Speech by Mr Edwin Tong, Senior Minister of State for Health, at the Ministry of Health Committee of Supply Debate 2020, on Thursday 5 March 2020

             As the Minister for Health has shared, we have delivered on our Healthcare 2020 objectives. Today, Singaporeans live longer, healthier lives than when we made these goals in 2012. We enjoy some of the best healthcare in the world, and this remains affordable and also accessible to all.

2.         But the future will bring new challenges, and we cannot afford to rest on our laurels. It will take bold steps – from Government and the community in partnership – to ensure that we can continue keeping these commitments to our citizens.

Strengthening our Financing Schemes for Better Affordability

Overall Financing Framework – “S+3Ms”

3.      Our healthcare financing system has weathered the test of time.  Each financing scheme plays a unique role in ensuring that no Singaporean will be denied appropriate care because of an inability to pay.

4.       First, Singaporeans enjoy means-tested subsidies across public healthcare settings, covering up to 80% of the costs of treatment.

5.         Singaporeans are also covered by MediShield Life for large hospitalisation bills and costly outpatient treatments. Coverage starts from the moment one is born, and is for life.

6.     Next, MediSave helps Singaporeans set aside some income towards future healthcare needs. It can be used to offset out-of-pocket payments, and pay for health insurance premiums.

7.            Finally, MediFund provides a safety net for those facing financial difficulty.

8.           This framework has worked well for us. Seven in 10 subsidised hospitalisations by Singaporeans do not incur any out-of-pocket expenses or payment, while eight in 10 incur payments of less than $100.

9.            Still, we regularly review each pillar of healthcare financing to give Singaporeans peace of mind in seeking the care they need.

Expanding support for patients with chronic conditions

10.      As our population ages, we can expect more Singaporeans to face chronic conditions.

11.          Ms Tin Pei Ling asked how we are supporting chronic disease patients, and Dr Chia Shi-Lu asked specifically about what we can do to encourage them to seek early intervention in the community.

12.        In June 2018, we raised MediSave withdrawal limits for conditions under the Chronic Disease Management Programme, or CDMP, from $400 to $500. We also expanded CDMP to cover ischaemic heart disease and pre-diabetes. Today, CDMP covers 20 conditions, including four mental health conditions: schizophrenia, major depression, bipolar disorder, and anxiety. We regularly review the list of CDMP conditions in consultation with clinical experts, and will include conditions such as eczema in our next review.

13.           Last November, we introduced higher subsidies for complex chronic conditions for Community Health Assist Scheme (CHAS) Blue and Orange card-holders, and also expanded CHAS Orange to cover common illnesses.

14.         We also launched CHAS Green – part of a wider initiative to shift healthcare beyond hospitals and into the community. All Singaporeans are now eligible for subsidised CDMP treatments at CHAS general practitioner (GP) clinics, regardless of income level. This represents a fundamental shift in primary care financing, with universal subsidies for GP treatment.

15.          Ms Irene Quay asked for an update on the success of these measures. Let me outline the broad parameters with reference to a few facts. I am happy to share that around 200,000 Singaporeans received their CHAS Green cards in 2019, entitling them to the programme I just outlined a moment ago. Altogether, 1.7 million Singaporeans have received their CHAS cards, seven times more than when CHAS was first launched in 2012.

16.          With our continuing efforts to bring more clinics onto the scheme, CHAS card-holders can now receive subsidised treatment at close to 2,000 GP and dental clinics island-wide. In 2019, we disbursed more than $160 million in CHAS subsidies, significantly alleviating the cost of outpatient treatments for Singaporeans.

Enhancements to MediSave500  

17.          This year, we will be further expanding the use of MediSave for CDMP treatments in outpatient settings.

18.        Currently, Singaporeans can tap onto MediSave500 scheme for CDMP treatments, for approved vaccinations and screenings.

19.          From 2021, we will increase support for patients with complex chronic conditions by raising the annual withdrawal limit from $500 to $700. Patients with complex chronic conditions include those who have visits for two or more CDMP conditions, or one CDMP condition with complications, within a year. This is aligned with the higher CHAS subsidies we implemented for complex chronic patients in November. In effect, rather than MediSave500, these patients will in fact, benefit from an extension of the scheme, MediSave700.

20.          Administratively, we will align MediSave500 with all other MediSave schemes, shifting from a per-account to a per-patient limit.

21.         Overall, we expect more than 176,000 patients to benefit from the enhanced MediSave700 scheme.

22.        Ms Tin Pei Ling also asked to consider greater flexibility in the MediSave withdrawal limits, especially for seniors with significant balances. Mr Pritam Singh raised the same issue.

23.          We have been working to increase flexibility under MediSave in a few key areas and let me outline that.

24.          First, covering new treatments and services. We are expanding MediSave to cover severe disability under the upcoming MediSave for Long-Term Care scheme. With cash withdrawals, patients will also have greater flexibility to choose the appropriate care options, relevant for themselves and their particular circumstances.

25.         Second, increasing flexibility within existing schemes. So first we cover new schemes and new treatments and second, we look at increasing flexibility within the scheme itself. One example is lowering the age threshold for Flexi-MediSave in 2018 from 65 to 60. Another example is the MediSave700 scheme I just outlined. The higher withdrawal limits increase flexibility for patients with complex chronic conditions, as they are likely to incur higher costs for their CDMP treatments.

26.         Overall, these enhancements are designed to strike a balance, as we have to continue to do, between current medical expenses and future healthcare needs down the road. We will continue to take on board the suggestions to review our MediSave withdrawal limits in light of the overall financing framework, to introduce greater flexibility where possible, and to ensure that they are adequate for the majority of patients in the subsidised settings.

Long-Term Care Financing

27.          Dr Chia Shi-Lu has also asked how we plan to keep healthcare affordable for elderly Singaporeans. The three pillars of our long-term care financing framework – CareShield Life, MediSave Withdrawals for Long-Term Care, and ElderFund – mirror the ‘3M’ schemes for acute care, and that has worked well for us. They complement existing subsidies of up to 80% for long-term care services, such as day care and home care.

28.          The first two pillars represent significant changes. CareShield Life provides better protection for severely disabled policyholders with lifetime payouts. MediSave Withdrawals for Long-Term Care, or MediSave Care for short, will allow Singaporeans to withdraw directly from MediSave in cash, providing flexibility for long-term care expenses. Both schemes will be launched later this year.

29.          Mr Daniel Goh asked how we are supporting families who might fall outside of the subsidy thresholds. So we have those within the framework that I have just outlined. What happens to those who might fall outside the subsidy thresholds? First, let me clarify that the current income criterion of $2,800 for long-term care subsidies covers close to two-thirds of all resident households in Singapore. The median household income per member quoted by Mr Goh includes employer Central Provident Fund contributions, which we exclude in assessing eligibility for subsidies. The figure is also based on all employed households, and does not consider households with no working persons. Elderly households, or households with elderly members, tend to have a lower income per household member. Hence, a larger proportion of such households will qualify for subsidies, with many qualifying for the maximum rate of subsidies. Together with CareShield Life and other schemes highlighted by Mr Goh, most Singaporeans will be adequately covered for basic long-term care needs. In addition, as I mentioned in the House last year, we will allow private insurers to introduce additional severe disability coverage on top of CareShield Life, with premiums payable from MediSave.

30.          The third pillar is ElderFund, a safety net for lower-income and severely disabled Singaporeans. It supports those who are unable to benefit from schemes like ElderShield with monthly cash payouts, and opened for applications on 31 January.

31.          Mr Muhamad Faisal Abdul Manap asked if patients with physical impairments can obtain support from MediFund for transportation costs. This is an area where new measures complement existing schemes to provide multiple layers of support. We provide means-tested subsidies of up to 80% for patients requiring transport for centre-based services, dialysis, or medical appointments at polyclinics and also at Specialist Outpatient Clinics. Patients who need additional assistance may tap on cash payouts under ElderFund, or other schemes, to defray the costs of travel to and from medical appointments. So we look at the overall framework and these are the schemes that sit outside, that supplement and work with the existing framework.

Supporting our Caregivers by Alleviating their Burden

Caregiver Support Action Plan

32.          Financial concerns represent only some of the challenges that Singaporeans face when loved ones encounter disease or disability. Beyond being able to afford care, we want Singaporeans to feel supported in caring for each other.

33.          Ms Yip Pin Xiu has asked about our long term plans for eldercare. Over the years, we have improved the accessibility of aged care services and also deepened the range of care options in community and residential care settings.

34.          Last year, we launched the Caregiver Support Action Plan to support those caring for seniors on their caregiving journeys. Since then, we have been working with the Agency for Integrated Care (AIC) and various community partners to roll out new initiatives.

35.          Some initiatives focus on care navigation and caregiver training. Caregivers can obtain information and access referral services at four new AIC Links touchpoints in Toa Payoh, Nee Soon, Pasir Ris, and Choa Chu Kang, which complement eight existing touchpoints already existing in our heartlands. We have also worked with healthcare professionals to introduce a course on the ‘ABCs of Caregiving’, with customised components to help caregivers with the different mobility needs of their loved ones.

36.        Within the eldercare landscape, there is a range of caregiving options. Many families engage foreign domestic workers (FDWs) to provide care, and Ms Yip Pin Xiu asked if caregiver training initiatives will be extended to them as well. There are indeed merits to training FDWs and families can decide on how to best to equip them. We have initiatives to support those who choose formal training for their FDWs, such as the Eldercarer FDW Scheme, which we have run since 2016. Training is done before placements in households that they serve, and includes both classroom theory and on-the-job practical training in managing the day-to-day care of an elderly person. Caregivers can tap on an annual $200 subsidy under the Caregivers’ Training Grant to offset the costs of training for their FDWs, or other approved courses.

37.          Mr Christopher De Souza has asked about our measures to provide respite care, and how effective they have been. He will be pleased to hear that we have respite care options at more than 20 eldercare centres and 40 nursing homes, where more than 3,700 so far have benefitted.

38.          We have recently expanded the range of respite care options as well, starting with a respite care pilot in September 2019 for caregivers of cancer patients on home palliative care, and a night respite care pilot in December 2019 for caregivers of persons with dementia, who experience behavioural and sleep issues at night, and sometimes these difficulties cause a caregiver not to have his or her own rest, so that option is available. We have also been helping caregivers access respite care at short notice. Caregivers under our Go Respite pilot launched in April last year were able to pre-enrol for these services, and activate respite care at short notice. To date, over 450 caregivers have been pre-enrolled.

Home Caregiving Grant

39.          Beyond expenses for home and community-based services, caregiving expenses can take many forms and we recognise that. In October 2019, we launched the Home Caregiving Grant, which replaced the previous Foreign Domestic Worker Grant with an enhanced quantum of $200 per month. By providing cash support directly to care recipients with permanent disability, caregivers now have greater flexibility as to how best to deploy these resources.

40.          We have since approved more than 4,900 applications for the Home Caregiving Grant, bringing the number of beneficiaries under this scheme to over 16,000.

41.        Allow me to share the story of one caregiver, to illustrate how our schemes address caregivers’ different types of needs. Mr Shahril lives with his wife, three children and 79-year-old father, who is bed-bound after a stroke and heart attack.

42.          In October 2019, Mr Shahril needed a break from caregiving duties, as his helper had left the country for home leave. He shared this with AIC Link staff at Changi General Hospital, where his father was treated. Within two weeks, they enrolled Mr Shahril’s father on AIC’s Go Respite programme at the NTUC Health Nursing Home, across the road from their home, and he began his 3-week stay there. This arrangement made it easier for Mr Shahril to continue to provide for his own family, at the same time, with the assurance that his father was cared for during this period.

43.          At the same time, Mr Shahril also applied for the Home Caregiving Grant. Today, his family receives a monthly payout of $200, which they use for essential items such as diapers, milk supplements, other disposables, as well as for his father’s medical expenses. All in all, our schemes have given Mr Shahril the flexibility and assurance to care for his father in the long term.

Focusing on Preventive Health for Downstream Savings

Pre-packaged Beverages

44.          I have shared how the Ministry is taking important steps to help address the cost of care – both financially and otherwise. These will support Singaporeans in seeking necessary care. At the same time, we must take bold steps to encourage healthier lifestyles. This will delay the onset of disease, and reap downstream savings for our healthcare system.

45.          Members will also be nonetheless familiar with our efforts on this front. Minister has described some of our efforts to promote healthy living under the War on Diabetes initiative.

46.          Although we have made progress in encouraging Singaporeans to exercise more and eat healthier, our daily sugar intake remains high. In particular, beverages contribute more than half of our sugar intake.

47.          Both Mr Charles Chong and Mr Gan Thiam Poh asked for an update on our plans to control the consumption of such beverages. The same issues and questions were raised by Dr Intan Azura Mokhtar in the House last week, while Mr Leon Perera also made some suggestions on what else we could do should these measures not prove to be effective. As a start, we will implement two new regulatory measures for pre-packaged beverages: a nutrient-summary label, and an advertising prohibition for beverages with high sugar and saturated fat content. We want to provide Singaporeans with the right information to make their own healthy choices, and at the same time, encourage manufacturers to reformulate products and create healthier options – a point that I think Mr Perera also raised.

48.          Under this new regulatory framework, all pre-packaged beverages will be given a colour-coded nutrient-summary label, called the ‘Nutri-Grade’. With your permission, Mr Chairman, may I display an example of the label? Thank you.

49.          Grade A, which you will see in dark green, corresponding to the lowest sugar and saturated fat thresholds,  while Grade D, corresponding to the highest sugar and saturated fat thresholds, is in red. This provides a quick, at-a-glance summary of the nutritional quality of the beverage, allowing consumers to compare across products at the point of purchase. Besides the grade, we will indicate the sugar level of the beverage as a percentage of the total volume. So 12 per cent on the label represents 12 per cent sugar of the total volume in that particular product. This provides Singaporeans with more information so they can compare sugar levels across beverages within the same grade and across different pack sizes.

50.          Pre-packaged beverages will be graded on a single set of nutrient thresholds, based on their sugar and saturated fat content. For example, beverages with more than 5 per cent sugar content will be graded ‘C’, while beverages with more than 10 per cent sugar content will be graded ‘D’. But beverages may be ‘downgraded’ to Grade D, if they also contain a high amount of saturated fat.

51.          We encourage all manufacturers to label their products with the Nutri-Grade, but the label will only be mandatory for beverages in Grades C and D. The label is intended to facilitate Singaporeans’ decisions when they go and purchase these products at the point-of-purchase. Therefore, it will not only be displayed on the front of product packaging, but also at points of sale where customers do not have direct access to the product, such as e-commerce websites, vending machines and drink fountains.

52.       In addition to labelling requirements, we will prohibit advertising for Grade D beverages on all media platforms, including traditional and new media platforms across all time belts. This will reduce the impact of advertising on consumer preferences and encourage manufacturers to reformulate.

53.         We will continue to allow advertising of Grades A to C beverages, as well as all brand advertising, as we want to encourage manufacturers to reformulate. The point is not to deprive Singaporeans of their favourite drinks, but to encourage manufacturers on their journey to reformulation, to create a wider range of healthier beverages for all to enjoy.

54.          The new regulations will be published at the end of 2020, coming into effect a year later. If manufacturers start today, they will have almost two years to reformulate their products in line with these regulations and avoid being in Grades C or D where they have to compulsorily put up the label. The Health Promotion Board (HPB) will continue to support industry reformulation efforts through initiatives such as the Healthier Ingredient Development Scheme. HPB will also launch a campaign to educate consumers on using the Nutri-Grade labels to guide purchases and consumption decisions.

Extension of Measures to Freshly Prepared Beverages

55.          At the same time, we have heard strong calls from all quarters to also regulate freshly-prepared beverages, such as herbal drinks and bubble teas. It is clear that they are a substantial and growing source of sugar intake for many Singaporeans. Dr Intan Azura Mokhtar asked whether there are plans to extend our regulations to these drinks.

56.          Over the past few months, I have met representatives from the freshly-prepared beverage sector to hear their views on how we can help consumers make that transition to healthier decisions. Most understand the need to inform consumers about the nutritional quality of their products, and support our objective of reducing Singaporeans’ overall sugar intake. After a careful review of the local landscape, we have decided to extend the labelling and advertising measures to freshly prepared beverages.

57.          As a start, these measures will apply only to the larger chains, which are more likely to have consistent recipes, as well as significant reach and impact locally. We will study the local landscape to determine the appropriate criteria for what comprises a ‘large chain’. Other jurisdictions with mandatory labelling in F&B settings have, in their own countries, adopted thresholds between 10 to 20 outlets as the definition of large chains. We will take reference from what has been done in other countries, which means that small businesses with one or two stalls, such as those in hawker centres, would not be affected in this first instance.

58.          Nevertheless, we will monitor the impact of these measures, and may gradually seek to extend them to more establishments. Concurrently, we encourage F&B outlets not considered ‘large chains’ to voluntarily adopt these measures. We will continue to engage the industry in the coming months to finalise the details of these measures, including how to implement them in a cost effective manner. More details will be shared when they are ready.

59.         All these initiatives are part of a longer-term approach to reshape consumer behaviour towards healthier living, not just in the choices that they make but in consumption. Some have suggested stronger measures, such as an excise duty or an outright ban. These will require further study, like those suggestions that Mr Perera raised. In the meantime, we will work closely with industry partners to support Singaporeans in making those healthier choices.

Make Plain Water More Widely Available

60.      Finally, as a complement to our regulations, we also want to encourage Singaporeans to go for more plain water instead – zero calories, very healthy on the overall grading scale. On that front, we have been working with agencies like the National Environment Agency, Housing and Development Board, Land Transport Authority (LTA) and National Parks Board to increase the availability and accessibility of drinking water in the community.

61.          Water dispensers are available in 30 hawker centres, and are easily found in parks across Singapore. By mid-2020, more water dispensers will be installed at the remaining 82 hawker centres. In addition, 14 bus interchanges and terminals already have water coolers. We will work with LTA and public transport operators to install water points in bus and MRT stations where suitable.

62.          In mid-2020, HPB will also launch a nation-wide campaign to promote plain water, as part of their nutrition literacy campaign. Whether you are exercising in our public parks, enjoying a meal at the hawker centres, or about to take a bus, we encourage you to choose plain water, stay hydrated, and enjoy a healthier life.

Conclusion

63.       To conclude, the Government will continue to enhance the affordability of healthcare, and expand support for caregiving.

64.          Policies such as the enhanced MediSave700 scheme will provide additional peace of mind for those with chronic diseases.

65.       At the same time, we will pursue downstream savings for our system by encouraging healthier living, and supporting Singaporeans in making healthier and wiser choices in what they consume.

66.          Better health for all is a vision and responsibility we must all share: we urge Singaporeans to partner with us as we strive for a healthier Singapore in 2020 and beyond.