– International Medical Centre: A Missed Opportunity, or Not Too Late? By Dr Toh Han Chong, Editor

The Singapore healthcare sector has been in flux and yet also in transformation. While well regarded internationally to be robust and reputable, it will continue to face imminent challenges. The speaker for this year’s SMA Lecture, Mr Ngiam Tong Dow, taps on his deep and wide experience in various ministries to offer insights and wisdom on many issues: Singapore as an international medical centre, the possibility of supplier-induced demand in healthcare, as well as his political vision and opinion on Hainanese chicken rice. For the full transcript of the SMA News interview with Mr Ngiam, please go to http://goo.gl/AGQHCQ.

SMA Lecture 2013 this insight with then Prime Minister prowess, which will give us the thrust Dr Toh Han Chong – THC: The , but he didn’t want to to become an international medical upcoming SMA Lecture is titled interfere directly. I think he passed the centre. Developing Singapore as an word to the Ministry of Health (MOH) International Medical Centre. Why did though. THC: If Singapore becomes an you choose this topic? MOH thought their job was only international medical centre, it might to train enough doctors to meet the create more pressure points, especially Mr Ngiam Tong Dow – NTD: In needs of the Singapore economy. But in the public sector. What are your Economics, there are two types of from EDB’s point of view, they need to thoughts? economies – production-based and think outside the box. This is because knowledge-based. The former depends our original economy was expanding NTD: In my view, the public sector on land, labour and capital, but it is the since the middle class in the region was should compete. If Singapore is to latter that Singapore really needed. sourcing for better medical services become a medical centre, we have to This was clear to me as Chairman of than what they could get at home. develop our public hospitals, as they Economic Development Board (EDB) The initial ratio was to have one are at the forefront of local Medicine. in the 1980s. We could not offer cheap doctor for every 600 Singaporeans, If you have a very serious complex labour and cheap land for long. We which then became 450, but they were illness, you would probably not go to needed to have a significant niche. only looking at the domestic market, a private practitioner, but engage an At that time, we identified two which had limited growth. I suggested established and experienced medical key areas. The first was banking and aiming for growth within the Southeast team who see a high volume of such finance, and the second, Medicine. Asian region, and true enough, the a disease, who can get to the problem The first niche was identified by Mr region prospered and many patients immediately. The method you use to Van Oonen from the Bank of America. from the region started coming to pay for it depends on MediShield and He felt that Singapore could become Singapore, instead of London or New copayments. We should develop our one of the centres of foreign exchange York! After the Middle East problems, public hospitals, instead of running trade, which operates round the clock the Arabs also came here. We are them down, so that doctors will want – so it could start from Tokyo, come an ideal knowledge and healthcare to stay on and not leave once they get to Singapore, and then reach London. delivery centre for Medicine; that is higher qualifications. Medicine was singled out by me as why I was so firm in my belief then. the other possible area that Singapore My next question was how do THC: The issue is whether our hospitals could compete in. You see, among we become an international medical can cope with the rising number of

Photo: National University of Singapore my schoolmates, only the best go to centre? We must first increase medical foreign patients coming into Singapore. medical school. How then can we school enrolment. Fortunately, the use these brilliant minds to be part of Government agreed to my suggestion, NTD: If I may say so, that would be the knowledge economy to build up and we expanded from one medical a pleasant problem for us. When Singapore as an international medical school to three. In time to come, I you’ve got the demand, it’s up to you centre? I thought we had a chance expect this expansion to produce to organise to meet the demand. You to succeed with Medicine. I shared around 1,000 doctors with intellectual only need to start worrying when INTERVIEW you have no demand, when you pa bang (Hokkien for “swatting flies”, meaning “lack of business”). The other interesting thing is that when local patients see people from all over the world coming to our hospitals, they will realise that they’re also getting good healthcare services. But now, many Singaporeans don’t realise that.

Folly of supplier-induced demand? THC: Some health economists have been known to say that supply induces demand. The more doctors you produce, the more demand you create, the more healthcare costs would go up, which will result in severe health expenditure repercussions. What is your take on this?

NTD: Yes, a very influential local health economist in Singapore once said that. He was referring to the backwards sloping supply curve, and thus felt that we needed to restrict the number of doctors. I once sat on a committee chaired by Lee Hsien Loong and S Dhanabalan, and he was the health economist there too. I completely disagree with him because he has missed the wood for the trees. The demand for doctors does not come only from our own population, but also from the regional economies. As the middle class becomes richer, they want better medical services, and this is true today! If you look at all the paying patients, the demand is coming from the Indonesian and Vietnamese. In fact, we are very worried about the increase in the costs of Medicine. My point is there will be greater economies of scale if you serve not just your own people, but also that of the region. With economies of scale, you can restrain the growth of health expenditure. Today, it is 4% of the gross domestic product (GDP). Therefore, I think greater economies of scale can restrain costs but not growth, so we have to be realistic. This is the reality today. Great credit should be given to our private sector; it consists of businessmen who bring in all the whole idea came from that health patients who indirectly help us restrain, economist! not add to, the rising costs of Medicine. This policy stems from a premise of distrust of the medical profession, THC: In national health systems which should not be the starting point across Europe, they will tend not of a policy. Why would busy hospital to overinvestigate, overtreat or doctors prescribe unnecessary “overprocedurise” because of the procedures just to collect fees? Most national guidelines and regulatory doctors don’t even have time for a cup frameworks that are in place. But in of coffee! If you look at the breakdown the US, third party payers (private of a medical bill, the doctors’ fees insurance companies) dominate constitute, at most, 10% to 20%. The the health payment landscape, so rest goes to paying for facilities and there is a higher chance they might salaries of other staff such as the overinvestigate or overmanage administrators! I don’t want to be too patients. What about Singapore? harsh on that health economist, but our medical sector would have advanced NTD: That is why I think the Singapore further if this theory of supply creating healthcare system is in fact one of the demand had not been proposed, at best in the world. We have copayment, least not for the public hospitals. whereas the British and Americans do not, and the private insurance Uniquely Singaporean issues companies are the ones who rip THC: We’ve invested so much into everybody off! We should not only biomedical research. There is a strong look at what others do. Our health feeling that in order to bring it to financing system is a very balanced one, relevant applications and real patient with copayment and a bigger market care, there must be more connections Yet, our employers refuse to take with greater economies of scale. between R&D hubs like the Biopolis them on because they say that while Although it will not reduce the amount and the clinical institutions. What are the graduates may have the theories, of GDP used for healthcare, we can your thoughts about the substantial they may not be able to do the job! As restrain rising cost. However, we should investment that has gone into such, I proposed that MOF, using the not restrain the salaries of doctors and biomedical research? money set aside, pay for the salaries nurses, as they have chosen to be in of new graduates that employers hire the healthcare sector, even though they NTD: I’m afraid that so far, we’ve gone and train for the first year. If these have many career choices. for trophy scientists as a key strategy. In employers hire them permanently, the The health economist I mentioned the 70s, when we were building Changi training will be free; if not, half of their earlier came up with a theory that Airport Terminal 1, Mr Ng Pock Too total salaries must be returned! I think autonomous public hospitals should brought the Chinese to the terminal. that’s the best way, as we can reduce a only be allowed to keep a part of the Of course, as typical Singaporeans, we lot of manpower wastage. I have not increase in revenue. I then told Hon boasted about being the best in the received a response yet! Sui Sen that the excess money should world. The Chinese leader said, “Mr Ng, be returned to the Ministry of Finance who built this terminal?” Alas, we had THC: After the General Elections in (MOF) if the health economist decided to say Takenaka Corporation of . 2011, many Singaporeans were angry that the revenue had exceeded a He rested his case. about the issue of increased foreign stipulated amount! Mr Hon asked me, We shouldn’t buy trophies. The talents on local shores. As a result, “Whatever for?” As such, the hands of best thing is to train our own people we have fewer foreign talents in this the autonomous hospitals were tied and give them the experience. I wrote country now. Since then, our small and for a long time. The idea is for the an article some time ago on how we medium enterprises have suffered, and additional revenue to be used to pay were spending over $6 billion trying to our local manpower is insufficient to the doctors, upgrade equipment, and raise productivity. I found out that we cope in various industries, including so on. It is a mistaken socialist policy that have 30,000 trained workers each year, healthcare. What are your views? the revenue received by autonomous if we took into account the graduates hospitals must be capped so that the from all our universities, polytechnics NTD: My own hospital stay has really doctors do not overprescribe. This and Institutes of Technical Education! opened my eyes. Other than the

22 • SMA News September 2013 – , S Rajaratnam, Toh Chin Chye, Hon Sui Sen and Lim Kim San. Goh Keng Swee is a real thinker and very innovative. Hon Sui Sen is the perfect Permanent Secretary; he once told me, “When I look at you, I never think of your weak points. I always think of your strong points, and I use your strong points to do my work for me rather than spend day and night on your weak points.” Of course, we need to be aware of the weak points of a person but we should always identify the strong points and develop them. Lee Kuan Yew is the political messiah, Goh Keng Swee is the architect, Hon Sui Sen is the builder, and Lim Kim San provides business insights. In a way, Singapore and Lee Kuan Yew were lucky to have such a team then. Sorry to say, but I don’t see such a team today.

THC: You have been very outspoken after your retirement. Is the perception that you are more outspoken now in radiologist who was a Singaporean, all care and social needs of the silver retirement than before while in the the hospital technicians were Chinese, tsunami in Singapore? civil service accurate? Filipinos or Indians. If we send all of them back, the hospitals may have NTD: I am part of the silver tsunami. NTD: I have always been outspoken. to close down. I think a lot of these (laughs) Actually, it is a very tough When I was Permanent Secretary to pseudo-economists and pseudo- problem to solve for the nuclear family then Prime Minister Lee Kuan Yew, he politicians say Singaporeans should be and the state. It is a dilemma that we invited me for lunch twice a year, only employed first, but are Singaporeans fit are facing. Do we spend taxpayers’ the two of us. He was always a perfect or willing to do some of these jobs? money to prolong the elderly’s lives, gentleman. He once said, “Ngiam, For example, the delivery of medical or leave it to the hands of God? It is we’re not having lunch today as Prime care falls squarely on the shoulders a really tough decision, and I have no Minister and Permanent Secretary. of our nurses, so I was very upset to answer for that yet. However, the silver We’re both intellectual equals. You can read that our Population White Paper tsunami is inevitable because of better tell me what you think, and I’ll tell you classified nursing as a “low-skilled” medical care. In the animal kingdom, what I think.” Those were very robust job. Whoever passed that document the old and infirm just die. In fact, the conversations. should have his pay revoked. (laughs) pack will just leave them. But we’re One of these conversations Nursing is for the toughest minded, as different because we’re human beings. involved the Certificate of Entitlement nurses take care of patients for long (COE) scheme. I had a big fight hours in the frontlines. Sometimes, the Politically speaking with him over this because the patients get impatient and scream at THC: Lee Kuan Yew, Goh Keng Swee, implementation of the COE scheme them. It’s a job I wouldn’t want to do Hon Sui Sen, Lim Kim San, etc, are all meant that we were taxing every man, myself, but I respect nurses for it. different in strengths and personality, woman and child in Singapore, from what were the key qualities they the day of his birth till the day of his THC: What about the silver tsunami? possessed that helped to build this death. As COE taxes transportation, Many local elderly patients, who are country in those early years? nobody can avoid it. You can avoid in their 80s or 90s, are alone at home eating good durians, but you cannot because their children are working full- NTD: Lee Kuan Yew has the ability to avoid using transportation. He saw time. How do we address the heath attract the best people in the country that I was right, but he was a charmer.

September 2013 SMA News • 23 I’m very proud of our chicken Are you a fan of Hainanese a fan Are you My mother was a verya was mother My remarkable only only scored “credits” in the O-Level a Grade I was awarded examinations, pass to me enabled which certificate, 1 entrancethe admission for examination where I into the University of Malaya, I was Philosophy. read Economics and a First awarded subsequently Class HonourswhenEconomics in degree hadI Although graduatedI 1959. in had 40 years I only a good career, In terms of of it and no distinctions. veryI’m but mediocre I’m intelligence, veryhave lucky to mentors good who inspiration. are my at a veryShe was widowed woman. young age, leaving job any on take would She children. her with I’ll always she could find to support us. five remember her admonition to me, should starve,to you have you if “Even starve in Singapore rather than back home in Hainan.” My three brothers and I benefited went in Singapore and eventually from meritocracy As a to university on scholarships. the I believe Christian looking back, hands good Lord has been holding my life. in my through the ups and downs THC: rice?chicken NTD: won’t you go to Hainan, if you but rice, findany chicken rice astarted Kee, Swee in Singapore by there. It was who carriedhawker the rice around a journalist wrote One day, to sell. storya fragranthis about rice and it was it melted in the mouth; how how was that but exaggeration, an story Kee’s Swee grew. the business rice chicken His one. good a quite is the is excellent because he mixes pass never will he and himself, chilli he Also, else. anyone to on secret the personallyevery chickens the buys the birds and after feeling morning, I think But, ensuring quality control. which I’m the secret lies in the chilli, inherited. his sons never sorry to say, rice a pity because their chicken has It’s been the same since. never The civil service has definitely example of I am the perfect You said that there were many many said that there were You what share with us Could you want to leave your job, make sure you you sure make job, your leave to want When enough have money.” walkaway ministerwhich salarythe high, so is unless they decide to dares to leave, become the opposition party?As a the entire political arena has result, become a civil service, and I don’t see speaking up anymore. anyone THC: which is not good become tamer, need a contest of ideas. because we is that no one wants to The difference make a The sacrifice. first generation was Action Party (PAP) of the People’s problem the but grassroots, purely is a bit too elitist. is that PAP today life A glimpse into personal THC: mediocrity any score not did I because Senior Cambridge As in my O-Level Although I examinations in 1953. exchanges of ideas and even criticismsexchanges of ideas and even yearspioneer the in service.civil the of see this happening much Do you today? NTD: inspires and drives you? NTD: In the early days, Lim Kim San In the early days, You have said that you were were said that you have You When you raise ministers’ salaries raise When you ministers’ September 2013 September and Goh Keng Swee worked nightand Goh Keng Swee truly were they and dedicated. day, and Yew whether Lee Kuan I don’t know it startedwill agree but going downhill startedwhen we to raise ministers’ pegging them to the not even salaries, national salary aligning them with but the top ten. earning to the point that they’re everymillions of dollars, minister – no he wants to turn much up matter how and tell Hsien Loong off or whatever – will hesitate when he thinks of his if he wants Even million-dollar salary. Lim Kim will stop him. his wife to do it, you if “Ngiam, me, tell to San used Looking at me, he asked, “Ngiam, are “Ngiam, asked, he me, at Looking Secretary Permanent the you the of atDivisions Revenue and Budget I MOF?” said to yes, which he replied, wrong with collecting more “What’s money?” THC: worried of the politicians that some qualitiessame the have not do today are What generation. pioneer the as and the newer hoping to see in you politicians today? younger NTD: SMA News

• Dr Cheong Siew Keong Chorh and Prof Chuan Tan Singapore Honorary Degree of Doctor of Letters on Dr Lee in 2009 Seng Tee L to R: Ngit Mr Wong Liong, Dr Andrew Minister Chew, for Defence Dr Ng Eng Hen, Dr Lee Seng then Tee, President Mr S R Nathan, Mrs S R Nathan, Mrs Lee Seng Tee, Photo: National University of Singapore Mr Ngiam (third from right) at the Istana for the conferment of the National University of 24