Saturday, September 09, 2006

Healtcare Costs ... Again

[This will definitely never make it to the MSM. Thank goodness for the internet!]

Here we go again.

Dear Minister of Health, you just don't get it do you?

Sep 9, 2006
Five steps to keeping health care affordable

Excerpts from a speech by Mr Khaw Boon Wan, Minister for Health, at the China-Singapore joint health care forum yesterday in Xiamen, China

LAST week, I met Health Minister Gao Qiang in Beijing. We chit-chatted and shared our experiences. We both knew that it is tough being a health minister. [Probably tougher on the Chinese Minister due to his dramatically lower salary, must be mired in corruption by Singaporean logic.]

This is because patients expect us to do magic. They expect us to deliver a very high standard of medical service but at a very low cost, preferably free. These objectives are almost contradictory. How can we deliver First World health care at Third World costs? [Yes yes, it is a condition endemic only to Singaporeans & Chinese apparently. Of course nobody in the world will want to pay Third World rates for First World goods, we all really really want to pay First World rates for questionable goods on which some of us are tested.]

Early this week, I read a newspaper article (ST, Aug 4) which quoted Indian Tourism Minister Ambika Soni as saying that India offers 'the best treatment for one-fifth of the cost (in the West)'. For example, bone marrow transplants cost US$30,000 (S$47,000) in India as compared with US$250,000 in the US. Likewise, cardiac surgery in India costs a quarter of that in the US.

But hospitals offering US standards of care are rare exceptions in India. [As is the story of Singapore. But why can we not strive to be like that Indian hospital? As a tax payer I would happily send a team from your Ministry with MY money to India to study how this hospital pulls off this feat then try to replicate that in Singapore to the benefit of Singapore citizens while creating a possible medical tourism plus point. In this flattening world, price will be the ultimate dictator of where most of the spending dollar goes. Gucci and Mount E. nuts aside.]

The bulk of health care in India remains at Third World level. Hence, it is possible for a few hospitals to offer US standards of care while leveraging on the large number of health-care workers who remain on Third World wages. [Dear Minister, in the international medical community Singaporeans probably ranks as an oddity. First world country, Third world painkillers. Having been treated in the US and here in Singapore ... I would have to say we Singaporeans tend to suffer a lot more pain rather unnecessarily due to your controlled substances acts. Your policy on proven drugs simply does not qualify for any price increases.

Singaporean workers bore the brunt of bringing Singapore to the First World on Third World wages. You are expecting us to now pay for First World priced medicine?]

The challenge is to keep wages and costs at Third World levels while the rest of the health-care system moves to First World standards. It is almost impossible. [Last I heard in Singapore we have a very close tripartite working relationship where Singaporeans will gladly suffer cuts in CPF and raises in broad based taxation like GST and ERP. Our wages have not really gone up sir! And before you pull that Progress Package stunt again ... where is that money going to come from?]

With globalisation, the wages of health-care workers as well as the prices of medical products are converging. Cross-border migration of health-care workers is now common. For a small country like Singapore, we import most of our medical products, like drugs and X-ray equipment. We have to pay international prices for these imports. [I called for local production of generic drugs during this past GE, you responded that we do manufacture medicine here. I have to ask again sir: we produce only Panadol and Axe Oil here? Why can't we produce and possibly export generic drugs that have run their patent life duration? We'll have to ask your colleague Mr. George Yeo I believe. Are drug prices and the ability to produce generic drugs in Singapore bound by FTAs recently signed by any chance? Are Singaporeans being made to pay more for costly drugs in exchange for what the EDB or MITI can later proclaim to be a victory of negotiation at the trade table?]

With people living longer and mothers producing fewer babies, uncontrollable healthcare costs can potentially wreck our finances, not to mention create major political problems. [I believe it too! And the issue at hand is cost! Not whether or not we have more money, through CPF or other means, to pay for escalating medical costs! Costs needs to be contained please, not alleviated by simply allowing us to spend our own money which we otherwise would not have been able to till after retirement.]

Singapore is fortunate that our founding fathers were successful in developing the economy. With clean water, clean air and good sanitation, the health of our people has improved over the years. We now enjoy high life expectancy and very low infant mortality rates.

Our [health-care] system today is not perfect but it is not bad. WHO has rated our system as among the top 10 most cost-effective in the world. [Dear Minister, independent research shows your statement to be in sync with what has been published. May we move on and try to gun for a better and cheaper system then please?]

Today, we spend only 4 per cent of our GDP on health. The average public hospital bill size for the unsubsidised Class A ward is about one month of the average salary. In the heavily subsidised Class C ward, the average bill ($786) is less than a week of salary. [Yes, but we also spend 24% of our salaries, in one form or another, on our beloved HDB flats according to a Cisco international salary survey - the highest in the world! Add the differing costs together and you do not have a low cost model that is attractive to MNCs .... and eventually citizens as well.]

For the high standard of medical care that hospitals provide, we think this is very good value for money. [Comparing with John Hopkins or with the above mentioned Indian hospital?]

Five aspects of managing a health-care system

First, we work on the basis that health-care cost will continue to rise. While we do our best to manage medical inflation, we know that the trend is rising. The reason is simple. Doctors and nurses will continue to command high salaries and advances in medical science will continue to churn out new drugs and new equipment which are more expensive than their replacements.
The key to managing health-care cost is therefore to ensure that there is a constant and expanding flow of money going into the health-care sector to pay for new services. There is no short cut to this problem. [I concur, there is no short cut to this problem. Allowing the population to understand how medical costs are derived will allow for greater transparency which you argue for later on. Let's talk about the real cost of medical treatment in Singapore. Dollars and cents, just like what you forced to be published last year for some treatements at different hospitals.]

We are more likely to succeed if we share the financial burden widely. If we load the burden on one payer - whether the government as in the British system, or the employers like the American system - we will cause very severe strains. In Singapore, we involve both the Government as well as employers, and in addition, we rope in patients and their families as well. Our health-care system is supported by all the major stakeholders: Government, employers, patients, family members, insurers and charities. [So the new major shareholder in tripartism is now the patient and their families? At times I feel my tax money goes to supporting our incredible high Ministerial salaries. Perhaps it is time to once again raise the platform of medical national service for doctors / nurses who graduate from our 'heavily subsidised' educational system? If you crank out 100 doctors a year and they have to serve say, 4 years at NS pay levels, would that help lower costs?]

Second, we believe that the health-care market can work better under competition. Market competition is the best way to allocate resources efficiently. Compared to other economic sectors, the health-care sector is notoriously unproductive. But there is no fundamental reason why the health-care market must fail. It fails only because we allow it to fail. [Another common reason for market failure is imperfect information. In Singapore, yet another reason exists for market failure - governmental intervention.]

For markets to function, there must be timely information so consumers and producers can make rational decisions. When we want to buy a mobile phone, we shop around for the best prices for the functions that we desire. But how many patients shop around before they go for their cataract eye operation or knee cap replacement? And how can they shop around when information on how much patients pay for such operations is not easily available?
In Singapore, we are trying to push out timely and relevant information. We gather data from our hospitals and publish them regularly. [Great first step Minister! *applause*]

Third, we must empower patients and get them to take greater responsibility for their own health. This is particular so in the management of chronic diseases like diabetes and hypertension. If we manage chronic diseases well, we are more likely to avoid or at least delay or minimise the onset of future medical complications requiring costly treatment. [Sorry, this is a no-brainer, no applause here. Only thing I will say is to encourage the PAP to continue with its nanny function. Keep it up! Keep it up! .... "Don't worry, the government will take care of it. They have the best brains and they know what they're doing. No one else should interfere!"]

Patients should take responsibility for their own health and work with their doctors and change their lifestyle. Eat healthily, exercise regularly, avoid obesity and smoking, take medication as prescribed by their doctors while regularly monitoring their own health and looking out for signs of complications. Many pilot studies of such structured disease management programmes have shown the benefits to the health of patients, while saving them money. [Please don't give me this whole bullock cart worth of bovine manure. How much time off does your assistant get? How much time off does a wannabe-high-flyer civil servant get? You have a paunch too Minister. We live in Singapore. There is no time to muck around other then to work and to please our bosses. You have not watched 'Singapore Dreaming' have you?]

Fourth, we must revive the important role played by the primary health-care sector. In many countries, this sector has been marginalised as patients and doctors flock to the more glamorous tertiary sector. An over-swing to the tertiary sector has been a major contributor to escalating health-care costs in many countries, without any corresponding improvement in health outcomes. [You said upgrading is good right? So how can you describe the move into the tertiary health sector as an overswing sir? They are merely following their societal instincts to make hay while the sun shines at the risk of being labelled - "see how much they earn? so little" which I believe is attributable to you in the month of August 2006.]

As a rule, we need to keep patients away from unnecessary care by specialists at expensive hospitals. When a patient who can be adequately treated by a GP is instead managed by a specialist in a tertiary hospital, it means a waste and abuse of expertise.

Often, financial incentives and remunerations for the doctors work against the right siting of care. [Is this not where governmental policy would do some good though it is intervening in a market model? To acheive a slightly more socialistic outcome in terms of primary medical care?]

When insurers reward high-intensity, high-cost surgical treatment but do not reimburse GPs who provide low-intensity, low-cost health education and dietary advice to their chronic sick patients, we should not be surprised that the outcome is disappointing. [Yes sir! Because at one point in time not too long ago, primary health care cost was affordable. Insurance had no business there because it was not a marketable model, no one would buy insurance then for primary healthcare. Now the cost of primary healthcare has gone up, which publicly listed or private insurer in their right mind will provide insurance where the payouts are likely to be equal to or more then the premiums collected. ...... ]

Fifth, we should exploit globalisation to help lower cost. While globalisation is itself pushing up wages of health workers, we should leverage on it to average down our cost. [If you guys want to muck around with the market then continue to do so and not shove the final responsiblity on the citizens when the market begins to behave out of expectations due to your shortsightedness or 'globalization'.

And hey, 'globalization' has been taking place since ships first sailed. it is not a recent phenomenon. It is truly a wonder few people in Singapore flip when the government cites 'globalization' as a factor for everything bad. And everything good must be a result of wise decisions and policies by the government. Complete bollocks!

In any event, an elected government is beholden to the people in terms of their welfare. I have to ask what your annual KPIs are Minister? Achieving budget surpluses?

If you can't take the heat, get out of the kitchen!]

So Singapore ...

Now why is it that Singaporean firms who go overseas (particularly GLCs) tend to fail? Could it be because they are so used to getting their own way (like the PAP) that they don't know how to play by the rules of others? Even when the others are guests that represent a sort of institutionalization of international law?

It would be hilarious if only the totalitarian portion weren't true.

First, here is what the locals (you and me) read:

Sep 9, 2006
Singapore stands by decision to bar some activists
By Tracy Sua & Tanya Fong

SINGAPORE authorities yesterday stood by their decision to deny entry to foreign activists deemed 'undesirable' for the upcoming International Monetary Fund (IMF) and World Bank meetings.

So far, some 20 individuals will be barred from entering Singapore if they turn up at any of the border checkpoints, The Straits Times understands. Among them is anti-globalisation activist Walden Bello, the executive director of the Focus on the Global South. He has been a regular at protests held during World Trade Organisation meetings, such as the 1999 conference in Seattle which was eventually known as the 'Battle in Seattle' because of the violence that took place there.

Mr Bello was also jailed in 1978 for taking over a Philippine consulate in San Francisco.
Police would not provide details of individuals barred from Singapore but said that 'every country reserves the right to determine whether a foreigner would be eligible for entry into the country''.

'Under the current security environment, we will be cautious on who we allow into our borders, especially when a high-profile event like the IMF and World Bank meetings are held here.''
The spokesman added that the meetings will attract the attention of many, 'not least those who may want to use the ready platform and presence of the international media to stage events that will pose a security threat to Singapore and compromise the level of security arrangements we have put in place'.

The police were responding to protests from the IMF and World Bank, over Singapore's decision not to allow representatives of some accredited civil society organisations from attending the meetings.

In a joint statement, the IMF and World Bank said: 'In the interest of good governance, transparency and accountability, we urge the Government of Singapore to allow all properly accredited civil society representatives to attend our meetings.''

They added: 'We have consistently opposed any restrictions on full participation and peaceful expression of views. 'Open dialogue and civil society are also important for the effective operation of our institutions.''

So far, a record number of nearly 500 civil society organisations from more than 45 countries have been accredited to attend the meetings starting next week. At about the same time, more than 700 international activists had intended to gather in Batam, because of Singapore's ban on outdoor demonstrations. But this too seems in doubt now, as the Indonesian police were reported as saying they would not allow it to go ahead.

An Indonesian Foreign Ministry official yesterday brushed aside suggestions by some non-governmental organisations that the Indonesian decision to stop the Batam gathering was taken after diplomatic pressure from Singapore.

Now, this (below) is what the response was to (bearing in mind that our beloved 66.6% PM in the same breath called the MSM reliable while they varioulsy scrambled to cover his 'mee siam my hum' comment into stuff like laksa my hum [CNA - awared winner for best reporting in Asia?], mee siam my hiam [ST - another award winner in Asia Pac for good reporting?]etc):

IMF and World Bank rebuke Singapore

By John Burton in Singapore and Shawn Donnan in Jakarta

Published: September 8 2006 13:16 Last updated: September 9 2006 02:07

The International Monetary Fund and World Bank on Friday issued an unprecedented rebuke to Singapore over a ban on accredited activists invited to attend the annual meetings of the two financial institutions next week.

The IMF/World Bank suggested that Singapore had violated the terms of its agreement to host the event by blocking the entry of 19 civil society representatives, who allegedly posed a security threat.

"Singapore had promised to faciliate the entry of accredited representatives under the memorandum of understanding with us," a World Bank official said. The IMF/World Bank was only informed this week of Singapore's plans.

The crackdown is part of tough security measures that Singapore will implement during the September 11-20 meetings. The government will also ban all outdoor demonstrations and has warned it will shoot at violent protesters, citing the threat of terrorist attacks.

The incident represents a setback to the IMF/World Bank, which has sought to improve relations with non-governmental organisations that have accused them of conducting policies that have ignored the plight of the world's poor. A record 500 NGO representatives are accredited to attend this year's meeting.

"This is a major blow to the credibility of the IMF/World Bank. It's terribly embarrassing since the World Bank had adopted good goverance as the theme of this year's meeting," said Antonio Tricarrio with Campagna per la Riforma della Banca Mondiale, who was one of those banned.
Mr Tricarrio said he was "astounded" at Singapore's decision since his group was a widely-respected organisation that had never been associated with violent activities.

Some NGOs alleged that the IMF/World Bank, which holds its annual meetings outside Washington every three years, had selected Singapore as the venue for this year's meeting because of its authoritarian reputation. Previous IMF/World Bank meetings have been marred by violent protests.

Among those banned by Singapore were representatives from the UK-based World Development Movement, Thailand's Focus on the Global South, the Freedom from Debt Coalition in the Philippines and the Forum on Indonesian Development (Infid).

The IMF/World Bank said these "individuals have been cleared to attend the annual meetings by their respective governments and we have accredited them according to our standard procedure."

"We strongly urge the Singapore government to act swiftly and reverse their decision on entry and access to the meetings for these representatives," the IMF/World Bank said in a joint statement.

The Singapore police force said this week that it had compiled a list of potential "troublemakers" who would be denied entry to the city-state. “Every country reserves the right to determine whether a foreigner would be eligible for entry into the country,” said the Singapore police on Friday.

Some NGOs had planned to hold rallies on the neighbouring Indonesian island of Batam because of the security measures in Singapore. But they were told this week by the local police that the protest would be banned because foreign groups were involved in violation of the law.

The chief of Indonesia’s national police, Sutanto, told reporters that NGOs would not be allowed to hold protests on Batam, although authorities would let them meet. “Seminars are welcome,” he said. “But there should be no political agenda, let alone rallies, because this could make foreigners think Indonesia is not safe for investment.”

Additional reporting by Alan Beattie in London and Taufan Hidayat in Jakarta

Copyright The Financial Times Limited 2006

Thursday, September 07, 2006

Thanks for the comments

Hello Dear Reader,

thank you for your many comments and valuable links, particularly on NTU's 're-written' history. Though I do probably do not personally know many of you I would like to ask a favour to help keep these versions of history alive. Not just about NTU but also about many other things in Singapore especially occurring during the 'Merdeka' period.

To the person whose eyes got zonked reading white, red & blue on black, pai seh, my choice, but thanks for your 'advice' in any event. For me it is a reflection on the state of political affairs here in the little red dot.

Others in democracies speak of tabula rasa, we here speak of tabula furvus. Perhaps one day in the future when enough white words appear, perhaps just perhaps, the slate will be clean again and we can rebuild. I've used white, red, blue liberally : Blue / White / Red - Liberty / Equality / Fraternity. The greens are healthy.

Wednesday, September 06, 2006

Flat (HDB) World - Commentary

Just finished reading Friedman's Flat World which is an apparent hot seller. Also just read MM's remarks in the ST today on how Singapore needs to buck up and be open, right after yesterday's comments wherein he claimed that Singapore will never have a culture to call her own even after 400 years. IMHO a bit of a cut and paste job from Friedman's book with some modifications to suit the local context and imperial-like tastebuds.

The two are inextricably entwined. In more ways then one. We have been an open and inclusive society from the get go pre-Independence in '65.

(I choose to believe that the racial riots were manufactured incidences - I was not born yet and only have 'written' history as a guide along with oral recounts of the older folk who are diminshing dramatically everyday. This belief is based on a cursory 'study' of the politics of those times - again in part based on re-written history and oral transmissions from our 'founding fathers & mothers.' In short the racial riots were a political gambit - just like how the triads were initially allowed then slowly eradicated once their usefullness diminished.)

And Singapore remains very open to foreigners to this day.

What remains unplatable and has not been addressed as a root cause of worry for the influx of FTs can be found reflected in Jack Neo's 'I Not Stupid' productions. Recall the how the MD accepts the Ang Moh's recommendations based on (translated from Hokkien) "as long as it is produced by a foreigner / ang moh it must be good."

Until this system of thinking which is rampant in our Mandarin caste is eradicated and locals are given a chance to shine through .... really given a chance .... the concern about FTs taking away our jobs will forever remain.

To add salt to an open wound MM Lee furhter went on to comment that Mao Zedong was a great man despite a low education level because he had a 'capacious' mind. Easy for you to say Mr. Lee but your policies and your social engineering tweakings which you in the same breath still ascribe to have condemned all Singaporeans to an endless paper chase to prove self worth and worth to society. So which is it you want now? Highly educated narrow thinkers the system produces today or lowly educated but broad thinkers who are just so because of the lack of constraint imposed by the system of education and social engineering?

But how is it a single man is able to chart the history and the future of a nation? It is theoretically and physically impossible unless supported by a large group of people who perpetuate the system. Brings to mind the civil service.

So how does one go about breaking a mindset within which an entire generation has grown up? How does one go about telling the older generation that their attitudes and beliefs in life will only serve to condemn the next generation into obscurity when for a brief flicker in history these folk proved to themselves that their system was right, that their beliefs were right. It is far easier to consign people to the past then ideas. I have no answer short of a revolution of the mind in Singapore. How can one reverse the thinking of an entire generation?

If you interpret these words as a condemnation of the publicly proclaimed 'confuscianistic values' so intrinsic to Asian society you are right. But let it be known that I am not anti-chinese nor anti-chinese values. The problem lies in extremes. We have pushed ourselves too far to one end of the scale.

Normally, one might say that tomorrow will pay the price for today's excesses but in the case of Singapore where everything is played out at ten times the speed of life ..... this afternoon we shall pay for this morning's excesses. Excesses in social engineering, excesses aspiration, excesses in gaining wealth, excesses in the educational system, excesses in governance without a strong check, excesses in curbing a people's natural inclination to dream, excesses in demolishing a mish-mashing of culture that makes Singapore truly unique, excesses in sycophantic behaviour, excesses of a Mandarin system.

Nope, I still do not have an answer on how to address all these issues at one go even if I were Prime Minster tomorrow.

Friedman's book is an eye opener. A possible road map for countries going forward. I've previously made several recommendations (particularly in education) in the same light. But as a normal Singaporean I stand nowhee in terms of policy making. As an opposition figure my standing is constantly in legal and financial jeopardy. As an employee I have no control over the international economy which is moving quickly into Singapore. As a budding entrepreneur I face Himalayan obstacles in the local civil service in terms of regulations. In total, as an average Tan / Lim / Lee / Muhammad / Gopal / de Silva I have no ownership of my future in MY country.

I'm 35 this year, married, and wondering what kind of Singapore my child will be born into if we choose to conceive. Will my child be free to explore the world's or the universe's possibilities unfettered by a system of constraints, which in my opinion are designed to control and constrain the mental growth of the whole population? Will my child succumb to the pressures of life and our local societal norms in Singapore and turn out to be some freakish, impolite, selfish sociopath (already a good many adults today are like that)? Will my child grow up learning that creativity is taught and should adhere to the sense of creativity of his/her teacher - that approval is required to be creative and that creativity standards are measurable?

Singapore, we can stop the brain drain from happening. We can start to put a halt to the damage created by the Mandarin system of governance.

A true celebration of diversity implies an acceptance of others - including those outside the norm. Parents today need to instill in their children the need for living a fulfilling life outside of school and work. We need more Universities that are open to admission to all Singaporeans without the red tape of the British legacy - that cater to courses that make human beings and not just economic digits. We need to demolish the Mandarin (but not necessarily the PAP) system of governance so as to achieve truer ownership of our land and country. We need to ponder, as a nation, the policies that will take us forward into a future that is bright with possibilities, unlimited potential.

Differences in thought, lifestyle, sexual orientation, political orientation, stages of personal development should not be constrained by public policies which, in Singapore, are translated into monetarily or criminally enforceable societal norms. True openess needs to be achieved if we are to move forward as a people for a greater cause. This is what diversity truly means.

Diversity has no boundaries, unlike what the national education programmes (the mainstream media and government mouthpieces) like Singaporeans to believe.

A full fledged democracy imposed overnight, in which every single citizen is responsible for taking Singapore into the future, will meet with a systemic failure. Many of us have been conditioned not to think or even dare to ponder issues of governance. Until we overcome this difficulty we shall forever remain individual digits who have relegated the rights of our existence to the Mandarins.

What Most Singaporeans Know About NTU

Kindly provided by a reader. Thank you dear reader.

This short synopsis of what went on and still goes on captures the main drift of my earlier argument on history being re-written.

It appears that the press was in on this as well. Does it then mean that the press, if so and by association, is also responsbile for the lack of rootedness felt by many Singaporeans?