeding at bay within the common areas under their purview.

     Since September 2005, NEA has helped the Town Councils put in place dedicated mosquito control programmes in their estates by providing technical advice and seed funding to kick-start these programmes.  Results have been very encouraging.  Aedes breeding in TC-maintained areas for 2006 has reduced by 60% compared to 2005, despite 30% more inspections carried out by NEA in the same period.  The number of dengue cases for 2006 in estates maintained by Town Councils is also 83% lower than in 2005.  Dr Teo Ho Pin and Mdm Cynthia Phua have asked whether my Ministry will provide funding to Town Councils for their dengue prevention programmes. 

     The good efforts put in by the Town Councils on mosquito control in their estates have contributed significantly to our ability to continue to suppress mosquito population.  We hope that the Town Councils will continue to keep up the good work.  I am therefore pleased to inform the House that my Ministry is introducing an incentive scheme for Town Councils to recognise Town Councils for their efforts in mosquito control and to spur them to further reduce mosquito breeding in their estates to even lower levels.  The scheme will provide some co-funding of Town Councils' mosquito control contracts, taking into consideration their performance in minimising the number of mosquito breeding sites.  My Ministry will offer this scheme to Town Councils for a period of two years to facilitate Town Councils to further develop their capacity and enhance their expertise in mosquito control. 

     To engage the community in our fight against dengue, NEA makes use of both multi-media advertising ("broadcast") and target-group outreach  programmes.  We also work with grassroots to notify residents to be vigilant when a cluster of dengue cases occur in their neighbourhood, eg, through dengue alert banners, such as those referred by Mdm Cynthia Phua.  I would like to clarify at this juncture that these banners can be customised according to how the grassroots feel the information can be better communicated, whether it is in terms of larger size, larger fonts or more colourful banners.  We have seen encouraging results through these efforts.  The number of breeding found in homes in 2006 is 44% lower than in 2005, despite 59% more inspections by NEA in 2006. 

     A survey in 2006 has shown that the level of awareness for dengue among the general public is high.  NEA will continue to improve its public outreach efforts to bring about greater awareness and to make the practice of keeping homes mosquito-free a way of life among members of our community. 

     In 2006, NEA had taken enforcement actions against 617 construction sites, 2,173 domestic premises and 1,525 non-domestic premises, such as factories and shophouses, for mosquito breeding offences.  NEA will continue with its regular audit checks and will take enforcement action against members of the public, land agencies alike, including Town Councils, for mosquito breeding offences.

     We recognise that research into the behaviour of the Aedes mosquito and dengue virus is key in formulating appropriate, preventive and control strategies, as alluded to by Dr Lim Wee Kiak.  The Environmental Health Institute (EHI) under the NEA was therefore established in 2002 to develop capability in vector research.

     EHI has successfully piloted the use of  ovitraps to monitor the level of mosquito activities in dengue-prone areas.  Our researchers have also developed an in-house test that allows earlier detection of dengue cases and determination of the infecting serotype.  Early detection of dengue cases will enable control measures to be put in place quickly, to curb further spread of the disease among the population.  The test has been made available to hospitals and GPs.

     EHI also actively collaborates with partners in both the private and public sectors in its research efforts.    For instance, EHI invites GPs in the vicinity of dengue clusters to send blood samples of suspected dengue patients to EHI for testing and confirmation of dengue.  This helps improve the detection of new cases and determines the dengue serotype.  Monitoring the virus serotype of dengue cases is important as the emergence of a different dengue serotype can result in a surge of dengue cases amongst the population without immunity to the serotype. 

    Singapore remains at risk, as we are located in a region endemic to dengue.  As pointed out by Dr Lim, what we can and should do further is to contribute towards enhancing the region's overall capability in understanding and tackling the dengue problem.  We can do so through promoting greater exchange of information, knowledge and expertise among countries in the region. 

     I am pleased to inform the House that Singapore's approach to dealing with dengue, focusing on vector control, has been held up by the World Health Organisation as an example for others.  Singapore supports the Strategic Framework for Asia-Pacific Dengue Partnership that the WHO is putting in place to help countries in the Asia-Pacific region build national capacity to prevent and control the disease.  Singapore will continue to contribute to the partnership effort by sharing our experience in dengue prevention, to help other WHO member countries in the region fight against the disease.  This includes partnering the WHO to provide training in vector control practices and sharing our knowledge in laboratory-based dengue surveillance.  Through these efforts, Singapore aims to become the regional centre of excellence for dengue research.

     Dr Lam Pin Min has asked about the potential economic cost of dengue to Singapore.  Without a doubt, dengue, if left unchecked, can impose tremendous economic burden on our country, although thus far there has not been any comprehensive study on the economic cause of dengue to a nation. 

     In conclusion, I would like to urge every member of the community to play their part to keep dengue at bay, for dengue control is the shared responsibility of every member of the community.

Water for All

     Dr Muhammad Faishal Ibrahim (Marine Parade): Sir, I would like to applaud the Ministry of the Environment and Water Resources on the recent launch of the ABC Water Programme.  I am excited and am looking forward to the transformation of Singapore's hydro-landscape to be integrated into our heartlands and HDB estates.  This would also be aligned to the Prime Minister's call to remake Singapore into a vibrant global city of gardens and waters. 

     I have met many Singaporeans who are equally pleased about this programme and they certainly look forward towards its realisation.  As such, as a citizen, I would like to call upon all Singaporeans from all walks of life to support and take ownership of the ABC Water Programme.  May I ask the Minister on how the programme would enhance the quality of life of Singaporeans from the various segments of the society.  I would also like to ask the Minister on the measures that are in place to discourage people from littering and polluting the water bodies in Singapore and how successful has been these measures. What other measures are being planned to reach out to Singaporeans to keep our reservoirs, canals and rivers clean, and realise the objectives of the ABC Water Programme?

Active, Beautiful and Clean (ABC) Waters Programme

     Dr Lim Wee Kiak: Mr Chairman, Sir, I am equally excited as our hon. Member, Dr Faishal, on hearing about the Active, Beautiful and Clean Water Programme by the Ministry, but, at the same time, I am also deeply concerned.  Finally, our children can enjoy what we did 30 years ago - playing and fishing in the streams and the ponds.  The programme will render our waterways as well as water bodies functional again and provide more water-based recreational activities.  Opening up our waterways will also enhance our environment.  The blue will certainly complement the green. 

     I have a short story to tell.  My best friend was an Indian boy by the name of Raja.  I used to go out with him to fish, especially during the December holidays.  That was from Primary One to Primary Four and I remember, in 1978, we went fishing just before Christmas at a pond and we had great times together.  When school reopened in January 1979, he did not turn up for class.  I was very sad on the first day of school to hear from my teacher that Raja attended a Christmas party and on the way back, there was a huge thunderstorm and he fell into a stream, and his body was found three days later, on his birthday.  That was December 1978, and that particular December recorded the highest rainfall compared to the one that we just had recently. 

    According to the Life Saving Society Annual Report  2005, there were 39 deaths by drowning in 2005, and the breakdown of cases was as follows: two in reservoirs; two in canals; three in rivers; 20 by the sea or by the shore; and three in swimming pools, and nine unspecified because they died in hospital, but they were classified as drowning.

     Opening up our waterways and water bodies will certainly enhance our living environment, but, at the same time, it will also increase the risk of water-related mishaps.  I do not wish to see more losing their best friends through drowning.  I do certainly hope that the Ministry will place more emphasis on ensuring public safety as we embark on this very exciting ABC programme. 

      Mr Chairman, I am also deeply concerned about the safety of our water.  I would like to ask the Minister what safety measures are in place today to ensure water safety at the inland water bodies.  Will the Ministry step up these safety measures or introduce more safety measures in the near future as we roll out the ABC Waters Programme?  At the same time, what measures are in place to ensure the safety of our precious inland water resources from contamination, both intentional, ie, act of terrorism, as well as unintentional, due to over-recreational use of our activities?

Water Policy

     Mdm Cynthia Phua: Mr Chairman, Sir, this plan to open up our water bodies is a brilliant move as this allows another of our limited resources to be used creatively and to enhance our living environment and living standards.

     I would like to congratulate PUB for the introduction of the ABC Waters Programme.  While work is being done to allow accessibility to our water bodies,  education and awareness programmes must step up to teach our children and adults alike, to keep our water bodies clean while using them. 

     We must step up the ownership programme and allow our children to be protective over our environment.  We must encourage each citizen to stand up and take on the responsibility that these water bodies belong to each and every one of us living in this beautiful island, and if anyone litters and causes harm to our water bodies, we must speak up.  However, it is always very delicate to deliver  this message directly to the culprit.  Efforts must be made to teach our children this responsibility and the approach.  Once our children are able to understand and take on these roles, I am convinced that our adults will not want to be left behind. 

     My main concern is the timing.  Once the water bodies are opened up and the people and the water relationships have not been built up and become "steady lovers", then there will definitely be additional cost to be borne by the citizens to realise this programme.  Bold and collaborative efforts must be made to ensure that our water bodies are always clean and beautiful.

     Despite the four taps, our water resources continue to be limited.  Will the Ministry ensure that we will continue to have sufficient water at an affordable price to meet the demands of our people,

industries and businesses?  What is the state of protection level of our two new sources of supply, that is, the NEWater and also the desalinated water?  Presently, our water tariff does not encourage large families as the tariff is higher for those consuming 41 cubic metres and above per month.  Although this works to encourage conservation of water and minimise wastage, large families require this additional amount of water out of  necessity.  My question then is whether the Ministry plans to review the current tariff rate to accommodate the needs of large families.

1.30 pm

     NEWater is one wonder as a result of research and development. There are many new technologies developing on the use of technology and in the management of our environment that we invest in, for example, the use of solar energy.

     Singapore is a sunny island.  However, the application of solar energy is minimum. The other area is in the management of waste, for example, food waste.  Presently, the disposal of food waste is very unhygienic in our markets and hawker centres.  One final area of concern is that the airconditioned environment in our buildings is too cold.  What is the Ministry's strategy on R&D on the use of energy and environmental management?  Are more resources being put into this area?  Is there any promising collaboration or emerging trend in this area?

     Mr Masagos Zulkifli B M M: Sir, I congratulate the Ministry for developing a comprehensive and sound water strategy for Singapore.  The four taps strategy, namely, the local catchment, imported water, desalinated water and reclaimed water, has put us on the map as a country and a city that many others are studying in managing potable water management.  More so because Singapore itself has no natural rivers or lakes to tap on.  In fact, it is no easy challenge to store all this water and yet balance the need to keep our urban habitat as flood-free as possible during storms.

      My questions for the Ministry are:  is the projected volume of imported and reclaimed or processed water sufficient over the future horizon and consistent with and sustainable to a city planned for 6.5 million people with all its drinking and hygiene needs as well as supporting industry and economic activity?  How are we, in terms of water usage or consumption per capita, when compared to other urban areas in the world of comparable affluence and does this reflect a consciousness of water as a valuable resource? How prevalent is the use of water-saving devices in our taps at home and in the offices?  Will the Ministry consider water-efficiency rating labels for appliances like washing machine and dish washing machine?

Water Pricing

     Mr Charles Chong: Sir, the issue of water is one that is very important to Singapore.  If we were to rely solely on local catchment sources, we would not have enough water to satisfy the demands of homes and industries.  So to encourage Singaporeans to conserve water, we have a well-established system of staggered pricing as well as a water conservation tax. 

     In recent years, we have developed NEWater and have undertaken investments to provide long-term sustainable solutions to our water needs, such as new reservoir schemes and the deep tunnel sewerage system.  Could the Minister please explain if these developments would have an impact on the way we manage the demand for water through pricing?  Is there a need to review the pricing policy that was formulated under different circumstances?

Flood Prevention and Control

     Ms Lee Bee Wah (Ang Mo Kio): Sir, I would like to raise the problem of heavy flooding during the recent monsoon season.  As a result of the flood, traffic had to be diverted and it resulted in congestion.  So everyone, from workers to school-going children, was affected.  After the flood occurred, the Ministry went into action, but it was a case of too little, too late.  Businesses suffered losses but, fortunately, no life was lost. 

     Then we started to talk about the flood meters that have been put in place, waiting to warn residents and shopkeepers of the rising water level.  But apparently, it did not work when the flood hit the nurseries at Thomson Road.  We certainly need to be more proactive and not reactive.  The flood left a lot of question marks.  What was the economic loss? Is our current drainage system sufficient?  Any research done to look for better alternatives for monitoring flood?  Can we prevent the flood in a more efficient manner and reduce damage to a minimum?

     As I understand it, the PUB is already putting their flood alleviation projects on a fast track.  My question is: why only now on fast track? Besides this, are there any other measures that the Ministry is taking to prevent similar flood from occurring?  I can only stress that these works be done faster and research on improvement of flood meters and other necessary equipment be emphasised on.

Water Tanks

     Mr Ang Mong Seng (Hong Kah) (In Mandarin ): [For vernacular speech, please refer to Appendix A*.]  Mr Speaker, Sir, currently, water tanks are installed on the building's rooftop for all existing buildings exceeding five storeys in Singapore.  It serves the purpose of supplying water to residents for major water uses.  On a recent trip to Dalian, China, involving a real estate development project, I discovered that China has abolished the installation of rooftop water tanks.  Instead, they have water pipes to channel water to each individual household up to 18-storeys.  Such a system is currently not available in Singapore.  With science and technology advancing so quickly, I would like to ask the Minister whether it is possible to consider abolishing the rooftop water tank system in Singapore.

     The cost benefits of abolishing rooftop water tanks are clear: lower construction costs and a simplified water-pipe system.  Most importantly, it is for the prevention of terrorist attacks.  The greatest security threat that the world faces today is terrorism.  Terrorism is anywhere and everywhere.  Currently, as a precautionary measure, the Town Councils have installed quality security locks at the rooftop water tanks, to ensure that supply of water is kept safe.  As we do not want to take any chances, even one in a million chance is unacceptable, it is thus important that we safeguard our water tanks to prevent possible water contamination from terrorist attacks.

     In this regard, I would like to ask the Minister whether the Ministry of the Environment and Water Resources has any precautionary and preventive measures to safeguard all our water tanks, so as to ensure that our water supply is safe and clean.

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, I would like to thank all Members who raised a very important issue for all Singaporeans, which is water.  First, Mr Masagos and Mdm Cynthia Phua have asked about the measures to ensure that we have sufficient water to meet our needs, and this is also a point raised by Mr Charles Chong in his opening speech.

    As the national water agency, PUB manages Singapore’s water resources in an integrated and holistic manner. Besides curbing water demand through water conservation practices, PUB manages the entire water loop by optimising our precious and limited resources to produce, treat, supply and recycle water to meet Singapore’s needs.

     With the introduction of desalinated water in September 2005 as one of the pillars of Singapore’s water supply, the Four National Taps strategy is now in place. This will ensure a diversified and sustainable supply of water for Singapore.

     Local water catchment is one of the Four National Taps, and PUB has been optimising our resources to increase the amount of water we can tap locally. We now have 14 reservoirs. Work on the Marina Reservoir is progressing very well. We have also started the construction of another two new reservoirs at Punggol and Serangoon last September. We will have 17 reservoirs when the three new reservoirs are completed in 2009. They will store water collected from our water catchments which forms two-thirds of Singapore’s land.

     A scheme to link a few of our reservoirs is also in progress. This will allow excess rainfall collected from one catchment to be transferred to a larger reservoir for storage, thus optimising the yield from our reservoirs.

     NEWater is another source and has been growing from strength to strength. Currently, it meets about 7% of Singapore’s water demand. It is well subscribed by industries which need ultra-clean water. To cope with growing demand, we will expand the production capacity of two of the three NEWater factories, mainly at Bedok and Kranji. Our fourth and largest NEWater factory at Ulu Pandan will be opened on 15th March 2007 by our Prime Minister.  With a capacity of 32 million gallons per day (mgd), it will boost our local water supply.

     The SingSpring desalination plant is operating successfully and has become a model for seawater reverse osmosis plants, attracting overseas attention and many international visitors. So to answer the questions raised by Mr Charles Chong and Mr Masagos, we would endeavour to develop as many water resources as possible to meet the demands of Singapore in the coming years.

     Sir, the Deep Tunnel Sewerage System (DTSS) is our long-term solution to meet Singapore’s needs for used water collection, treatment and disposal. The DTSS is on track for completion next year, and will act as a superhighway for channelling used water to a centralised water reclamation plant at Changi. I am pleased to announce that the deep tunnels, the influent pumping station and the outfalls of the DTSS have been completed. The remaining major works, including the link-sewers, have also been substantially completed.

     Sir, our efforts to diversify and develop our water resources will serve us well. During the last El Nino season in 1997, we relied on water from our local catchments and imported water which were dependent on rainfall. Today, we have NEWater and desalinated water, which are not affected by fluctuations in rainfall. This puts us in a stronger position to meet future challenges of potential extreme weather that might result in some drought conditions.

     While we may have enough water, this is only sustainable if we use water wisely. We must proactively manage our water demand and encourage water conservation.

     My Ministry recognises the importance of individual efforts at water conservation. Last year, we set a bold target of reducing our daily per capita domestic water consumption to 155 litres by 2012. We launched the 10-Litre Challenge to encourage each and every individual to reduce their daily water consumption by 10 litres. To recap, the initiatives under the 10-Litre Challenge included:  (a) nurturing of Water Volunteer Groups; (b) launching of the 10-Litre Challenge website; and (c) introduction of the water efficiency labelling scheme (WELS), which Mr Masagos alluded to. Let me give an update on these initiatives.

     Sir, the Water Volunteer Groups (WVG) initiative was launched in March last year to educate and spread water conservation messages to the public. The volunteers come from the People’s Association, the Community Development Councils (CDCs), grassroots organisations and even educational institutions. The initiative has received good support. To date, we have 54 WVGs in 32 constituencies with 2,090 volunteers, including 600 students. The WVGs have so far visited 4,100 households.

     Another initiative is the 10-Litre Challenge website, aimed at raising awareness and showing how everyone can play a part by reducing their water consumption by 10 litres per day. To date, 80,000 visitors have visited the website.

     Sir, in October last year, we launched the voluntary Water Efficiency Labelling Scheme (WELS). By providing information on the water efficiency of products, such as shower heads and washing machines, we hope to help consumers make well-informed purchasing decisions. So far, the scheme is voluntary and 150 models of water products have been certified under this scheme. PUB will monitor the response to the scheme before deciding whether to make it mandatory.

     I am pleased to note that our series of water conservation initiatives has resulted in a reduction of our per capita domestic consumption from 160 litres a day in 2005 to 158 litres a day in 2006. So we are on track.

     Sir, apart from our community efforts to promote good water habits and the use of water-efficient devices, Mr Charles Chong has rightly pointed out that pricing is also an important leverage in managing our water demand. So far, we have been pricing water to reflect its scarcity and the high incremental costs of additional water supplies. The Water Conservation Tax (WCT) is charged to encourage prudent use of water. As water remains a precious resource to us, the WCT remains relevant.

     With the development of NEWater, we have now closed the water loop by channelling and treating used water for consumption purposes. Currently, we price potable water and used water separately. As potable water and used water are now part of the same water loop, it is timely for us to view both as a single product. We will therefore consider moving towards charging a single price, as this better reflects the holistic manner in which we manage our water resources.

     We have also received feedback that the Sanitary Appliance Fee (SAF) is confusing, since having more sanitary appliances may not result in more used water being discharged. Charging on the basis of volume of water used will thus be more equitable. Currently, used water fees have two components, comprising the SAF and Waterborne Fee (WBF). We will look into restructuring the SAF and WBF into a single volumetric fee. This ties in with our idea of charging a single price for both potable water and used water.

1.45 pm

     Sir, Mdm Cynthia Phua has commented that our current water tariff does not encourage large families.  I would like to assure her that this is certainly not the intention of our water-pricing policy.  The domestic water tariff has a two-tier structure, with the threshold between the two tiers set at 40 cubic metres per month.  A higher price is charged for the second tier to discourage excessive use.  Based on our current average per capita consumption of 158 litres per day, 40 cubic metres would be sufficient for large families of up to eight persons.  The majority of households in Singapore consume less than 40 cubic metres monthly.  Hence, we find that the 40 cubic metres is a reasonable threshold, beyond which a higher tariff applies in order to encourage water conservation.

     Sir, an important aspect of our pricing reviews has always been the impact on users.  We will, therefore, study carefully the effect of pricing changes to the water bills of all household types, including those with large families.  We will strive to minimise the impact on households such that, on average, water users will not be worse off with the revised price structure.  We are working towards introducing this revised pricing structure in 2008 and will announce the details nearer to the implementation date.

     Sir, Ms Lee Bee Wah has asked what measures would be taken to prevent the future occurrence of floods.  I am not comfortable with her phrase "too little too late".  Over the past 30 years, we have invested $2 billion in our drainage infrastructure.  We have reduced flood-prone areas from more than 3,000 hectares in the 1970s to only 127 hectares today.  The flood on 19th December 2006, if you see it positively, was a good test of the efficacy of our drainage system.  Despite receiving the third highest rainfall in 75 years on that day, the majority of the drainage system held up well, with some flooding in isolated pockets of Singapore.

     PUB has an ongoing drainage improvement programme to reduce flood-prone areas from 127 hectares to 66 hectares by 2011.  So the programme was not put in place after the flood but has always been in place.  As it appears that we could see more instances of extreme weather, and this is the part where it is very difficult for us to predict, we have decided that the PUB will accelerate the drainage improvement programme.  These will be completed within the next three years instead of five years as originally planned, at a total cost of about $175 million.

     Sir, in addition to flood alleviation measures, we will also strengthen our early warning systems and procedures, which I agree with Ms Lee Bee Wah, to alert residents of impending floods and motorists of flood-affected areas.  PUB will work with LTA and the Traffic Police to warn motorists of areas to avoid ahead of and during heavy rainfall through radio broadcasts and lighted signages.  It is not possible for us to predict where the next localised flooding will occur.  But we have studied the whole of Singapore and identified the potential areas and we are working aggressively to improve those areas.

     Every occurrence of extreme weather is a test of our drainage system and the flood alleviation measures that PUB has put in place.  In general, they have worked well.  At places where they have not, and we admit, PUB will investigate and implement long-term measures, as we have done last year in Bedok North and the Commonwealth Road areas and, recently, in the Joan Road areas.  While the long-term measures are underway, PUB will also put in place interim measures.  The aim is to minimise and prevent recurrence in the same location.

     Sir, let me now move on to the ABC Waters Programme.  Dr Muhd Faishal, Mdm Cynthia Phua, and even Dr Lim alluded to it, have asked how the ABC Waters Programme will contribute to improving our quality of life.  The ABC Waters Programme will make Singapore into a city of Gardens and Waters, with water as a pervasive and welcome feature in Singapore's landscape.  Our drains and canals will be transformed into beautiful flowing streams and rivers leading to our reservoirs.  Our ongoing reservoir schemes to dam up our rivers at Marina, Punggol and Serangoon will tie in nicely with the ABC Waters Programme, by keeping the water level in these rivers at a constant level, instead of being subject to tidal influences.  This allows us to have constant flowing streams and rivers, which we can beautify and bring into our living environments, including our HDB heartlands, condominiums and schools.

     ABC Waters will also bring opportunities for water activities and create new community and  recreational spaces for the public's enjoyment.  With the Programme, we will be able to enjoy waterfront living in the heartlands and an improved quality of life.  Imagine if you are living in Bishan now.  The huge canal which is empty most of the time there will be transformed into a beautiful flowing river, with landscaped banks and rivulets running inland where children can play in.  These features and more will be incorporated at other estates, all aimed at getting people closer to water, a point noted so aptly by Mdm Cynthia Phua as "steady lovers".  As shown in the recent ABC Waters Exhibition, 28 such projects will be carried out over the next five years.  But to have clean water flowing continuously requires the concerted efforts of the Government and the public.  The Government will do its part through good land use planning and by curbing litter and silt discharge into our waterways.  This is important, as raw water collected in our catchments is one of the four sources of Singapore's water supply.

     Our Marina Reservoir will be unique among all reservoirs in Singapore and around the world as it collects urban run-off from the highly built-up and densely populated city centre.  Drinking water quality is not a concern as these contaminants can be removed by membrane technology in the water treatment process.  However, the challenge is in ensuring that the aesthetic and recreational quality of the Marina Reservoir would not be adversely affected.  PUB is putting in place a holistic strategy that includes both prevention of pollution at source and downstream measures.  For example, to restore ageing public sewers, PUB spent about $270 million in the last 10 years and will further invest another $150 million to restore the public sewers within the Marina catchment over the next few years.  This is to ensure that leaky sewers do not cause pollution to the raw water collected in our drains and canals.

     In addition, PUB has also installed float-booms and drain coverings to reduce the daily load of litter and flotsam.  Through a dedicated catchment surveillance team, PUB hopes to intensify checks on catchments and waterways and, at the same time, educate the public, industries and construction sites on proper housekeeping and pollution-control practices.

     Sir, while our reservoirs and waterways have been opened up for more recreational activities, PUB will ensure that these activities are eco-friendly and non-pollutive.  Water is a shared resource that we all need to protect and cherish.  All of us have a stake in keeping our waterways and reservoirs clean.  By having ABC Waters throughout Singapore, we hope to bring water closer to everyone, so that we can all bond with it, develop a better appreciation of it and be committed to keeping it clean.  It is like a marriage, Sir.  I urge each and every one of us to play our part by not littering and not allowing dirty or silty water from getting into the drains, so that we can have clean and beautiful waterscapes in the vicinity of our homes, schools and work places.  Let us work together to turn Singapore into a “City of Gardens and Water” that we can all live, work and play in.

     I am sorry to hear about the loss of your childhood friend, Dr Lim, and I share your concern about water safety.  Dr Lim pointed out that while we encourage more activities within or near our waterbodies, these should be carried out safely, and we cannot agree more with him.  All our ABC Waters projects are designed with public safety as our foremost concern.  For example, metal railings can be replaced by earth mounds, boulders or shrubs to form a natural barrier along the river bank.  Play features will be in areas away from the main streams, with shallow waters for children to play safely in.

     At all reservoirs and selected waterways where there are water activities, existing safety measures will continue to apply.  For example, if you go to MacRitchie, you want to kayak there, you must wear a life vest.  Buoys are used to demarcate areas where the water activities can be carried out.  The Singapore Canoe Federation and People’s Association operate water activities centres at MacRitchie Reservoir, Bedok Reservoir and Jurong Lake with full-time staff to supervise the activities.  During bad weather, all water activities are suspended.

     Sir, these existing safety measures have worked well and there have been no drowning incidents since PUB started actively promoting water activities at selected reservoirs in October 2004.  While we have put in place safety measures, I would like to encourage everyone to exercise individual responsibility and good sense when having fun in the waters.  For example, parents should educate their children on how to play in the water safely.  Water users should stay within the demarcated zones and approved activities, and they should avoid any actions that could put themselves or others at risk.

     Mdm Cynthia Phua has raised some questions on alternative energy.  I will address these later.  Let me now turn to the final point by Mr Ang Mong Seng on whether we can review the requirement to install water tanks in HDB blocks.

     Sir, in Singapore, treated water is distributed mainly by gravity from service reservoirs to various parts of the island through an extensive pipe network.  Service reservoirs are large storage tanks sited on high ground to maintain sufficient water pressure in our system.  As Singapore is generally flat, our service reservoirs are not sufficiently elevated for water to be supplied directly to highrise buildings.  Hence, water tanks at the top of these buildings are necessary.  This method of supplying water is an engineering practice adopted by other countries, as it is energy-efficient and cost-effective.  It would be costly to supply water directly to high-rise buildings without water tanks, as this requires PUB to increase the water pressure by having additional pumping stations throughout the island to bring water up to the highest floors. 

     Besides the high cost of pumping, maintaining a high pressure in our system will put additional strain on the pipe network and increase the likelihood of leaks.  Though proper maintenance and security of such tanks are required, the water tanks help to ensure continuity and reliability of water supply to the premises, especially in the event of power or pumping system failure.  For example, during the Nicoll Highway incident, the water tanks in the high-rise buildings in the vicinity provided continuity of supply even though our water mains were affected.

Quality of Living Environment

     Mdm Ho Geok Choo (West Coast): Sir, MEWR's and Town Councils' efforts have contributed in no small way to making Singapore one of the cleanest cities in the world and, in time, a green and blue scenic spot and a quality of living that many in the region envy. 

     In the spirit of continuous improvement, allow me to raise a few other environment related issues.

     On noise pollution, Sir, with an increase in en bloc acquisition, including SERS and replacement with new buildings, retrofitting of old buildings, conversion of bigger flats to smaller ones, there will be increasing construction activities.  Especially for those projects close to housing estates, we are receiving complaints from residents of increased noise pollution.  I do believe that MEWR has a certain threshold for noise emission and that this level can be monitored.  Beyond this level, what is MEWR doing to manage the noise level?

     I note that noise pollution or its management does not appear on the agenda of briefings for members on the GPC for Environment.  It also does not appear in the Environment Report 2005, the latest copy which I have.  Is the Ministry serious about managing noise pollution?

     Although the Minister has answered on the haze question, the haze still continues to plague us because it affects our quality of living.  The question is: are there more specific forms of assistance to our neighbour?  It is good to provide support to combat the problem, but what are we doing to prevent the haze from occurring in the first place?  Since haze is caused by land clearing for economic activities, can we consider some form of economic assistance as an incentive, eg, grants for clearing land without burning, fertilisers, and even health grants to address respiratory problems of Indonesians affected by haze? 

     Sir, I also wish to ask, considering the state of bilateral relations with Indonesia today, what further challenges does the Minister anticipate in working with his Indonesian counterpart in combating the haze problem this year at the local level? 

     The next issue is on climate change.  My next question to MEWR is that further to the Inter-governmental Panel on Climate Change, it has been predicted that the sea level will rise between seven and 23 inches within the next century.  This naturally worries many countries with large coastal areas.  Sir, Singapore is not just a coastal nation.  We are also an island surrounded by bodies of water.  I would like to ask MEWR whether the Ministry sees this as a problem for us.  What plans does the Minister have to mitigate problems arising from climate change, especially rising sea levels, on Singapore?  What other challenges does he see from the IPCC report on Singapore in the coming years?  Although we are located in the equatorial zone and relatively safe from earthquakes, is the Ministry anticipating possibilities of earthquakes?  Are there measures that the Ministry is looking to address in safeguarding buildings?  I was told that just a while ago, at about 12.30 pm, the whole of NTUC Building was shaking because of an earthquake felt, and also in other parts of Singapore.  Can the Minister please address this question?

2.00 pm

     Finally, Sir, I have noticed that there is no significant publicity given to energy labelling to consumers.  I believe the level of awareness of energy labelling is still quite low among the public.  I would, therefore, like to ask MEWR the status of this energy labelling campaign, both to manufacturers and consumers.  How successful has this effort been and what is the adoption rate to date so far?  What plans does he have to further promote energy labelling to manufacturers and consumers?

     Mr Edwin Khew Teck Fook: Mr Chairman, may I request that I take both my cuts, one after the other?

     The Chairman:  No, there is someone in between.

Waste Management

     Mr Edwin Khew Teck Fook: Thank you, Sir.  I would like to support and expand on the concerns on this subject of waste management brought up by Mr Charles Chong and Mdm Cynthia Phua.

     Sir, the continuing problem being faced by Singapore must be the increase of waste caused by the increasing population and the construction of mega development projects, such as the two IRs and also many high-end condominiums which are targeted at high net worth foreign talent and foreign professionals.

    Looking at the latest recycling figures provided by NEA, the following waste categories are very much below the 2012 targets of SGP 2012 and will get worse, if not checked. Some examples are horticultural waste. The current recycling rate is 51%; 2012 target, 70%.  Glass - current recycling rate, 5%; 2012 target, 50%. Food waste - current recycling rate is 7%; target 2012, 30%.

    How is the Ministry of the Environment and Water Resources addressing this projected increase in waste, especially when the Ministry of National Development is planning, in their Concept Plan, for a population of 6.5 million?  Has MEWR allowed for this increase of Singapore's population and the larger than usual volume of waste generated with respect to a capacity of a landfill in Pulau Semakau?  And, more importantly, what happens when Semakau is full in 35-40 years?

   Another question I would like to ask is with regard to the construction and demolition waste, which would be caused by the larger than expected waste generated because of the active en bloc sale market.  Many of these buildings, which are sold en bloc, will generate many tonnes of construction and demolition waste, as each is destroyed and make way for new buildings. How much of this waste can be recycled?  What efforts are being made to ensure that as much as possible of the waste materials from these buildings are being recycled?  Apart from bricks and concrete, what happens to the thousands of doors, windows, sinks, kitchens, cupboards, toilets, etc, which are part of the en bloc destruction of these buildings?  What is MEWR, and possibly other Ministries, doing to recycle this waste, because if much of it cannot be incinerated or recycled, it will fill up Pulau Semakau even faster?

Climate Change and Energy Efficiency

     Ms Lee Bee Wah (Ang Mo Kio): Sir, a lot has been said and reported in the media about global warming, the El Nino effects and so forth.  I would like to know how much knowledge has the Ministry acquired in studying the impact of global warming, the changing temperatures, the rise in sea levels and the impact on plants and ecology in Singapore.  Are we well prepared for the impact of the climate change? We talk about tree-planting and going ABC Waters as though the climate has not changed.  We set up homes close to our shorelines, assuming that all that works well ends well.  I do not want to be a pessimist, but all I want is that our Ministry is staying well ahead in the management of our environment.

    Lastly,  I would like to ask the Minister what is being done in the area of energy conservation.   In Australia, we have read about how they are trying to phase out the use of environment-unfriendly incandescent bulbs to cut greenhouse gas emission.  How widespread is the use of such light bulbs in Singapore? 

   Still on energy, can the Minister tell the House how dependent are we on our neighbouring countries for the supply of natural gas to generate electricity?  What other alternative fuels are being considered so that we do not become beholden to only one fuel type?  And, certainly, we cannot afford to have another sand saga happening to our power supply.

     Mr Edwin Khew Teck Fook: Sir, hardly a day goes by without some news reports on natural disasters, climate change and global warming and as mentioned by many Members of this House.  From the Stein Report and, more lately, the IPPC Report or Intergovernmental Panel on Climate Change report, it is obvious that the world must act now to reduce carbon emissions or face the increasing fury of weather changes globally, eg, the highly destructive hurricane Katrina in New Orleans, and the recent tornadoes in the US, the floods in Asia caused by heavy and persistent rainfall, droughts in Australia and certain parts of China, etc.

   Of special concern to us, as a small low-lying island, as shared by many others in this House, is the melting of the ice in the polar caps and the resulting rise in sea levels.  If the world does nothing to reduce carbon emissions or business-as-usual scenario, it is projected by the Stein report that by 2050, temperatures will increase some 2-3 degrees centigrade.  And this will bring a 5-10% increase in the wind speeds of hurricanes, doubling the annual damage that they would cause in the USA.

   Heatwaves in Europe will kill more people and severe agricultural losses of over US$15 billion in 2003 will be commonplace and will affect many countries.  Closer to home, Singapore was affected by, for example, rising sea levels and heavier floods, examples that were already raised by Ms Lee Bee Wah, because of heavier rains.

   Second, vector-borne diseases, like dengue and malaria, will become more widespread with the increase in temperature and unseasonal rainfall patterns.

     Third, declining crop yields either because of too much rain causing floods or too little rainfall causing droughts around the region.  This unnatural pattern will adversely affect Singapore's food supply as well as its water supply.

   Finally, forest fires in our neighbouring countries will exacerbate because of droughts leading to more days of polluted air in Singapore, causing more respiratory illnesses and reducing our economic efficiency. 

   These are not doomsday scenarios, but a phenomenon that Singapore has experienced over the last 12 months. With climate change and temperature increasing, this phenomenon is going to occur more regularly and with greater intensity. 

   I know some would argue that we are a small city-state, a little red dot, and that, therefore, even if we have the most efficiently-run economy in terms of energy efficiency, and even if we have the lowest carbon emission per capita in the world, our contribution to the global carbon emission level will be miniscule.  By taking such a viewpoint, Sir, it is unwise, as Singapore should be a responsible global citizen. Singapore must face up to its responsibilities as a developed First-World nation and take the lead in addressing climate change.  Indeed, we have done so by rectifying the Kyoto Protocol. We therefore have to take steps to reduce our emissions of greenhouse gases and increase energy efficiency. We must therefore facilitate and encourage businesses to strive towards making Singapore a leader in the following four areas.

     (i) energy efficiency for all sectors, both commercial and industrial;

     (ii) technologies and systems for renewable energy;

     (iii) resources and funding for renewable energy systems for the whole East Asian region; and

     (iv) R&D in developing better, cheaper and more efficient renewable energy systems.

    I would therefore like to propose that the Government look at establishing Singapore as an Asian centre or hub for sustainable energy, as Singapore would then be in the position to (1) provide and promote solutions to mitigate climate change; (2) develop, engineer, fund, supply, install, commission and operate many renewable energy systems in Asia; (3) attract technology and R&D foreign talent to come to Singapore; (4) generate many more high-paying jobs for Singaporeans and facilitate the training of many from the region to operate and maintain these systems; and (5) develop Singapore into a major carbon trading centre for Asia.

   Sir, I would therefore like to ask the Minister two questions.  First, will the Government take the lead in this new but very important sector for Singapore and the region to develop Singapore into a centre for sustainable energy, technology, R&D and carbon trading?  Second, will the Government look at setting up a central agency to include the various Ministries that are already involved, in one way or another, in climate change or in energy efficiency to provide a one-stop shop? This is to attract renewable energy technology companies to Singapore, to attract energy and renewable energy project funding to Singapore and, obviously, attract the funds to come to Singapore.  Third, will the Government provide clear guidelines and support for test-bedding, grit-feeding, allocation of sites for factories, tax incentives, etc, for these technologies?  Fourth, to promote and develop markets for these companies and, finally, to develop a regional carbon trading centre.

   Sir, Dr Tony Tan and the National Research Foundation have said that the Government will put aside billions of dollars to spearhead R&D in water and environmental technology.  I hope a considerable part of these sums will be allocated to energy projects, as this is the most important field, now that we have our four taps in place and our water supply is stable. We can now turn to being the world's expert on renewable energy and energy efficiency. This is where we can have a headstart and make a difference and a considerable impact globally.  It can only be a win-win situation as we will save energy for Singapore, thus reducing our production cost as well as making an impact regionally and globally by marketing our expertise in this area.

Energy Consumption

     Ms Jessica Tan Soon Neo (East Coast): Sir, the industry sector accounts for 54% of all carbon dioxide emissions in Singapore. Greenhouse gas emissions are said to be responsible for the effects of global warming, which Mr Edwin Khew has so elaborately talked about.  In Singapore, greenhouse gas emissions are mainly due to carbon dioxide emissions. 

    Can the Minister inform the House on the energy consumption trends in the industry sector as it is the largest contributor of energy consumption in Singapore?  Given investments on growth and the impending initiatives like the IRs, I am sure that our energy consumption will be rising. Hence, it is important that we take positive steps to address the increasing energy consumption. 

  Can the Ministry also share on what is being done to help and promote local industries and industries operating in Singapore to be more efficient and responsible in their energy consumption? Is the public sector taking the lead in this area, and where do we stand vis-a-vis other developed markets?

   As mentioned in my Budget speech, there are also good economic reasons for promoting responsible energy consumption, eg, increasingly, companies in the US are realising the consumers' favourable impression of their bottomlines. 

   Sir, Singapore has made good efforts to continue to improve infrastructure and quality of living.  Beyond infrastructure, we must complement this effort with how we live and work. Otherwise, our efforts will be like someone making efforts to be clean and well-dressed but forgetting about oral hygiene - nice to look at but, when we start to speak, everyone will avoid because of bad breath.

Alternative Energy Vehicles

     Mr Hri Kumar (Bishan-Toa Payoh): Sir, I do not have bad breath!  Any effective regime which encourages efficient energy usage and good environmental practices must include measures to encourage Singaporeans and local businesses to purchase and use energy-efficient and environmentally-friendly cars.

   The two areas we are focusing on are diesel technology and hybrid technology. The Minister has made reference to the changes in the rules in relation to diesel technology earlier.  He said that from October 2006, all diesel engines imported into Singapore must be EURO IV compliant. That is correct.  However, what we did see in the market was that there was a rush to purchase EURO II compliant cars before the deadline took effect in October 2006, with the effect that there are actually many EURO II compliant vehicles right now on our roads.

   The Minister did mention that, over time, these would be phased out.  But it really depends.  If the COE premiums work a certain way, it may just encourage owners to renew the EURO II compliant cars and therefore keep those cars on our streets for far longer than we anticipate.

So we are looking at years before all diesel engines actually become EURO-IV compliant.  In the meantime, as the Minister cited the statistics in relation to the PM2.5 hazardous level, we are 40%-50% over the US EPA-recommended range.

2.15 pm

     On the second issue of hybrid technology, I understand the Minister will be commenting on this later.  I hope the Minister will address what I consider to be the anomaly in our tax regime.  While hybrid technology is obviously much more efficient, the cost of a hybrid car is almost 20%-30% higher than the equivalent petrol car.  And in Singapore terms, that translates to many thousands of dollars.  As far as the consumer is concerned, it is really a no-brainer which one they will buy.  In addition to that, hybrid cars are taxed according to their power or engine output, which means they pay quite a high road tax as well.  So even with the green rebate which is in place, again, it is a no-brainer on the choice of cars.

     Finally, Sir, I notice that this particular issue of which technology to promote and so on is featured in a number of the COS debates, which gives me the impression that there are a number of Ministries which are looking at this particular issue.  But what has not come out clearly is which Ministry is actually taking the lead in this particular issue.  I would like the Minister to clarify that.

Hybrid Vehicles

     Dr Lam Pin Min (Ang Mo Kio): Sir, modern technological advances have pushed car innovations to cater to the changing needs of Singaporeans.  Previously, cars were gas-powered, and now car manufacturers have created hybrid cars.  A hybrid car actually uses a combination of petrol as well as electricity, and hybrids are known to be environmentally friendlier compared to the conventional gas-powered cars.  It consumes less energy, quieter to drive and emits significantly less pollutants to the environment.  I would like to ask the Minister what is the population of  hybrid vehicles in Singapore since the implementation of the green vehicle rebate in year 2001, and whether there are any further plans and added incentives to encourage more Singaporeans to drive such hybrid cars or other alternative green vehicles.

Environmental Responsibility

     Ms Eunice Elizabeth Olsen (Nominated Member): Sir, opinion in the scientific community world-wide increasingly agrees that human activities are changing the global climate at an alarming rate with considerable dangers and uncertain consequences.

      Singapore is a country that has been proud of being clean, green and efficient.  We can do even more to play our part in dealing with this problem.  We must do so for Singapore to have a future and to keep future generations secure.  We can do so in many ways that will not necessarily impact our economy negatively.  Indeed, a lot more can be done by ordinary citizens if they can be encouraged to recognise their stake and ownership of the environment.

     While public education is needed, it does not mean that the Government should shy away from increasing regulations or offering more subsidies to improve energy efficiency and lessen contributions to climate change.

     Let me give three examples.  The first is the use of plastic bags.  The Government has been working with supermarkets on a voluntary basis.  May I enquire how well these voluntary measures are working?  When I was living in Seoul, the cashiers would stuff my plastic bag to the brim with my groceries.  At other stores, I had to purchase a minimum amount before they gave me a bag.  Otherwise, I had to pay 100 won, or about 15 cents, per bag.  However, in supermarkets here, you would think a plastic bag costs less than a smile. It seems that while there is some improvement in Singapore, the habit of using plastic bags is ingrained.  Will the Government consider regulating on the issue - to impose a cost on plastic bags or otherwise more strongly promote reusable bags?  We must see plastic bags as a burden to the environment.

     The media also plays a role.  I know that Today and the Straits Times have highlighted the issue before and should continue to do so.

     A second example is on energy use in homes and buildings. In Singapore, the air-conditioning in buildings seems to be designed for the polar bears, Inuka and Sheba, in the zoo.  Can the Government regulate and require higher standards for energy efficiency in our buildings?  Can it also ensure that consumers and home-owners get more information when buying electrical equipment, especially refrigerators and air-conditioners, which consume the bulk of energy in homes?

     The civil service should take the lead.  Does MEWR have any say in the construction of Government offices or the retrofitting of old ones?  For example, MOM is spending $18.3 million for the renovation of the MOM building and replacement of its air-conditioning system, and MCYS is spending $9.7 million for the upgrading works to MCYS' offices.  Does MEWR ensure that the money is spent in an environmentally friendly way?

     A third example is hybrid and other green cars, as other Members have mentioned.  While there have been increased rebates for hybrid cars, these cars still command a premium over normal cars of comparable size.  Can the Government increase the rebate so that these greener cars are on par with others?  Alternatively, can the Government consider a "carbon tax" to make gas guzzlers pay more for the cost they are imposing on our climate?

     Dr Amy Khor Lean Suan:

Sir, Mr Charles Chong has asked, going forward, how do we intend to strengthen and capitalise on our 3P partnership to raise environmental standards and inculcate environmentally friendly habits.  My Ministry has been actively promoting environmental
consciousness and ownership among our 3P sectors, as it is not sustainable to have the Government manage our environment and water resources alone. We have come a long way in working with our 3P partners in managing our environment and water resources.

     We are seeing an increase in cooperation amongst the 3P sectors in promoting environmental awareness and activism.  Earlier in my speech, I had mentioned how public agencies are working together in initiatives, such as the Inter-Agency Dengue
Taskforce and the Committee on Youths for Clean and Sustainable Environment.  My Minister will touch on the private sector’s involvement in the environmental and water sector later.

     For the people sector, it is important for the community to play a big part to maintain and improve their living environment.  MEWR, NEA and PUB have been working closely with NGOs on various initiatives to reach out to the public.  These initiatives are carefully thought through and implemented to either raise awareness on environmental and water issues, or enhance the general state of our living environment.  For example, the Singapore Environment Council has been our partner in programmes, such as the 10 Litre Challenge, as mentioned by my Minister earlier; and the Climate Change Awareness Programme.  As for the Waterways Watch Society, we have been partnering them to promote litter-free waterways and catchment areas.  The Waterways Watch Society is also putting in place a five-year plan to reach out to the youth community, schools, national sports associations and corporate organisations.  We have also been supporting the Restroom Association of Singapore in programmes, such as the Happy Toilet School Education Programme and the Portable Toilet Research Project.

     We want to have more of such partnerships to further strengthen our outreach efforts.  But I must emphasise that even as the Ministry does so, we will ensure that public monies are spent well and outcomes achieve our objectives.  In all instances, we have the responsibility to evaluate proposals carefully, and work with our partners to shape the desired deliverables. We should not indiscriminately endorse and fund all ideas coming to us.

     Over the past years, my Ministry has introduced various awards, including the Singapore Green Plan 2012 Award, to honour worthy individuals and organisations for their significant environmental contributions to Singapore.  Past winners of the Singapore Green Plan 2012 Award include Senoko Power Ltd, Mr Jack Sim from the Restroom Association of Singapore, and Nan Hua Secondary School.  Last year, we elevated the SGP2012 Awards to a Presidential level and renamed it as the President’s Award for the Environment.  This is the highest accolade in Singapore’s Environment and Water Resources field and gives top-level national recognition to individuals, organisations and
companies for their outstanding efforts that have contributed towards Singapore achieving environmental and water sustainability.  The inaugural winners for this award are Prof. Tommy Koh, Dr Geh Min and the Waterways Watch Society.

     To complement the President’s Award, PUB and NEA will also introduce the Friends of Water - Watermark Award and the EcoFriend Award in 2007 respectively.  The Friends of Water - Watermark Award is a 3P initiative to get individuals and organisations interested in water and develop an interest to do things to sustain Singapore’s water supply.  The Eco-Friend Award aims to give due recognition to proactive individuals such as school teachers, NGO volunteers and grassroots who have contributed selflessly to the environment through efforts beyond their immediate job scope.  Through these Awards, we hope to recognise role models who have made a difference to our environment and water resources in their own unique ways and encourage them as well as inspire others to do the same.

     I am glad to note that there is a growing awareness and concern over environmental and water issues among our youths.  My Ministry, together with our 3P partners, is committed to creating more avenues to engage our youths.  Through annual dialogues
with youths and initiatives, such as the Environment Champions and Youth Environment Envoy Programmes, we hope to inculcate the value of environmental ownership in them.

     I am also heartened to learn about the range of environmental activities being driven by our youth.  Let me mention two such individuals.  The first is 26-year-old Angela Lee.  Her passion for the environment started as early as in secondary school, and she has since been sharing ideas at youth exchanges in countries like Switzerland, Malaysia and Northern Ireland.  She has also helped organise an International Water Forum which saw 150 participants from eight countries discussing water issues.

     Our second environmental youth ambassador is 20-year-old Oliver Goh.  He has been passionate about environmental conservation since he was young.  Oliver and members of the Building and Environment Green Volunteer group have been managing an educational and fun-filled programme on nature conservation for the public and school students at Hindhede Nature Park.  As trained guides, they also provide a guided tour for visitors to the Bukit Timah nature reserve.  The programme has so far benefited over 300 members of the public, 150 secondary school students and a 13-member Swiss delegation.

     My Ministry has a great challenge ahead of us.  A recent survey by NEA has shown that despite greater awareness of environmental issues among the youth - nine out of 10 are aware of environmental issues - awareness of individual responsibility and action is still not high.  For instance, nearly 42% of the respondents felt that it was the responsibility of the Government to keep the environment clean and green.

     My Ministry will continue to explore more creative ways to convert this awareness into action, and to encourage more youths to come forward to organise themselves and make a difference to their environment.

     Sir, Mdm Ho Geok Choo, among the many issues that she has raised, has asked us about our efforts to keep noise levels down.  Indeed, excessive noise can be a source of irritation that detracts from our quality of life.  To maintain our quality living environment, NEA works closely with various agencies to monitor noise levels and address noise pollution from different sources such as construction sites and factories. NEA also engages construction industry associations in regular dialogues, and takes in feedback from the general public.

     Over the past few years, the NEA has received an increasing number of complaints on noise from construction sites.  In particular, there has been a significant increase in the number of complaints against construction noise at night and on Sundays and
public holidays.  Noise measurements by the NEA, however, showed that for more than 90% of the complaints received in 2005 and 2006, the noise levels were actually within the legal permissible limits.

     Nonetheless, in view of public concerns, my Ministry has reviewed the noise regulations for construction sites which were last tightened in 2001.  For construction sites within 150 metres of residential premises, my Ministry, in consultation with key stakeholders from the construction industry, will further tighten the permissible noise limits for night time and on Sundays and public holidays.  The noise limits for these periods will be revised to be the same as those for hospitals and schools.

     Singapore is a highly urbanised and compact city, and noise cannot be eradicated completely. The increased level of construction activities is a sign that our economy is booming, but it may bring with it more construction noise,

as has been alluded by Mdm Ho Geok Choo.  We therefore need to strike a balance by allowing some level of construction activities to carry on without depriving our population of a good rest during the night and on Sundays and public holidays.  NEA will review the construction noise regulations regularly to ensure that they are in line with international practices.

2.30 pm

     Sir, Mr Chong, Mdm Cynthia Phua and Mr Edwin Khew asked about our efforts in tackling waste and increasing the recycling rates.  Singaporeans throw away a lot of waste, about 7,000 tonnes of it every day. In many countries, much of their waste ends up in landfills.  In Singapore, we do not have the luxury of land and landfills, given the many competing demands for our limited land space. In fact, our only landfill in Pulau Semakau, the Semakau Landfill, was constructed in the sea at a cost of $610 million. However, it is not sustainable for us to keep building new landfills. Hence, it is important that we take action to reduce waste and thereby extend the lifespan of our existing landfill. We must move towards a sustainable waste management system.

     We are glad to note that the waste disposed of in Singapore has decreased from a peak of 7,600 tonnes per day in 2000 to 7,000 tonnes (equivalent to about 1,000 refuse truck-loads) per day last year. This decrease is significant against the backdrop of continued growth in GDP, population and tourist arrivals. It indicates that efforts to reduce waste through recycling are working. I am pleased to announce that our recycling rate has reached a new high of 51% in 2006, up from 40% in 2000, and we are on track to achieve our Singapore Green Plan recycling target of 60% by 2012. For some waste streams such as metals and construction and demolition waste, we have achieved high recycling rates of over 90%. These efforts have reduced the amount of waste going to the Semakau Landfill and increased its projected lifespan by 10 years to 2040.

     While the results are encouraging, our GDP, population and tourism arrivals will continue to increase. There are also many  major development projects, including the en bloc projects and the IRs mentioned by Mr Khew.  All these bode well for our economy and quality of life, but will inevitably generate even more waste.

     We must therefore continue to push for more recycling.  As highlighted by Mr Khew, there are still lots of food waste, plastic waste, wood waste and used slag that are not recycled and disposed of at the incineration plants and landfill.  NEA has been facilitating the private sector in setting up recycling facilities for these wastes.  We expect a number of new recycling facilities for food waste, wood waste and household waste, among others, to start  operation in the next one to two years. This would further boost our effort and our capacity in waste recycling.

     Mr Khew also asked specifically about  the recycling of construction and demolition waste.  Given the booming construction industry, more of this waste can be expected in the next few years. NEA has helped a number of companies to set up recycling facilities in Singapore to treat C&D waste into recycled aggregates for construction materials such as non-structural drain slabs and road kerbs. I am glad to inform the House that the recycling rate for construction and demolition waste has reached 98% last year through the various recycling efforts.

     But recycling cannot be left to the Government and industry alone. Each and every Singaporean should do his or her part to reduce the amount of waste we throw away as a nation. To make it easy for residents to practise recycling at home, my Ministry introduced the National Recycling Programme (NRP) in 2001 to provide residents in HDB flats and landed estates with recycling services at their doorsteps. During Recycling Day 2005, it was announced that we are putting in one recycling bin for every five blocks of flats in HDB estates. This means that the majority of HDB residents will need to travel not more than 150 metres to reach a recycling bin. I am pleased to inform the House that all HDB estates will have these centralised recycling bins by end of this year.

      Residents in condominiums and private apartments are not covered in the National Recycling Programme as their estates are managed by Management Corporations. But they are certainly
not forgotten. NEA is currently working with Management Corporations to provide recycling facilities for their residents. We would consider making it mandatory for condominiums to provide recycling facilities if need be.  Our target is for all households in Singapore to have access to recycling facilities. 

     We are also addressing the waste generation problem at source. Sir, last year, my Minister announced that the Ministry is working with manufacturers and distributors to develop a voluntary packaging agreement for the food and beverage industry to reduce the amount of packaging used and enhance the recovery of used packaging materials for recycling. I am pleased to announce that to date, five industry associations representing more than 300 companies and another 10 food-related companies have agreed to participate in the voluntary packaging agreement. They aim to have the agreement ready for signing in June this year. This is a good example of how the Government and industry can work together to jointly tackle common challenges such as waste reduction.

     Ms Olsen also asked  how the Ministry is dealing with the issue of plastic bags in Singapore and whether we are considering any incentive schemes or tax systems on its usage, such as making the consumers pay for the plastic bags.  In many countries where waste is landfilled directly, plastic bags pose an environmental problem as they are nonbiodegradable and hence remain in the landfills for many years.   However, in Singapore, used plastic bags are disposed of at our incineration plants together with other wastes and the heat produced is used to generate electricity. So it is not entirely wasted.  Moreover, many Singaporean households re-use plastic bags for their refuse and this is a good habit which we want to encourage.

    What we are concerned about is the excessive and unnecessary usage of plastic bags. We are tackling this by raising awareness and educating the public. Last February, NEA, together with the Singapore Environment Council, launched a "Why waste plastic bags? Choose reusable Bags!" Campaign.  This campaign was aimed at educating shoppers as well as cashiers at retail outlets to reduce the use of plastic bags and promote the use of reusable shopping bags.  I am pleased to inform Ms Olsen that from our survey, we found that the cashiers were indeed, because of this campaign, stuffing the bags to the fullest before they give it to the customers.  Then, in November, we launched the "Spot the Green Shoppers" contest. Volunteers from the Singapore Environment Council were stationed at supermarkets to spot shoppers who used reusable bags. Those who were spotted received a shopping voucher each. This year, we will be launching a "Bring Your Own Bag" Day to encourage shoppers to bring their own reusable bags to bag their purchases and we are likely to encourage the cashiers to ask the patrons to donate some money, if they ask for plastic bags, for a useful cause of course. We hope to make this an ongoing event so as to drive home the message of not wasting plastic bags.

     All these efforts will help us reach the overall recycling target set under the SGP 2012, and bring us nearer our goal of having a sustainable solid waste management system.  My Minister will now touch on the issues on climate change, energy efficiency, and the environment and water industry.

     Assoc. Prof. Dr Yaacob Ibrahim: Mr Chairman, Sir, let me just address the point raised by Mdm Ho about earthquakes.  I just want to report to the House - this is of course subject to confirmation - that there were two earthquakes this morning: one at 11.50 am, registered 6.6; another at 1.49 pm, registered 6.1, in Sumatra, at about 420 kilometres from Singapore.  NEA, as you know, provides the Singapore Police Force, the Civil Defence Force, BCA and HDB with detailed information of earthquakes that have caused tremors in Singapore within five minutes of detection.

     Sir, Mr Edwin Khew has asked about the progress that we have made in the development of the environment and water industry.  The National Research Foundation (NRF) has identified the environment and water sector as a key growth area, and has committed $330 million over five years to promote strategic R&D in this area.  To spearhead the growth of this industry, we have formed the Environment and Water Industry Development Council (EWI) under my Ministry in May 2006.

     The main aim of the Council, which includes key agencies such as the PUB and EDB, is to grow our economy and create more jobs. By 2015, employment in the water industry in Singapore is expected to double to 11,000 with the value-add to the economy tripling to $1.7 billion. As the industry grows, it will need more specialist technical manpower, which means more jobs for Singaporeans.

     Over the past year, we have also attracted value-added investments from major global water players to Singapore.  So now, we have Siemens Water, GE Water, CH2M Hill, Black & Veatch, just to name a few.  The presence of these global MNCs will help increase the vibrancy of our water industry and create many, many job opportunities.

     Our home-grown companies have also achieved good success overseas. For example, Keppel, Hyflux and SembCorp made further inroads into the Middle-East market in 2006 and clinched large water and environmental projects in Qatar, Algeria and UAE respectively. My Ministry, together with other Government agencies, will continue to support the expansion of our companies to overseas markets, for example, through trade missions to key markets like China, Middle East and India.

     Sir, going forward, technology will be a key enabler in growing our environment and water industry.  To ensure that Singapore stays on the forefront of R&D developments, we launched the Environment and Water Research Programme (EWRP) last September.  The programme will support R&D projects in Environment and Water Technologies (EWT) with funding of S$100 million over the next five years and there was good response to the first Request-For-Proposal under the programme, with more than 120 proposals received from the universities, public and private sectors.  We have also recently launched the TechPioneer scheme to encourage early adoption of new technologies that may come through the R&D pipeline.

     In addition, Sir, we will have schemes to help individuals and entrepreneurs capitalise on the opportunities in the EWT sector.  The EWI plans to provide post-graduate scholarships to train professionals and researchers in EWT.  For new companies and technology start-ups, a new funding scheme, known as Fast-Tech, will provide assistance in transforming ideas and research into commercially feasible prototypes.  More details on these will be released in the coming weeks.

     Sir, our efforts to promote EWT will have a positive spin-off  on the MICE and tourism sector.  Plans are being finalised for the staging of an International Water Week (IWW) in Singapore starting in 2008. The IWW will be an annual event to showcase water technologies, and create business and networking opportunities among water experts and industry players from all over the world.  The event will help strengthen Singapore’s position as the hub in the Asia Pacific for leading water technologies, as well as the gateway for business opportunities in the regional and global sector.  Some 800 delegates and 5,000 trade visitors are expected to attend the inaugural IWW, and this figure is estimated to reach 2,000 delegates and 25,000 trade visitors by the year 2015.

     So through investing in R&D and growing the EWT sector, we can reap the opportunities that our environment presents to attract more investments, talent and jobs to Singapore.

     Sir, let me now address the issue of climate change.  Sir, the many questions raised by my fellow Members, including those questions raised during the Budget debate last week, indicate the growing concern over climate change.

     The Intergovernmental Panel on Climate Change (IPCC), established by the United Nations Environment Programme and the World Meteorological Organisation, projected in its latest report released earlier this year that global temperatures and sea levels are likely to rise, while extreme weather patterns that have been associated with climate change also often dominate headlines worldwide.  Mdm Ho Geok Choo has asked about the problems arising from climate change on Singapore.

     Sir, like other nations, Singapore will not be spared from the effects and the impacts of climate change.  We have already put in place measures in response to the earlier IPCC studies, for instance to safeguard against the anticipated sea level rises.  So today, all our reclaimed land are designed with a platform level of about 125 cm above the highest recorded tide.  This should be sufficient to address a sea-level rise of 59 cm, which is the worst-case scenario in IPCC’s latest report.  But to ensure that we address all the key risks, we have commissioned a study to better understand the possible long-term effects and the impacts of climate change on Singapore, such as changes in rainfall patterns, sea levels and extreme weather conditions.

This study, which is conducted by a team of local and foreign experts, will incorporate the latest scientific research on climate change, including the latest IPCC report.  In fact, a number of the foreign experts that we have engaged have been actively involved in the drafting of IPCC's reports.  We expect that this detailed study will be completed within two years, with preliminary findings expected next year.  NEA will continue to work closely with other Government agencies to monitor and manage Singapore’s vulnerability to climate change.

2.45 pm

     Sir, I also announced last year that my Ministry would be carrying out public consultation on the National Climate Change Strategy (NCCS).  I am pleased to inform the House that the consultation has been completed.  We have received more than 1,300 responses in our online consultation.  We also conducted dialogue sessions with companies, industry associations, academics, environmental groups and youths.  The feedback received has made the NCCS more robust.  A notable theme from the consultation was the need to make Singapore an energy-efficient nation.

     Sir, improving energy efficiency is a strategic priority within the NCCS.  Singapore is reliant on fossil fuels for much of its energy needs at present, but this does not mean we cannot do anything about greenhouse gases.  Efficient energy use is a proven way of reducing greenhouse gas emissions.  Using more energy-efficient equipment and appliances, or designing more efficient buildings, can save significant amounts of money in the long run without sacrificing comfort.  As noted in a recent Newsweek magazine article, and as echoed by Ms Jessica Tan, energy efficiency is "one of the hottest topics in business - and a way to add billions of dollars to the bottom line".  So it makes economic sense.

     Becoming energy efficient is not just good for the bottom line.  It is also an important aspect of sustainable development for Singapore.  Energy is a critical resource used by many different sectors, such as industry, building and transport.  Mr Hri Kumar asked whether there is a lead agency in this.  MTI is leading a group of agencies looking into energy sufficiency and security.  My Ministry has been co-ordinating the initiatives for energy efficiency under the National Climate Change Committee, or N3C, chaired by my colleague, Dr Amy Khor.  The N3C provides a valuable consultative forum to discuss views and feedback from members who comprise public sector representatives, industry leaders, NGOs and academics.

     Drawing from the N3C inputs, there is a need for a central agency to ensure effective implementation of energy-efficient measures.  Just as PUB oversees water conservation, NEA will be the lead agency on energy conservation and efficiency.

     Both water and energy conservation are critical for Singapore to remain a sustainable and economically competitive country.  NEA will take the lead through a focused effort to promote and monitor Singapore’s performance in energy efficiency.  Much more can be done, including working together with the other Government agencies to implement targeted sectoral measures.  For these efforts on energy efficiency to be successful, we also need to cultivate a culture of energy consciousness among industry and consumers.

      Sir, we can learn from the experience of other countries.  In Japan, a country that also faces resource constraints, the industrial sector nearly tripled its output between 1973 and 2005 while keeping its energy consumption almost constant.  Denmark, too, has seen its Gross National Product increased by 70% from 1973 to 2004, with almost constant energy consumption over the same period.

      Energy efficiency can reduce greenhouse gas emissions, reduce costs, and enhance our economic competitiveness at the same time.  Yet, we know that, for a variety of reasons, energy-efficient choices are not made.  Perhaps, this is because energy savings are often not immediately obvious, and so we tend to focus on the price tag and not the long-term savings, as quoted aptly by Mr Hri Kumar, as a 'no-brainer'.  But I disagree.  For example, many of us do not realise that the cost of energy to run a fridge is often greater than the purchase price of a fridge itself over its useful lifespan.  This is where the Government programmes can help address these market failures, by bridging the information gap and by demonstrating the benefits of energy efficiency.  Let me take this opportunity to elaborate on some of our planned initiatives.

     Sir, Ms Jessica Tan and Mr Edwin Khew asked about energy efficiency among industries.  Industry is the largest energy-consuming sector, accounting for 54% of Singapore’s carbon dioxide emissions.  To promote energy efficiency in the industry, NEA launched the Energy Efficiency Improvement Assistance Scheme, or EASe, two years ago.  EASe co-funds energy audits in the manufacturing and building sectors to identify potential areas for energy efficiency improvement.  As a result of the scheme, 54 manufacturing facilities and buildings have identified energy efficiency measures which will result in $13 million in annual energy cost savings, and reductions of about 111,000 tonnes of carbon dioxide annually.

     To further encourage companies to implement recommendations from energy audits, NEA will promote EASe, together with EDB’s Investment Allowance, or IA Scheme.  The IA Scheme gives an incentive to companies that invest in improving the efficiency of resource utilisation or bring in new technology into an existing industry.  Under the IA, energy efficiency investments can enjoy a tax exemption on income of up to 50% of the qualifying fixed capital expenditure.  This should improve the return on investment on energy efficiency projects.

     NEA has also been actively promoting energy-efficient technologies through the Innovation for Environmental Sustainability (IES) Fund.  For example, NEA recently supported two projects with IES funding to demonstrate trigeneration technology.  The two projects will help reduce carbon emissions by 23,200 tonnes annually and provide significant savings in energy costs to the facility owners.  The annual savings for one of the facilities have been estimated to be over $900,000 annually.  I am pleased to announce that we will extend the IES Fund for a further four years, up to Financial Year 2010, to continue to support innovative environmental projects.

     Sir, Ms Tan has asked who should take the lead. Buildings also consume a significant amount of electricity.  The building sector alone accounts for almost 20% of the electricity consumed by commercial and institutional buildings in Singapore.  Having energy-efficient buildings is in the Government’s long-term interest as it not only reduces carbon dioxide emissions, but also reduces our expenditure on energy.

     Sir, I am pleased to announce that the Government will lead by example by making our buildings more energy-efficient, and I hope this Chamber will also follow suit.  All large air-conditioned Government office buildings, as well as polytechnics and ITEs, will conduct energy audits to improve their energy efficiency by March 2010.  Some agencies, including MEWR of course, MOF and MOM, have already completed their energy audits and are projected to reap combined savings of $240,000 annually.

     We will ensure that new Government buildings are designed with energy efficiency and environmental sustainability in mind.  As my MND colleague, Ms Grace Fu, announced late last year, all new large Government buildings and new schools will meet the Green Mark certified standard.

     We hope that, with the Government taking the lead, the private and people sectors will be encouraged to be more energy-efficient.  In fact, some have already done so.  For example, I understand that Alexandra Technopark has undergone an energy audit and is in the process of implementing the energy efficiency measures identified by the audit.  They expect to realise total potential savings of about $600,000 annually.  Aljunied Town Council has also conducted an energy audit on 40 blocks, with co-funding of about $60,000 from the IES fund.  The recommendations from the audit, which include the use of more energy-efficient lights and power-saving devices, have been shared with the other Town Councils.  I am heartened to note that several Town Councils have started implementing these recommendations.  Even our Singapore Zoo and the Night Safari have managed to reduce their electricity consumption by about 8%.  They achieved this through a range of energy-saving devices, such as installing automated lights and fans at their visitor areas, and switching to solar-powered as well as more energy-efficient light bulbs.

     Sir, one key NCCS feedback on improving energy efficiency was to provide more information to the public.  In response to Ms Eunice Olsen’s query, one of the ways in which all of us can help play our part in addressing climate change is by using energy-efficient household appliances.  A consumer who chooses a three-tick air-conditioner, instead of a one-tick, would save about 1,400 kg of carbon dioxide emissions and $525 a year.  That is a little price to pay to go green.

     I announced last year that the voluntary Energy Labelling Scheme for air-conditioners and refrigerators will be made mandatory.  This will begin as scheduled on 1st July this year.  NEA will give the industry a six-month grace period to comply with the mandatory labelling scheme.  I hope that consumers will make use of these labels to lower their electricity bills.

     We will also extend the existing voluntary energy labelling scheme run by the Singapore Environment Council to include other appliances, such as clothes dryers, in the coming years.  These energy labels will be made mandatory later on, if necessary.

     Besides buying efficient appliances, we can also save energy by adopting good practices.  Yesterday, Mr Sam Tan had brought up the need to help households reduce their energy consumption.  I would like to take this opportunity to commend my colleague, Dr Amy Khor, on the new South West Community Development Council (CDC) initiative called Cool@South West. Cool@South West encourages residents to conserve electricity and cut their utilities bill at home, such as switching off appliances at the mains when they are not being used, and using energy-saving light bulbs.  As yesterday’s Straits Times aptly pointed out, each energy-saving bulb can save $24 a year and I am glad to note that South West CDC residents have taken energy efficiency to heart.  A survey conducted in Hong Kah found that about 80% of  households are already using energy-saving light bulbs.

     Similarly, choosing more fuel-efficient vehicles leads to lower costs and a cleaner environment.  Mr Hri Kumar has asked about measures to encourage the use of more energy-efficient vehicles.  In 2003, we introduced a voluntary fuel economy labelling scheme.  The fuel economy label helps car buyers identify more fuel-efficient cars, although the actual fuel consumption also depends on individual driving patterns. As at the end of 2006, 84 vehicle models are labelled under the scheme.  For the fuel economy labels to be more effective, car buyers need to be able to compare fuel economy figures of all available models.  My Ministry will look into making it mandatory for all passenger car models to display the fuel economy label at the showroom.

     Sir, in addition, my Ministry is encouraging the use of green vehicle technologies.  I agree with Dr Lam and Mr Hri Kumar that hybrid cars are more fuel-efficient and less pollutive than conventional ones.  We know that they cost slightly more.  Indeed, such green vehicle technologies are becoming more widely accepted internationally.  More models are being introduced, and our motor traders are doing their part by bringing them into Singapore.  The decision to purchase a green vehicle is a lifestyle choice, but I am heartened to note that more car-owners are embracing these green vehicle technologies, despite the high prices.  Since the enhancement of the Green Vehicle Rebate in January 2006, the number of green vehicles has gone up substantially from about 200 to 700.  And I know at least two owners of such cars.

     I am therefore glad to inform Dr Lam that the Government will continue to support green vehicles, and the Green Vehicle Rebate (GVR) will be extended for another two years to December 2009.  With growing awareness, better technology driving down costs, and more models available in the market, I am hopeful that the take-up rate of green vehicles will continue to rise.

     Sir, I believe our energy efficiency initiatives will enhance economic growth.  We can make Singapore a more energy-efficient economy by helping manufacturers, building owners, drivers and ordinary citizens reduce energy consumption, increase savings and reduce greenhouse gas emissions.

     Sir, Mr Edwin Khew has raised a few questions relating to renewable energy as well as economic opportunities from climate change.  Let me try and address him within the limited time I have.  Energy is a scarce resource that we must use as efficiently as we can.  For this reason, NEA has invested in the state-of-the-art waste incineration plants that also recover energy to generate electricity.  In total, energy from incineration contributes about 2%-3% of the total electricity consumed in Singapore.

     Increasing worldwide concerns over climate change will mean an increase in demand for renewable energy and energy efficiency technologies.  Renewable energy will also help to reduce our dependence on fossil fuels, a point noted by Ms Lee Bee Wah.  While the costs of renewable energy still need to be brought down, NEA has been encouraging private and public sector partners to explore and test-bed renewable energy technologies through schemes, such as the IES Fund.  For example,

NEA has provided $1 million through the IES Fund to test-bed solar photovoltaics at the Biopolis.

3.00 pm

     We have identified clean energy as a strategic growth area for Singapore and are working towards growing a vibrant industry in this field, as noted by Mr Khew.  In recent years, Singapore has had pioneering investments in solar energy, biofuels, wind energy and fuel cells.  One important strategy in growing this industry is to build up the R&D and technology base on clean energy.  My Ministry will continue to work closely with the Ministry of Trade and Industry to research on and test-bed clean energy technologies in practical settings in Singapore.  For instance, NEA and EDB have brought together companies, such as Robert Bosch and DaimlerChrysler, to test-bed the use of biodiesel in our local setting. 

     Sir, we will also focus on carbon trading.  As rightly pointed out by Mr Edwin Khew, there is an opportunity for us here.  In fact, the Government has put in place the necessary process to help companies take advantage of the economic opportunities associated with emissions trading and Clean Development Mechanism (CDM) as provided for under the Kyoto Protocol.  NEA has been appointed the Designated National Authority for the approval of CDM projects that support sustainable development in Singapore. 
 NEA will work closely with IE Singapore, which is the lead agency to establish Singapore as a Centre for Carbon Trading.  NEA and IE Singapore have facilitated dialogue between project developers and financiers to create greater awareness of these economic opportunities.  In June 2006, Singapore joined the Renewable Energy and Energy Efficiency Partnership (REEEP), an international partnership of governments and businesses that promote clean energy.  Following this, a Renewable Energy Exchange was set up in Singapore to bring together investors looking for projects and developers looking for financing. 

     Sir, we have also supported the formation of the Sustainable Energy Association of Singapore (SEAS) to grow the energy services and technologies sectors in Singapore.  Whether we will become a hub or not, I think it is important to put all of these measures in place first.  But, certainly, I share Mr Khew's optimism of us becoming a centre for such an activity.

     I hope our efforts to tackle climate change will make Singapore not just clean and green, but also lean.  We can be environmentally sustainable and play our part in the global effort on climate change while making Singapore more economically competitive.  But we have to be realistic.  We cannot do it alone.  Climate change actions require all countries to play a part.  Singapore acceded to the Kyoto Protocol last year, and we will continue to be active in international discussions to work with the international community on this global challenge.

     Sir, in summing up in 30 seconds, I thank MPs who have raised concerns and offered their views.  We have come thus far in the environment and water areas because of far-sighted policies and consistent practices through four decades.  All these have been achieved even as we grew our economy.  We are a small city-state that has shown that it is possible to safeguard our environment while we chalk up economic growth.  But we should not rest on our laurels or even throw up our hands to say there is nothing we can do more or that our efforts are too small to make an impact.  MEWR will continue to lead with other Government agencies and like-minded partners, hand-in-hand with members of the public who care for and want to do more for the environment.  Where necessary, we enforce against lawbreakers to protect the public, but we do so with some sadness, as it is a breakdown of responsibility.  We must continue to promote ownership of our environment in both our young and old.  I hope Members too can also encourage residents to continue to be responsible for our environment and waters and choose habits that are environmentally-friendly.  It is our environment, so let us all play our part and make this little red dot a little green, Sir.

     The Chairman:  Dr Yaacob, you still have time left.  Yes, Mdm Ho.

     Mdm Ho Geok Choo: Thank you, Minister, for the very comprehensive response to the questions asked.  I think there is one question which I have asked and which the Minister has, perhaps in the interest of time, not responded.  Could I get the Minister's response to my question on haze?

     Assoc. Prof. Dr Yaacob Ibrahim: I have replied earlier on the haze issue.  But in short, Sir, the five countries involved in the haze have been working actively.  Mdm Ho asked about our relationship with Indonesia and our assistance. 

     Singapore has decided to adopt a province in the Muaro Jambi Regency in Sumatra to work together with the local government and the Ministry of Environment in Indonesia to develop a master plan to deal with the forest fires over there. 

     We have also agreed to contribute US$50,000 to the ASEAN Haze Fund.  We were the first to do so.  As a consequence, Indonesia, Malaysia and Brunei have also agreed to contribute US$50,000 each.  The target set by ASEAN countries is half a million US dollars for the Haze Fund.  Meanwhile, we will develop the master plan, together with our Indonesian colleagues, so that the master plan can be successfully implemented, hopefully towards the second half of this year, so that we can make sure that we can deal with the forest fires and the haze that may come again this year.

     The Chairman:  I am afraid I have to give priority to those who have made cuts under the Head first.  Mr Charles Chong.

     Mr Charles Chong: Sir, while we are on the subject of haze, could the Minister confirm that Indonesia has yet to sign the ASEAN transboundary haze agreement, and which other ASEAN countries have failed to do so, and the reasons, if he knows?

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, two countries have not ratified the agreement, namely, the Philippines and Indonesia.  According to the Philippine Head of Delegation in Brunei, I think it is because the Philippines is going through an election.  They will have to delay this until the next parliament sits or get elected sometime in the second half of this year. 

     I have also impressed upon my Indonesian colleague, Pak Rachmat Witoelar, that they should ratify the haze agreement as soon as possible.  As I understand it, the agreement is now in the Indonesian parliament and it is still being debated.  We have impressed upon him that it is important that he ratifies this as soon as possible because it has been there for the last 10 years. 

     Notwithstanding that, Sir, we will continue to develop the master plan because we need to make sure that we can deal with the forest fires as soon as possible.

     Mdm Cynthia Phua: Mr Chairman, Sir, I have just two clarifications.  I would like to request the Minister to throw in little guppies into our little streams, because this is also a natural way of indicating the cleanliness of our waters. 

     The second clarification is, in the management of food wastes in our hawker and market centres, is there any better way to dispose of our food wastes because, currently, it is very unhygienic?

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, I will leave it to the PUB to decide whether guppies or koi or whatever that is necessary to keep our water clean.  We will explore all forms of biological methods. 

     On food wastes, I agree entirely with Mdm Phua, and that is why we are encouraging food waste recycling.  I think Mr Edwin Khew's plant will be ready by the end of this year, and will be the first food waste recyling plant in Singapore.  Meanwhile, we will endeavour with all the hawkers' associations to find better ways of dealing with the food wastes being produced at our hawker centres.

     Mrs Josephine Teo: Mr Chairman, Sir, I would like to also thank the SPS for responding to my questions on First-World restrooms and First-World cleaners. 

     Firstly, I would like to ask the Minister if he would consider making NSRS training for cleaners a requirement in all public-sector cleaning contracts. 

     Secondly, the designs of our restrooms are very important in order for the cleaners to do their jobs properly.  Would the Ministry consider having an in-house consultant to help developers and who else may be interested who are renovating their restrooms to make it really a job that a First-World cleaner can do well?

     Dr Amy Khor Lean Suan: Mr Chairman, Sir, we encourage the cleaning contractors to get their cleaners trained under the NSRS scheme.  Yes, we are certainly looking into the possibility of getting the cleaning contractors under our management to get their cleaners trained under NSRS. 

     As regards the design, actually we have changed the regulations before to increase the number of cubicles for women, as many of the problems with cleanliness really pertain to high usage of the women's toilet cubicles.  Certainly, we are also working together with BCA to see how else we can improve on the design of toilets, not just the number of cubicles but where we place the hand dryers, soap dispensers, and so on, because that will also contribute to the whole cleanliness standard of the toilets.

     Dr Lily Neo: Mr Chairman, Sir, may I ask the Minister whether he expects the haze in Singapore to be worse this year, in view of the El Nino effect?  May I also ask him whether the cooperation with the Jambi Regency on the master plan will be on time to save Singaporeans from the afflicted episode and the dreaded recurrence of haze, and would he put his best efforts to prevent this haze recurrence?

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, I share my fellow Jalan Besar GRC Member's concern about haze, because it is affecting all of us.  This year, earlier predictions were that El Nino was coming in the second half.  But the current prediction is that it is weakening towards the first half of this year.  All prediction models can only predict about three or four months ahead.  So we will only know some time in May or June what will happen in the second half of this year.  But, certainly, if El Nino is coming, it will be a drier season and, therefore, the likelihood of haze.

     We will work very hard to make sure that the Jambi master plan gets implemented.  The workshop will be conducted next week.  In fact, I have been told that even the Governor might turn up for the workshop, because he wants to sit down with the Jambi officials to develop the plans, as they have to own the master plan.  We will be in Singapore, but they will be there and they have to monitor the situation, work with the plantation owners and the kampongs.  So we will do our best to make sure that the plan takes off this year. 

     A lot will depend on two things.  There must be political will.  We are fortunate that the Governor of Jambi, Pak Zulkifli, who is an old friend of Singapore, is a hands-on person and is very keen.  But at the same time, he will need support from the central government, because this plan must also be owned by the Environment Ministry (the KLH) in Jakarta.  We have informed Jakarta that we want to make this plan successful.  The fact that Malaysia has noted that this is a good collaboration to follow shows that we are on the right track.  If we can get all these factors aligned before the dry season hits us this year, we have a chance to deal with the haze.  I am not sure whether we can prevent it entirely but, at least, we are doing something on the ground to work together with the plantation owners so that they can adopt better land-clearing practices.

     Dr Teo Ho Pin: Sir, I want to re-emphasise that dengue prevention requires the efforts of all stakeholders.  So I hope the Ministry will also play a role in dengue prevention.  I also hope that the Ministry can give us more details on the size of the mosquito fund which it is going to give us and what are the details of this mosquito incentive fund that it is going to give to the Town Councils.  We need to know the quantum.  Is it $5 million, $10 million or $15 million?  We need to have an answer so that, at least, we know how to proceed with our pest control operations.

     Dr Amy Khor Lean Suan: Sir, certainly, the Ministry will continue to play its part to mitigate the problem of dengue in Singapore and work together with the grassroots, the Town Councils, CDCs as well as all other stakeholders to ensure that our fight against dengue would reduce the number of dengue cases further. 

     As regards the size of the mosquito fund, actually the size is not commensurate with the size of the mosquito!  It is far larger.  Let me just recap.  NEA had actually earlier provided $4.3 million in funding in 2005, just for the Town Council to help kick-start the dedicated mosquito control programme in the Town Council-maintained areas.  That does not include the funds that we ourselves put into increasing the number of staff for vector control, and so on.

     The new incentive scheme for Town Councils, which will be in place for two years, is estimated to cost us about $3.4 million a year.  Only Town Councils which have put in place dedicated mosquito control programmes in their estates, ie, they have source reduction via weekly inspections and checks for mosquito breeding sites, which has to be the principal control measure, then they are eligible to participate in the incentive scheme. 

     The scheme comprises a fixed co-funding component at 10% of the Town Council's contract sum and a variable reward component that is tied to the number of breedings as well as the number of blocks in the Town Council maintained estates.  So Town Councils with a higher number of breedings will receive smaller rewards or quantums, not higher, or none at all, if they actually exceed their threshold.  Rewards will be disbursed to eligible Town Councils on a monthly basis.

3.15 pm

     Dr Lim Wee Kiak: Mr Chairman, two points of clarification.

  First of all, I would like to thank the Minister for highlighting that there is generally an improvement, in terms of the dust pollution problem in Sembawang Town through the tripartite efforts of the shipyard, the NEA as well as the grassroots organisations.   The shipyard was there even before the flats were built. In fact, the shipyard is as old as I am.  The shipyard has currently spent a lot of money in terms of putting measures in place. Will the Ministry assist the shipyard, in terms of providing some financial incentive as well as providing some form of funding, so that it could put in more measures to control the problem better?

    The second point of clarification is on the safety of our inland waters. Will the Ministry consider setting up stations with telephones, whereby someone could call the ranger if there are some problems. These facilities are not available in our reservoirs as well as in our parks.  If something happens, we do not know how to call for help.

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, Dr Lim is right.  The shipyard has been there.  They have been doing their activities.  We control pollution at source.  So we work with shipyard.  If their emission exceeds the standard, we will penalise them.  I do not think there is a case for us to incentivise them.  We have to work together with them, and they have been more than cooperative in this particular instance.  We have to make sure that they meet our standards.  If they do not, we penalise them.  We will continue with that modus operandi.

    On the issue of safety in our waterways, I agree with Dr Lim that this must be in place.  Most of us have handphones. So it is very easy to call for help.  Perhaps, one way of doing this is to have certain signages so that people are kept informed of the numbers to call just in case of an accident.  I will ask PUB to study that.

     Mr Edwin Khew Teck Fook: Sir, just a point of clarification for the Minister.

     I understand that there are large sums of money that are going to be spent on R&D.  Is there a Masterplan on the EWI R&D for the next five years?  If there is not, can the private sector contribute to the Masterplan?

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, my apologies to Mr Khew.  He raised that question earlier.

    There is a Masterplan for the R&D.  We look at what are the capabilities that we have at this point in time and where we want to grow the sector. Based on that, together with an international advisory panel, our staff in EWI have been consulting and we have identified a few areas.  I do not have the details here.  I am more than happy to provide the information to Mr Khew.  We also consulted the private sector. We had dialogues with the various water companies to understand what are their concerns, what are the areas that they like to look into.  We set up the $100 million fund for R&D and we called for proposals.  We have criteria on how we select the projects that we want to fund, and these criteria are based on the Masterplan.  I will be happy to provide the details to Mr Khew later.

     Mr Zainudin Nordin (Bishan-Toa Payoh): Sir, just one point of clarification.  I am very happy by the efforts of the Government to lower the number of smokers in Singapore.  But there is always this observation that I made regarding the basements of major shopping centres and buildings.  Is there a misunderstanding that people think they can smoke in the basement of car parks in major buildings?

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, I have to check on that.  I am not sure whether there is a restriction on that, but I have to check.  In enclosed places, due to the secondary smoke effect, we do have restrictions.  I will check and get back to the Member on this.

     Dr Lam Pin Min: A point of clarification to the Senior Parliamentary Secretary. Although the size of a mosquito is small, the impact on our lives as well as the economic cost is quite significant, I believe, although we do not have any statistics to substantiate that. 

    In addition to vector control, I would like to urge the Ministry to also look into research and development of the dengue vaccine, because with the vaccine, we can solve most of the dengue woes that we are facing right now.

     Dr Amy Khor Lean Suan: Sir, we certainly agree. Although the size of the mosquito is small, we are not taking any chances and, therefore, we are enforcing very strict regime in mosquito control.  As regards research into the vaccine, certainly, EHI is also working with the Ministry of Health and other partners in the region to look into this.

     Mr Sam Tan Chin Siong (Tanjong Pagar): Sir, I would like to move from the mosquito problem to birds.  I notice that in many estates, there are always large crowds of birds gathered together to produce bird symphonies.  I know that NEA has been very effective in dealing with the problem of crows. I just wonder whether the Ministry has got any plans to deal with the bird symphony.

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, unfortunately, the birds do not listen to us.  But NEA will continue to cull crows as and when we receive feedback that the numbers are growing.  This is done not by NEA officers but we have outsourced to some private agencies.

     Mr Hri Kumar: Sir, a clarification. I accept that the purchase of a car is a lifestyle choice, but surely one of the most important considerations in making that choice is the cost. While hybrid cars are substantially more than equivalent petrol cars, most consumers will not make that choice.  Just as an example, the last time I checked, I do not believe that there is a hybrid car which is below $80,000.  I think the Minister missed out on the mass market car section.

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, the cost of a hybrid car depends on two things. 

     One, technology.  As we understand it, some American car makers are now looking into slightly less efficient hybrid cars, as compared to the Japanese model. That may lower the price.

     Second, is the question of volume.  It is a chicken-and-egg situation.  If more people are prepared to buy hybrid cars, more cars will be brought into Singapore.  I met up with Toyota in Japan about two years ago.  They told me that Singapore is not their primary market.  Their market is in America, where the Hollywood stars and other personalities who are more green in nature are prepared to purchase such cars as a lifestyle choice.  But as a consequence of that, the number of green cars have grown in America and the cost has begun to come down. 

     On our part, we will continue to work with MOF to see how much more we can move, in terms of the rebates, to encourage Singaporeans to take the first step.  I agree with Mr Hri Kumar that cost is an important factor and Singaporeans, by nature, are sensitive to cost.  So 40% is already a good start.

    But, at the same time, we should continue to encourage Singaporeans.  When we started the GVR, the number of the take-up rate was very low.  It was only about 70 car buyers.  Now, we have got 300 buyers.  I think this is a good sign.  More Singaporeans are turning to green vehicles and I think we should encourage it.  But I must also emphasise that our transport policy is not just about motor vehicles, but also about public transport.  We must also encourage Singaporeans to use public transport so that we can balance the modal split between public and private.

     Mr Liang Eng Hwa: Sir, I would like to get an indication from the Minister whether the Ministry will push for a smoking ban in public areas where there are children and children's facilities, such as outside the kindergartens or the playgrounds. Because I do not see these places as less important compared to the entertainment outlets.

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, it is difficult for us to enforce a ban in an open area. As I mentioned in my reply, we need to also give some space to smokers. I agree with him that it is not good or healthy for children to be in the vicinity of smokers.  I would urge kindergarten teachers not to bring their kids to playgrounds where there are smokers.  At the same time, we should also ask smokers not to hang around in the vicinity of kids. But all our kindergartens are smoke-free. We will continue to explore whether we want to extend the smoking ban to other public places.

     Mdm Ho Geok Choo: Mr Chairman, I wanted to ask the Minister whether he could elaborate on the haze grants. Specifically, what would they be used for and in which area?

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, at the last AMMH in Brunei, the Ministers directed the Secretariat to study the Haze Agreement in terms of the financial regulations.  At this point in time, we have to develop what we call "protocols" in terms of how the fund will be used.  It has not been developed as yet.  The agreement provides for a fund, but how it is going to be used will have to be developed by the ASEAN Secretariat.  But, certainly, I think the sentiment of the Ministers there is that we do not want to fund projects for putting out fires only.  Fire prevention will be our priority.  Singapore would want to see the money go into capacity building, training local plantation owners and farmers on alternative land clearing practices, and even buying of equipment.  Instead of burning, they could use tractors to clear the plantation.  These are areas in which we are going into, but the financial rules are being developed now.

     Dr Lily Neo: Mr Chairman, earlier, the Minister said that Singapore reclaimed land to cope with the sea level rise of 59 centimetres.  May I ask him whether he knows of the study which estimated that the sea level will rise to 140 centimetres?  Does it mean that the reclaimed land will be inundated should this happen?

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, the details of the fourth IPCC Report stated various scenarios at which water level may rise.  This fourth Report is a step better than the third Report where they put probabilities - likelihood, higher probability - on certain scenarios.  The 59 centimetres is the global average given in the fourth IPCC report.  As regards 140 centimetres, I am not sure where that was obtained by Dr Neo.  So, our provision for 125 centimetres above the highest recorded tide is sufficient to cover the 59 centimetres.  But as I mentioned in my reply, we are studying this in greater detail.  In fact, there is a committee led by MND to study what are the measures, after we have completed our impact studies, to make sure that we are safeguarded from any sea level rises in the impending future.

     Dr Teo Ho Pin: Sir, I do not think the 10% fixed and 90% variable mosquito fund is fair to the Town Councils, taking into consideration that 17% of the breeding grounds are due to littering, which is the responsibility of NEA.  I still hope that the Ministry can consider providing more fixed funds to support the Town Councils in its dengue prevention efforts.

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, let us put an end to this biting question.  This is a start.  I think we understand the role of Town Councils in dengue prevention and we appreciate the role of Town Councils.  We will continue to work together with the Town Councils.  I appreciate the fact that funding is an important part of this exercise. And this is the first scheme that we are testing out.  We will do it for the next two years.  We will work together with the Town Councils to appreciate better their demands, and we can review as we go along.  But let us have this scheme tested out first.  There is a fixed component, because we understand that there is some fixed cost, and if the Town Councils' performance is good, they will be able to get the remaining 90%.  So let us test it out first and then improve as we go along.

     Mdm Halimah Yacob (Jurong): The Minister has outlined various measures to cooperate on fighting the haze this year with Indonesia and other ASEAN countries.  I would like to ask the Minister, in the light of the recent sand ban and other developments, how will that affect the efforts at cooperation to fight the haze.

     Assoc. Prof. Dr Yaacob Ibrahim: Sir, I like to echo the response of Minister George Yeo yesterday during the Foreign Affairs' COS.  He said that we should look at these issues and how they affect our own interest.  Whether the sand ban continues or not, the haze, if it happens in Indonesia, will affect Singapore and, therefore, we have an interest.  Therefore, I see this as an important part of our effort to maintain the high air quality that we have here in Singapore.

     Notwithstanding whatever spats that we may have and in the interest of Singaporeans' health, we will continue to work with our Indonesian partners.  But we are realistic, as I mentioned in my reply, that there must be political will on the part of the Indonesian government.  Since the October meeting in Pekan Baru, a lot of things have happened and I am a bit more optimistic this time around that Indonesia is prepared to do its part.  The fact that they are prepared to put their targets out publicly shows a certain amount of commitment.  Will they achieve it?  We do not know.  We hope they will.  We will continue to work with them.  On Singapore's part, our role in Jambi will continue.  The workshop will continue next week.  We have informed the Indonesian Environment Minister.  He has given his blessings.  As I mentioned earlier, even the Governor is coming down next week because he wants to be hands-on on this.  If we can put the measures in place to prevent land and forest fires, then perhaps other provinces may want to replicate.  And in the long term, it will help us because then, we will have a haze-free region.

     Mr Charles Chong: Sir, I would like to thank the Minister and the Senior Parliamentary Secretary for their comprehensive responses. I think they have answered most of Members' questions to the best of their ability.

     With that, Sir, I beg leave to withdraw my amendment.

     Amendment, by leave, withdrawn.

     The sum of $469,055,490 for Head L stand part of the Main Estimates.

     The sum of $401,164,400 for Head L stand part of the Development Estimates.

     The Chairman:  Order.  I propose to take the 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 again at 3.50 pm.

Sitting accordingly suspended

at 3.25 pm until 3.50 pm.

                                    Sitting resumed at 3.50 pm

                                     [Mr Speaker in the Chair]

     Debate in Committee of Supply resumed.

                                     [Mr Speaker in the Chair]

     Head O  -  Ministry of Health

          The Chairman:  Head O, Ministry of Health.  Mdm Halimah.

     Mdm Halimah Yacob: Sir, I beg to move,

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

    Sir, much has been done to improve our healthcare system but affordability remains a concern.  The recent DOS statistics show that people are spending more on healthcare, which had gone up by 8% in 2005.  Out of a total healthcare expenditure of $5.9 billion last year, the Government's portion is only $1.7 billion, which means that people are bearing the bulk of the cost.  This has been the trend in the past and is likely to continue.  In this year's Budget, only $1.4 billion has been allocated as operating subvention to the restructured hospitals and institutions, polyclinics and VWOs to enable them to provide subsidised medical care.  Yet, the MOH estimated in the Budget this year that the average bill size for subsidised patients will increase further at a rate not exceeding the health CPI, which is usually higher than the general inflation rate.  So healthcare cost is going up faster than wages, particularly for those at the bottom 30th percentile whose wages have stagnated or declined.

     Sir, I would like to ask the Minister what more can be done to contain healthcare cost and ensure that healthcare remains affordable.  Is the amount of Government subvention given to hospitals and other institutions for subsidised patients sufficient, considering that our population is ageing very rapidly and the significant increase in the number of those suffering from chronic illnesses?

     Sir, it is true that we have high levels of subsidy for the B2 and C classes, but using the subsidy level alone as a reference point to determine affordability is not sufficient.

     MOH should also look at two other factors.  First, the subsidy should be based on the total bill and not only part of the bill.  In other words, when the hospital says that it is subsidising 80% of the bill for the C class, then this should cover all the items in the bill and not only some of them.  If the subsidy is not on the total bill and the patient has to pay the full cost of some items, then it actually means that the subsidy for the C class patient is less than 80%.  This is very hard on low-income patients especially if the items excluded from the subsidy are expensive, and most who are on long-term care would have exhausted all their savings.

     Sir, I would also like to ask the Minister to consider publicising the exclusion list of drugs and medical implants or accessories that are not covered by the subsidy or MediShield, so that people know upfront what is the total cost of treatment to them, as many believe that everything on the bill will be subsidised and they do get a shock when they receive their bill.  This exclusion list could be displayed on the Internet or other forms of communication.

     The Ministry could also track the total amount that the patient has to pay by treatment or procedures to determine affordability and if this keeps on increasing, then the hospitals should be asked to explain the reasons for the increase.  The subsidy levels can be high but if the hospital charges keep going up, then it would still be expensive for the subsidised patient as the portion that he has to pay will be higher too. 

     Sir, we must also ensure that public hospitals continuously look at ways to reduce wastage and unnecessary cost to the patient, and provide greater transparency.  The total project cost for the Computerised Physician Order Entry (CPOE) system and Inpatient Medication Records (IMR)Applications, for instance, for the two clusters alone is $41,905,000, which is a huge investment.  But the question is: how has this helped to reduce wastage arising from duplication or multiple tests done on the same patient, and how has this helped in seamless care?

      Sir, what cost savings or greater productivity can the public  expect from the $11.5 million investment in teleradiology - again not a small amount?  Or what is being done by the two hospital clusters to synergise and leverage on economies of scale in purchasing or other areas so that the cost savings can then be passed on to patients?  Why is there a need for each cluster to maintain duplicating areas of specialties, such as heart, cancer or eye, for instance?  Or now that we are trying to right site the management of chronic illnesses to primary care physicians, is there a need for a hospital to maintain a Diabetes Centre, which contradicts this effort?  

     Sir, what the public wants to see is greater accountability and transparency and concrete measures to address their concerns.  I urge the Ministry to keep a close watch on affordability, as this is still a concern for Singaporeans.  And I hope that the Minister can enlighten us on the issues that I have raised.

     Sir, I think the problem is also that the two healthcare clusters see themselves as competitors with their own priorities, rather than collaborators in delivering a very important public good, and that is in delivering an affordable and quality healthcare system.

     Next, SingaporeMedicine and Public Private Partnership.  The decision to attract one million foreign patients by 2012 is a very bold plan, and the economic arguments are clear.  However, there are concerns over how this will impact on subsidised patients when public hospitals too start chasing after foreign patients and treating them in the same hospitals as the subsidised patients. 

There are a number of issues here. Compared to other developed countries, the general sense is that there is no firewall when the doctors in public hospitals treat the private patients leading to concerns of conflict of interest.  So such concerns already exist now, hence, the question is whether it will be exacerbated when public hospitals start marketing and intensifying efforts to woo foreign patients.

4.00 pm

     The question being asked is whether this will dilute the public hospitals’ core mission of providing affordable healthcare to Singaporeans. There are concerns that this will happen because, in the first place, foreign patients who come here do so because they want better and faster treatment and will have to be given priority in the use of scarce hospital resources, such as access to specialists or the use of medical technology, if we want to establish a reputation and continue attracting them. As it is, we are already suffering from a shortage of doctors, nurses and other allied professionals. The moral hazard becomes even more evident when the remuneration package of doctors is structured in a way which will incentivise them to treat more foreign or fee-paying patients. We need to address these concerns as it would appear that there is a policy shift in our public hospitals from one where its social mission is to provide good quality affordable healthcare to Singaporeans to one, which includes a commercial mission also, of providing excellent medical care to foreign patients.

     Sir, I would like to ask what steps will be taken to ensure that subsidised patients will not be affected by the push to attract more fee-paying and foreign patients into the public hospitals.  What checks and balances are in place? Is there a need to adopt a more arms-length approach when public hospitals deal with private/foreign patients? Would it not be better for public hospitals that want to attract foreign patients to do so under a separate company, so that there is separate funding, accounting and full accountability to prevent concerns about conflict of interest from arising, as one of the complaints is that doctors in the public hospitals have the advantage of using the facilities funded by Government but yet do not face the risks undertaken by private hospitals. I think a more arms-length approach in wooing and treating foreign patients in the public hospitals is important. This will lead to better accountability in the use of public funds. It will also ensure that our public hospitals do not suffer from schizophrenia - a serious branding problem - unsure of how to project themselves and who they should serve, subsidised or richer foreign patients.

     Sir, I hope that the Minister would address some of the concerns and issues which I have raised.  I must emphasise again that our public healthcare system is one of the better ones in the world and a lot of good changes have been made over the past few years, which I must credit the Ministry.  But these two issues of affordability and the need to maintain and relook at structures and systems pertaining to the SingaporeMedicine and public/private hospitals are important issues of concern to Singaporeans.

     Dr Lily Neo: Mr Chairman, may I ask MOH what are its proactive plans in meeting the new challenges of our ageing population?  Is MOH expecting a ballooning demand for its services due to increasing life expectancy of people?  How is MOH strategising to meet this demand in terms of both the infrastructure and the medical expertise?  Is MOH prioritising preventive healthcare to keep the ageing population as healthy and fit for as long as possible?  Is there a need to manage and alleviate increasing demand for the dependence on acute hospital beds?  How does MOH plan to do this?  Should there be further improvements and enhancements in step-down care and community care?  Are there other viable solutions such as homecare system?  Has there been study done to better postulate on the future healthcare demand of our ageing population to help us plan better for this need?  How does MOH plan for the possible 6.5 million population growth in terms of healthcare? Does MOH have funding for this?  Finally, is there an urgent need to look at ways to improve the capabilities and capacities of geriatric medicine to meet the needs of our changing demography?

Health Insurance

     Mr Yeo Guat Kwang (Aljunied): Sir, the 3M (Medisave, Medishield and Medifund) system is one of the key pillars of our social safety net.  Through this financial framework, Singaporeans can better cope with the medical costs and able to enjoy favourable standards of medical care.  However, this framework provides just the basic.  We hope that more could be done to help Singaporeans understand better the healthcare challenges that they face and options available, eg, more comprehensive coverage for everyone and family. 

     To kick off, MOH could consider actually working hand in hand with the labour movement and the grassroots organisations to promote public awareness of medical insurance.  We need to help all to first understand the whole 3M framework fully and the need to get adequate personal and family medical insurance coverage to ensure that they can cope with hefty medical bills through better risk-pooling.  Singaporeans should also be encouraged to ensure that their spouse and children also have adequate medical insurance coverage, with at least Medishield coverage. 

     I welcome the announcement by the Minister to make Medishield an opt-out scheme for the young.  In fact, we should also consider actually making it an opt-out scheme at the point of marriage for all the housewives, so that all the men can easily include their wife who might not have been able to make contribution to CPF.

     Sir, to strengthen our healthcare financing framework, we should also encourage Singaporeans to take up private enhanced Shield plan and, if need be, additional rider insurance scheme.  This will ensure that working Singaporeans will not be dependent on or shortchanged by the loss of group hospitalisation and surgical insurance schemes that are in force, only if the individual remains in the company's employment.  As lifelong employment is no longer prevalent in view of changing employment trends, working Singaporeans need a more comprehensive and integrated portable medical insurance scheme that is built upon the basic Medishield plan. 

    Sir, through greater awareness concerning the variety of the medical insurance policies available, individual Singaporeans then can better tailor their medical coverage to suit their needs. 

Portable Medical Benefits Scheme

     Ms Cham Hui Fong (Nominated Member): Singapore's healthcare financing framework aims to ensure fiscal sustainability and affordability for all Singaporeans.  The 3M framework has worked well over the years and the linking of the Workfare to the CPF or Medisave should encourage more Singaporeans to join the social safety net. 

     For regular employees, most are already provided hospitalisation benefits by their companies while they are in employment, while most of the contract and the casual workers do not have such benefits.  

     Currently, Medisave can be used to purchase Shield plans or other Medisave-approved insurance scheme with co-payment and deductibles.  We agree that this is a sound principle as it helps to eliminate the buffet syndrome.  However, the employment landscape has changed over the years.  There is now high turnover in the job market due to attrition, restructuring and many other reasons.  So, while one is out of employment, especially for the lower-income workers, the only insurance he will have is probably the Medishield, that is provided he has not opted out. 

     Some insurance companies have introduced rider plans which help to cover for medical expenditure not covered by the Shield plans.  Such scheme can be individual based and is portable. So, the tripartite partners, together with MOH, have discussed about the portable medical benefits scheme and the transferable medical insurance scheme (TMIS) for many years.  The Economic Review Committee has also suggested that we promote both the PMBS and TMIS, but over the years, we have made very little success with both schemes to date.

    As at end November 2005, only 109 companies have made additional contributions to the employees' Medisave.  There is mention of insurance playing an even larger role in Singapore's healthcare financing in the MOH's Budget report.  May I ask what kind of enhancement in the insurance design is the Ministry looking at?  In the meantime, with more workers on Medisave, will the Ministry also review the use of Medisave for purchase of at least a basic Medishield rider, subject to a cap, just as what the Ministry has mentioned recently about using Medisave to purchase the Eldershield rider, subject to a cap?

     With the withdrawal of medical subsidies for the foreign workers, employers are now obliged to purchase compulsory medical insurance for their foreign workers.  From what I know, most of our Singaporean contract or casual workers do not have any hospitalisation medical insurance for themselves.  While we are not asking for the Government to pay for them, can we at least allow them to use their own Medisave money to purchase for this rider?  This will at least give them some certainties about their in-patient expenses.  With the Government topping up Medisave contribution to the casual and the informal workers, allowing the use of part Medisave for rider scheme will certainly benefit those casual workers with no medical coverage by their employers.  It will also help us to encourage more to join the CPF scheme.

Medisave

     Mr Low Thia Khiang (Hougang): Mr Chairman, Sir, the Government has allowed Medisave to be used in the Chronic Disease Management Programme with the following conditions: A deductible of $30 is set on each outpatient bill; bills below $30 will continue to be paid in cash; a cash co-payment of 15% on each outpatient bill in excess of the deductible will be set; and an annual withdrawal limit of $300 per Medisave account. 

     Sir, I would like to know what is the average bill size incurred by such patients at polyclinics.  The feedback I had was that the majority of patients seeking treatment for chronic diseases at polyclinics would cost around $40 to $50 for a two-monthly review.

     Due to the $30 deductible, the amount of benefit to patients from using Medisave to defray the cash payment under the Chronic Disease Management Programme is minimal, since based on the average bill size of $40 to $50, only about $10 to $20 is payable using Medisave.  On top of this, an administrative fee of $4 is also levied. It seems that the effect of the $30 deductible and co-payment requirement runs contrary to the intention to ease the financial burden of the patients who have chronic disease.

     Many of such patients are senior citizens with no active income and are relying on their cash savings and children's contribution to pay their medical bills.  The deductible and co-payment requirement pose the same heavy burden as before.  So, I would urge the MOH to consider reducing or waiving the deductible of $30 and cash co-payment for senior citizens who have reached retirement age, but maintain the annual withdrawal limit of $300.  I am also of the view that MOH should also consider waiving the $4 administrative charge, since this charge will be significant compared to the actual bill which will be incurred by this group of patients.

Awareness of Medisave, MediShield and Medifund

     Dr Muhammad Faishal Ibrahim: Sir, in recent years, we have seen various efforts by the Ministry of Health to make changes to the health system, particularly in the use of the Medisave to enhance its relevance to the changing needs of the society.  These changes have been well received, in particular to those who have been following the news and are affected by health issues.  I believe this has certainly enhanced the level of confidence in our health system. 

     As one grows older and with an ageing population in the horizon, I think it is natural for an individual, as well as a society, to be concerned about health issues.  As Singaporeans, we often hear about the 3M being one of our safety nets.  However, during  my block visits, I often meet elderly and low-income residents relating their concern about health matters.  When I asked them about the concept of 3M and if they understood what Medisave, MediShield and Medifund meant to them, the majority of them did not have a full understanding about this. 

     To go on further, I did ask more than 100 students the same question.  I received similar answer and they told me they have not come to that stage yet.  While many understand about Medisave, the majority of those I spoke to did not have a full understanding about Medishield and Medifund.  Wherever possible, I try to explain to them as well as work with my grassroots leaders to disseminate the information to my residents. 

     I would like to ask the Minister on the measures to enhance the awareness and understanding of the concept of the 3M, as well as individually, namely, Medishield, Medisave and Medifund.  Are there any specific measures to reach out to the elderly and low-income Singaporeans?  In addition, are our students well informed about such concepts as part of their school syllabus?  What are the plans of the Ministry to increase the participation rate in this scheme?

Manpower Development

     Mdm Halimah Yacob: There is a shortage of doctors, nurses and allied professionals in the healthcare sector.  The situation will get worse as demand goes up due to an ageing population and the decision to attract one million foreign patients.  Could the Minister give an update on the manpower situation and what plans the Ministry has to address this problem, so as not to affect the standard of medical care in Singapore?  What more can be done to increase the supply without compromising standards, as there are also some concerns over the recent liberalisation of the registration process for foreign doctors and the addition of new foreign medical schools on the list.

     Sir, while we are training more nurses in the polytechnics, retention is an issue as the attrition rate is high.  After SARS, many were attracted to the nursing profession, which suddenly became glamorous, but reality sets in when they are posted to hospitals and find that the work is not suitable for them.  So, there is a need to find a better fit.  Recently, nurses' pay were raised and they also now have better career progression leading to the APNs, but for allied professionals, the situation does not seem to have improved as they feel that there is better recognition for them in the US and other developed countries

where they are treated as professionals compared to Singapore.

 4.15 pm

    Sir, as most of the nurses are women, could the hospitals consider providing more flexible work options so that they do not have to leave the service after having babies?  The other option which the hospitals could also consider is re-employing people beyond the age of 62, ie, extending the re-employment. And I would like to commend SGH for their Silver Connect programme which is an excellent programme.  I hope all the other hospitals would also emulate that programme.

     Finally, Sir, there is also a concern among the APNs that, while they are required to take over some of the tasks of doctors, they feel that they are not sufficiently protected, in terms of litigation or other actions taken against them.  Apparently, doctors have better protection compared to them.  So the APNs are concerned about that. They also would like to be given the chance to have more challenging tasks assigned to them in the hospitals.  Could the Minister please look at these issues?

     Dr Fatimah Lateef (Marine Parade): Sir, with the current doctor to patient ratios, many studies have shown that it is going to be a big challenge for the elderly in many ageing nations to receive the optimal holistic care they require.  Unless we can make managing healthcare issues of the elderly top priority, the supply of trained healthcare personnel will be insufficient to meet our elderly explosion.  Currently, there are only a handful of geriatricians in Singapore.  The British Geriatrics Society recommends one consultant geriatrician for 4,000 population over 75 years, or one consultant per 50,000 general population, and this refers to a full-time consultant.  A significant proportion of the healthcare budget is allocated towards manpower training and upgrading.  Can the Minister please share with us the numbers of doctors and nurses who have received specialised training in disciplines, such as geriatrics, psychological medicine and psycho-geriatrics?  And also, will the Ministry of Health be opening up the number of slots available for basic and advanced training in these disciplines over the next five to 10 years?  We need to attract more young and interested doctors and nurses into these areas and we are still short of role models and mentors for them locally.

     Finally, Sir, I also have a suggestion to add.  Geriatricians must be utilised more efficiently.  They should not become adjunct primary healthcare providers, but instead be allowed to focus on age-related syndromes that fall through the cracks.  We cannot overload the limited number of geriatricians we are going to have. Rather than being a vertical discipline which focuses on one area or one organ system, geriatricians will manage diseases in a horizontal fashion, cutting across organs and systems.  We should also, on the other hand, train every medical student, every medical officer and every trainee with some basic knowledge of geriatrics.  This is because not every old person needs a geriatrician, but every physician needs to have some training in geriatrics.

     Mr Zainudin Nordin (Bishan-Toa Payoh): Sir, with the development of the new hospital in the north of Singapore, I would like to know whether we have enough medical officers to cope with the Health Ministry that is growing at the moment.  Specifically, Sir, I would like to know how is the progress of our training for nurses and what is the quality of our nurses compared to the other developing and developed countries.  I would also like to know whether the number of nurses that we are training is enough and are we producing enough Advanced Practice Nurses (APNs) that are equipped with up-to-date and advanced skills to reduce the over-dependency on doctors to perform basic operations, like what is being practised in the developed countries.

     I would like to echo the same comments made by the GPC Chair about the need for us to protect our APNs more. Because if we want to treat the professional nurses as equal partners in the treating of our patients, we also need to give them proper protection so that they can do their job better and perform their task better.  May I also ask the Minister what is the progress of our hospital in the north?  Is the progress up-to-date and when can we expect the hospital to be ready?

     The Minister for Health (Mr Khaw Boon Wan): Sir, this is my 4th Health Budget. Having dealt with the more immediate issues for three years, I will from now on focus on gearing up Singapore for its 2020 healthcare needs.

     Sir, I will be 68 by then.  My wife and I will be silver haired.  What about you, Sir?  Actually, I am already silver haired, except for the wonders of hair dye. My daughters should be married by then and, hopefully, we will have a hall full of grandchildren. My family and I would need much more healthcare than we do now.  That is why I am most mindful that 2020 is only 13 years to go. We must not let it slip by casually.  The questions posed by Mdm Halimah, Dr Lily Neo and Members are all pertinent ones.  We must find answers to those questions over the next few months and continue to refine them over the next few years.

     The socio-demographic changes to come are well known.  Still, it is worth highlighting what are the key factors that would significantly impact our future healthcare demands.  Most Singaporeans would be better educated, have higher expectations and they want high-quality care and, I hope, they are able and also willing to pay for it.  But for the bottom 20% or 30% striving to cope with global competition, money will always be tight and healthcare cost will be their key concern.

     The number of people above 65 will increase; fortunately, most will be healthy and well.  Many will however be health conscious and will seek medical attention without hesitation to address any discomfort or just to get a reassurance.  The number of "old-old", exceeding 80 years, will increase many-fold.  By the time they hit this age, many will have some medical problems.  Just now, over tea break, I remember discussing this particular problem of elderly patients with Mdm Cynthia Phua and Ms Denise Phua.  Many will be financially comfortable, but there will be a sizeable number who will be very tight financially.

     Scientific discoveries and medical technologies will accelerate and make available diagnostic and treatment modalities that we can only dream of today.  But many of these will be costly and the companies are not going to give it away for free.

    Clearly, one size cannot fit all. As Health Minister, my duty is to put the big pieces in place so that, by 2020, we will have a healthcare system that offers a whole spectrum of care that meets the needs of the young and the old, the rich and the poor and the large numbers in between, and we have the financial resources to pay for them. So, let me start with funding.

     In the musical cabaret, Liza Minnelli had that popular line, "Money makes the world go round" and our Jack Neo made "Money no enough" part of our psyche.  Money does not make the world go round, people do.  And we will have money for healthcare if we save for it, have the right expectations and do not waste it.

     What are the realities of healthcare?  Everyone will need it, most of them towards the latter part of life when they are not at their peak in earnings.  Social welfare and comprehensive insurance are seductive ideas - no need  for co-payment, make it free at the time of consumption, so that nobody needs to worry about healthcare cost.  But we all know that both lead to the "buffet syndrome" of abuses, over-servicing and financial disaster.  And when the healthcare system is overwhelmed, it is the poor who suffer because unlike the rich, they cannot afford the other alternatives. The truth is that healthcare demand is unlimited but supply is, because not many people are willing to pay more taxes or insurance premiums, which are needed to expand supply.

     The rational approach is therefore to require some co-payment by patients.  Co-payment makes a dramatic difference to patient behaviour and even doctors' behaviour. For everyone to afford the co-payment, we have  to get everyone to save through Medisave for a rainy day. And, on top of that, we pool the risks through a basic insurance plan, MediShield, as a backup.  Finally, we provide sensible social welfare through Medifund as the ultimate safety net. This is how we tackle our financing challenge, with 3Ms providing multiple layers of safety nets. Each layer does not cover everybody, but together the multiple layers of safety net cover everyone.  Dr Faishal asked that we explain our healthcare financing schemes more thoroughly and frequently to Singaporeans. I fully agree, and we will.  We must keep the schemes easy to understand, because healthcare can sometimes be very complex.  And we will improve our public communication efforts. Let me use this opportunity to reiterate our model.

     For minor treatment and healthcare needs at GPs and polyclinics, $20, $30, $40, or even $50, I think, preferably use cash. Our GP services are very competitive, inexpensive and affordable for most people.  But for larger medical expenses that require hospitalisation, our Medisave scheme is working as designed, especially after we have fine-tuned it in recent years. Every year, some half a million transactions are funded through Medisave.  I have now extended Medisave to cover outpatient treatment of four common chronic diseases. And the full impact will be felt over the years when the scheme matures. I am optimistic that, if participating chronic patients cooperate with their family physicians and actively change their lifestyle, comply with medication, their health would improve.  This will avoid future complications and save patients money and suffering.

    Mr Low Thia Khiang asked that we remove or reduce the cash co-payment; I think that will be unwise.  Remember that Medisave was not designed for outpatient care.  I make an exception here, and we must not unwittingly deplete it for purposes not originally planned.  Because if you do, then the contribution rate will not be enough.  You have to raise the contribution rate.

     Collectively, there are now $36 billion in our Medisave Accounts today, and this is still growing at more than $1 billion a year.  This is healthy but only because we are still a very young society.  Medisave is our savings for the future when we will all grow old. The only structural problem now is that some Singaporeans, a minority, are not saving.  They are naturally worried about healthcare cost.  The solution is not to make healthcare free but to get them to save.  Workfare and Government top-ups will help them build up their Medisave for the future rainy day.  But they must themselves make some effort.

     For larger medical expenses requiring intensive and prolonged hospitalisation, we have MediShield.  After the reform in 2005, it is now working better.  We will continue to refine it to reduce the co-payment by patients, but we must not make it a comprehensive medical insurance scheme without any need for co-payment.  Some insurers sell MediShield riders to eliminate co-payment.  This is not wise and we do not encourage this.  That is why we do not allow Medisave to pay for the premiums of such riders, as proposed by NMP Cham Hui Fong.  But if Singaporeans want to buy such riders out of their cash savings, I cannot stop them.

     I have a couple of ideas to enhance MediShield further.  MediShield coverage among active workers is not bad, 90%, nine in 10 workers.  But 390,000 Singaporeans below 20 years of age are still not insured.  The premium at their age is inexpensive. It is only $30 a year.  And young parents can use their Baby Bonus to pay for the premium in full.  So cost is not an issue.  Many parents already do so, in fact, about half of our youths are covered by the enhanced MediShield promoted by private insurers.  Some parents who did not do so told me that they know MediShield is a good product, but inertia is the reason for their lack of participation.

      I will make it easier for these parents to sign on their children for basic MediShield coverage.  We will introduce an opt-out scheme for infants to be automatically covered under MediShield from the time their births are registered.  Premiums can be deducted from their fathers' Medisave Accounts or, alternatively, their mothers'. Parents who do not want such coverage can opt out any time by informing the CPF Board.  We would get this done soon so that all babies born on Christmas can have MediShield.  I would try to get it done hopefully in less than nine months so that some babies who are already conceived can also benefit from it.

     For those who are already born but below seven, we will work with the Ministry of Education to provide this opt-out service at the time of Primary 1 registration.  For older students, we will work with MOE to see how we can get them in as a one-off exercise.  I think this can happen next year.

4.30 pm

     I thank Mr Yeo Guat Kwang for his support of the measure, and I hope all parents will support it too.  It will be good for their children.  To keep basic premiums affordable for the majority, MediShield will continue to exclude coverage of congenital illnesses.  But for the vast majority, MediShield coverage from young will give parents peace of mind that, should their children develop any illnesses as they grow up, they will have insurance coverage for such illnesses and the subsequent treatment.  After I have brought the children into MediShield, I will see how best to bring in the 100,000 or so housewives who are still outside MediShield.  I will study Mr Yeo Guat Kwang's suggestion for an opt-out scheme for husbands to sign on their wives.  Actually this is already the case.  At the time of marriage, there is this opt-out scheme in place.  But for some couples, after marriage, somehow, some husbands decided to opt out their wives.  We have to find some way to get them in. 

     Medifund provides the ultimate safety net to catch anyone who drops through the Medisave and MediShield nets.  We aim to build up Medifund to a capital sum of $2 billion.  So this year, the Government has topped up with $200 million, making it now $1.5 billion.  Every year, we make use of the interest income to help those who fall through the net.  Our hospital Medifund committees work very hard to prevent any Singaporeans from falling through the cracks.  These are good-hearted, busy and successful people who volunteer their time, expertise and wisdom to help us manage this piece of social welfare in a wise and compassionate manner.

[Mdm Deputy Speaker (Ms Indranee Rajah) in the Chair]

4.31 pm

     Last year, Medifund handed out $40 million to 290,000 applications for financial assistance.  About one-third of these beneficiaries are over the age of 65.  With ageing, we know that such demand will only grow.  We need to build up Medifund when our economy is doing well and whenever there are budget surpluses.  Some elderly patients are worried if their Medifund needs will be squeezed out by the needs of their younger applicants, and I get such feedback occasionally.  We have reassured them that all cases will be assessed based on needs, and that we do not bias our decisions towards the young or the old.  However, we will give our senior citizens added peace of mind.  I am thinking about carving out a portion of Medifund, ringfence it as the Medifund for the elderly.  We can call it Medifund-Silver, protected for the use of needy senior citizens above 65.  It can have a capital sum of $500 million, about a third of the entire Medifund today.  This way, we can address the needs of the elderly patients in a more targeted manner. 

     With the financial resources through the 3M system, we can then work to match supply of physical resources with demand.  Just to maintain this year's standard of care, in the year 2020, we will need more hospital beds, clinics, doctors and nurses than what we have today.  That is why we are building a new general hospital of 550 beds in Yishun.  When it fully opens in 2010, our acute hospital beds in the public sector will total 6,500.  But between now and then, we will add beds, where there are opportunities to do so.  This year, for instance, we will add 120 beds in Tan Tock Seng Hospital, Changi General Hospital and National University Hospital.

     In parallel, we will continue to expand day surgeries to reduce unnecessary hospitalisation.  Last year, I remember discussing the Jurong Medical Centre idea.  It has now materialised.  I visited it not long ago and am very pleased with the development there.  Alexandra Hospital, which runs it, has started to systematically transfer their day surgeries and outpatient follow-ups for their patients who live in Jurong.  This brings good specialist services closer to their homes.  The patients I spoke to were very happy with the change.

     The private hospitals will also need to expand to cope with rising demand.  They are important partners, serving the middle and higher-income groups, or about 20% of the national patient load.  They provide Singaporeans with more choices.  As our medical standard is high and our fees internationally competitive, naturally we attract many foreign patients in the last few years, increasing by more than 20% a year.  It could actually have been higher, but the private hospitals had under-invested in the past and they are now missing out on opportunities.

     EDB’s feedback is that private hospitals are now ready to invest and expand their capacity.  There are also international investors who are interested in setting up in Singapore.  The Government intends to launch two land sites for private hospital use in the second half of this year, so this will be quite soon:  one near the Novena MRT Station by URA, another within One-North by JTC.  Both sites can add about 400 beds to the private hospital bed capacity, which is quite significant.  Meanwhile, we are also preparing other sites for possible release in the next few years.

     The beds described above are acute hospital beds.  But healthcare is more than that.  As emphasised by Mdm Halimah and Dr Lily Neo, with ageing, there will be increasing demand for longer-stay, lower-cost, lower-tech facilities in the step-down care sector.  We will need more community hospitals, nursing homes, hospices and day-care facilities for rehabilitation and home-nursing services. 

     We have not had to pay much attention to this sector as our population is still young.  But by 2020, the needs for step-down care will be significant.  To gear up for 2020, we have to ramp up supply and systems from now on.  Briefly, we need to do four things for step-down care.

     First, we need to expand capacity.  We are reviewing the requirements for community hospitals and nursing homes, and will facilitate investments at the appropriate time. 

     
     Second, we need to widen participation by all providers in this sector because the needs of the elderly are diverse, from the higher-income to the indigent.  Today, our step-down care facilities are largely run by charities and they do a reasonable job.  But higher-quality nursing homes to serve the needs of the middle-class elderly are still in the early developmental stage.  We must widen the range of choices, at different pricing levels and at different service standards.  It costs much more to run Ritz-Carlton than Hotel 81.  If Ritz-Carlton were to charge less than Hotel 81 or the same, there would be a long queue outside Ritz-Carlton and Hotel 81 will be empty.  But because hotel pricing is sensible and undistorted by Government subsidies, both businesses are full with their respective clientele.  I know some might not agree that the economics of healthcare should be the same as the economics of hotel services.  But the reality is that healthcare services need to be financially viable in the long run, and there is no other way.  Even if the Government pays for it, it is still taxpayers’ money.

     Third, we need to attract more allied health staff to this sector - and several Members talked about this - with better skills and higher education level, to service the rising demand for a higher level of care.  We will need more physiotherapists, speech therapists, occupational therapists, podiatrists, counsellors, psychologists and also doctors and nurses with skills in geriatric medicine, as highlighted by both Dr Lily Neo and Dr Fatimah Lateef.  We will also push up the skills of our nurses so that they can take over those routine tasks from doctors, as advocated by Mr Zainudin Nordin.  We call them Advanced Practice Nurses (APNs).  I remember we discussed this in this House when I moved the Nurses and Midwives (Amendment) Bill two years ago.  I have noted the point about liability issues and I will take a look.  I am sure our cluster would have adequate coverage for them but I will take a look. 

     Fourth, we need to address the financing of this sector.  The needy will need some subsidy by Government or charities.  But with healthy competition among providers, the majority of patients should be able to self-fund either through savings and/or long-term disability insurance, like ElderShield.  ElderShield, as a product, is rather new to Singaporeans.  I agree with Mr Yeo Guat Kwang that we should educate the public more on the different types of insurance products and their users.  For example, there is still confusion between MediShield and ElderShield.  MediShield is for acute hospitalisation, with payouts based on reimbursements.  But ElderShield is a cash supplement for step-down care in the community, often at home or in a nursing home.

     I am reforming ElderShield to make it work better for Singaporeans with their needs in 2020 in mind.  I shared my thoughts on this during my recent Ministerial walkabout.  I will continue the public consultation and welcome feedback and suggestions.  We will get the reform implemented this year. 

     Beyond financial and physical resources, human resources are the key to a good healthcare system, as highlighted by Mdm Halimah and Mr Zainudin Nordin.  Our doctors, nurses, allied health professionals and other support staff work very hard in public hospitals and polyclinics.  To keep healthcare cost low, we run our facilities at very high occupancy rates.  Our doctors and nurses see many more patients than their counterparts elsewhere.  If not for their sense of public duty, many would have quit for an easier time.

     Yes, we may have service lapses at times.  But most of the time, our healthcare workers do a competent job, and often go beyond the call of duty.  They do not expect gratitude, although we do receive many complimentary letters that cheer them up and keep their morale high.  So, please, give them your moral support.  They are the unsung heroes and heroines of our excellent healthcare system.  They deserve our appreciation and understanding. 

     Medical specialists take a long time to train.  It is especially difficult to get manpower planning right in Singapore because we have a significant foreign patient load which fluctuates from year to year.  I have noted Mdm Halimah’s comment on SingaporeMedicine and foreign patients and their possible impact on local patients.  I will address them in my next speech.  Meanwhile, we are recognising more good medical degrees and we are recruiting more foreign-trained doctors.  From about 85 a year in 2003, last year, we took in 180 foreign-trained doctors from very good medical schools, bearing in mind we ourselves produce only 230 last year.  So it is almost one to one.  This is good, but we remain particularly short of certain specialists who are also in huge global demand, like renal physicians, neurologists and cancer specialists.  We have to devise more effective schemes to attract such specialists from abroad to augment our team.

     As I said earlier, we will also pay attention to the allied health professionals.  The good news is that many more excellent students have been entering nursing, pharmacy, radiography, therapy and other courses in recent years.  They are bringing up and changing the profile of our allied health workers.  Many existing staff are also upgrading themselves.  We encourage and facilitate this through many scholarships and overseas attachments.  Our healthcare team is getting stronger.

     Students and mid-career Singaporeans are discovering the job satisfaction of a healthcare career.  We must be doing something right in our hospitals.  We will press on.  Recently, I suggested to my parliamentary neighbour, NTUC Secretary-General Mr Lim Swee Say and also WDA’s CEO, that let us work together to get more mid-career workers to work in hospitals.  We have a successful scheme for nurses.  Let us now promote other professions like physiotherapists, speech therapists, podiatrists, and so on.  At the same time, we will work hard to retain staff.  This requires us to keep our wages competitive.  This is also the reason why medical fees need to be raised periodically because manpower cost is a major component, more than half, of our medical cost. 

     Sir, let me conclude.  Gearing up for 2020 does not mean that we can simply do more of the same, because patients’ expectations are changing.  Patients Google the latest information on their illnesses and treatment options, and want to engage the doctors in our treatment choices.  This is good, but it means a longer consultation time.  Such patients will not be satisfied with a 10-minute consultation.  But if everyone demands a 20-minute consultation, we will have to double our doctor-patient ratio, double the number of doctors and, of course, double the unit cost of treatment.

     We will maintain our current subsidy policy of Class C patients paying 20% of cost, polyclinics, 50% of cost, and so on.  But when unit cost goes up in line with a higher standard of care, the dollar co-payment by patients will have to go up accordingly.  These are the types of adjustments that Singapore

will need to make over the next 13 years, if we want the medical standard of Singapore at 2020 to match the expectations of Singaporeans and to stay ahead of our neighbours. In practice - let me assure Mdm Halimah and other Members - we will weave in such adjustments gradually, compassionately and pragmatically.

4.45 pm

    We will pace the adjustments according to what Singaporeans can afford.  Maybe, a couple of hospitals can move ahead slightly faster than others. All hospitals will receive the same unit subvention from my Ministry for the same illnesses, and all patients will receive competent medical care.  But the hospitals, which can offer shorter waiting time because they have a higher doctor-patient ratio, will need to cover their higher operating costs with slightly higher fees. 

    My mission is to ensure that our healthcare services remain affordable to Singaporeans in general, particularly the lower half of the population.  It requires careful planning and cooperation from all the stakeholders.  It requires all of us to have realistic expectations. My Ministry will do its best to expand our capacity and our service levels to meet up with the rising demand and rising expectations. That is why the Finance Minister, in his Budget Speech, talked about healthcare budget, rising from about $2 billion to $3 billion within five years.  This is a very substantial expansion in the Government's commitment to healthcare.  My job is to make sure that the funds are wisely spent.

Management of Chronic Illnesses

     Mdm Halimah Yacob: Mdm Deputy Speaker, for chronic illnesses to be managed effectively, we require a well-functioning and effective primary care system. This is one weakness in our healthcare system, as a result of which there is a high dependence on specialists pushing healthcare costs up.  So there is a need to expedite the training of GPs as family physicians to take care of the chronically ill.  Could I ask the Minister to give us an update on this and other measures to better manage chronic illnesses in Singapore? 

    One major complaint of the elderly suffering from chronic illnesses is the poor integration of services from the hospital to step-down care, such as community hospital or nursing home, which are subject to means-testing and are under-funded as they enjoy lower subsidies.  There are also insufficient homecare services for those suffering from chronic illnesses and there is no subsidy for such services which act as a deterrent for families to take care of the elderly sick at home.  So, what more can be done to ensure better integration of services for the elderly sick suffering from chronic illnesses?

    Could the Minister consider extending the same level of subsidy to the step-down care services as the ones that are found in the hospital and do away with the requirement for means-testing for those moving from the hospitals to step-down care?  Because once they are out of the hospitals, they go through any means-testing for step-down care and sometimes, they do not get subsidies as a result of that.  As a result, patients do not want to move from the hospitals to the step-down care. Also, the level of subsidies are different compared to the hospitals and the step-down care.

    Could the Minister consider extending subsidies to the elderly sick who are taken care of at home to lessen the burden of families and reduce the overload on hospitals? Because there are some families who want to take out the elderly sick, but they do not have any subsidies for providing homecare services to their parents or elderly sick. Could the Minister also look into that?

    One final point is that I support the ElderShield changes.  Could the Minister review the qualifying criteria, which I think are too stringent and many do not qualify?

Focus on Patients

     Mr Sam Tan Chin Siong: Madam, the Ministry of Health has been given an extra $300 million in this Budget.  So, the Ministry has more money to spend in this financial year.  My concern, and I am sure the Minister's as well, is that the fund should go to the right places.

    To begin with, I must say that our restructured hospitals are already one of the best, if not the best, in the region.  However, like many other things, there is always room for improvement.  In my opinion, building a large water feature, three-man high and about the length of a small swimming pool, in a place mostly meant for hospital staff, is not the best way to spend the money.  Hiring high profile consultants at millions of dollars is not the best way either.  Having more non-professional than professional directors is also not the best way too.  Yet, all these are being done in a large restructured hospital.

     I believe we can afford to be more restrained in our landscaping and renovations in our restructured hospitals, especially those at the staff block where few patients go to.

    Madam, my second point is more paradoxical.  I believe that our restructured hospitals should be more concerned with taking care of patients than the bottom line.  It is good to be able to say that our private patients subsidise our public patients, and hence, each hospital is able to cut its spending, require less funding support from the Government, and lower the tax burden on Singaporeans.

    To me, this is an attractive argument but not a convincing one.  I feel that our restructured hospitals should not be in the business of competing with private hospitals to improve their bottom line.  My GPC Chairperson had elaborated on this point in her speech just now.  I fully agree with her that our restructured hospitals should focus on taking care of the public patients and improving their services. 

      I would like to share a personal experience at a large restructured hospital recently to illustrate the importance of patient care.  A few weeks ago, I visited a relative and found him to be quite ill.  So I accompanied him to a restructured hospital.  He was sent to the A&E Department around 2.30 pm.  Within an hour, the A&E doctor had examined him, and informed us that he needed to be hospitalised for treatment.  This was an excellent and speedy action taken by the doctor, and I think the doctor deserved a commendation. We were told to wait for a ward and a bed.  At 5.00 pm, the ward admission procedure was done as a bed had been made available.  However, from 5.00 pm to 7.00 pm, the patient and family members were made to wait outside the A&E Department.  Despite making four enquires on the status, the patient was still left at the A&E Department.  At 7.00 pm, I finally went up to the A&E counter to enquire about the long wait.  The nurse on duty checked and explained that due to manpower shortage, they could not send the patient to the ward early.

   I am not sure whether it is manpower shortage or communication gap, or both, that had resulted in two hours of unnecessary waiting time.  This is not a unique experience to us.  I asked some people waiting around at the A&E Department, and they told me they had been waiting for between four and six hours, and they were still waiting.

     Long waiting time is just one of the many complaints we often hear from people, or read about in the newspapers' Forum articles.  Indeed, Lianhe Zaobao carried two more complaints on 12th February 2007 and yesterday.  While acknowledging the hardwork and good work of our healthcare professionals, I think the service gaps need to be plugged.  While focusing on improving the facilities and amenities, I feel that the restructured hospitals should adopt a patient-centric approach in providing medical care and services.

     While we strive to become a medical hub, we need to ensure that our focus remains on patient care, not just making sure that our hospitals can attract more foreign and well-paying private patients, not just making sure that doctors and nurses are well trained, not just making sure that we have the state-of-the-art equipment, but also making sure that we turn our attention to things that matter to the patients and their families.

    With so many medical advances today and even more rapid advances tomorrow, I am sure that the care for the patient can only become more complicated and sophisticated with an ageing population, and all the more reason then to focus on getting our basics right.

     The Chairman:  Mr Low Thia Khiang, you might like to take both your cuts together.

Healthcare Cluster

     Mr Low Thia Khiang: The healthcare clusters, mainly SingHealth Group and the National Healthcare Group, were set up when public hospitals were restructured in the 1990s.  In my view, it seems that the intended objective of promoting competition with the presence of two healthcare clusters has led to some unnecessary shortcomings and wastage as a result of this artificial market competition created. 

   Firstly, there is duplication of services. All public hospitals have cardiology, respiratory unit, ENT, Eye Department, etc.  These disciplines require costly specialised equipment.

     Secondly, having two clusters incur double the overhead costs, such as manpower and resources in administration, corporate support functions, as well as management staff needed to manage these two clusters.

     Thirdly, there are different IT set-ups and technical requirements for the two clusters, for example, the software used by SingHealth and NHG Polyclinic is different and not integrated.  When a patient changes his healthcare provider from one cluster to another, the patient's record cannot be transferred seamlessly between the two clusters because they are not integrated.  This lack of integration increases the administrative hassle and potentially impacts the efficiency and effectiveness of delivering healthcare, particularly for patients who have chronic diseases, such as hypertension and diabetes. This is because the patient's history is critical for proper referral to ensure a complete handling over of care between the previous and the current doctor managing the patient. The two clusters may also have different policies and treatment protocols. This may also result in confusion for the patient.

    Madam, the long waiting time, especially at outpatient clinics, which according to MOH's survey, was due to the uneven workload.  Would the MOH study the possibility of centralising the scarce medical resources and set up specialist-based HQs, and let these HQs handle the workload and distribute manpower according to the patients' workload of individual hospital?  This would reduce the resources, wastage of specialist manpower in specialist outpatients clinics, with lower patient load.  For example, the ENT and Eye Clinic of Alexandra Hospital and Changi General Hospital have a lower utilisation rate than those at SGH, TTSH and NUH. 

    I believe that it is time for MOH to examine the cluster model of healthcare, particularly to assess how a better integration of medical services and administrative systems can be achieved and an efficient delivery of healthcare services. The clusters could be restructured into centres based on services, such as polyclinic service, hospital in-patient services, etc.

Human Organ Transplant Act

      The recent scuffle between the relatives of a brain-dead man and the SGH team over the harvesting of the deceased's organs has raised a few disturbing questions about how the SGH implements the HOTA.  Could MOH release more details of the case as the public has so far been relying on media reports and blogs for information about the incident?

    The public understandably is concerned about the case because it raises the question of how HOTA is implemented and how organs are removed from brain-dead patients.  I would like to know:  does the hospital has the discretion to unilaterally determine when should life support be turned off when the patient is declared brain-dead?  What are the considerations in deciding when to switch off life support?  Would the relatives of the brain-dead patients have any say in the decision? What processes are there in place to handle such requests from relatives to delay the turning off of life support?  Would the hospital have respected the relatives' decision in this case if the patient was over 60 years old and whose organs were not suitable for transplant?

    Madam, in light of the strong public concern over the incident, I would like to know whether the Ministry have any plans to educate the public and to build up public confidence on the issue of brain-dead and the implementation of HOTA   I would also like to know whether the Minister would consider amending the Act to respect the wishes of the family members should they have strong objections towards the organ donation, notwithstanding the fact that the deceased has not opted out.

Dementia in an Ageing Population

     Dr Fatimah Lateef: Madam, we are on the brink of a dementia epidemic in the Asia Pacific region.  The disease burden will increase significantly in the coming years with tremendous economic and social impact.  How this translates into cost in public health will vary according to the country and the mix of care provided.

    Currently, there are 22,000 elderly diagnosed with dementia in Singapore - this is about 6.8% of our population.  By 2020 and 2050, the numbers will be 54,000 or 15.7% and 188,000, that is about 56.7% patients with dementia and related illnesses respectively.

   Direct cost will include quantifiable cost from hospitalisation, treatment, drug, nursing care, etc. There will also be indirect cost incurred to the family, the healthcare system and society as a whole. Will MOH be conducting some analysis on this projected cost to Singapore to fine-tune our public healthcare system, our 3Ms, ElderShield, and so on? The Kyoto Declaration which provides a framework for determining the actions required may be used as a reference document.  Indeed, we just heard earlier that the Minister has mentioned some reform to the ElderShield as well as the Medifund Silver.  Certainly, these are steps in the right direction.

5.00 pm

     We may also have to consider some different imputation

algorithms based on international statistical data to reach an appropriate estimate for Singapore in Singapore dollars, as we may not have local current statistics.

Electronic Medical Records Exchange and Telemedicine

     Dr Lam Pin Min: Madam, an electronic medical record is a medical record in digital format.  Its use facilitates access of patient data by clinical staff at any given location - sharing of patient information and clinical notes with other healthcare providers, enhancing safety by building automated checks for drug interactions and allergy, scheduling and easier archiving and storage of records.  Electronic medical records exchange (EMRX) established in 2004 is an initiative by the MOH and the two public healthcare clusters to share electronic medical records across all public hospitals and polyclinics in Singapore.

     The initiative also helps reduce cost as doctors from different institutions can now view the results of any recent blood test, X-rays and investigations online, thereby reducing the need to repeat the tests.  In addition, teleradiology was also implemented in December 2005 at certain polyclinics where digitised X-ray images were diagnosed by a foreign country outsourcing partner.

     With the Ministry's mission to ensure healthcare remains affordable, I would like to ask the Minister the following questions:

     (i)  to provide an update on the usage rate and the benefits of EMRX and teleradiology in Singapore since their implementation;

     (ii)  to consider extending the EMRX to all private healthcare institutions and practitioners, as the sharing of the medical information would minimise unnecessary and duplicate medical investigations being performed when patients cross between public and private sectors; and

     (iii) to consider broadening the scope of tele-medicine to achieve cost and time savings for patients without compromising on quality and safety of healthcare delivery in Singapore.

Managed Healthcare

     Mr Sam Tan Chin Siong: Madam, I would like to dive into a relatively murky water, which is the managed healthcare scheme.  I say it is murky because much of it is unknown to most people and yet it affects many Singaporeans' healthcare.

     In Singapore, there are many healthcare schemes.  The one that I would like to talk about is the kind that requires doctors to provide medical services and care to workers at a group rate that is fixed for the year.  Many large companies here are on some kind of managed healthcare system.  Under this kind of scheme, doctors are contracted by managed healthcare companies to see patients at a fixed rate for consultation and medicine.  They have a set of parameters to abide by.  All these, including the price of consultation, are not transparent to patients or their companies.  These managed healthcare companies are generally called health maintenance organisations, or HMOs in short.

     As an illustration, let us say a company engages an HMO to provide medical services to its employees, and the company pays the HMO $20 per patient per visit.  How much of this goes to the doctor?  We do not know.  The doctor and the HMO staff, of course, know, but under the terms of the agreement, they are not allowed to disclose the amount.  One doctor, writing in the Singapore Medical Association's newsletter, recently said that he gets no more than the price of a meal at the McDonald's per patient. 

     In 2003, a survey of 220 doctors by the Singapore Medical Association showed that doctors are generally unhappy with the way that they have to treat patients under their contract with a HMO.  Their grievances include low consultation fees, slow payment by the HMOs and, at times, even restrictions on the type of medicine they can prescribe and the specialists they are allowed to refer the patients to.

    I am not fighting for doctors to make more money, but I think all these conditions and restrictions do affect the quality of care provided by doctors.  We know that there is always a trade-off between cost and quality of care.  I am not advocating a Rolls Royce standard in a company healthcare scheme.  But what I am concerned with is an adequate level of care for patients, particularly those whose employers contract out their healthcare service to HMOs.

     In Singapore, doctors are subject to a strict code of ethics for their conduct.  As far as I know, HMOs are not subject to any regulatory framework.  In fact, anyone can register an HMO and start soliciting business from employers to provide healthcare services to their employees.  So, how then can we ensure that the HMOs' business and coffee-making agenda do not compromise the healthcare services quality? 

     In Hong Kong, there has been a legislation put in place to regulate the HMOs compelling them to observe a certain set of code of conduct to ensure that a certain quality of healthcare is delivered to patients under their programme.  As the situation and conditions between Singapore and Hong Kong are quite different, it may not be necessary for Singapore to also provide similar regulatory framework on the HMOs.  Notwithstanding this, I think we can still start cautiously and prudently on the monitoring of the HMOs at the current stage.

     For a start, I would like to suggest that the Ministry conducts a review, if this is not done yet, on the HMOs to see if the delivery of the healthcare service is up to the industry's benchmark.  The review should be able to provide useful findings for the Ministry to consider the next course of action.

     Many employees in Singapore rely on the healthcare given by their company's doctor, as a major part of their healthcare planning.  It is estimated that spending by companies account for about 30% of the national health expenditure in Singapore.  This is quite significant.  It is therefore in the interest of our healthcare system to make sure that there is some oversight on this matter.

Singapore Medicine

     Dr Fatimah Lateef: Madam, as we formalise SingaporeMedicine, the numbers of health-related visits will certainly increase.  It is projected that by 2012, the number is going to hit a million.  With regard to this, what are the plans and programmes by our healthcare institutions to cope with the increasing numbers and complexity of medical problems?

It is anticipated that we will require more inpatient beds, outpatient clinic slots, high-tech and state-of-the-art equipment and an increase in certain types of manpower, such as allied health personnel, nurses, pharmacists and specialists.  There will certainly be competition from our rapidly ageing populace and also the increment from a larger population of foreigners and foreign talents that we are trying to attract to Singapore.  We would also have to improve our service standards significantly, enhance communication skills, and this includes perhaps also some officers who are trained in foreign languages and also to strategise our plans to face the increasing medical tourism competition from countries in the region, such as Malaysia, India and Thailand.

     Mr Khaw Boon Wan: Madam, just now, we discussed how we must gear up Singapore for our healthcare needs of 2020.  We discussed the three key resources that we will need - financial, physical and human resources.  But having more resources alone will not necessarily lead to a better healthcare system.  Witness the huge amount of resources some countries are pouring into their healthcare today and yet they deliver much poorer outcomes than other countries which spend much less.   More of the same will not do.  We need to have the courage and the wisdom to transform healthcare.

    Some analysts in the automobile industry compared General Motors with Toyota, and they criticised General Motors for being too product-focused.  They praised Toyota for focusing on the changing needs of customers over their lifetime.  Parents buy a small car for their child when he graduates from high school.  A young adult buys a Corolla, then an MPV when his family grows, and when he gets a promotion, he buys a Camry, and later on, he upgrades to a Crown and perhaps a Lexus.  Toyota made over a hundred models to meet the different needs of the different market segments.   

    Healthcare, unfortunately, is more like General Motors than Toyota.  We focus on buildings, equipment and skills.  This is not wrong, but I think we are not paying enough attention on the varied needs of our patients.

     Let me give some examples.   An infant with a hole in the heart needs a one-off highly specialised care involving a large team of specialists and other staff to fix the problem using highly sophisticated equipment.  But once fixed, the infant will be, more or less, normal and well.

     Another infant born with severe brain damage will also require sophisticated care but the best outcome may still be a lifetime of pain, discomfort and total dependency.

     An 80-year-old with advanced cancer may also need highly specialised care involving experts and sophisticated equipment.  But the outcome may be a prolongation of life or postponement of death by a few weeks with pain and discomfort.

     Another patient in a similar condition may well choose a less aggressive treatment regime focusing mainly on palliative care and pain management.

     A young person with a broken bone needs a surgery and after a few weeks will be back to normal.  The surgeon plays a key role and the patient plays only a very minor role in that treatment episode.

     On the other hand, an obese patient with diabetes will need life-long medical attention.  The patient’s well-being is almost entirely dependent on his personal willingness to change his lifestyle and follow the treatment regime strictly.  The healthcare team can, at best, play a supportive role, a coaching role.

   As Members can see, a patient’s treatment choice is often determined by a complex interplay of his understanding of likely outcomes, the advice he gets from his doctors and friends, his personal expectations, values and philosophy, and his ability and willingness to pay for treatment.  Clearly, one size cannot fit all.  Even a dozen sizes will still not fit many.  There is a need for us in healthcare to segment patients more, clearly understand their needs by observing them closely and consulting them.  We have to develop practical treatment strategies, innovate and continuously fine-tune approaches to improve outcome and to reduce cost.

     To transform healthcare to better meet the different needs of our patients, we must innovate.  To innovate to meet diverse needs, we must have diversity in organisations, structures, models of care and pricing.  This requires a change in mindset on the part of the healthcare providers.  In particular, hospital specialists will need to work more closely with family physicians and step-down care facilities as a team, with patients at the centre.  Ideally, they will all share a common medical record for each patient, and they consult regularly and they function as one team whose sole purpose is to advance the health of the patient.

     This is challenging even when all the healthcare providers are from one single employer and serve patients with the best of intentions.  Complications multiply many-fold as such a team often comprises members coming from all the three sectors - public, private and charity sectors.  Coordination and trust take time to build.  That is why true care integration has not yet happened, whether here in Singapore or in other countries.  It will take us years, not months, to achieve such an optimal outcome.  Many pieces have to fall in place.  Let me highlight some of them.

     First, an important infrastructure is the Electronic Medical Record (EMR).  I have coined the slogan, “One Singaporean, One EMR” to catalyse this initiative.  Right now, it is one Singaporean, many medical records, stored away in different clinics and hospitals in different formats  -  some in papers, some in CDs -  and not connected or consolidated.  As a result, when patients visit different doctors, their tests have to be repeated, x-rays redone.  This adds to unnecessary cost.

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    We are moving towards this target of “One Singaporean, One EMR”.  Because of legacy systems, we cannot achieve it in one step.  But we have made progress.  As pointed out by Dr Lam Pin Min, public hospitals now have the EMR eXchange (EMRX).  We achieved a first but very important psychological step in 2004 when public hospitals began to electronically exchange their Hospital Inpatient Discharge Summaries.   These are summaries that each time a patient is discharged, the

consultant-in-charge will summarise it up - what exactly is the problem with the patient, what were the treatments made or given to the patient and what is to be expected in the future.  And sharing this is crucial because when the patient appears again in another hospital, access to this summary immediately updates the doctor about this particular patient.  Since then, we have made the EMRX more comprehensive by adding other patient records such as laboratory tests, radiology reports and medication information.  The electronic volume of  laboratory results exchange has grown seven times in two years. Thousands of patients benefit from EMRX every month.

     Our doctors' feedback is that EMRX has made their work easier.  I am sure Dr Lam agrees with that.  In particular, our Emergency Department doctors have said that the EMRX gives them greater reliability and confidence in treating patients, especially those with long and complicated medical histories.  And I am glad to see Dr Fatimah nodding her head.

     Extending EMRX to private doctors would be a natural step and it is the objective.  As Dr Lam pointed out, a national EMRX will minimise unnecessary medical investigations.  More importantly, I see EMRX playing a critical role in the integrated delivery of care to patients.  However, this is a very complex national project.  Very few countries, if any, have successfully implemented a system that links up public, private and the charity sectors.  This is because there are many issues such as data protection, regulation and audit to be addressed.  We need to take a measured approach to pilot and then put together a comprehensive framework that takes care of these issues.  This will begin with common data standards.  We will do this within the public sector first, test it out, and extend this to the step-down facilities.  We have started to build the linkages to the private sector GP clinics by helping them to set up their IT systems under the Medisave for Chronic Disease Management Programme.  I am confident that we will get there.

     Second, we need to strengthen the collaboration between acute hospitals and community hospitals to achieve seamless care for patients when they move between these two types of institutions.  For patients who no longer need medical treatment in acute hospitals and who should move into community-based care, we must ensure the continuity of patient care and eliminate barriers and bureaucracy.  The handover must be smooth, as though it is from one ward to another in the same hospital.  For a start, we need to enhance medical collaboration between the doctors in our hospitals and either their counterparts in the community hospitals or the family physicians who look after the patients over the long term.  Patients at the end of the day must feel confident that they are getting seamless care. 

     The same approach is needed for patients who require care and nursing homes.  We are working with MCYS on this.  We are also studying the longer term feasibility of integrating different residential and community-based healthcare and eldercare facilities so as to help the elderly to age in place and to continue using familiar facilities even as their care needs change with time.

     Third, we need to have patients treated in the most appropriate locations by medically-competent teams at the lowest possible cost.  This is commonly referred to as "right-siting" of  healthcare services, and the logic is obvious. But the outcome is seldom the case.  Today, many patients who choose to be treated at SGH or NUH, in fact, should not be there.  They can be and should have been treated by their family physicians, less hassle and at a lower cost.  For various reasons, they get wrongly-sited there.

     Wrong pricing, as observed by Mdm Halimah, is one factor.  Mdm Halimah's proposal is for us to reduce prices at step-down care so that patients will have an incentive to leave the hospital.  To achieve this, Mdm Halimah suggested that we exempt such patients to be transferred from hospitals from means testing at nursing homes.  I am afraid I do not agree.  The correct solution is to extend means testing at nursing homes to the hospitals so that we eliminate this policy anomaly.  I have asked Ministry of Health to study how we can do so, at least for those patients who have exceeded the average length of hospital stay. 

     Meanwhile, we will continue our push, through the Medisave scheme for chronic disease management, to shift chronic disease management to the primary care level by family physicians and in the community.  If patients can be right-sited to family physicians and they feel confident that they will be well looked after, we can reduce overcrowding at hospital specialist clinics.

     Fourth, we must exploit technology to improve care and lower cost. Telemedicine is a good example and can potentially bring benefits to many areas of healthcare.  As Dr Lam pointed out, we have started with tele-radiology in our polyclinics with very good results.  Patients save time as they no longer need to make a return trip just to get their results.  Increased competition has resulted in cheaper x-rays and improved turnaround times from local radiologists.  Almost 60,000 patients can benefit from this per year. 

     We are moving beyond simple x-rays now to CT scans and MRIs.  I have no doubt this will bring further benefits and those cost savings will be even more significant.  We will continue to study other applications of telemedicine and get it to work for our patients here.  I have also encouraged our radiologists, wherever there is spare capacity, to sell their services to buyers in developed countries.  We can sell tele-radiology services as well as buy tele-radiology services.

     Fifth, medical science here will continue to progress and we have reached a stage where Singapore should be part of the global search for faster diagnosis, better and more cost-sustainable care for patients.  Our public sector doctors have always been bogged down with heavy patient loads.  If we are able to recruit more doctors to improve our doctor-patient ratio, we can ease their burden somewhat. 

     Through this process, we hope some doctors with special interest in clinical research will find more opportunities to do so.  Every generation of doctors has always yielded a few outstanding researchers, for example, Professors Wong Hock Boon, the late SS Ratnam and more recently, Ng Soon Chye, Yap Hui Kim, Donald Tan, and so many others.

     With our latest emphasis on life sciences development, public hospitals will now be better supported with research funds to pursue this interest.  Over the next five years, Ministry of Health, National Research Foundation and A*Star will jointly contribute $1.55 billion to support translational and clinical research.  It is a major boost to our researchers, although in the scheme of things, it is not really a huge pool of funds.  So we will have to prioritise and focus on specific areas where Singapore-based researchers already are strong or in diseases where strong capabilities can best benefit Singaporeans.  Because the greatest potential impact will come from areas where we are strong along the value chain from basic sciences to clinical treatments, we will encourage our doctors in the hospitals and the scientists in the laboratories to work very closely together.

     We will not be able to allocate research funds equally to each hospital.  Hospitals and researchers will have to compete for them.  Those who are able to better manage unnecessary overcrowding and free up manpower resources will have an advantage and that is why it is so important for hospital specialists to learn to work with the GPs, to co-manage or joint-manage the chronic patients and make right-siting of care a reality.

     Sixth, we should not shy away from organisational changes that can help us achieve our mission more effectively. That is why we restructured our hospitals more than 20 years ago.  We moved from central planning by Ministry of Health Headquarters to a decentralised competitive model.  This allows individual hospitals greater room to innovate.  How else can we nurture experimentation and bring about improvements?

     Mr Sam Tan asked if our restructured hospitals are wasting resources on rich patients and foreign patients at the expense of subsidised patients.  All patients, rich or poor, receive competent clinical care.  Hence, all patients requiring urgent medical attention are promptly seen: three minutes for the critically ill, 30 minutes for other true emergency cases.  For non-emergency cases, service standards vary and we publish such data so that patients can choose the less busy hospitals.  All doctors who practise in the public sector will treat subsidised patients.  This is part of the ethos of public service which our doctors feel very strongly about.

     As for physical provisions, the Ministry decides on the distribution of beds among classes.  The fact is that 80% of beds in Singapore are in public hospitals and over 70% of public hospital beds are the heavily subsidised B2 or C.  In other words, more than half of the patients treated in Singapore are subsidised by the Government to more than 65% of the cost at least.  We also have guidelines in place to ensure that public hospitals do not spend on lavish fittings and renovations.  But some renovation is inevitable to enhance efficiency and to meet public expectations.  Nobody want to be admitted to a run-down hospital.

     Mr Low Thia Khiang asked if our hospital cluster system has led to wasteful duplication and if integration has led to better service level.  One key objective of clustering is, in fact, to facilitate better integration of care between hospitals and polyclinics.  This remains an important objective which I have discussed earlier.  We have made some progress integrating public hospitals and polyclinics but full integration requires us to bring in the private GPs and the rest of step-down care providers.  So our journey to restructure and bring about organisational change continues.  Certainly, our hospital clusters will make a big push on this front this year but it will always be work-in-progress.  We must never be fossilised into a concrete structure and become unresponsive to external changes and expectations.

     Mr Low made an added point which is, for certain specialties, is it not better to centralise instead of mini-units spread out in the various hospitals?  I think both solutions are relevant. It depends on the specialty.  My preference is always to have at least two competing departments because competition will always push up standards and I have an added reason.  Having run hospitals and dealt with doctors, I know they are highly individualistic and sometimes, for various reasons, you just cannot work for a particular Head of Department. So we must allow some space.  There is a Chinese saying: "Yi shan bu neng cang er hu ".  So sometimes, you need two mountains to hold the two tigers. But as far as possible, we try to decentralise it for the convenience of the patients. Of course, if decentralisation means one-man-team in a department, then it does not make sense.  If you look at how we handle it, for example, neurosciences, neurology, it is centralised.  But because accidents, like head injuries, can crop up anywhere, and if you centralise it, all ambulances will rush to SGH, we will have a mad-house there, and Dr Fatimah will have no time to attend Parliament.  So the neurology services are decentralised, but the department running it is centralised. The department is the one who decides on staff deployment. That way, you can sub-specialise and you rotate staff accordingly.  But once the specialty has reached a certain size where it is possible to have two very well-run departments, I encourage them to split up.  I do not encourage families to break up though but for clinical departments, it is always better that way.  Two, three, or four departments, so long as the volume can justify it.  And this is one of the reasons why SingaporeMedicine has some benefits to Singaporeans because if more patients are coming in, then you can justify a higher level of care and you can allow this decentralisation to take place.

     But at the end of the day, organisational structures are merely the means to an end.  Our mission is to serve patients, particularly those in the lower half of  the population.  When a person falls sick, what does he want out of our healthcare system?  Talking to patients, I reduce it to just two basic questions:  what is wrong with me?  What can you do for me so that I can recover fully, if possible?  These are the two basic questions. 

     Our job is to provide accurate answers to these two questions and then to do so in a way which makes the total care experience for patients as smooth as possible and does not bankrupt him or society.

But as I stressed just now, patients too have a big part to play, particularly, while they are healthy.  So while you are healthy, ask yourself a different question.  How do I maintain my health so that I do not fall sick and have to go and visit Dr Loo Choon Yong or Dr Fatimah?  And we know the answer, that is, please adopt healthy lifestyle.  Many do, but many still do not.

     Mr Sam Tan spoke about Health Maintenance Organisations (HMOs).  They organise GPs and then they market their services to some company employees.  It is an idea imported from the US a few years ago.  I do not know how wide is their coverage today but while we do not regulate HMOs, we do regulate the doctors working for them.  And I am sure any attempt by HMOs to cut corners will be resisted by our GPs as they have high ethical standards.  Otherwise, the Singapore Medical Council will run after them. Companies and unions should also chip in to ensure that their employees do not get short-changed.

     Seventh, we will release even more information to Singaporeans.  We will measure and publish outcomes and performance indicators to increase market transparency and help patients make better choices - which doctors to consult, which clinics to go to.  NUH, KKH and SGH have recently, just a few weeks ago, through their own initiative, begun to publish clinical outcome data selectively on their respective websites.  This is the first for any hospital in Singapore.  I applaud their public commitment to quality improvement and greater transparency.  I will encourage all our hospitals - public or private - to publish outcomes and benchmark themselves with international outcomes.  Maybe Raffles Hospital will do that too.

     This will similarly apply to step-down care providers.  My Ministry is working with them to develop indicators to measure their performance in service development, utilisation and clinical quality.  We will ensure that minimum care standards and patient safety are met.  For those who do not perform well, we will help them improve their standards.

     Eighth, we need to further empower our patients by engaging them in their care and their care choices. Patient empowerment led me to introduce the Medisave scheme for chronic diseases last year.  We know that chronic diseases account for the bulk of the workload in public hospitals and the polyclinics.  And these diseases will not go away because today, there is still no cure, and if left unmanaged, they would only get worse, not suddenly, but gradually over time.

     Fortunately, medical science is now clearer on how to manage these chronic diseases to minimise future complications.  The correct approach comprises three elements: early detection, regular ongoing low-tech, low-intensity treatment by family physicians, and good compliance by patients in changing their lifestyle and habits.

     I remember Dr Lily Neo reminding us about this frequently in this House.  The wrong approach is to ignore the disease, persists with an unhealthy lifestyle and then when complications emerge, rush into hospitals for high-tech, high-intensity attention by multiple specialists, hoping for a cure and a quick return to the same lifestyle.  But there is no such cure.  When a chronic illness is still mild, that is the time to change your lifestyle and begin treatment.  If you wait, the complications are a lot harder and much more costly to manage.

     With the Medisave scheme for chronic disease management, I hope to bring about a mindset change among our chronically ill. Through Medisave, we have eased the financial burden.  It is now up to the patients to come forward and help themselves, to work with their doctors to actively manage their chronic diseases.  If they do so, their health will improve.  It can be done.  In small-scale pilots, we have seen such improvements among participating patients.  Through Medisave, we are scaling this across the nation.

     Mr Low asked about the cost of treatment for the chronic disease.  I think he specifically asked about polyclinics.  It depends on the state of the illness.  If you neglect it, and it has become highly complicated, with all sorts of other problems, then of course, the treatment will be more complicated and the bill size is bigger.  But the key point is, if you come in early, then the treatment is simpler, the cost is lower.  So it really depends.  It also depends on what type of chronic disease, say, diabetes or stroke.  What we are also hoping to achieve out of all this is that patients do not hop from doctor to doctor.  For chronic diseases, it does not help the situation.  It is best to stay faithful.  You can shop around initially if you do not like this doctor for various reasons.  Once you find he or she is good, then stick to one.  I have another slogan for that, "One Singaporean, one family physician".  I think that works best for Singapore, and for other people too.

     With the Medisave scheme for chronic disease management, now that we have gotten over the implementation phase, we will use this whole year to collect and analyse the outcomes.  By next year, we should be better able to answer some of the questions, as posed by Mdm Halimah and Mr Low.  How do the various clinics perform, in terms of managing their patients' chronic diseases? How much do they charge their patients and for what treatments?  And very important, are their patients showing signs of improvement?  Then I am going to publish them. Then you can see if you are diabetic, there are diabetes care at Ang Mo Kio, Sembawang or Hougang. Is there a difference?  And then patients can make better informed decisions about which family physicians to be loyal to.

     Every patient should be given a personal health information folder by his doctor on his chronic disease and what he should do to improve his health.  His health status should be regularly tracked and charted and explained to him by his doctor.  If your doctor does not do this for you, ask him why not?  Suitably empowered, I hope many patients would take their health more seriously and work to improve on it. If we do it well, the long-term impact will be significant.  If we cut down unnecessary hospital care, it means major savings in dollars and human suffering.  Let us work to make it succeed.

     Finally, let me touch on SingaporeMedicine, the strategy to attract foreign patients to Singapore.  This is an economic objective, not a strictly healthcare mission.  In fact, my advice to the public hospitals' CEOs is that SingaporeMedicine is not our primary objective, but a secondary and consequential outcome.  Our primary objective is to serve Singaporean patients, rendering good medical care at competitive prices.  That is our mission.  But if our standard is high and our prices are reasonable, Singapore is bound to attract all sorts of foreign patients to come here.

     Our regional neighbours have raised their medical standards over the years.  But we remain ahead of them and should always strive to stay ahead.  If we do our job well in serving Singaporean patients, we will always attract foreign patients.  It is a validation of the quality of our healthcare. We should therefore factor in this reality when we make projections of beds, doctors, nurses, and so on.  If we do not do so, and since we cannot prevent foreigners from coming here for treatment, public hospitals and subsidised patients will get crowded out.  If nothing else, costs will go up because private hospitals will poach public sector doctors and nurses, pushing up wages. This is the reason why we are stepping up foreign recruitment of foreign doctors and nurses, even as we ramp up local training.

     While we may see some foreign patients in public hospitals, the fact is that the majority of foreign patients go to private hospitals and clinics.  80% of foreign inpatients stay in the private hospitals. Foreign patients make up less than 2% of public hospital admissions.  Ultimately, I agree fully with Mdm Halimah that SingaporeMedicine must benefit Singaporeans, and must not come at the expense of care for Singaporeans.

     Mdm Chair, I believe I have addressed all the queries by Members.  I know Mr Low Thia Khiang spoke on the Human Organ Transplant Act (HOTA).  He was not in this House last week when we had a full discussion on this when Dr Lim Wee Kiak raised  the same issue. In the interest of time, I do not wish to repeat the points already made here last week, except to say that we will learn from the SGH incident and try to do a better job.  We will certainly step up public education on organ donation and brain death and help Singaporeans think about the plight of those fellow Singaporeans on the waiting list.   As I said in this House last week, it is the luck of the draw.  We cannot be sure whether we may end up on the waiting list.  Before HOTA, we could only save five lives in one year.  After HOTA, we now save one life every week.  So from five a year to one every week.  HOTA is good both for the dead and the living, from the religious point of view.  But we respect the wishes of those who want to opt out of HOTA.  We will facilitate it.  Every year, about 2,500 opt out of HOTA.  The number went up soon after the SGH incident but has since come down to about 80 a day, which is high.  But I respect the wishes of those who opted out but I worry for the poor patients on the organ waiting list.

     In conclusion, I acknowledge that our healthcare system is not perfect.  But actually, it is not bad.  My foreign counterparts told me so. And they would happily trade off their system for ours.

     But it can be better.  Over the next few years, we will get the pieces together and be better ready for the challenges ahead.  And I thank Members for their continuing support and advice.

Health Promotion Programme

     Dr Fatimah Lateef: Mdm Chairman, health promotion has been given a new prominence.  The increasing focus on health outcomes reconfirms the priority placed on investment in the determinance of health through health promotion.  Continually asking ourselves the question, where and how is health created will link us to two major reform debates, firstly, the formulation of new public health strategies and, secondly, the need to reorient and refine health services. 

    Health promotion is the science and art of helping people change their lifestyle to move forward to a state of optimal health.  Optimal health is the balance between physical, emotional, spiritual and social health.  Lifestyle changes are facilitated through efforts to enhance awareness, change of behaviour and promotion of environment that supports good health.  The Ottawa Charter of Health Promotion from WHO Geneva 1986 emphasises the prerequisite for health promotion.  It touches on advocacy for health, enabling all people to achieve their full health potential and mediating between the different interests in society in the pursuit of health. The Jakarta Declaration on Leading Health Promotion into the 21st century is also relevant as well in this context and stresses on the importance of participation through sustained efforts.

     For the sum of $86 million expenditure on health promotion programmes every year, like the healthy lifestyle programme and the school health services programme, are we seeing the results that we expect?  Is Health Promotion Board tracking some of the KPIs on these?  And are we meeting the targets that we have set, for example, the identification of early psychosis results from the Trim and Fit programme in our schools or even the numbers coming forward for cancer screening? 

Preventive Healthcare

     Mr Yeo Guat Kwang: Madam, one of my key concerns is how we are going to help Singaporeans monitor and reduce health risks.  What are these risks?  These are risks arising from not eating right, not exercising enough and smoking.  Based on the statistics, we know that more than half of the deaths and disability from heart diseases and stroke can be cut down.  All it takes is a national effort and individual action to reduce health risk factors, such as smoking, high blood pressure, high cholesterol and obesity.

Let us now make a more structured approach and effort to make all Singaporeans, particularly those above 40 years old, first, to be aware of and, then, take efforts to manage their health risks.  We should make basic health screening more accessible, followed by way of facilitating Singaporeans, particularly those who are working, to take personal responsibility to improve their health risk profile.  In short, raise their awareness and help them create the drive to take action.

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     What are the actions that we can take?  I think we can simply round it up to say, "CHEERs", ie, "C" for "Cease smoking"; "HE" for "Healthy Eating"; "ER" for "Exercise Regularly"; and make the "s" small for manage "stress". 

     Madam, I wish to highlight that while many companies readily agree and say openly that they would like to re-employ older workers and even employ them beyond retirement age, more often than not, the health of the older workers is an important criteria in determining whether the company is going to grant him employment or not.  Many companies, in fact, specify very clearly in their documents for re-employment to make it a point that the workers must, first, have to be assessed to be medically fit to work.  So, no matter how successful our efforts are in getting our older workers to be re-employed, up their skills, change their mindset, these would count for nothing if, at the end of the day, the worker is not healthy enough.  I would like to urge the Ministry to allocate more resources and work more closely with the labour movement and any organisation involved to help workers regularly assess and monitor their basic health profile and better manage their health risks before it is too late.  This will, in fact, help strengthen the employability of all our mature workers.  I hope MOH could spend more on preventive healthcare.

Mental Health Programme

     Mdm Halimah Yacob: Madam, could the Minister give an update on the Ministry's plans to upgrade Singapore’s mental health programme to make Singapore an emotionally resilient community?  

     Recently, I met a man who was suffering from severe bipolar disorder.  He has two young children and his wife is the main breadwinner as he is not able to hold down a job.  He pointed out the many gaps in our current services for the mentally ill.  The stigma and rejection is one thing, but he feels that even the standard of medical treatment needs improvement.  At one public hospital, where he was treated, he was seen by a different doctor at every appointment, as he was a subsidised patient.  He also feels that in that hospital, the very ill patients were mixed with the less ill patients.  As a result, his condition did not improve.  He has since changed hospitals and he feels better now.  His own illness was left untreated although he was ill since he was a teenager and, as his family did not understand that the extreme mood swings were signs of mental illness, he got treatment only when he was in his 30s.  When he was finally treated years later, his condition was actually quite bad.  He now pours most of his energies into his art work but he finds it difficult to get a place to advertise his drawings for free.  His family is suffering from financial difficulties as his wife does not earn enough to support the family and he worries about his children’s future. 

     This man’s journey of anguish and pain is typical for sufferers of mental illness.  They suffer many setbacks.  Many find the cost of treatment a drain on their resources but, if they stop treatment, they will suffer a relapse, which worsens their condition.  Many cannot hold proper jobs as the stigma against them is still very strong.  Many need temporary shelters but there is not enough of such facilities.  Many cannot cope on their own and need support.  Many parents with children suffering from mental illness worry in case they die and there is no one to take care of their children.  Their problems require a multi-agency approach involving not just MOH but also MOM, MOE and MCYS, even maybe MHA, with very strong community support in order to put in place a more comprehensive framework to assist them, as well as an extensive public education programme to remove the stigma and prejudices that they have to endure and to help our population understand the critical importance of seeking treatment early. 

     Could the Minister please give us an update on what is being done to improve our mental health programme and assist them?

     Mrs Josephine Teo: Madam, last week, during the Budget debate, several MPs spoke on the implications for Singapore, if indeed our population grows to 6.5 million.  I think the number of 6.5 million has captured the public's imagination.  Regardless of when and how  we will arrive at 6.5 million people, with increased population density and the faster pace of economic restructuring, stress levels can be expected to rise and, as the Minister has said earlier, in a way, we will have to move away from a more product-focused type of system to one that is focused more on the varied needs of the patient, and I think mental healthcare is one of those growing needs. 

     This stress will manifest itself in many ways, from neighbourly disputes, breakdown of marriages, higher incidence of elderly living alone or ending their lives prematurely, all of which are very sad, to even just poor road behaviour, including speeding and reckless overtaking.  Some school children nowadays also say that they are stressed.  The language of stress is very common amongst and very well used by children.  A migrant society like ours that is fast-paced and becoming more crowded by the day must pay attention to the quality of mental healthcare and there is no turning back to the days of the leisurely kampong.  So we need to ask people to learn to deal better with the stresses in our lives.  In some ways, we are already doing so, eg, through ensuring that there are enough green spaces, making our cityscape more pleasant, keeping traffic relatively smooth.  I have several questions for the Minister. 

     (1)  How much of the Ministry's budget is allocated to support mental health promotion and care?

     (2)  Do we have enough trained counsellors, psychologists and psychiatrists in Singapore?  If we do not have enough, is there a plan to increase the supply, either through training or augmentation from foreign sources?

     (3)  Does the IMH have sufficient capacity to cater to demand which, over time, could be expected to rise perhaps proportionately more so than other healthcare services?

     (4)  Can the Ministry step up efforts in mental health promotion?  For example, can we adopt a more holistic approach to tackle the issue?  One of the ways perhaps is to work with the MOE to equip our children from young with coping strategies.

     (5)  What steps would the Ministry be taking to ensure that long-term care for mental health patients remains affordable?

     Mr Low Thia Khiang: Madam, I would like to ask why the Institute of Mental Health suspended its night outpatient clinic.  Previously, mental patients who are working in the day could go to the night clinic for their regular follow-up treatment.  When the night outpatient clinic is not available, patients would have to ask their employers for leave or time off to seek treatment during the day.  In doing so, they would have to reveal their condition to their employer, which may affect their employment prospects.  This is because mental illness today is still a very much misunderstood illness.  I would also like to ask the MOH to consider the possibility of training polyclinic doctors who handle mental patients so that their follow-up can be done at polyclinics.

     Next, I understand that there is this early psychosis intervention programme to treat newly-diagnosed psychosis, as early intervention is a key factor in effecting management of the illness.  I would like to know what the programme has achieved.  I also understand that some patients are not complying with the anti-psychotic treatment because conventional therapy brings with it some side effects.  Although there is new treatment on the market with lesser side effects, these drugs are expensive.  Are there available measures to help farm the treatment of patients with good prognosis or who respond well to the new treatment?  I understand that this group of patients can be treated effectively to a stage of continuing employment, thus helping them to be economically independent. 

     It is difficult for people who are suffering from chronic schizophrenia to take on complicated work tasks.  I would also like to ask whether there are assistance schemes available to maximise employment of Singaporeans who suffer from such illness.  How is the Ministry helping fellow Singaporeans to understand and to be aware of the nature of mental illness?  Are there public education programmes to help the public and family members of the patients to better understand mental illness and to foster a positive attitude among Singaporeans to be inclusive and not shun away from fellow Singaporeans who suffer from mental illness?

Assessment for Eldercare Services

     Assoc. Prof. Kalyani K Mehta (Nominated Member): Madam, this budget cut emphasises the need for a single comprehensive assessment process which will ensure that older people receive appropriate, effective and timely responses to their health and social care needs, and that professional resources are used effectively.  Currently, in Singapore, there is a great deal of duplication of resources as well as delays when older persons are referred from one agency to another, because each agency has its own assessment procedure.  For example, when an older patient is referred from a hospital to a nursing home for step-down care or from a community hospital to a case management service where there is not only unnecessary delay but also frustration on the part of the caring families.  If there are family relationship problems, the delays could cause rapid deterioration of the older person's physical and/or mental well-being and, in some extreme cases, even elder abuse. 

     With the rapid greying of Singapore's population, we need to implement ways to increase the effectiveness and efficiency of our service sector.  Health and social care are inextricably linked to the total care system for older people.  Hence, health and social sectors will be required to work closely together, if such a single comprehensive assessment system is implemented.  This will enable the development of a seamless delivery of services for the elders, a goal that has been mentioned in earlier reports on ageing population.

     On top of that, quality of services for the various sectors would be better monitored.  Currently, we have a situation where there is much disparity between the care rendered by nursing homes in the private sector as compared to voluntary welfare homes.  I have members of the public voicing views like: "We pay more at the private nursing home but the quality of care received is even worse than the VWO nursing homes.  But there is no space in the VWO nursing homes."  I want to cite a recent article on 31st January 2007 in Today which was entitled "Where did the bruises come from?", a case reported of a 96-old-year gentleman in a nursing home mysteriously suffering from severe bruises.  Subsequently, he died at Tan Tock Seng Hospital.  Members of the House, can you imagine the anguish of the adult children who have made a police report?  When questioned, the nursing home staff said they had no idea how it happened.  I have not read any further articles on this episode.  I was surprised that there were not many letters in the Forum page regarding such an unfortunate death.  It makes me wonder if there is a societal attitude of paying less attention to violent death of elderly as compared to violent death of a young adult.  It would be a negative reflection of our value system if it were really so.  I would like to know from the MOH, an update, if possible, on this episode. 

     Madam, as a responsible and developed society, we need to be concerned not just about availability and accessibility of services but also the quality of care provided.  Quality assurance and accountability to taxpayers, whose money is used to subsidise the patients in nursing homes, are at stake here.  A good assessment provides the blueprint for a well thought out care plan. 

     Currently, there is an international initiative underway that seriously promotes such streamlining of processes of service delivery in several different contexts, such as home care, nursing homes, day care, home help, and so on.  It is called "InterRAI", with R-A-I representing Resident Assessment Instrument.  It is a not-for-profit organisation aiming to improve the care of elderly worldwide.  The Minimum Data Set (MDS) Version 2.0 is now being implemented in more than 20 countries, including the US, Canada, Japan, Hong Kong, and so on. 

     The main objective for developing this instrument was to introduce the idea of a comprehensive assessment as the foundation for care planning.  Once the initial assessment has been made by a trained assessor, the information can be shared by all the relevant service providers.  And because it is a standardised instrument, all the different professionals concerned with taking care of one patient have the entire set of information for them.  In countries where there are different Ministries looking after their healthcare and social needs of older people, the information on health may not be accessible to the professionals in the social sector, and vice versa.  Unfortunately, the patient or the client suffers, of course, due to the structure of the systems. 

     In Australia, there is an Aged Care Assessment Service (ACAS) which is highly developed.  They use the Resident Classification System (RCS) across the board and funding available to each individual patient is calculated on the full assessment.  In England, a different model has been launched for this purpose. 

     We can see an international trend for a standardised comprehensive assessment, so that not only do we reduce wastage of resources but efficiency and efficacy of services to older populations are increased.  In the long run, we hope the quality of care

and best practices in gerontological care can be improved.

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    Accreditation can be introduced to distinguish the better care providers from the ones with poor quality. A single assessment process helps to address gaming or strategies used by nursing home managers to cherry-pick the applications. Research based on the data that is collected over time using locally derived outcome measures or KPIs would assist us in identifying which method of care is effective or ineffective.  In this way, research and improvement in services and policies can become a dialectical process.

    I shall cite the case of Hong Kong to illustrate a country that has adopted this idea.  A colleague, Prof. Iris Chi from the University of Hong Kong, started talking to the Hong Kong Bureau of Health and Welfare a few years ago about the need for such a standardised instrument in order to streamline the long-term care service system there. After much consultation and review of the pros and cons of introducing InterRAI, the Hong Kong government decided to introduce it in small steps.  For government and non-profit providers, this assessment is available free of charge. At first, a simpler version of the instrument, which is referred to MDS, was launched. As there was a heavy backlog of older people waiting to get into nursing homes, the homecare protocol was used so that while waiting, these people could be assessed and helped by community-based services.  In fact, the homecare protocol is also used to educate families in cases where nursing home admission is not required. 

     It is recommended that the assessment be re-administered annually as well as whenever a major crisis has occurred. The beauty of RAI version II is that not only medical information is elicited, but also data on social, financial, functional, psychological, nutrition, dental, care-giving and service utilisation is also collaborated.

   For the information of the House, I am aware that there is a waiting list in the ICS of about 40 elders who are waiting for a place in nursing homes in Singapore. In our Singaporean nursing homes and sheltered homes, mainly the physical needs' fully shelter safety are met.  In our nursing homes, their medical needs are addressed.  However, their psycho-social needs, such as need to be treated as an individual, need to be mentally stimulated, need for self-worth, are often not met, except for those nursing homes that employ a professional social worker.  There is a strong need to increase the professionalism in our eldercare services. 

   On Social Workers' Day, 20th January this year, Minister Vivian Balakrishnan stated in his speech that he would look into greater professionalisation in the social service sector.  My proposal may be in tandem with his goals too.  With our population ageing rapidly, the importance of providing good medical and social care in Singapore, I feel that the Health Minister has brought many positive changes into the Singaporean's healthcare system. I applaud his efforts to enable ordinary Singaporeans to assess outpatient treatment for major chronic illnesses through Medisave and increasing their cap for hospitalisation expenses and MediShield.  I would be grateful if his Ministry studies my suggestion of a standardised single comprehensive assessment and a study team may be set up to look at the various models in different countries and choose the model that suits us best and work collaboratively with MCYS.

    It will take a few years to set it up and get it running, hence, the urgency.  I am aware that this idea may not be new to MOH or MCYS. However, if some plans are already underway for such an idea, I would request the Minister to update the House on its status.

Elderly Depression and Suicide

     Ms Irene Ng Phek Hoong (Tampines): Madam, last year, I attended a funeral wake of a resident who committed suicide.  He was 92. He suffered from gangrene caused by diabetes. His doctor told him that his leg had to be amputated. He could not take the news. He woke up one night, looked out the window and jumped out of his flat. He was depressed. His family was devastated. 

   Madam, every year, about 65 elderly residents commit suicide. Singapore has one of the highest elderly suicide rates in the world with about 25 in every 100,000 of our elderly killed themselves each year. While the family is the first line of care, medical staff in hospitals are better-placed as gate-keepers to spot depression in our elderly sick and to identify potential suicide victims.  Medical staff should be trained specifically to recognise such symptoms and to intervene quickly. 

    Sir, in Hong Kong, which also has higher elderly suicide rates, its Kwai Chung Hospital has a Elderly Suicide Prevention Team.  Last year, it started a support group to help elderly patients face their illness and to persuade them to receive treatment. The hospital recognised that many elderly refused to seek help, due to a lack of awareness about depression.  So, it roped in nurses and also former patients, in their 60s and 70s, to motivate them to stick to treatment.

    With our elderly living longer, we need such proactive suicide prevention measures in our hospitals as part of a holistic approach to address this problem. As the elderly is the fastest growing group, we can anticipate more late life suicides in absolute numbers if we just keep to the status quo. I would urge the Minister to urgently invest more in services for geriatrics support and mental health. There is also an urgent need for more medical social workers trained in caring for the elderly. VWOs reported a sore lack of such medical social workers despite an ageing population that needs more such services.

    I would also urge hospitals to work more closely with the family and the community in preventing elderly suicides.  I had often wondered, if the doctor treating that elderly man with gangrene, had sent him for counselling, would he have coped with his situation better?  If the medical social worker had spotted his depression and helped his family to care for him, would he have woken up one night, looked out the window, and jumped?

    Sir last night, I attended another funeral of a resident.  He died at age 74 of lung cancer.  In the last three months of his life, he suffered great pain and his children took turns to keep an eye on him throughout the night as he could not sleep. During the day, he had the support of the community.  For many years, he had been active as a grassroots leader.  And right till the day before he died, he still insisted on going down to the RC Centre.

     So last night, his family made a request, "Can we allow his body to be taken around to the RC Centre as part of the funeral rites, to give him one last look at the place?"  This was arranged.  As all of us - wife, nine children, 17 grandchildren, grassroots leaders and residents - paid our respects to him.  I thought this was a touching tribute to a life well lived. It was also a graceful way to leave this world. 

    Our elderly, especially those with chronic and terminal illnesses, need our help to go gently into the night.  And their family, hospitals, community, all of us, must do our part.

Support for the Disabled

     Ms Denise Phua Lay Peng (Jalan Besar): Mdm Chairman, our healthcare system for the general population is, I believe, one of the best in the world.  There are three areas I would like to ask the Ministry to consider in support of the disabled in Singapore.

    One, help those who have previously been excluded from MediShield.  I applaud a new opt-out feature of the MediShield plan to immediately cover all newborns, whether they are born perfectly or not.  I thank the Minister for that.  I speak now for the thousands of children, youths, adults born with congenital conditions, but have missed this window and the Minister's good news.  These citizens are still excluded and deprived of the 1M of the 3Ms scaffold that typical Singaporeans enjoy.

     Madam, I urge the Government to ensure the national insurance vendors, like NTUC Income and so forth, to make sure that they are educated on the major disabilities. Advise insurers to assess the risk factors before conveniently refusing the medical coverage or upgrade request of citizens who are disabled or who have special needs.  I was recently told of a teenager with Asperger's syndrome was refused medical insurance coverage upgrade when his mother honestly reported that he has some form of mild disability.  He is at no greater risk than someone who is typical.

    Two, I hope that Minister also consider underwriting the basic hospitalisation and surgical benefits provided to any citizen, extend it up to the ceiling under the same scheme for those who were rejected by commercial insurers. This "self-insurance" benefit is a practice that is adopted by progressive firms for their employees who, for some reason, are rejected by their insurance vendors.

    Next, I would like to urge the Ministry to allocate resources for applied research and educate families with special needs children.  Many parents with children born with congenital or developmental problems are bombarded with advice on how to help their children.  In their desperation, they try all kinds of treatment options - some without any evidence base - and some very expensive. Some people without proper training and credentials have set up clinics and promised cures for these desperate parents.  It would really be great if the Ministry should allocate resources to the CDUs and CGCs in hospitals to ensure some basic applied research is done and aggressively educate parents on the validity of these various treatments for those born with common developmental problems, like global developmental delay, speech delays, autism, hyperactivity and so forth. This will save many children who are put through treatments which are not just a waste of money but also precious time that could have been used to improve their prognosis better.  I firmly believe that this will not cause a dent in the Ministry's budget and it will help many of these children.

    Lastly, I would like to ask the Ministry to consider developing Singapore into a regional centre of excellence for disability treatment, especially in disabilities that are reportedly on the rise, eg, developmental conditions of children, mental illnesses and geriatrics in the area of medical tourism, instead of playing the same space of lasik treatment, cosmetic injuries, botox, and so forth, like in some other countries in ASEAN.  Nowhere is demand so strong and supply so weak in disability medicine, and this is a great opportunity for us to go into.  As our neighbouring countries become more affluent, the attention they give to disabilities will be greater and Singapore should be well poised for the lead here.

Community Health Screening Programme

     Mr Ang Mong Seng (In Mandarin):  [For vernacular speech, please refer to Appendix A*.]  Mdm Chairman, the grassroots organisations of Bukit Gombak has spearheaded a health screening programme for all elderly residents of Bukit Bombak constituency since 1999. This scheme has been very well received by our residents. In 2000, MOH implemented a health screening programme at the national level, and has extended this programme to all various constituencies in Singapore.  It has since become an important healthcare management regime for our residents.

     However, over the past two years, there has been a decrease in the number of elderly people going for health screening. Feedback shows that the elderly people are afraid of finding out their health screening results. They fear to be confronted by test results indicating that they have contracted chronic diseases such as high blood pressure, high cholesterol and diabetes, etc. Such chronic conditions require regular follow-ups and treatments, and the cost of treating these chronic diseases, over the long run, can be extremely costly. As such, many of them are unwilling to come forward for the health check-ups. This certainly defeats the purpose of the health screening programme.

     In this regard, I would like to ask the Minister if MOH is able to formulate an affordable healthcare package for our elderly folks. This can help to lessen their financial burden for step-down care services, and hopefully they can come forward voluntarily for health screening organised by the grassroots communities. Regular health screening will also help in the early detection of chronic conditions and thus achieve the purpose of implementing the health screening programme for our elderly.

Traditional Chinese Medicine

     Dr Ong Seh Hong (Marine Parade): Mdm Chair, I declare my interest as an employee of Ren Ci Hospital which also provides Traditional Chinese Medicine (TCM) service. 

     Madam, the past two decades have seen a growing configurance of several trends, TCM doctors approaching TCM on a more scientific basis, western doctors and researchers recognising the potential of Chinese herbs and patients becoming more open to non-western practices.

    China is clamouring to modernise its vast TCM infrastructure and increase its market share.  Hong Kong and Taiwan are hoping to leverage on their Chinese heritage to become TCM hubs. Western pharmaceutical giants are in search of TCM partnership in the lucrative world market of herbal medicines estimated to grow to $12 billion over the next 10 years.

    Given our Chinese heritage, good location, medical tourism hub status and high medical standards, Singapore should seize the opportunities to develop into a TCM hub. We have done some good work so far. The Traditional Chinese Medicine Act was passed in 2000. I must commend the TCM Practitioner Board for putting up the regulatory framework which ensures only properly trained and qualified TCM practitioners are allowed to provide consultation and treatments to the public.

    However, I feel that much more can be done. One such area to promote is specialised TCM practice.  Unlike western medicines that have an established history of well structured training and practices, the development of TCM in Singapore has been left in the hands of the private and voluntary sectors.  Hence, we only have a handful of well-established TCM institutions, like Chung Hwa Free Clinics, Public Free Clinics, Thong Chai Medical Institution and the affiliate teaching facilities.

    While they provide good services, we do not have expertise in specialised field or in research development.

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     We need to import specialists.  To this end, the TCM Board can play a facilitator role. 

     Currently, TCM Board's policies do not augur well for institutions wanting to bring in foreign experts to set up specialist centres.  For academically-qualified foreign TCM doctors, the Board's criteria requiring "at least eight years of experience and holds at least the post of "Deputy Head", complete three years of TCM clinical attachment under conditional registration at an approved local institution" are, at best, restrictive.   In comparison, a Singaporean with similar qualifications only needs to complete one year of clinical attachment.  This disparity smacks of double standard. 

     I was equally befuddled by the requirement that for each foreign doctor hired at each individual clinic, there must be at least three TCM physicians on full registration, which under current system, means only Singaporeans.  This sounds like a protectionist quota system.  As it was introduced after February 2006, it is also unfair to practitioners and clinics set up before the new regulations.

     So I urge MOH to review its policies and welcome more highly qualified and experienced TCM experts to come and practise in Singapore.  This will raise the standard of TCM and help us in our pursuit to be a TCM Hub.

Influenza Pandemic Plan

     Dr Lam Pin Min (Ang Mo Kio): Madam, an influenza pandemic is a large scale epidemic of the influenza virus, such as the 1918 Spanish Flu, 1952 Asian Flu and the 1968 Hong Kong Flu.  The WHO warns that there is a substantial risk of an influenza pandemic within the next few years.  The strongest contender will be the H5N1A Avian Flu virus which is rapidly mutating and could mutate into a variant that transmits easily between humans.  The influenza pandemic of 1918 killed about 50 to 100 million worldwide in just 18 months, dwarfing the bloodshed due to the First World War.  Interestingly and ironically, in those dark times, children would skip rope to the rhyme, "I had a little bird.  It's name was Enza.  I opened the window and in flew Enza." 

      The origin of this influenza variant was not precisely known till evidence from a recent reconstruction of the virus suggested that it jumped directly from birds to humans.  With advanced medical knowledge and surveillance, we do not want similar catastrophic event to happen again, at least, not at that magnitude.  While we have succeeded in coping with SARS in 2003, the threat of an influenza pandemic continues to loom worldwide, making our national surveillance system and preparation for disease outbreaks even more crucial and important.  I would, therefore  like to ask the Minister for an update on its influenza pandemic plan which was drawn up in 2005 and ask him how prepared are the public and private medical sectors in coping with the impending outbreak.  In addition, as part of the preparation, the Ministry has stockpiled huge supplies of anti-virals and vaccines.  Would the Ministry update us on its stockpiling policy and the disposition of soon-to-expire and expired anti-virals and vaccines?

     The Minister of State for Health (Mr Heng Chee How): Madam, I thank Members for their valuable comments and suggestions.

     Dr Fatimah Lateef asked for the outcomes of our health promotion efforts.  Since its establishment six years ago, the Health Promotion Board has focused on motivating Singaporeans to lead healthier lifestyles so that they may live long and well, and with peace of mind.  Its key initiatives include: the annual National Healthy Lifestyle Campaign; collaboration with hawkers to offer healthier choices at hawker centres, restaurants and school canteens; working with food manufacturers to make healthier food products (such as fortifying food with nutrients like calcium); as well as working with corporate and community partners to encourage chronic disease prevention and management, exercise, smoking reduction, stress management and mental and emotional health.

     Surveys show Singaporeans have become more healthy.  The public's awareness of the importance of healthy living has risen and more are adopting healthier lifestyles compared to a few years ago.  The prevalence of hypertension, diabetes and smoking has decreased while the proportion of Singaporeans who exercise regularly and who eat more vegetables and fruits has increased.  Smoking prevalence decreased from 15.2% in 1998 to 12.6% in 2004. 

     Students benefit from the efforts of the School Health Services.  Immunisation coverage is high at 95%.  The DMFT (Decayed, Missing and Filled Teeth) index of 0.72 is among the best achieved by developed countries.  The "CHERISH" Award, introduced in 2000, encourages schools to establish comprehensive school health promotion programmes. Since the inception of the "CHERISH" Award, the number of schools that achieved the award has increased from 84 in 2000 to 276 in 2006. 

      As for the workplace, the HPB facilitates the setting up of workplace health programmes by employers. To this end, the HPB has provided grants of up to $5,000 to companies that implement and sustain workplace health programmes.  HPB also works closely with the Singapore National Employers Federation (SNEF) and the NTUC to organise regular talks and dialogue sessions with business and union leaders, HR personnel and workplace health facilitators.  Surveys show that the number of private sector companies with a comprehensive workplace health programme increased from 32.6% in 998 to 45.1% in 2003.  Benefits from such programmes include improvements in the health profile of workers - more workers are now exercising, fewer are overweight, leading to a reduction in medical costs per employee and reduction in medical leave taken in these companies.  So HPB will continue to pursue these initiatives. 

     Mr Yeo Guat Kwang reminded us not to forget about older workers.  I fully agree with him.  If employers think that older workers would inevitably incur more healthcare costs and, thus, are more costly to employ, then they will be less willing to employ older workers. In the light of an ageing workforce, we must do more to help older workers maintain and improve their health, so as to enhance their employability.  One key area is the management of chronic diseases.  As persons in middle age stand a higher risk of getting these conditions, early detection, treatment and management will directly reduce the damage, suffering and lifetime medical costs to both employee and employer. 

     Going forward, HPB will be stepping up its collaboration with the NTUC through the new U-HEALTH (Union-Helping Employees Achieve Lifetime Health) initiative.  Under this initiative, the HPB and NTUC will spearhead regular health chronic disease screening for workers. For the workers who suffer from diabetes, high blood pressure and high cholesterol, they will be helped with follow-up treatment.  NTUC has already secured the commitment of 30 companies to pilot the programme.  Once this pilot is proven effective, it will be ramped up. And as the health of workers improve, their employability and prospects for employment or re-employment will correspondingly strengthen. 

     Madam Halimah and Mrs Josephine Teo asked about mental health initiatives. I  agree with them that good mental health is important for the well-being of individuals and their families and for society at large, especially in an increasingly fast-paced environment.  To meet the challenges in this area, the Government has set up a National Inter-Ministry Workgroup, headed by the Permanent Secretary of Health, with representation from employers and unions, to look comprehensively into intersectoral issues related to mental health. The National Mental Health Blueprint recently drawn up by the MOH describes the national strategy for the prevention and treatment of mental diseases, including dementia.  Under the Blueprint, MOH will train more mental health specialist doctors, nurses and healthcare professionals to meet expected demand.  This will be done through increasing specialist training places, offering training scholarships and including a mandatory posting in psychiatry for family medicine trainees.  Mental healthcare training will also become a regular part of GP partnership programmes to help strengthen such services at the primary care level.

     MOH is also examining the possibility of assembling multi-disciplinary community teams to better serve the varied needs of different segments of society.  These teams can comprise psychiatrists, nurses, social workers and other mental healthcare professionals and they will work alongside schools, community organisations and social services to help children, adults and the elderly achieve improved mental health outcomes.  MOH and HPB will continue to promote greater public awareness about mental health through partnership with VWOs.  HPB's own "Mind your Mind" education programme will also be expanded to give special attention to vulnerable groups such as the elderly and those facing crisis events.  To foster positive mental health in our young, HPB will engage teachers and counsellors, parents as well as work through youth-centric media like the Internet.

     Ms Irene Ng asked about depression amongst the elderly.  Depression and the past history of attempted suicide are risk factors for suicide among the elderly.  When such indications are picked up, health professionals refer the patients to the psychological medicine services and hospital medical social workers for assessment, treatment, counselling and support.  We will explore additional ways to equip medical teams with the ability to help such patients with early identification of the symptoms so that proper and prompt intervention can take place.

     Sometimes, medical problems cause a certain degree of disability in elderly patients which then becomes a source of stress and depression.  In severe cases, that may also lead to suicidal tendencies.  To minimise this likelihood, restructured hospitals have set up geriatric units to teach elderly patients and their caregivers how to take proper care in the light of those disabilities.  Hospitals also work closely with community-based services and family physicians so that after an elderly patient's discharge from an acute hospital, active rehabilitation continues in a step-down care facility, if needed. 

     Dr Fatimah Lateef spoke on dementia in Singapore.  Today, its prevalence in Singapore is 6.2 per 1,000 population.  This is low compared to other developed countries in the Asia Pacific region, such as Japan and Hong Kong, with prevalence rates of 14.6 and 8.6 respectively.  The prevalence of dementia in Singapore is expected to reach 12.3 per 1,000 population by 2020 as a result of the ageing of our population.  We do not currently track detailed cost data associated with dementia but we can look into facilitating such studies.  We recognise that well-formulated policies that tapped collaboration with private and community organisations can reduce the cost impact of the projected prevalence growth through effective interventions for people with dementia.  We will consider ways of doing so.

     Mr Low Thia Khiang asked about the support for IMH.  Since the restructuring of IMH in October 2000, the Budget given to IMH to pay for subsidised services has doubled from $41 million in FY 2000 to $80 million in FY 2005.  MOH has also supported new mental health initiatives introduced by IMH over the years.  Examples included the Early Psychosis Intervention Programme (EPIP) which Mr Low referred to, in-patient psychiatric rehabilitation service, mobile crisis team and hotline service.  Pioneered by the IMH, the EPIP has successfully shortened the time taken to detect, manage and treat patients with psychosis, and this has helped many more such patients to continue working.  Our work in this area has been validated when IMH's EPIP received the inaugural "State of Kuwait Prize" for research in health promotion which was awarded by the World Health Organisation in May 2006.

     MOH also provides proportionately more Medifund to IMH compared to other public hospitals because the IMH patients are on the whole more long-staying patients and many more do not have financial support from their families.

     Mr Low asked about the night clinic service at IMH.  IMH had piloted such a clinic but experience had shown that it had low volume and demand and, hence, the night clinic ceased to operate, so that the resources could be better focused elsewhere to help the patients. We will continue to monitor the patients' feedback when determining the feasibility of these services. But, at the same time, there is also a national network of GP clinics, fully-trained and equipped to help these patients.  So, in terms of the hours in which they can do so, there are different avenues to do so. 

6.30 pm

     Assoc. Prof.  Kalyani Mehta spoke on ways of assessing healthcare needs and of improving nursing home service standards.  The MOH and MCYS presently use the Residence Assessment Form (RAF) to assess the nursing care needs of persons who require residential care in nursing homes or sheltered homes.  The RAF is a concise 9-item assessment tool which can be applied easily and quickly by Eldercare professionals to determine care needs.  It was introduced in 1993 and it was adapted from the Australian System of Resident Classification.  In 1999, the RAF's use was extended beyond assessing the physical needs of residents to also assessing patients with dementia and psychiatric needs.

     The InterRAI, which Prof. Mehta referred to, is an international scientific consortium of researchers, clinicians and policy-makers and they have developed a series of uniform assessment tools to assess and plan the long-term care needs of the elderly and disabled persons.  Some countries have adapted the RAI for their use, eg, the US and Japan.  Compared to the RAF, the RAI is more complicated.  But, having said that, we are continually studying ways of strengthening our assessment system and we are presently in discussion with the InterRAI to assess the feasibility of adapting that instrument for use in Singapore.

    I certainly share her views on the importance of maintaining and upgrading service standards within nursing homes and of collecting and making known comparative data, so that users and their families are in a better position to make those comparisons and choices.  Prof. Mehta referred to a particular sad case of a death and that the police is investigating.  I do not have details of that particular case to provide at this juncture.

     Mr Ang Mong Seng asked about the community health screening programme.  The "Check Your Health" community health screening programme screens for high blood pressure, diabetes and high blood cholesterol.  Early detection and treatment is definitely better and cheaper than late detection.  Hence, residents detected with such problems are advised to see their family doctors and be treated as soon as possible. 

    Recently, the conditions screened for under the "Check Your Health" initiative have been included in the Chronic Disease Management Programme.  Patients may now use their Medisave to pay part of the cost of the treatment.  The children may also use their Medisave to help pay for that treatment.  So, this significantly reduces their out-of-pocket treatment cost.

    Ms Denise Phua asked about support for the disabled. Currently, the same rules apply to all under the 3M system.  In respect of Medisave, the disabled and non-disabled are treated alike and are subjected to the same withdrawal limits.  My Ministry has just announced increases to some of these withdrawal limits, and the relief will extend equally to the disabled.  While Medishield does not cover pre-existing illnesses or disabilities, disabled persons have been able to secure Medishield coverage for health risks unrelated to the disabilities themselves.

     The reason why insurers do not insure against pre-existing illnesses or pre-existing disabilities is that it undermines the viability of the insurance product and causes it to fail.  Insurance is to pool risks.  In other words, it is to hedge against something which may or may not happen.  If something has already happened, then there is no question of hedging.  If an insurance cover includes things that have already happened, then there would be every incentive for people to wait until the condition develops before joining and there would be no incentive for the healthy to join or to stay on, and this is known in the industry as "adverse selection".

     It is for this reason that my Ministry's approach is to persuade Singaporeans that it is critical for them to get themselves on to basic Medishield insurance as early as possible and to help them do so.  So the initiatives just announced by my Minister pertaining to enrolment at birth, as well as at point of marriage, trying to cover the housewives, are a move in this direction.  In this way, the population would have more protection against big medical bills before the onset of illnesses and disabilities. 

     Ms Denise Phua did make a point about educating the insurers, the way in which they would want to exclude coverage for certain illnesses or disabilities and how they relate to the disabilities themselves.  In other words, are they being overly conservative in comparison with international benchmarks and practices?  It is something that the Ministry will bear in mind in our ongoing discussions, dialogues and feedback to the industry and, certainly, through the process of dialogue as well as through opening up the insurance markets to more competition as time goes on.  We do hope that the best benchmarks in the world would also apply in Singapore to the benefit of all, including the disabled. 

     As for Medifund - I am just completing the 3M description - that helps Singaporeans who, owing to financial difficulties, are assessed to be unable to afford their already subsidised treatment.  This help extends to both disabled and non-disabled Singaporeans and the help is calibrated to the circumstances of each case. 

     Having described the 3M system that we have, my Ministry fully understands the additional difficulties faced by the disabled and we want to do more for them.  We currently have a scheme called the Primary Care Partnership Scheme (PCPS).  This scheme currently enables the elderly poor to seek treatment at participating private GPs for acute conditions like cough and colds and then pay polyclinic rates, which are clearly highly subsidised.  We have decided to extend the convenience and benefit of the PCPS to the eligible disabled by the end of this year.  Details will be announced in due course. 

     On research into intervention methods for common special needs, the Child Development Units, or CDUs, currently monitor the incidence of child development problems in Singapore.  They also conduct some amount of research on diagnostic and intervention methods.  They have plans to research into the areas of skills training and mediated learning for persons with special needs in time to come.  I also agree that more education and information provided to parents of the disabled children would be most helpful.

    As for disability medicine, rehabilitation services are currently available in various settings, including acute and community hospitals and day rehabilitation centres.  The four community hospitals provide inpatient convalescent and rehabilitation care for patients after they have been discharged from the acute hospitals, while the day rehabilitation centres provide day programmes for persons with disabilities.  There are about 30 of these day rehabilitation centres spread across the island. 

    Now, I move on to TCM.  I agree with Dr Ong Seh Hong that developing TCM would enhance our position as an international medical hub and would also help with the SingaporeMedicine initiative.  Singapore is well placed to do this because of our recognised strengths in Western medicine and our proximity and close links to countries like China and India, which have strong roots in traditional medicine. 

    Demand for complementary medicine is strong and growing.  Just to give an example, I recently accompanied my Minister to visit the TCM clinic at Raffles Hospital.  We were told that the demand there has grown very quickly over the last two years, perhaps tripling, and the facilities to support the use of TCM in inpatient settings have also been expanded to cope.  We saw both Singaporeans as well as foreign patients at that clinic.  I believe that successfully developing TCM in Singapore will give the patients, both local and foreign, additional good options to choose from.

     Of course, in doing so, we must make sure that quality and safety are always maintained.  The systematic training and qualifying of TCM practitioners will boost their credibility and give confidence to patients.  Having foreign TCM practitioners of high standing come to practise in Singapore will also contribute positively to this capability building. 

     In this regard, the two main local TCM schools, namely, the Singapore College of TCM and the Institute of Chinese Medical Studies, started TCM degree courses in 2006, with my Ministry's encouragement.  These courses are carried out in collaboration with respected TCM universities in China.  The TCM Practitioners Board, which is the industry regulator, currently allows TCM practitioners with Bachelor's degrees from six approved TCM universities in China to be registered here and practise.  The TCM Practitioners Act also gives the TCM Board the means to allow practitioners, whose qualifications lie outside the approved list but who are assessed to have outstanding skills and expertise, to register and practise in Singapore.  But I take note of Dr Ong's feedback just now pertaining to the specific criteria and requirements and we would take that into consideration in terms of reviewing whether or not it is too tight in allowing this kind of practitioners to come into Singapore.  Foreign practitioners currently form about 5% of the pool of registered TCM practitioners in Singapore and the total pool is about 2,000.

     Dr Lam Pin Min asked for an update on our pandemic plans.  Effective surveillance is important in detecting disease outbreaks early.  MOH does this through continuous monitoring of news reports of disease outbreaks overseas and assessing the risk of these occurrences to Singapore, keeping the hospitals and doctors informed of  developments and providing guidelines for detecting and reporting suspect cases, and enhancing laboratory capabilities and capacities for disease detection.

     Beyond surveillance and detection, prompt and correct response is equally important to retard and limit the spread of the outbreaks.  In the latest review of the Pandemic Plan, focus was placed on bringing in the participation of private GPs and private hospitals to expand the healthcare resources available nationally to cope with demand during a pandemic. 

     MOH conducted exercises with public and private hospitals in April and May 2006 to test their preparedness for the avian and pandemic influenza.   These were followed by a system-wide exercise in July 2006 that involved MOH, hospitals, polyclinics, GP clinics, nursing homes and relevant Government agencies.  The lessons learnt from these exercises served to improve the design of the plans.  Exercises will be conducted from time to time to ensure our continued preparedness.

     On our anti-viral stockpile, we have now stocked 1.05 million courses of Tamiflu. They will be used to treat infected persons during an avian flu pandemic. The stockpile of Tamiflu was delivered to us in batches and the first batch will expire in 2008.   While there is limited scope of rotating this Tamiflu with clinics and hospitals because there is overall very low usage, my Ministry will, nonetheless, do our utmost and look at different ways to minimise the stocking cost of this anti-viral stockpile, but  without compromising Singapore ’s pandemic preparedness.

     Mdm Halimah Yacob: Madam, I would like to seek clarification from the Minister on a couple of points and also to seek answers to a couple of points which I had raised but were not answered. 

     First, on the question about affordability that I had raised and the point that the current subsidy does not cover all the items on the bill.  In fact, some of the items that are excluded can actually be expensive items.  Would the Ministry consider including all the items, so that when we talk about a subsidy of 80%, we are actually talking about the subsidy of the total bill and not only some of the items on the bill?  Because the items that are not included are expensive, this can cause hardship to the subsidised patient if he has to pay.  For example,  I gave an example of a cancer patient that has to use the colostomy bag, and some of the medications are not subsidised for these patients, whether they are in "C" or "B2" class wards. 

     My second point is on the SingaporeMedicine initiative.  We are not at the stage yet where we are rapidly taking in foreign patients.  Therefore, there is still scope for the public hospitals to think carefully on the structure that it has to put in place, to prevent possible conflict and also questions arising as to why are public resources being used for private patients.  So, there is a clear need for there to be a better firewall to separate the two - service to public patients using public resources and private patients using completely private resources.  I seek clarification on this point, ie, whether the Minister can think of this particular structure that I was talking about. 

     My third point is to seek clarification from the Minister on whether the level of subsidy for step-down care can be enhanced because currently there is a difference in the hospital subsidy and the step-down care subsidy.

     My final point is on ElderShield.  Can the Minister consider relaxing the qualifying criteria so that more people can be covered under it?  Because if you increase the period and also the amount, but if the qualifying criteria remain rigid, people will not be able to come under it.

          The Chairman: Mr Khaw, you have about four minutes to respond.

     Mr Khaw Boon Wan: I probably will only be able to respond to one or two points, but we have time tomorrow to continue.  Let me take the easier ones first.

     On ElderShield - ElderShield reform is something I am committed to do and I want to do it, and I am glad that Mdm Halimah supports it in principle.  The qualifying criteria are certainly one of the criticisms usually levied on ElderShield.  For the information of the Members, right now, we require certain threshold.  You have to cross the threshold and professionally what we do is we look for disability measurements, like inability to, say, bathe and feed yourself, and so on.  There are six such criteria and the patient must not be able to do three things, then you qualify for ElderShield.

     What I plan to do, going forward, is, for the basic product, we keep these three disabilities criteria.  The reason is this.  If you start lowering the threshold, that means easier to get payout, then your premium, unfortunately, will be quite high.  So there is a trade-off.  My actuaries are still doing the computations.  Most likely, I think we keep to the basic product - three qualifying thresholds but as I have already shared with the public a few weeks ago, what I plan to do is we allow "rider".  I used the term "rider", which has confused NMP Ms Cham just now.  "Rider" has a technical meaning and actually "rider" is the wrong word to use.  The better word I can think of is "supplement".  So I am asking my colleagues in the Ministry of Health not to use the word "rider", but use the words "ElderShield supplements". 

     For the basic, it applies to everybody.  But if you can afford and want better payout, you buy a supplement, like health supplements.  So, basic ElderShield plus supplements.  We leave it to the industry to develop different "supplements".  So, some supplements could have two criteria, instead of three, but, of course, the premium will be higher.  For some supplements, instead of paying just $300 or $400 a month, maybe they pay $800 a month or $1,000 a month, and some other supplements maybe, instead of just paying five years, they may pay six years or seven years, or even lifetime annuity, all at different pricing.  I think that will make the whole ElderShield system much more diverse, which is really the theme of my speech this afternoon, ie, our needs are diverse, so we need a wide range of diversity.

     On SingaporeMedicine in public hospitals and separation of local patients from private patients.  Actually, the separation right now, which we are doing, is by class - C, B2, B1, A - and foreign patients or Class "A" patients really is one category.  In other words, we do not subsidise foreign patients, just like we do not subsidise the Class "A" patients.  I am not very keen to have a special  block for Arab, another block for Koreans, etc, because I doubt the numbers are of such big numbers to begin with.

          The Chairman:  Order.  It is 6.45 pm.

     Thereupon Mdm Deputy Speaker left the Chair of the Committee and took the Chair of the House.

     Mr Khaw Boon Wan: Madam, I beg to report that the Committee of Supply has made further progress on the Estimates of Expenditure for the financial year 2007/2008, and ask leave to sit again tomorrow.

     Mdm Deputy Speaker: So be it.