Healthcare & Medical Technologies Singapore Market Study
APRIL 2019
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The information and views set out in this study are those of the author(s) and do not necessarily reflect the official opinion of the European Union. Neither the European Union institutions and bodies nor any person acting on their behalf may be held responsible for the use which may be made of the information contained therein. The contents of this publication are the sole responsibility of EU Gateway | Business Avenues and can in no way be taken to reflect the views of the European Union. The purpose of this report is to give European companies selected for participation in the EU Gateway | Business Avenues Programme an introductory understanding of the target markets countries and support them in defining their strategy towards those markets. For more information, visit www.eu-gateway.eu.
EU Gateway to Singapore
Central Management Unit
Singapore Market Study
April 2019
Submitted to the European Commission on 04 April 2019
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TABLE OF CONTENTS
LIST OF FIGURES ...... 6
LIST OF TABLES ...... 7
TABLE OF ABBREVIATIONS ...... 9
1. EXECUTIVE SUMMARY ...... 10
OPPORTUNITIES ...... 14
2. WHAT ARE THE CHARACTERISTICS OF SINGAPORE? ...... 17
2.1. POLITICAL OVERVIEW ...... 17 2.2. ECONOMIC OVERVIEW ...... 18 2.3. TRADE OVERVIEW ...... 19 2.4. MARKET ACCESS ...... 22 2.5. BUSINESS AND COMPETITIVE ENVIRONMENT ...... 23
3. MARKET OVERVIEW & EU ENTRY OPPORTUNITIES IN SINGAPORE ...... 25
3.1 THE SINGAPORE HEALTHCARE & MEDICAL TECHNOLOGIES SECTOR...... 25 3.1.1 The Singapore Healthcare System ...... 25 3.1.2 The Public Healthcare Infrastructure ...... 30 3.1.3 Research & Development ...... 34 3.1.4 Key Associations ...... 36 3.1.5 Entry Strategies ...... 37 3.1.6 Challenges & Entry Barriers ...... 40 3.2 ASSISTIVE TECHNOLOGIES ...... 41 3.2.1 Market Overview ...... 41 3.2.2 EU Entry Opportunities ...... 47 3.3 MEDICAL EQUIPMENT ...... 54 3.3.1 Market Overview ...... 54 3.3.2 EU Entry Opportunities ...... 58 3.4 ICT FOR HEALTHCARE ...... 67 3.4.1 Market Overview ...... 67 3.4.2 EU Entry Opportunities ...... 74 3.5 TELEMEDICINE AND REMOTE HEALTH MONITORING ...... 82 3.5.1 Market Overview ...... 82 3.5.2 EU Entry Opportunities ...... 88 3.6 NANOTECHNOLOGY HEALTHCARE ...... 95 3.6.1 Market Overview ...... 95
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3.6.2 EU Entry Opportunities ...... 99 3.7 LIFE SCIENCES / BIOTECHNOLOGY FOR HEALTH ...... 104 3.7.1 Market Overview ...... 104 3.7.2 EU Entry Opportunities ...... 113 3.8 RESEARCH & DEVELOPMENT TECHNOLOGIES & SERVICES ...... 120 3.8.1 Market Overview ...... 120 3.8.2 EU Entry Opportunities ...... 130 3.9 DENTAL PRODUCTS ...... 133 3.9.1 Market Overview ...... 133 3.9.2 EU Entry Opportunities ...... 138
4. REGULATIONS ...... 144
4.1 GENERAL IMPORT PROCEDURES ...... 144 4.2 MEDICAL DEVICE IMPORT LICENCE ...... 145 4.3 MEDICAL DEVICE REGULATIONS ...... 146 4.4 GOVERNMENT TENDERS ...... 147 4.5 SINGAPORE CONSUMER PROTECTION (SAFETY REQUIREMENTS) REGISTRATION SCHEME (CPS) ...... 149
5. ANNEX ...... 154
5.1 LIST OF USEFUL CONTACTS ...... 154 5.2 STARTING A BUSINESS IN SINGAPORE ...... 158 5.3 USEFUL STATISTICS ...... 163 5.3 BIBLIOGRAPHY ...... 186
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List of Figures
Figure 1: Map of Singapore ...... 17 Figure 2: EU-Singapore FTA ...... 20 Figure 3: Singapore has a Mixed Financing System for Healthcare ...... 27 Figure 4: The 3 Integrated Healthcare Clusters in Singapore ...... 32 Figure 5: Robotic Therapy at the Centre for Advanced Rehabilitation Therapeutics ...... 43 Figure 6: A Wheelchair Automated Bathing System ...... 49 Figure 7: Reysone Wheelchair Bed ...... 50 Figure 8: Coselgi’s Hearing Aids ...... 53 Figure 9: The AMDD Creates Opportunities in the ASEAN Market ...... 60 Figure 10: The VereChip ...... 62 Figure 11: Essilor’s New Facility in Singapore ...... 65 Figure 12: Evolution of Singapore’s Healthcare IT ...... 67 Figure 13: HealthHub allows Singaporeans to Access a Wide Range of Health Content ...... 70 Figure 14: Reasons Why Technology is Important in Managing Health, Singapore Survey ...... 72 Figure 15: iHIS' GPFirstAide Mobile App ...... 73 Figure 16: Sentec’s Blood Glucose Monitoring System ...... 77 Figure 17: The Official Inauguration of Biotronik's Production Plant in Singapore ...... 80 Figure 18: Perceived Advantages of Virtual or In-Person Visits, Singapore Survey ...... 83 Figure 19: The SoundEye ARK Monitoring System ...... 88 Figure 20: Remote Rehabilitation Solutions by NUS ...... 90 Figure 21: Philips’ New Facility Includes a Tele-healthcare Centre ...... 93 Figure 22: Map Showing ANF’s Member States ...... 97 Figure 23: Biomedical Research Highlights ...... 105 Figure 24: Biomedical R&D ecosystem in Singapore ...... 106 Figure 25: Biomedical Corporate Presence in Singapore ...... 106 Figure 26: First Three Stages of Biotechnology Development in Singapore ...... 108 Figure 27: Allocation of R&D budget under RIE2020 ...... 120 Figure 28: The R&D Ecosystem in Singapore ...... 121 Figure 29: Main Public Biomedical Research Institutes in Singapore ...... 122 Figure 30: Top 10 global CROs in 2018 ...... 129 Figure 31: IDEM 2018 - Breakdown by Profile of Attendees ...... 137
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List of Tables
Table 1: Ease of Doing Business in Singapore 2019 ...... 23 Table 2: Admissions and Outpatient Attendances, 2015-2017 ...... 28 Table 3: Composition of the 3 New Healthcare Clusters in Singapore ...... 33 Table 4: Dentists in Singapore ...... 134 Table 5: Dental fees for selected procedures at public institutions and private clinics ...... 135 Table 6: HPA's Risk Classification ...... 146 Table 7: Definitions of Controlled Goods and Safety Standards ...... 151 Table 8: Requirements for Controlled Goods ...... 153 Table 9: Government Health Expenditure ...... 163 Table 10: Healthcare Financing, 2014-2016 ...... 163 Table 11: Health Facilities in Singapore, 2014-2016 ...... 164 Table 12: Beds in Inpatient Facilities, 2014-2016 ...... 165 Table 13: Health Manpower Key Statistics, 2014-2016 ...... 166 Table 14: Imports of Wadding, gauze, bandages and the like (adhesive) ...... 167 Table 15: Exports of Wadding, gauze, bandages and the like (Adhesive) ...... 167 Table 16: : Imports of Wadding, gauze, bandages and the like (non-adhesive)...... 168 Table 17: Exports of Wadding, gauze, bandages and the like (non-adhesive) ...... 168 Table 18: Imports of Syringes, with or without needles, used in medical, surgical, dental or veterinary sciences ...... 169 Table 19: Exports of Syringes, with or without needles, used in medical, surgical, dental or veterinary sciences ...... 169 Table 20: Imports of Tubular metal needles and needles for sutures, used in medical, surgical, dental or veterinary sciences ...... 170 Table 21: Exports of Tubular metal needles and needles for sutures, used in medical, surgical, dental or veterinary sciences ...... 170 Table 22: Imports of Needles, catheters, cannulae and the like, used in medical, surgical, dental or veterinary sciences (excluding syringes, tubular metal needles and needles for sutures) ...... 171 Table 23: Exports of Needles, catheters, cannulae and the like, used in medical, surgical, dental or veterinary sciences (excluding syringes, tubular metal needles and needles for sutures) ...... 171 Table 24: Imports of Electro-cardiographs ...... 172 Table 25: Exports of Electro-cardiographs ...... 172 Table 26: Imports of Ultrasonic scanning apparatus ...... 173 Table 27: Exports of Ultrasonic scanning apparatus ...... 173 Table 28: Imports of Magnetic resonance imaging apparatus ...... 174 Table 29: Exports of Magnetic resonance imaging apparatus ...... 174 Table 30: Imports of Scintigraphic apparatus ...... 175 Table 31: Exports of Scintigraphic apparatus ...... 175
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Table 32: Imports of Electro-diagnostic apparatus, incl. apparatus for functional exploratory examination or for checking physiological parameters (excluding electro- cardiographs, ultrasonic scanning apparatus, magnetic resonance imaging apparatus and scintigraphic apparatus) ...... 176 Table 33: Exports of Electro-diagnostic apparatus, incl. apparatus for functional exploratory examination or for checking physiological parameters (excluding electro- cardiographs, ultrasonic scanning apparatus, magnetic resonance imaging apparatus and scintigraphic apparatus) ...... 176 Table 34: Imports of Ultraviolet or infra-red ray apparatus used in medical, surgical, dental or veterinary sciences ...... 177 Table 35: Exports of Ultraviolet or infra-red ray apparatus used in medical, surgical, dental or veterinary sciences ...... 177 Table 36: Imports of Apparatus based on the use of X-rays or of alpha, beta or gamma radiations, whether or not for medical, surgical, dental or veterinary uses ...... 178 Table 37: Exports of Apparatus based on the use of X-rays or of alpha, beta or gamma radiations, whether or not for medical, surgical, dental or veterinary uses ...... 178 Table 38: Imports of Computer tomography apparatus ...... 179 Table 39: Exports of Computer tomography apparatus ...... 179 Table 40: Imports of Apparatus based on the use of X-rays for dental uses ...... 180 Table 41: Exports of Apparatus based on the use of X-rays for dental uses...... 180 Table 42: Imports of Apparatus based on the use of X-rays, for medical, surgical or veterinary uses (excluding for dental purposes and computer tomography apparatus) ...... 181 Table 43: Exports of Apparatus based on the use of X-rays, for medical, surgical or veterinary uses (excluding for dental purposes and computer tomography apparatus) ...... 181 Table 44: Imports of X-ray tubes ...... 182 Table 45: Exports of X-ray tubes ...... 182 Table 46: Imports of Dental drill engines, whether or not combined on a single base with other dental equipment ...... 183 Table 47: Exports of Dental drill engines, whether or not combined on a single base with other dental equipment ...... 183 Table 48: Imports of Instruments and appliances used in dental sciences, n.e.s...... 184 Table 49: Exports of Instruments and appliances used in dental sciences, n.e.s...... 184 Table 50: Imports of Instruments and appliances used in medical, surgical or veterinary sciences, n.e.s...... 185 Table 51: Exports of Instruments and appliances used in medical, surgical or veterinary sciences, n.e.s...... 185
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Table of Abbreviations
A*STAR Agency for Science and Technology ACRA Accounting and Corporate Regulatory Authority AEC ASEAN Economic Community AFTA ASEAN Free Trade Area AMDD ASEAN Medical Device Directive AMDI Association of Medical Device Industry APACMed Asia Pacific Medical Technology Association ASEAN Association of South East Asian Nations ATF Assistive Technology Fund CAGR Compound Annual Growth Rate CGH Changi General Hospital CGH Changi General Hospital CHART Centre for Healthcare Assistive and Robotics Technology CPS Consumer Protection Scheme EDB Singapore Economic Development Board FTA Free Trade Area FTZ Free Trade Zone GDP Gross Domestic Product GDPMDS Good Distribution Practice for Medical Devices in Singapore GeBiz Government Electronic Business GST Goods and Services Tax HPA Health Products Act HPB Health Promotion Board HAS Health Sciences Authority IBN Institute of Bioengineering and Nanotechnology ICT Information & Communication Technologies IDEM International Dental Exhibition and Meeting IHRC International Healthcare Research Centre MERCI Medical Engineering Research and Commercialisation Initiative MOH Ministry of Health MTI Ministry of Trade and Industry NDC National Dental Centre NSTB National Science and Technology Board NTU Nanyang Technological University NUS National University of Singapore R&D Research & Development WHO World Health Organisation
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1. Executive Summary
Singapore is a modern bustling city that has embraced the conveniences of modern life and technology. Western culture is embraced, and plays a big role in brand and lifestyle consumerism. The city-state, which is recognised as a leading financial and high-tech hub of the region, is a high-income, free-market economy in South East Asia. It offers an open and corruption-free environment to businesses in the market, and attracts prominent companies from across the globe to invest and operate in the country. Currently home to a population of 5.8 million, consisting of both locals and foreigners, Singapore recorded an estimated GDP of S$ 487.1 billion (EUR 316.8 billion) in 2018, exhibiting real GDP growth of 3.2% over the previous year.
Across South East Asia, the adoption of modern lifestyle habits and rapid economic growth are reshaping the healthcare industry and presenting unprecedented opportunities to businesses to fill the rising healthcare demands of Singapore and the region. Singapore is known as one of the medical hubs of the region and has enjoyed particular success in the private healthcare and medical tourism sector, buoyed by its flourishing clinical research and biomedical industries. The Singapore government has also actively promoted the nation as a regional hub for surgery, medicine and specialist services. Similar to healthcare trends in Europe, Singapore's healthcare needs are characterised by a fast-ageing population and a sharply rising burden of chronic and non-communicable diseases, such as heart and respiratory disease, osteoporosis, obesity, depression and type-2 diabetes. This is reflected in the expansion of government funds to support the healthcare needs of the elderly continued in the 2019 budget, as well as the five therapeutic areas under the RIE (Research, Innovation and Enterprise) 2020 plan, namely, cancers, cardiovascular diseases, diabetes mellitus and other metabolic/endocrine conditions, infectious diseases, and neurological and sense disorders.
Assistive Technologies
More than 10% of Singapore’s population is over 65 years old and the number is forecast to increase to 25% by 2030, resulting in a projected elderly population exceeding 900,000. With both a rapidly aging population as well as the highest proportion of elderly people among the ASEAN
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countries, the country’s per capita healthcare expenditure for the elderly is projected to grow from US$ 8,200 (EUR 7,258) in 2015 to US$ 37,400 (EUR 33,095) in 2030. In response to this trend, the government is encouraging the development of assistive technologies, resulting in new business opportunities for European companies operating in this sub-sector.
Medical Equipment
The Singaporean medical equipment sub-sector has been growing rapidly and the country is proving to be among the leading locations for the industry worldwide. According to Singapore’s Economic Development Board, the country’s medical equipment and technology manufacturing output reached over S$ 11 billion (EUR 7.2 billion) in 2016, up from S$ 1.5 billion (EUR 978 million) in 2000, and employs more than 12,000 people. Foreign manufacturers dominate the medical equipment market. Although domestic production volume and value are high for the small state, around 90% of the output (mainly non-medical devices products such as contact lenses, research instruments and scientific & analytical equipment) is exported. In 2018, the Health Sciences Authority (HSA) Singapore updated its regulatory legislation to facilitate faster access for certain lower-risk medical devices.
ICT for Healthcare
In recent years, Singapore's healthcare institutions have been pushing the envelope in using ICT to improve existing methods and introduce innovative applications into the healthcare system. ICT spending in the Singapore healthcare sector in 2015 was estimated to be around US$ 275 million (EUR 243 million), growing at a compound annual growth rate of 5% between 2012 and 2015. The market was projected to grow at a CAGR of 4% between 2016 and 2019. In 2017, Singapore’s public sector healthcare system alone, which provides 20% of primary care and 80% of hospitalisation care, spent S$ 300 million (EUR 195 million) on ICT projects. In South East Asia, which is the fastest growing region for the eHealth market, Singapore attracts key eHealth players for its IT infrastructure reliability and its strategic location. Singaporeans are also very receptive to innovative products. Recent studies show that Singaporeans are becoming even
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more open towards digital health, with more and more consumers utilising health apps and health wearables.
Telemedicine and Remote Health Monitoring
The Telehealth market in the Asia-Pacific region, which includes telemedicine, remote patient monitoring and mobile health was worth approximately US$ 1.02 billion (EUR 0.9 million) in 20161, and it is expected to grow to US$ 1.79 billion (EUR 1.6 billion) in 2020 at a compound annual growth rate of 12%. While Singapore is relatively small and is not facing remote location problems like its neighbours, the country has to deal with an ageing society and decreasing number of health professionals due to retiring personnel. The two issues compel the government to focus on enabling greater access to care for every Singaporean by encouraging the development and implementation of telemedicine and remote health monitoring. In 2018, the government took important steps in this direction. Singapore’s Health Sciences Authority clarified that telehealth devices intended by their manufacturer for medical purpose will be regulated as medical devices, while the Ministry of Health launched the city-state’s first healthcare regulatory sandbox for telemedicine services, as part of the Ministry’s new Licensing Experimentation and Adaptation Programme.
Nanotechnology healthcare
According to experts, the global nanomedicine market is expected to be worth US$ 528 billion (EUR 467 billion) by 2019. However, nanotechnology for healthcare is a comparatively new field of medical technologies in Singapore, where most nanotechnology companies are focused in the petroleum, automotive and construction industries. Overall, developments in the Singaporean market are being driven by public initiatives funding research in the sector. Much of nanotechnology development in the country is thus focused on the R&D stage, with emphasis given to educate students and attract talents.
1 Frost and Sullivan (2016): Care Delivery Transformation through Telehealth Provides Growth Opportunities in Asia-Pacific
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Life Sciences and Biotechnology in Health
Over the past 15 years, Singapore has grown its life sciences and biotechnology industry to a region’s leading biotechnology cluster, which today is also the fastest growing bio-cluster in Asia. Business expenditure on biomedical manufacturing stood at S$ 377 million (EUR 245 million) in 2017, compared to around S$ 200 million (EUR 130 million) five years earlier in 2013 ,while the biomedical R&D expenditure grew at 5.7% CAGR during 2006-2016 to reach S$ 1.8 billion (EUR 1.2 billion) in 2016. In addition to significant private sector investments, the government has committed over US$ 3.7 billion (EUR 3.3 billion) in life science funding over the next five years, which will offer various opportunities for companies in the biotechnology and life sciences sub- sector.
Research & Development
S$ 4 billion (EUR 2.6 billion) was allocated to health and biomedical sciences research in the National Research Foundation's RIE (Research, Innovation and Enterprise) 2020 plan. Singapore has a robust R&D ecosystem that promotes close partnerships between the private sector, government ministries, public and private research institutes, start-ups and regulatory agencies. The government has developed Biopolis, a biomedical science R&D and innovation hub, which hosts nine public research centres along with nearly 40 corporate research labs for companies such as Novartis, Danone, Abbott and Procter & Gamble. Furthermore, the various public hospitals and specialist clinics in Singapore have established Clinical Research/Trials Units within their walls. Government support, IP protection, research infrastructure and a highly-educated workforce have supported the growth the contract research outsourcing (CRO) industry in Singapore. Nearly all of the top 10 global CRO organisations have a presence in Singapore.
Dental products
The oral care market in Singapore stood at US$ 87.3 million (EUR 77 million) in 2018 and it is expected to grow at CAGR of 2.6% between 2019-2023 to US$ 99.7 million (EUR 87.7 million in
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2023.2 The Singaporean market for dental products, estimated by BMI (Business Monitor International) to be worth US$ 29 million (EUR 25.2 million) in 20173, is expected to grow to US$ 44.7 million (EUR 40 million) by 2022. Singaporeans have a strong dental and oral hygiene culture. Dental practitioners in Singapore have shifted to an approach that focuses on enhancing the patient’s aesthetic appearance. Being a wealthy nation, Singaporeans tend to go for restorative treatment when tooth decay or loss occurs, or go for aesthetics/cosmetic teeth treatment for severe cases.
Opportunities
Access to South East Asia
Singapore has a strong position as a gateway for companies in the healthcare sector, both local and foreign, to access growing markets in the region. A 2018 white paper from Solidiance estimated that healthcare spending in the 6 major ASEAN economies (Indonesia, Malaysia, Philippines, Singapore, Thailand and Vietnam) will increase to US$ 740 billion (EUR 650 billion) in 2025 from US$ 425 billion (EUR 374 billion) in 2017. According to PwC, a new era of healthcare is blossoming in the region, headlined by technological advances, empowered consumers and rising demand by an ageing population. While many of these trends have been emerging for some time, never before have they been accompanied by such a rapid shift of money, triggering major changes in behaviour and fundamentally altering the business of healthcare. To tap onto the opportunities in the region, international players have established their regional headquarters in Singapore, and local companies have built an excellent network of factories, distributors and clients in the ASEAN market.
Medical Tourism
International patients come to Singapore each year for a whole range of medical care from health screenings to high-end surgical procedures in specialties such as cardiology, neurology, oncology, ophthalmology, organ transplants, orthopaedics, and paediatrics. With well-respected
2 Statista (Accessed in March 2019). Oral Care- Singapore 3 Business Monitor International (2018). Singapore Medical Devices Report, Q2 2018
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doctors trained in some of the best centres around the world, internationally-accredited hospitals and speciality centres, Singapore is a major destination for medical tourism. In 2014, medical expenditure generated from travellers was S$ 994 million (EUR 648 million). Singapore was ranked 4th out of 41 countries worldwide in the 2016 Medical Tourism Index (MTI) from the International Healthcare Research Centre (IHRC). However, the country is facing challenges due to rising healthcare costs and stiff competition from Thailand and Malaysia.
Emerging technologies
Singapore provides an excellent base for companies to develop new technologies and product innovations, test-bed new solutions and systems for the regional and global market, as well as to nurture the growth of R&D and commercialisation activities. Companies can collaborate with scientists in Singapore’s public-sector research institutes to work on developing new medical technology innovations and applications. These institutes have established strong capabilities in various technologies across multiple disciplines such as bio-imaging, cell biology, materials engineering, microelectronics and nanotechnology that can be translated into novel applications for life science instruments and medical devices.
Government Support
Over the last decade, Singapore has invested significantly in R&D related to the Medical Technology industry. For the period 2016 to 2020, the Singapore government released a budget of S$ 19 billion (EUR 12.4 billion) for R&D, out of which around S$ 4 billion (EUR 2.6 billion) or 21% is expected to be used for the health and biomedical sciences domain. Medical Technology research has been identified as a key priority area and the country will continue to focus on the development of its core capability in translational and clinical research. Fresh funds to promote industry-public sector research collaborations have also been instituted.
Online Channel
According to a November 2018 report by Google and Temasek Holdings, the e-commerce market in Singapore is expected to grow to US$ 5 billion (EUR 4.4 billion) by 2025, from US$ 1.8 billion
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(EUR 1.6 billion) in 2018.4 Excluding the more mature online travel sector, annual growth rate exceeds 25%. Singaporeans are increasingly spending on medical products online. The success of online players makes the e-commerce channel an attractive option for European medical device companies seeking to test the market.
4 Google/ Temasek (2016). e-conomy SEA 2018
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2. What are the characteristics of Singapore?
Figure 1: Map of Singapore Source: Wikimedia Commons
Singapore is a small, multi-cultural and cosmopolitan city-state of 5.64 million people in the very heart of South East Asia. Its total area is recorded at 719 km2, with 10 km2 of that made up of water. Singapore experiences hot, humid and rainy conditions all year long, with north-eastern monsoon from December to March and south-western monsoon from June to September.
The country is one of the most politically stable nations among the ten Members States that make up ASEAN. Different ethnic groups live harmoniously in Singapore, which recognises English, Mandarin, Malay and Tamil as its official languages. The Chinese make up the largest ethnic group, with 74.3%, followed by Malays (13.4%), Indians (9%) and others (3.2%).
2.1. Political Overview
As a parliamentary democratic republic, Singapore’s parliament is very much modelled after the Westminster system. The Head of State is the President who is elected directly by the people through popular vote in a presidential election, following the amendments to the Constitution of
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Singapore in 1991. The current incumbent is President Halimah Yacob who is Singapore’s 8th President and the country’s first female President. She was elected in September 2017.
Since 1959, The People’s Action Party (PAP) has been the ruling party governing Singapore. Members of Parliament are chosen through a general election for a term of five years. The last general election was held in 2015 with PAP securing a landslide victory with 69.86% of the vote, winning 83 of the 89 elected seats in parliament. The three organs of state are the Executive, the Legislative and the Judiciary. The Prime Minister, Mr. Lee Hsien Loong, is the effective head of the executive branch of government since August 2004. The Supreme Court, together with subordinate courts, holds the judicial power.
2.2. Economic Overview
A leading global business hub, Singapore offers an open and trade-driven economy that was ranked 3rd globally in terms of GDP per capita (based on PPP) in 2017.5 Singapore registered a GDP growth of 3.2% in 2018, and is projected to grow by a range of 1.5% - 3.5% for 2019.6 Categorised as a high-income nation, its current GNI per capita is US$ 70,828 (EUR 62,676).7
The Singaporean government has pursued an outward-looking, export-oriented economic policy that encourages two-way flows of trade and investment. This has enabled Singapore to become a global trading hub with a trading capacity almost three times its GDP.
Singapore’s major industries include electronics, financial services, oil drilling equipment, petroleum refining, pharmaceutical manufacturing, processed food and beverages, rubber products, aerospace and ship repair, as well as its biotechnology, chemical and petrochemical industries. Singapore has also become an important financial, trade and wealth management hub for the South East Asian region and a global hub for currency and commodity trading, transhipment and oil and gas refining.
5 International Monetary Fund (2018). World Economic Outlook Database, January 2018. 6 https://www.straitstimes.com/politics/singapore-economy-grew-by-33-in-2018-enters-2019-with-renewed-vigour-and-purpose-pm-lee 7 Data.gov.sg (2018). Per Capita GNI and Per Capita GDP at Current Market Prices, Annual.
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Singapore's economic success is likely to be maintained in the future, but given the country's reliance on trade, it will be at risk of periodic slowdowns or recession when key export markets face economic pressure. However, healthy public finances, a strong net-creditor position, and solid economic fundamentals all contribute to Singapore's economic stability.
2.3. Trade Overview
Singapore continues to top global rankings when it comes to enabling trade, according to the Global Enabling Trade Total EU-Singapore trade in goods grew by 4.5% in 2017 to Report 2016, which found that the domestic market here is reach EUR 53.3 billion one of the world’s most open, with 99.7% of goods entering duty-free, while border clearing processes are the world’s best in terms of efficiency, predictability and transparency.8
Free-trade agreements are a cornerstone of Singapore's economic policy. The country depends heavily on foreign trade and it has implemented 21 FTA agreements with 32 trading partners. It has inked bilateral trade deals with the US, Japan, Australia, New Zealand, South Korea, India, Jordan, China, India, Costa Rica, Panama, Turkey, and Peru. Singapore is also a member of the ASEAN Free Trade Area (AFTA), which plays a key role in Singapore’s intra-Asian trade. ASEAN has FTAs with China, India, Japan, South Korea, Australia and New Zealand.9 Singapore is also a party to the Trans Pacific Partnership, which was signed in March 2018 between 11 countries, including Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore and Vietnam.10
In October 2018, the EU and Singapore signed three trade agreements, namely the EU- Singapore Free Trade Agreement; the EU-Singapore Investment Protection Agreement; and the Framework Agreement on Partnership and Cooperation. On 13 February 2019, the European Parliament gave its consent to the three agreements following a vote. The trade agreement is likely to enter into force before the end of the current mandate of the European Commission in
8 World Economic Forum (2016). The Global Enabling Trade Report 2016. 9 Enterprise Singapore (2018). Singapore Free Trade Agreements. 10 Channel News Asia (2018). Singapore Inks New TPP Trade Pact with 10 Countries.
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2019, while the investment protection agreement will also follow ratification procedures at Member State level. The Partnership and Cooperation Agreement will need to be ratified by EU Member States and submitted to the European Parliament before it enters formally into force.
When in force, the free trade agreement will bring dividends for both parties. It will remove nearly all remaining tariffs on certain EU products, improves market access for services, reinforces intellectual property protection, competition policy and technical barriers to trade and government procurement. The Investment Protection Agreement will replace 12 existing bilateral investment treaties between Singapore and EU Member States and offer investors the option of a modern and reformed investment dispute resolution mechanism –the Investment Court System- in line with the EU’s new approach.
Figure 2: EU-Singapore FTA Source: The Straits Times
The EU is Singapore’s third largest trading partner, with bilateral trade in goods exceeding S$ 114 billion (EUR 74.3 billion) in 2018. Singapore is also an important trading partner for the EU and is the largest EU trading partner in ASEAN. In 2018, Singapore’s total exports in goods to the EU were approximately S$ 49 billion (EUR 32 billion), while imports from the EU were
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approximately S$ 65 billion (EUR 42.4 billion), resulting in a trade balance of S$ 16 billion Singapore’s cultural and linguistic 11 connections across Asia, highly qualified (EUR 10.4 billion) in favour of the EU. workforce, and openness to top global talent makes Singapore the preferred Bilateral trade in services between the EU and location to support the global business Singapore exceeded S$ 79 billion community in their expansion in Asia (EUR 51.5 billion) in 2017. The EU was Singapore’s second largest source of services imports, valued at over S$ 40 billion (EUR 26 billion). In turn, Singapore’s exports of services to the EU were valued at approximately S$ 39 billion (EUR 25.4 billion) in 2017.
Singapore is the EU’s top ASEAN trading partner in services. In 2016, Singapore was the seventh largest destination for EU services exports, and fifth largest source of services imports for the EU.
The EU is the largest investor in Singapore, putting EU Foreign Direct Investment (FDI) stock in Singapore at over S$ 350 billion (EUR 2 billion) in 2017. The robust inflow of EU FDI has also made Singapore the largest EU FDI destination in ASEAN. The top sectors for EU FDI in Singapore are manufacturing, wholesale and retail trade, and financial and insurance services.
In 2017, the existing bilateral foreign direct investment stock between the EU and Singapore was roughly EUR 344 billion, having expanded rapidly over the past years.
Singapore’s economy depends heavily on exports, particularly in consumer electronics, IT products, pharmaceuticals, petroleum products, and on a growing financial services sector. As a strong advocate of free trade, Singapore is generally a free and open economy. It has few trade barriers except for selected dutiable goods - alcohol, petroleum products, tobacco products and motor vehicles. There are some import restrictions based mainly on environmental, health, and public security concerns.
11 Ministry of Trade & Industry Singapore (2019). European Parliament Approves EU-Singapore Free Trade Agreement and EU-Singapore Investment Protection Agreement
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2.4. Market Access
There are at present over 10,000 European companies in various sectors operating in Singapore. Most of these companies are using their establishment in the city-state to serve as their regional hub to Asia. European companies looking to do business in Singapore can expect integrity, adaptability and respect for intellectual capital to be emphasised upon by a strategic-minded administration, which is attuned to the needs of companies to protect invention and innovation.
Using agents or distributors is a common and effective way to serve the Singapore market and, from there, the other countries in South East Asia. Many distributors in Singapore deal not only with the local market but also with the broader regional market. Prospective exporters to Singapore should be aware that competition is high and that buyers expect good after-sales service. Singapore has sophisticated telecommunications networks, extensive When business warrants, many companies have public transportation, well-managed found it useful and sometimes necessary to set up healthcare and education and ultra- modern air and seaport facilities offices in Singapore.
On 31 December 2015, the ten ASEAN Member States established a common market, the ASEAN Economic Community (AEC), a boost to South East Asia's combined economic clout as the world's seventh largest economy. The AEC has an estimated economic value of US$ 2.6 trillion (EUR 2.3 trillion) annually, powered by a fast- growing market of more than 600 million people.12 Being part of the AEC makes Singapore an attractive choice for firms looking to tap the growth potential of the bloc.
Singapore’s strategic location in the heart of Asia enables businesses to access the region’s rapidly expanding markets. Singapore has strong business, cultural and linguistic links to many Asian markets. Singapore’s cultural and linguistic connections across Asia, highly qualified workforce, and openness to top global talent makes Singapore the preferred location to support the global business community in their expansion in Asia.
12 World Economic Forum (2016). The ASEAN Economic Community: What You Need to Know.
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2.5. Business and Competitive Environment
The World Bank ranked Singapore at the number two spot in its Doing Business Rank for 2019, recognising it as among the most business-friendly nations in the world. All the more significant is that Singapore has been ranked as one of the best places for doing business for more than a decade.
Well-organised governance has given rise to some of the world's finest infrastructure, including sophisticated telecommunications networks, extensive public transportation, well-managed healthcare and education, and ultra-modern air and seaport facilities.
Ease of Doing Business in 2019 Rank 2018 Rank Change in Rank Singapore
Overall Rank 2 2 0
Starting a business 3 6 +3
Dealing with construction permits 8 16 +8
Getting electricity 16 12 -4
Registering property 21 19 -2
Getting credit 32 29 -3
Protecting minority investors 7 4 -3
Paying taxes 8 7 -1
Trading across borders 45 42 -3
Enforcing contracts 1 2 +1
Resolving insolvency 27 27 No change
Table 1: Ease of Doing Business in Singapore 2019 Source: World Bank
Singapore Changi Airport has received multiple awards and accolades, and is consistently ranked by numerous airport rating agencies as one of the best international airports in the world. In 2018, it handled a record 65.6 million passengers (a growth of 5.5% on 2017), 386,000 landings
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and take-offs, and 2.15 million tonnes of airfreight movements, making it one of the busiest airports on the globe.13 Changi International Airport is linked to 300 cities in 70 countries.
Singapore is one of the world’s premier hub ports, offering a breadth and range of maritime services that few can match. The Port of Singapore recorded a total of 630 million tonnes in cargo in 2018, while annual vessel arrival tonnage reached 2.79 billion gross tonnes.14 It is currently the busiest transhipment port in the world, connecting Singapore to over 600 ports in over 120 countries. Other modern infrastructure in the country includes extensive lines of roads and railroads, which ensure efficient movement of people and goods.
The tax system is well established and considered to be investor-friendly, reflecting Singapore's overall favourable attitude towards foreign investment. The government is keen to attract foreign investment and is unlikely to undertake tax or other measures that might dissuade such investment. The responsibility to handle tax issues is vested in the Inland Revenue Authority of Singapore. It offers various taxation schemes for individuals residing and corporations operating in Singapore. Tax incentives are available to R&D activities of all industries and a special tax regime for the banking, fund management, leasing and shipping sectors.
To encourage enhancement in economic and technological development, tax incentives in the form of reduction of tax rate or exemption from applicable tax are offered to various industries including manufacturing and services, investment and financial services, shipping and trading. Apart from that, Singapore also offers regional and international headquarters tax incentives to corporations operating from the country to serve international and regional markets.
13 https://www.straitstimes.com/singapore/transport/changi-airport-handles-all-time-high-of-656m-passengers-in-2018-traffic-increase 14 http://www.seatrade-maritime.com/news/asia/singapore-container-port-volumes-up-8-7-in-2018.html
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3. Market Overview & EU Entry Opportunities in Singapore
3.1 The Singapore Healthcare & Medical Technologies Sector
3.1.1 The Singapore Healthcare System
Singapore’s healthcare system has been hailed as one of the most efficient healthcare systems in the world,15 It has solid foundations in healthcare excellence, providing strong infrastructure and universal health coverage. This emphasis on quality care has enabled the country to achieve high life expectancies, fourth in the world, and the lowest infant mortality rate in the world. Life expectancy rates, estimated by the World Health Organisation in 2017 to be at 80.1 for males and 86.1 for females respectively, are also amongst the world's highest. A key challenge for Singapore is that the country has one of the fastest ageing populations in Asia - currently, one in seven Singaporeans is aged 65 years or above. By 2030, this number will grow to around one in four.
The country, which has arguably Asia’s best healthcare system, also serves as the healthcare, bio-medical and life sciences manufacturing and R&D hub of the region. Singapore is keen to strengthen its reputation as a centre for healthcare excellence offering, first class healthcare delivery systems and facilities to both its resident population and the international market. Singapore is a well-established destination for medical tourism, and international patients come to the city-state each year for a whole range of medical care from health screenings to high-end surgical procedures in specialties such as cardiology, neurology, oncology, ophthalmology, organ transplants, orthopaedics, and paediatrics.
According to the Singapore Tourism Board (STB), in 2014, medical expenditure generated from travellers was S$ 994 million (EUR 648 million).16 While STB no longer publishes current data on the number of medical tourists or annual revenue generated from them, indications are that the strengthening Singapore dollar and high medical inflation is diminishing the city’s attractiveness
15 Top 10 Countries with the Best Health Care in 2018, The Gazette Review, 2018 16 Straits Times (2016). Medical Tourism Ambitions Under Threat.
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as a medical tourism hub, with patients opting to turn to neighbouring countries such as Malaysia or Thailand for their medical needs.
The government spends approximately 2.2% of GDP annually on healthcare and long-term plans are in place to raise this to 3% of GDP over the next decade.17 For the 2019 financial year, the government has budgeted to spend S$ 11.7 billion (EUR 7.6 billion) on healthcare, which represents a 10.3% increase over 2018.18 It projects that healthcare spending will rise to S$ 13 billion (EUR 8.47 billion) per year by 2020.19
While Singapore’s healthcare system has a favourable ratio of spending versus health outcomes, the country has a lower proportion of healthcare professionals per capita, when compared to healthcare systems in other developed countries.20 As of 2017, Singapore had around 13,386 doctors working in its health facilities, together with 41,440 nurses and close to 20,000 ancillary and support staff.21
To address the skills shortage, the country is looking to reinvent the healthcare system using technology as an enabler. The Minister of Health recently emphasised the need to transform the very core of the healthcare system by redesigning processes and reinventing delivery models and concepts, instead of just tacking on technologies to current healthcare services and solutions.22 In line with this, a recent survey of health by Royal Philips, a health technology company, found that Singapore scores well for technology adoption, with the highest end-use rate of electronic health records (EHRs) in hospitals (per hospital beds) and ambulatory care (per capita), as well as of software solutions for inventory management, computerised physician order entry and clinical decision support system solutions (per physician).23
Singapore offers universal healthcare coverage to its citizens, with a financing system anchored on the twin philosophies of individual responsibility and affordable healthcare for all.
17 Business Times (2018). Singapore Budget 2018. 18 https://www.straitstimes.com/politics/overall-budget-surplus-of-21-billion-for-fy2018 19 Singapore’s Ministry of Communication (2017) Government Spending on Healthcare Set to Go Up in 3-5 Years. 20 https://www.businesstimes.com.sg/opinion/work-smarter-to-tackle-singapores-healthcare-skills-shortage 21 https://www.tnp.sg/news/singapore/core-healthcare-must-be-transformed-technology-gan-kim-yong 22 https://www.tnp.sg/news/singapore/core-healthcare-must-be-transformed-technology-gan-kim-yong 23 https://www.enterpriseinnovation.net/article/sg-healthcare-system-tops-future-health-index-hurdles-threaten-access-care-1957461056
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Figure 3: Singapore has a Mixed Financing System for Healthcare Source: Ministry of Health, Singapore
Through a mixed financing system, use of market-based mechanisms to promote competition and transparency and the adoption of technology to improve the delivery of healthcare services, Singapore has secured good healthcare outcomes for its population. The country has done so with a national healthcare expenditure of about 4% of GDP, which is low among developed countries (although this is expected to grow with an ageing population).24
The public sector dominates the acute care sector, delivering 80% of the care in this sector. The primary care sector is dominated by private sector providers, which account for about 80% of the market. In the step-down care sector (e.g. nursing homes, community hospitals and hospices), service provision is mainly provided by voluntary welfare organisations, most of which are funded by the government for their services rendered to patients.
Over the years, Singapore has seen a rise in the hospital confinements and the number of people seeking medical help. The rate has been observed to have increased in both the public and private sectors. Whilst the total population grew by 1.4% between 2015 and 2017, admissions to general and specialty hospitals surged 13.6% over the same period, indicating that medical admittance has been outpacing population growth.25
24 Ministry of Health (Accessed in April 2018). Costs and Financing 25 https://sbr.com.sg/healthcare/news/singapore-public-hospitals-cave-under-pressure-overcrowding-0
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Admissions & Outpatient Attendances 2015 2016 2017
Acute Hospitals 499,889 546,256 568,117
Psychiatric Hospitals 8,986 9,028 9,316
Community Hospitals 10,670 13,881 16,355
Attendances at Specialist Outpatient Clinics (‘000) 4,658.1 4,921.0 4,937.0
Attendances at Polyclinics (‘000) 4,874.7 5,264.0 5,925.8
Attendances at Public Sector Dental Clinics (‘000) 996.8 1,048.2 1,051.5
Table 2: Admissions and Outpatient Attendances, 2015-2017 Source: Ministry of Health
Subsidies offered by the government have also been seen as a contributing factor. Half of Singapore’s population is entitled to the Community Health Assist Scheme (CHAS) subsidy when they get treated in general practice clinics and polyclinics, while 450,000 Singaporean senior citizens can take advantage of the pioneer generation subsidies. Of the total S$9 billion (EUR 5.7 billion) budgeted for the pioneer generation26 in 2014, more than S$ 1.8 billion (EUR 1.17 billion) has been spent on them to date.
In the recently released Budget 2019, it was announced that some 500,000 Singaporeans born in the 1950s will also be eligible for subsidies for outpatient care for life, in addition to receiving MediSave top-ups and subsidies for MediShield Life premiums as part of a new S$8 billion (EUR 5.2 billion) ‘Merdeka Generation Package’.27 This group will receive special subsidies for common illnesses, chronic conditions and dental procedures under the CHAS benefits.
The government has also announced that it will set aside S$ 3.1 billion (EUR 2 billion) towards the long-term care of Singaporeans in the form of premium subsidies and other types of support. This is on top of S$ 2 billion (EUR 1.3 billion) that was earmarked in 2018. The Long-Term Care Support Fund will help to help fund the CareShield Life subsidies and other long-term care support measures, such as the upcoming ElderFund.
26 The ‘Pioneer Generation’ is defined as a Singaporean born on or before 31 December 1949 and obtained citizenship before 31 December 1986 27 ‘Merdeka’ is a Malay word which means freedom, and refers to the pro-independence movement, when Singapore fought to gain independence from its colonial rulers. The ‘Merdeka Generation’ refers to a generation of senior Singaporeans who are in their 60s who lived through the period that led up to Singapore’s independence in 1965.
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The Healthcare 2020 Masterplan
Over the past decade, Singapore’s healthcare system has been undergoing a system-wide transformation to meet the country’s current and future challenges arising from a fast greying population, a shrinking workforce and growing chronic disease burden. Today, about 3 in 4 Singaporean residents aged 65 and above are affected by diabetes, high cholesterol or hypertension, or a combination of the three. It is projected that diabetes will affect more than one million Singaporeans by 2050. A 2015 study called the Well-being of the Singapore Elderly (WiSE) study28 led by the Institute of Mental Health found that one in ten people aged 60 and above in Singapore have dementia, translating to around 50,000 as of 2018. The number is projected to more than double from about 50,000 today, to more than 100,000 by 203029. According to the Ministry of Health, 1 in 2 healthy Singaporeans aged 65 could become severely disabled in their lifetime and may need long-term care. The median duration for which severely disabled Singapore residents could remain in disability is four years, but around 3 in 10 could remain in severe disability for 10 years or more.
As a consequence, one of the main thrusts of Singapore’s Healthcare 2020 Masterplan that was launched in 2012 is to increase overall healthcare capacity to cater to Singapore’s ageing population. While implementing Healthcare 2020, Singapore is also making three key shifts to ensure its healthcare system is future-ready. These are:
◼ Changing its healthcare delivery model from one built around the hospital to one that can meet the needs of more Singaporeans closer to their homes, at primary and community care settings.
◼ Keeping the healthcare system sustainable and affordable through nurturing the capabilities of its healthcare workforce, pushing for productivity and innovation, updating its regulatory framework and by providing more information for better decision-making.
◼ Helping Singaporeans proactively take charge of their own health and medical needs.
28 Institute of Mental Health (2015). Results of the Well-being of the Singapore Elderly Study 29 https://www.straitstimes.com/singapore/health/more-help-at-hand-for-dementia-patients
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3.1.2 The Public Healthcare Infrastructure
In recent years, Singapore has proactively stepped up medical infrastructure investments in anticipation of growing demand from its ageing population.
As of 2017, the country relies on a network of 18 acute care hospitals, 8 community hospitals, 1 psychiatric care hospital, 20 polyclinics, 73 nursing homes, 2 inpatient hospices, 2102 general practitioner clinics, 250 dental clinics and 243 pharmacies30. As part of an increased overall healthcare capacity, six new hospitals are scheduled for completion by 2022, which will bring the total number of hospitals up from 27 to 33.31 In 2018, the Minister of Health announced plans to develop additional polyclinics, and to enlarge the network of polyclinics to 30-32 by 2030.
Today, Singapore’s healthcare sector is rapidly maturing on the back of its steady and proactive infrastructure investments, giving it room to set its sights towards the provision and delivery of quality care.
Acute Care Services
The 8 public hospitals comprise 6 acute general hospitals, a women's and children's hospital and a psychiatric hospital. The general hospitals provide multi-disciplinary acute inpatient and specialist outpatient services and a 24-hour emergency department. In addition, there are 8 national specialty centres for cancer, cardiac, eye, skin, neuroscience, dental care and a medical centre for multiple disciplines.32
As of 2017, there were a total of 10,340 in acute care hospitals, with 8,623 beds in public hospitals, 1,446 in private hospitals, and the remaining in not-for-profit hospitals. Community hospitals, on the other hand, provided 1,663 hospital beds, of which the majority, 969, are in not-for-profit community hospitals.33
30 Ministry of Health. (Accessed in March 2019). Health Facilities 31 https://sbr.com.sg/healthcare/in-focus/healthcare-spending-shifting-hospital-building-maintenance 32 Ministry of Health (2015). Healthcare Services and Facilities. 33 https://www.moh.gov.sg/resources-statistics/singapore-health-facts/beds-in-inpatient-facilities-and-places-in-non-residential-long-term-care-facilities
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The Government's role as the dominant healthcare provider allows it to influence the supply of hospital beds, the introduction of high-tech/high-cost medicine, and the rate of cost increases in the public sector which sets the bench mark in terms of pricing for the private sector.
Primary Healthcare Services
In Singapore, primary healthcare is provided through an island network of outpatient polyclinics and private medical practitioner's clinics. There are 20 polyclinics and about 2,102 private medical clinics providing primary healthcare services.
Polyclinics meet 20% of the total demand for primary healthcare. Common primary healthcare services include outpatient medical treatment; medical follow-ups after discharge from hospital; immunisation; health screening and education; as well as diagnostic and pharmaceutical services. Patients can be referred from the polyclinics to hospitals, where they can receive more specialised treatment and be warded if necessary.
Key Players
The Ministry of Health (MOH) is responsible for the formulation of healthcare policies to ensure the accessibility, affordability, and delivery of good quality of health services to citizens and visitors of Singapore. It also aims to provide information, raising health awareness and education and is involved in the control of illness and disease in the country, coordinating the utilisation of resources and expertise where necessary.
MOH Holdings is the holding company of Singapore’s public healthcare clusters and agencies – National Healthcare Group (NHG), National University Health System (NUHS), Singapore Health Services (SingHealth) and agencies such as Agency for Integrated Care (AIC) and Integrated Health Information Systems (IHiS).
SingHealth is Singapore's largest group of healthcare institutions. The group was formed in 2000 and consists of three public hospitals across the island, five specialist centres and a network of nine polyclinics. The group operates Singapore General Hospital, KK Women's and Children's Hospital and Sengkang Health. The group runs five specialist centres which include National
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Cancer Centre Singapore, National Heart Centre Singapore, Singapore National Eye Centre, National Dental Centre of Singapore and the National Neuroscience Institute.
Reorganisation of Singapore’s Healthcare Clusters in 2018
Healthcare clusters were first formed in 2000 when the MOH reorganised its restructured hospitals and polyclinics into Singapore Health Services and the National Healthcare Group, to provide integrated and coordinated care among the institutes, and to offer more competitive rates to patients. The healthcare clusters grew in the last decade to also include the National University Health System, Alexandra Health System, Eastern Health Alliance and JurongHealth. Each had their own strengths – some have formed strong primary care networks, while others were stronger in Research. Singapore's public healthcare sector underwent a
major restructuring exercise recently, with the six regional health systems regrouped into three integrated clusters, a process that was completed in early 2018. With the changes, each of the three clusters will offer a fuller range of services, encompassing acute hospital care, primary care and community care. Every cluster will also have a
medical school. The changes are being made to Figure 4: The 3 Integrated Healthcare Clusters Source: The Straits Times strengthen the system for future challenges, such as dealing with an ageing population and more people
with chronic ailments.
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Table 3: Composition of the 3 New Healthcare Clusters in Singapore Source: Ministry of Health
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3.1.3 Research & Development
Over the last decade, Singapore has invested significantly in R&D related to the Medical Technology industry. For the period 2011 to 2015, the Singapore government spent a total of S$ 16.1 billion (EUR 10.5 billion) on R&D. Medical Technology research has been identified as a key priority area and the country will continue to focus on the development of its core capability in translational and clinical research. New funds to promote industry-public sector research collaborations have also been instituted. In 2016, the government released a new budget of S$ 19 billion (EUR 12.4 billion) for R&D in the period of 2016-2020, out of which S$ 4 billion (EUR 2.6 billion), or around 21%, would be used for the health and biomedical sciences domain.34
Singapore started a Ministry of Science and Technology as early as 1968 to lead the development of science and technology policies and to build up the scientific infrastructure and manpower to promote economic growth. The Ministry of Trade and Industry has the lead role of promoting and monitoring research and development in Singapore under the advice of the Science Council from the earlier Science Ministry. In 1991, the government launched the first National Science and Technology 5-year Plan, which established the National Science and Technology Board (NSTB) as the successor to the Science Council. NSTB was later restructured to become the current Agency for Science and Technology (A*STAR) in 2001.
In 2000, the Singapore government announced the launch of the Biomedical Sciences (BMS) Initiative with the aim of developing the sector into one of the key engines of the Singapore economy. This was deemed a bold move by the international biomedical community – as prior to that, biomedical research activities were mostly confined to the Institute of Molecular and Cell Biology (established in 1986), the Bioprocessing Technology Centre (established in 1990) and the National University of Singapore (NUS). Through technological innovations in the form of medical devices, NUS’s Medical Engineering Research and Commercialisation Initiative (MERCI) aims to help patients by bringing practical solutions to them. MERCI is led by a team of experienced doctors, engineers and business professionals in the medical device industry.
34 Science Magazine (2016). Singapore Lavishes Big Money on Its Scientists.
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Central to the initiative is the goal of developing cost-effective, innovative and clinically trial-able solutions that would benefit the Singapore healthcare system based on a systematic and low-risk operating model.
In late 2013, Singapore launched its JTC MedTech Hub, a 9-storey multi-tenanted development targeted at international manufacturers of medical devices, as well as suppliers and service providers that support the medical technology industry. The MedTech Hub is designed to facilitate compliance with relevant medical technology industry guidelines, helping companies reduce costs and risks in manufacturing their products to meet the regulatory requirements. The MedTech Hub also features shared common facilities and services, such as sterilisation services, specialised logistics, warehousing and specialised utilities, which are specially geared towards the needs of medical technology companies.
In November 2014, a Diagnostic Development Hub (DxD Hub) officially opened in Singapore, funded by Singapore's National Research Foundation. Led by the Agency for Science, Technology and Research (A*STAR), the DxD Hub aims to create local diagnostic products more quickly using the combined skills of experts, including clinicians, researchers, innovators and entrepreneurs. The S$ 60 million (EUR 39.1 million) hub collaborates with healthcare and academic medical institutions including SingHealth, National University Health System, National Healthcare Group and the Singapore Clinical Research Institute. Multinational players Johnson & Johnson Innovation and Thermo Fisher Scientific, along with small and medium enterprises and start-ups such as AITbiotech, Gencurix, HistoIndex, iPtec, InvitroCue and MiRXES are also involved.
In the same year, the National University of Singapore launched the Centre for Healthcare Innovation and Medical Engineering (CHIME). The centre focuses on developing innovative healthcare technologies that can address the needs of functional ageing, while working closely with the industry, the Agency for Science, Technology and Research (A*STAR) and many key local partners.
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To spur innovation in healthcare, the Ministry of Health (MOH) set up a S$ 130 million (EUR 84.7 million) Healthcare Productivity Fund in 2012, which has helped to finance hundreds of projects and led to the implementation of 250 successful projects benefiting more than 70 public healthcare and community care organisations. Some examples of projects that led to productivity gain include converting from traditional x-rays to digital radiography or redesigning traditionally manpower-intensive processes such as rehabilitation or showering. In March 2018, the MOH announced a further injection of S$ 80 million (EUR 52.1 million) to the fund to continue promoting productivity in healthcare over the next three years. The MOH has also set up an office for healthcare transformation that will focus on longer-term ideas that can be scaled up for system- level transformation.
3.1.4 Key Associations
The Association of Medical Device Industry
The Association of Medical Device Industry (AMDI) serves as a key representative body for the Health & Medical Technology industry in Singapore. It aims to advocate good practices and promote high industry standards among the sector. AMDI’s main objectives are:
◼ To represent the Health & Medical Technology Industry in Singapore in the engagement and dialogue with regulators and effective dissemination of information to industry members.
◼ To have their interest and concerns heard by the government agencies.
◼ To assist Small & Medium Enterprises to position for advancement and create an environment for greater opportunity and growth.
◼ To organise trade missions for members.
◼ To co-operate with various trade commissions.
◼ To promote and enhance industry standards.
◼ To act as a platform for members to interact and network.
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The Asia Pacific Medical Technology Association
The Asia Pacific Medical Technology Association (APACMed) provides a unifying voice for the Healthcare & Medical Technology industry in the Asia Pacific region. Founded in 2014 in Singapore, APACMed strives to promote innovation and impact policy that advances healthcare access for patients. APACMed’s mission is to improve the standards of care for patients through innovative collaborations among stakeholders to jointly shape the future of healthcare in Asia Pacific. APACMed is the first and only regional medical technology association that is headquartered in Asia, solely focused on matters of interest in Asia and the Pacific. The association works proactively with bilateral, regional, and local government bodies to shape policies, demonstrate the value of innovation and promote regulatory harmonisation. APACMed engages with medical device associations and companies in Asia Pacific to jointly advance regional issues, code of ethics and share best practices.
3.1.5 Entry Strategies
Singapore is considered the Health & Medical Technology hub for South East Asia and, with is modern infrastructure and educated labour force, it is an excellent place for European companies that want to enter the regional market. Prior to establishing a direct presence in Singapore, European Health & Medical Technology companies may test the Singapore market through:
◼ Partnerships
◼ Joint ventures
◼ Tendering opportunities
◼ Tradeshow participation
◼ Online commerce
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Partnerships
International Health & Medical Technology companies are being attracted by the huge potential of the South East Asian market, and Singapore is increasingly playing the role of a gateway and springboard to the region. This trend spurs local Healthcare & Medical Technology distributors in Singapore to seek collaborations with foreign companies in order to provide customers with a wider range of choices and brands.
System integrators are often software agnostic and usually expand their portfolio of partners to give clients choice. For European companies that offer ICT solutions in healthcare, engaging system integrators would be an impactful and low-cost strategy to enter a variety of markets in Singapore and South East Asia.
Joint ventures
Foreign companies operating in Singapore are not required to take on joint venture partners except in the few restricted industries (financial services, professional services, and media). Despite this, European Healthcare & Medical Technology companies may find it advantageous to enter joint ventures as this can expand distribution capacity, and local service providers can assist with providing after-sales repair and maintenance services. This may also be a popular option for European companies seeking to gauge their product’s potential in the wider South East Asian market.
Tendering Opportunities
European Healthcare & Medical Technology companies can sell their products in Singapore through direct submission of tenders to local government agencies. Foreign companies are usually allowed to bid for tenders, if this is not the case it will be clearly stated. All government tenders can be found on http://www.gebiz.gov.sg/. Government procurement tenders vary and range from simple purchases such as vaccines, to consulting services for complex projects such as a disease outbreak management system that will use sensors and wearables for contact tracing and monitor quarantines. Chapter 4.4 has detailed information on public tenders.
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Tradeshows
Medical Fair Asia is an important event for the medical and healthcare industry, gathering the region's hospital, diagnostic, pharmaceutical, medical and rehabilitation sectors in one convenient location and providing a platform to discover the latest industry innovations, to network and do business. Following the successful growth path since its inception in 1997, the 13th edition of Medical Fair Asia will be held in September 2020 at Marina Bay Sands Singapore.
Medical Fair Asia is an important procurement stage for industry professionals to experience new and innovative technologies, solutions, products, and services. At the 2018 edition, new disruptive digital healthcare solutions such as remote and wireless healthcare, IT platforms, wearable devices, smarter medicine and healthcare analytics are also expected to be showcased by participating exhibitors. Focused on equipment and supplies for the hospital, diagnostic, pharmaceutical, medical and rehabilitation sectors, the event continues to raise the overall capabilities and spur the growth of the region’s medical and healthcare sectors to meet the changing demands in both the public and private sectors, driving the next wave of healthcare modernisation.
Phar-East 2019 is the leading industry platform for pharma, biotech, CROs, CMOs, research institutes, investors and industry stakeholders to network and discuss the latest industry trends, partnership models and investment opportunities in Asia. It features the latest solutions and strategy driving growth across Asia’s biopharma industry. The first edition of the event was held in March 2018. In 2019, the event will cover immunotherapy, vaccines, biosimilars, partnering & licensing, market access, regulatory affairs, biotech innovation, and pharma 4.0. The event is held annually in March at the Suntex Convention Centre in Singapore.
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Medical Manufacturing Asia 2020 is the region’s leading specialist trade fair for Asia’s medtech and medical manufacturing processes sectors. Jointly organised by Singapore Precision Engineering and Technology Association and Messe Düsseldorf Asia, the event will feature an extensive product range covering the upstream and downstream processes in medical technology sectors, including new materials, components, intermediate products, packaging and services, to micro and nanotechnology, testing systems and services, as well as materials, substance and components form medical technology.
3.1.6 Challenges & Entry Barriers
Singapore is a prime destination for European Healthcare & Medical Technology companies seeking opportunities in the South East Asia region: the country has a world-class infrastructure for healthcare, educated labour force, a supportive government, and it is set to benefit from the process of integration among ASEAN members being a global hub for financial services and a high-tech centre. Furthermore, being an open market economy, it is less challenging to set up a business and operate in the country than in other markets within the region.
However, European companies should keep in mind that some challenges are present as well. The key challenge would be the higher cost of operating a business in the country, in comparison to the other ASEAN markets. Other issues are the relatively small size of the market, the dominance of multinational corporations, and Singapore’s tight labour market, as the government has moderated the growth of the foreign workforce. In addition, even though the ASEAN Medical Device Directive (AMDD) has been developed to harmonise regulations in the region, in terms of actual AMDD implementation dates, no official time frame has yet been set.
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3.2 Assistive Technologies
3.2.1 Market Overview
With already the highest proportion of elderly people among ASEAN countries, Singapore’s population is becoming increasingly older, and per capita healthcare expenditure for the elderly is projected to grow from US$ 8,200 (EUR 7,256) in 2015 to US$ 37,400 (EUR 33,095) in 2030. According to Marsh & McLennan Companies’ report published in 2016, the country’s elderly population is forecast to rise from 11% to 20% in the next 15 years.35 In response to this trend, the country is turning its attention to the development of assistive technologies.
Experts forecast positive growth for the Assistive Technologies sub-sector over the next five years:
◼ The Singaporean orthopaedics and prosthetics market (fixation devices; artificial joints; other artificial body parts) is projected to grow by an average of 9% each year, to reach an estimated S$ 150 million (EUR 97.8 million) by 2022.
◼ The market for patient aids (portable aids such as pacemakers and hearing aids; therapeutic appliances such as mechano-therapy apparatus), will also see strong growth, is also expected to grow at the same rate, to reach approximately S$ 150 million (EUR 97.8 million) by 2022.
◼ The market for wheelchairs (both mechanically and not mechanically propelled), although small, is also expected to grow to just under US$ 10 million (EUR 8.8 million) by 2022.
Various developments have contributed to the growth of the assistive technology market in Singapore:
◼ The Singaporean government is expanding subsidies for making use of assistive technology — such as motorised wheelchairs and hearing aids.36 More people with disabilities are set to qualify for the Assistive Technology Fund (ATF). Previously open only for education and work purposes, the fund is now open to cover people of all ages and for all purposes, including those who are in supported employment, therapy or rehabilitation, or trying to
35 Marsh & McLennan Companies (2016). Advancing into the Golden Years: Cost of Healthcare for Asia Pacific’s Elderly. 36 Today Online (2015). Subsidy Scheme for Assistive Technology to be Extended to More Persons with Disabilities & SG Enable (Accessed in April 2018). Assistive Technology Fund.
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become more independent in their daily lives. The Government has also raised the monthly per capita income cap for eligibility from S$ 1,500 to S$ 1,800 (from EUR 978 to EUR 1,173), to allow more families in the middle-income group to benefit, as well as doubled the lifetime cap for subsidies from the ATF to S$ 40,000 (EUR 26,073) per beneficiary in order to account for the fact that most assistive technology devices have a limited lifespan and need replacing. In addition, the government has also launched the Seniors’ Mobility and Enabling Fund, which provides holistic support for seniors to age in place within the community by extending subsidies to Singaporean seniors to purchase assistive devices. In 2018, the government committed to top up the fund with additional S$ 100 million (EUR 65 million).37
◼ The MOH is also exerting extra
efforts to help raise awareness “With robotic automation, we see 20% more and promote adoption of improvement in the upper limb functions of patients than those who undergo conventional treatment. We technology through the Centre for can also serve 20% more patients." Healthcare Assistive and Robotics Mr. Gribson Chan, Deputy Director Technology (CHART) which on Rehabilitation Services Division St Luke's Hospital February 2016 held a 2-day showcase of different cutting-edge robots and technologies for healthcare assistance, with 28 projects from 19 companies and academic institutions on display and demonstration. Since its establishment in 2015, CHART has worked on more than 20 projects with over 30 organisations from Singapore, Japan, South Korea and the United States.
◼ The Society for the Physically Disabled (SPD) was founded in 1964 with the aim to work towards the integration of people with disabilities into mainstream society. The Society advocates for the use of assistive technologies, and has established the Assistive Technology Centre in 2001 in order to conduct practice-related training to build capability in
37 Vulcan Post (2018). Singapore Budget 2018: Live Updates.
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assistive technologies and to provide advice, consultations and coaching sessions to serve people across all disabilities.
◼ A facility designed to provide training and employment opportunities for people with disabilities, called Tech Able was unveiled in 2015. The facility is co-managed by government bodies that offer services for people with disabilities. Tech Able and its two centres, the Singtel Enabling Innovation Centre and the ST Engineering Enabling Technology Centre, help persons with disabilities to live and work independently through assistive technology.
◼ In Tan Tock Seng Hospital, its Centre for Advanced Rehabilitation Therapeutics has been using robotic therapy since 2011 to treat stroke patients. The patient straps with a robotic arm to perform tasks in a virtual reality environment such as picking of fruits, cleaning of windows, and even shaving of carrots. The machine can be regulated and activates the right muscles to help the patient’s weakened body part to regain movement.
Figure 5: Robotic Therapy at the Centre for Advanced Rehabilitation Therapeutics
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◼ Similarly, researchers from Nanyang Technological University (NTU) have developed the “H-Man”, a robotic technology that helps stroke patients regain their movements via computer games.38 The NTU was planning to form a start-up in 2017 to commercialise the technology, but no news have been released so far.
◼ In 2016, researchers from the National University of Singapore developed a robotic glove, designed for people who have lost hand function due to injuries or nerve-related issues. The robotic glove was named “EsoGlove”, and is equipped with intuitive system that detects users’ muscle signals to guide the person to perform a certain task. The glove also has an RFID39 reader that can scan tags for a particular motion like pinching or grabbing an object. Patients can wear it anywhere and programme a customised therapy session without the need for the therapist to be at their side.40
◼ The Singapore-MIT Alliance for Research and Technology (SMART), involving the Massachusetts Institute of Technology and the National University of Singapore (NUS), has also developed Singapore’s first self-driving wheelchair in 2016, which is now being tested at Changi General Hospital.41 In November 2018, the Ministry of Communications and Information announced that persons with disabilities (PWDs) will now have greater access to Infocomm and Assistive Technology (IT/AT) tools with the launch of three satellite loan libraries in Singapore that will help PWDs and Voluntary Welfare Organisations (VWOs) identify and trial IT/AT devices and software before purchasing them to give them the opportunity to determine which IT/AT tools will be most useful and suitable for their needs. The three satellite loan libraries will be located at Ngee An Polytechnic, Singapore Polytechnic and Temasek Polytechnic. One of the assistive technologies in the satellite loan libraries is the Roger Pen, a handheld mobile device shaped like a pen that uses a cutting- edge wireless microphone to pick up the voice of the speaker. Via Bluetooth-enabled miniature receivers, voice is transmitted wirelessly into a user’s hearing aids. Speech is
38 Channel NewsAsia (2016). NTU Researchers Use Robotics to Offer Stroke Patients a Helping Hand. 39 Radio-frequency identification 40 ‘Singapore research team develops robotic glove to help those who have lost hand functions’, 2016, International Business Times 41 Straits Times (2017). Singapore Trials Its First Self-Driving Wheelchair at Changi General Hospital.
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clarified in noisy environments, whether at close range or a distance. All the user has to do, is point the pen toward the direction of the sound or lay it flat to pick up surrounding sounds.
◼ To drive further adoption of IT/AT by PWDs, the Infocomm Media Development Authority (IMDA) enhanced the IT/AT VWO Grant in 2017 to help PWDs engage in the programmes organised by the VWOs. Since then, IMDA has awarded six grants to six organisations, including the Down Syndrome Association of Singapore, SG Enable, and Metta Welfare Association, among others.
These organisations have embarked on projects to drive the adoption of IT/AT in their centres. For example, Fei Yue Community Services incorporated the use of Edamas Systems (Prosense, V-Step and Smart Wipe) and Timocco, into their Early Intervention Programme for Infants and Children. These are interactive solutions with customisations designed to engage and enhance the learning needs for children with special needs. The introduction of motion-based interactive provides educational and therapeutic gaming environments that respond to the child’s movements. With the incorporation of both solutions through the grant support from IMDA, Fei Yue has reached out to over 150 beneficiaries.
Local Players
Local companies in Singapore have shown dynamism in delivering innovative assistive technologies that can address the country’s challenges related to its healthcare system.
Rehab Mart Homecare was established in Singapore in 1995, with the aim of marketing a broad range of hospital equipment, medical and healthcare products and assistive devices for the disabled that enable the physically challenged and the elderly to undergo rehabilitation, lead a normal and productive life with the optimum level of independence, and re-integrate into the community. As part of its continual effort to exercise social responsibility and align itself with national policies, Rehab Mart supports the government’s health assistance plans for the pioneer generation, low and middle-income groups and the disabled with various discount schemes.
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Greenstyle Pte Ltd, which wholly owns Rehab Mart Homecare, performs the tasks of sourcing products and serving the needs of homecare and corporate customers, hospitals, nursing homes, associations for the disabled and other corporations. The company imports directly a wide variety of renowned brands from overseas manufacturers and also source locally, thus enabling versatility in stocking a wide range of hospital equipment and medical supplies.
Established in 1991, Lifeline Corporation Pte Ltd has built a reputation for supplying quality healthcare products at affordable prices coupled with responsive service. Lifeline has a wide range of rehabilitation products including wheelchairs, hospital furniture and other patient support aids. With the success in Singapore, the company expanded to Malaysia in 1995 with the same vision to provide customers their healthcare needs and the aged a better quality of life. Lifeline was the first medical company in Singapore to be awarded the Good Distribution Practice for Medical Devices in Singapore certification in October 2008.
Founded in 2007, Falcon Mobility is an established distributor specialising in mobility scooters and motorised wheelchairs for elderly and physically disabled people. Falcon Mobility sources its products from the United States and Taiwan, and also has shops in Malaysia. In Singapore, the company partnered with the Central Singapore Community Development Council’s for the “Mediwheels” Programme in 2012.
Figure 6: The Falcon e-Lite Mobility Scooter Source: Falcon Mobility
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Falcon Mobility has also developed the world’s lightest scooter, with the aim to enhance the comfort of its customers. The prototype of the scooter was unveiled at the RehabTech Asia 2015. Weighing 16.3 kg, the scooter costs S$ 2,500 (EUR 1,630).
Assisted Living, which was established in 1998, is a well-known distributor in Singapore specialising in homecare products and medical devices for the elderly, such as wheelchairs, mobility aids, adult diapers, hot / cold packs, hospital equipment, orthopaedic supports & braces, ripple mattresses, test kits and others. The company represents one of the largest authorised distributors of a wide range of internationally recognised medical products such as Abena, OppO, Sunrise, Karma, A&D, Apex Medical, Lifeplus, PMS, Backjoy, R&R, Etac, Atlas Medical and others. Assisted Living supplies to all major hospitals, clinics, chained pharmacies, nursing homes, physiotherapy centres, healthcare shops, departmental stores, and others as well as selling directly to the end consumer through its own very unique one-stop home care shop. The company currently has 2 showrooms in Singapore.
3.2.2 EU Entry Opportunities
Singapore has turned its attention on assistive technologies and robotics to address the needs of its ageing population and to bridge the gaps in manpower resources. There is a growing demand in the country for services such as geriatric medicine and rehabilitation medicine, with the government looking to invest in more facilities for the elderly, such as nursing homes and rehabilitation centres. While this provides plenty of opportunities for foreign players, there are also other areas that may be of interest to European companies:
◼ Research Collaborations
◼ Showcase and Test-Bedding
◼ Participation in Government-Led Projects
◼ Technology Innovations that Enable Elderly to Age at Home
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Research Collaborations
In 2015, the Changi General Hospital (CGH) with the support of Singapore Economic Development Board (EDB) unveiled the Centre for Healthcare Assistive and Robotics Technology (CHART). CHART, is designed to be a place for healthcare professionals, industry players, academes, research institutions, and end-users to work together to develop healthcare solutions based on robotics and assistive technologies. Healthcare solutions development in the centre focuses on five key healthcare domains – developing virtual hospitals, transforming aged care, optimised rehabilitation, automating processes and enhancing medical training. The centre has a Design Lab for ideation and collaboration, and a Living Lab with mock-up wards, clinics and minor surgery rooms to test prototype healthcare solutions. CHART also serves as a launch pad for the National Robotics Programme, an initiative for centralised end-to-end development of robotics technologies in Singapore. CGH has already signed memoranda of agreement with Nanyang Technological University (NTU) and Singapore University of Technology and Design as well as started collaboration projects with various local and foreign companies to test and develop solutions.42 Supported by the National Robotics Programme, CHART now works with industry partners and other government agencies to develop a standardised healthcare robotics middleware, such that robotics and medical systems can be integrated as a platform for Singapore’s smart health systems.43
Another facility in the country, the Tech AbleBB, which was born from a multi-agency partnership among the private and public sectors, was officially opened in 2015 by the Minister for Social and Family Development. The facility aims to help people with disabilities to learn and utilise assistive technologies to improve their lives and gain employment. Tech AbleBB primarily serves as a training facility, platform for collaborations to create new technology solutions, and resource centre to make assistive technology and ICT more accessible. Tech Able has two dedicated centres to address these goals. One of the centres is the Singtel Enabling Innovation Centre, which provides training and employment opportunities as well as being a venue for collaboration among different professional interest groups, such as therapists, researchers and people with
42 Changi General Hospital (2015). CGH Launches Healthcare Robotics Centre to Drive New Solutions in Healthcare. 43 Economic Development Board (Accessed in April 2018). Singapore Turns to Robots and Other Cutting-Edge Technologies to Improve Productivity and Reduce Reliance on Manual Labour.
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disabilities. The other one is the ST Engineering Enabling Technology Centre, which is the resource centre focusing on assistive technologies and ICT. The centre has an available specialist on site to assist the person with disabilities on what appropriate assistive device to use, including its facilitation, advice on purchase and applicable subsidies or government support.44
Showcase and Test-Bedding
Singapore offers many opportunities for showcasing and test-bedding assistive technologies solutions, and companies from all over the world have taken advantage of these chances. For instance, the 2016 CHART 2-days event offered several companies to chance to showcase their products.
Figure 7: A Wheelchair Automated Bathing System Source: The Straits Times
◼ One of the most successful was the solution developed by the Japanese company Tutti, a wheelchair Automated Bathing System that removes the risk of care patients getting injuries from fall or extensive manual bathing. The demonstration and its apparent benefits were enough to convince CGH, Peacehaven Nursing Home, and St. Hilda’s Community Service Centre to trial the product in their respective hospitals.45
44 ‘New Facility to Promote Adoption of Assistive Technology Among Persons with Disabilities’, 2015, SPD 45 ‘New assistive technologies to improve patient care’, 2016, TodayOnline
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◼ In 2015, Panasonic System Solutions Asia Pacific (PSSAP) begun testing for its Reysone Wheelchair Bed in CGH. Reysone Wheelchair Bed is an electric care bed that separates and converts into a wheelchair safely and conveniently. The electric care bed allows care staff to transfer and move patients efficiently and eliminates the risk of injury for both care staff and patients during manual transfer. Reysone has a one-touch function for transformation from bed to wheelchair and vice-versa, hence only one staff will need to do the complete operation.
Figure 8: Reysone Wheelchair Bed Source: New Atlas
◼ At the Changi General Hospital, PSSAP has also successfully tested another assistive technology, known as HOSPI. HOSPI is an autonomous delivery robot that can deliver fragile and bulky medicine, medical specimens, and patients' case notes 24/7.46
◼ At Tan Tock Seng Hospital, the Help Me Speak initiative also started employing advanced eye tracking technology to allow its patients to express discomfort, call for help in an emergency, hold conversations and even surf the internet. The specialised ATC now loans eye tracking devices to patients who need them.
46 ‘Panasonic Autonomous Delivery Robots - HOSPI - Aid Hospital Operations at Changi General Hospital’, 2015. Panasonic
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◼ Assistive Devices Centre run by the Singapore Association for the Visually Handicapped also offers a comprehensive range of devices for those with low vision, including lifestyle talking devices, refreshable braille displays and desktop or portable electronic magnifiers.
◼ Changi Airport is additionally conducting a trial for smart wheelchairs, which incorporate obstacle detection sensors and electric motor control to help people with disabilities navigate the airport terminals.47
Participation in Government-Led Projects
An additional interesting entry opportunity for European companies is participating in government- led projects. For example, in 2012 the Central Singapore Community Development Council’s (CDC) launched a programme called “Mediwheels” that provides a highly-subsidised and affordable community medical transport service to frail, needy elderly and residents with special needs. Under the programme, people with disabilities can rent motorised scooters for just S$ 10 (EUR 6.52) per month, which enable them to go out and move around the neighbourhood quite easily. A local distributor Falcon Mobility partnered with CDC and leased the scooters.
In 2017, the Infocomm Media Development Authority (IMDA) also launched the Enable IT Scheme, which provides grants to voluntary welfare organisations (VWOs) to acquire assistive technology devices to help more of their beneficiaries. Under the Government’s scheme, grants given to VWOs will be doubled to S$ 100,000 (EUR 65,183) per project. Efforts are also underway to raise awareness of built-in assistive technology features in popular devices such as the iPad tablet. IMDA is currently partnering with tech companies to train a pool of people with disabilities to be “assistive technology ambassadors” who spread awareness of built-in accessibility features on the firm’s devices and platforms. For a start, it plans to work with Apple and Microsoft. In April 2017, IMDA rolled out its first assistive technology workshop for the visually-impaired, training them on Apple products’ assistive capabilities.48
47 GovTech (2018). 48 Straits Times (2017). PWDs to Get More Help in Using Assistive Technology.
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Technology Innovations that Enable Elderly to Age at Home
According to Ageing Asia, a consultancy and social enterprise focused on overcoming the manpower challenges posed by an ageing population, the next opportunity in Singapore is technology innovations that enable older adults to age at home. This is the opportunity for healthcare monitoring technologies, assistive living technologies and smart living technologies. Local firms have been already focusing on these areas as well as home care services and vendor sourcing apps. For example, Cadi Scientific, which has been in the market for 14 years, designs and manufactures wireless sensing devices used in hospitals for tracking and monitoring patients, staff and assets and assisting them in daily task performance.49
European Players
Widex
Widex is a family-owned company founded in Denmark in 1956. Today, it is one of the world’s largest manufacturers of hearing aids. Widex hearing aids are sold in more than 100 countries around the globe, and the company employs over 3,800 people worldwide. In Singapore, Widex hearing aids are sold in Bloom Hearing Specialists clinics, The Hearing Specialist clinic, and major hospitals.
Moreover, Widex has recently bought the Italian provider of advanced acoustic eyeglasses and hearing aids Coselgi, whose products are now sold in over 30 countries. In Singapore, Coselgi’s products at hearLIFE, one of the leading hearing care centres in Singapore, equipped with the most advanced audiological solutions for all kinds of hearing losses.
49 Business Times (2017). Singapore Firms See Silver Lining in Eldercare Industry.
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Figure 9: Coselgi’s Hearing Aids Source: Hearlife
Ottobock
Since its founding in Berlin in 1919, Ottobock has specialised in improving the mobility of people with disabilities through innovative products. The company was created in response to the large number of injured veterans from World War I, and it has been responsible for several innovations in prosthetics, including the C-Leg, a computerised knee that adaptively varies its passive resistance to suit the patients' different walking gaits, and the Michelangelo Hand, a fully articulated robotic hand prosthesis. Ottobock has been a partner to the Paralympic Games since 1988. Today Ottobock has a representative office in Singapore, located in Sultan Road, as well as in other South East Asian countries including Thailand, the Philippines, and Indonesia.
Permobil
Since being founded in Sweden in 1967, Permobil has developed solutions aimed to enhancing the lives of people with physical disabilities. Today, Permobil has evolved into one of the global leaders in manufacturing power wheelchairs, with an estimated global market share of 25%. The company offers a wide range of wheelchairs for children, young people and adults. Focused on the complex rehab segment, Permobil’s wheelchairs are built to order and custom-fit to meet the unique medical needs of each individual. Permobil is headquartered in Timrå, Sweden and has approximately 1,000 employees. The company has operations in 40 countries worldwide, including Singapore, where its products are distributed by Rehab Mart Homecare. In East Asia, Permobil’s wheelchairs are also sold in Thailand, South Korea, Japan, Hong Kong, and China.
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3.3 Medical Equipment
3.3.1 Market Overview
The Singaporean medical equipment sub-sector has been growing rapidly, on the back of a strong domestic demand for medical equipment from public and private hospitals and clinics. With Singapore experiencing what is known as ‘hyper-ageing’ in the next twenty years, the government is continuing to invest heavily in primary care infrastructure such as polyclinics and community health centres.
Research experts forecast positive growth for the medical equipment market in Singapore: Smaller companies feel that they need to focus on one area of expertise rather than the whole value chain. So if you’re ◼ The Singaporean medical consumables market in the innovation space, the question (bandages and dressings; suturing materials; then comes down to how do you innovate faster than anybody else? No syringes, needles and catheters) is forecast to one has a monopoly on science. As expand by an average of 9% per year to reach such, for smaller companies it’s about finding a space where they can innovate approximately S$ 200 million (EUR 130 million) by and do much better than others, 2022. collaborating to complement any shortcomings, or amalgamating into a large organisation where it can unlock ◼ The market for diagnostic imaging products its value and distribute its products. (electrodiagnostic apparatus; radiation apparatus; Albert Lee – Chairman Medical Technology imaging parts and accessories), will expand by an Industry Association average of 7% per year, to also reach approximately S$ 200 million (EUR 130 million) by 2022.
The new medical subsidies announced in Singapore’s 2019 Budget, including the S$ 8 billion (EUR 5.2 billion) ‘Merdeka Generation’50 (elderly born between 1950 and 1959) package to an additional S$ 3.1 billion (EUR 2 billion) for long-term care needs of an ageing population, are also
50 ‘Merdeka’ is a Malay word which means freedom, and refers to the pro-independence movement, when Singapore fought to gain independence from its colonial rulers. The ‘Merdeka Generation’ refers to a generation of senior Singaporeans who are in their 60s who lived through the period that led up to Singapore’s independence in 1965.
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expected to boost the demand for healthcare services in the country, and by extension, the demand for medical equipment and supplies in the country.
Being a trading hub for the region, the majority of Singapore imports of medical devices are re- exported to other ASEAN countries and worldwide, as indicated in Section 5.3 of this report. Imports of medical devices were estimated at approximately US$ 10 billion (EUR 8.8 billion) in 2018.51 In 2018, the US remained the dominant supplier of medical devices to Singapore, accounting for more than a third of all imports.
The country is aiming to be a heavyweight in medical equipment and technology manufacturing. According to the Economic Development Board, Singapore’s medical equipment and technology manufacturing output reached over S$ 11.5 billion (EUR 7.2 billion) in 2016,52 and employs more than 14,000 people.53 In Singapore, medical technology companies make products ranging from contact lenses and pacemakers to life science tools and diagnostics equipment. Singapore also has global leadership positions in the area of scientific instrument manufacturing. There are, at present, more than 240 healthcare start-ups in areas such as digital pathology, diagnostic imaging and cardiovascular implants.54 Leading European players include Germany, the UK, and the Netherlands. Although domestic production volume and value are high for the small state, around 90% of the output (mainly non-medical devices products such as contact lenses, research instruments and scientific & analytical equipment) is exported.
With the country’s strong engineering capabilities and its pool of certified suppliers, Singapore manufacturers can develop complex and high-quality medical equipment ranging from syringes and catheters, to research instruments, and scientific analytical equipment. Around 10% of the world’s contact lenses, over 70% of the world’s microarrays, and about half the world’s thermal cyclers and mass spectrometers are manufactured in Singapore.55 Segments that are showing
51 https://www.export.gov/article?id=Singapore-Medical-Devices 52 Economic Development Board (2018). Singapore Dazzles as a World Leader in Medical Manufacturing. 53 https://www.straitstimes.com/business/shared-ideas-important-as-medtech-sector-grows 54 Channel News Asia (2016). Singapore's manufacturing output declines 0.5 per cent in March. 55 Retail News (2017). Singapore Transforms into Pharma and Medtech Hub.
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particular dynamism in the country include cardiovascular, eye care, diagnostic, imaging, research tools, scientific instruments and orthopaedics.
As part of Singapore’s ambition to become one of the top medical technology hubs in Asia, the Singapore government is extending its support to local companies in the medical equipment sector. At the research and development stage, high barriers to entry usually arise due to long development timelines and strict regulations, which are necessary to safeguard the testing of new devices, as well as the need to navigate the patents and intellectual property rights space. At this stage, local medical technology start-ups can apply for SPRING’s Technology Enterprise Commercialisation Scheme, which supports successful applicants for the development of new, innovative and potentially market-changing technology at the proof of concept and proof of value stages.
Local Players
Biosensors Interventional Technologies Pte Ltd started in Singapore as contract manufacturing company for critical care products in 1989. In 1991, the company setup its manufacturing facilities and started the global distribution of its critical care products. Today, the company has main offices in Singapore and Switzerland and continues to develop, manufacture, and market innovative medical devices for interventional cardiology and critical care procedures.
In May 2016, Biosensors signed a strategic distribution agreement with Cardinal Health. The companies expect that the agreement will significantly increase the market coverage and penetration of Biosensor’s Drug Eluting Stents (DES) while enabling Cardinal Health to sell Biosensors’ family of DES in various European countries, Australia, and New Zealand. The partnership will allow both companies in maximising the increased market coverage and geographical footprint to new frontiers such as the Middle East and Africa.
In 2013, Biosensors entered into a licensing agreement with Eurocor GmbH, a European Life Sciences Technology Corporation specialising in the research, development and manufacture of cardiovascular and endovascular products, for their Drug Eluting Balloon (DEB) technology and
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related intellectual property rights in relation to the treatment of both coronary and peripheral artery disease. The licensing agreement allowed Biosensors to acquire a new range of DEBs under the company’s existing portfolio of cardiac stents and facilitate its entry into the peripheral vascular disease market. In the same year, Biosensors acquired Spectrum Dynamics at approximately US$ 51 million (EUR 45 million) a company specialising in advanced functional assessment technologies, including those used to evaluate patients for cardiac interventions.
Veredus Laboratories Pte Ltd, a Singapore-based company founded in 2004 develops, manufactures, and markets innovative multiplexed molecular solutions in the clinical, specialty, and custom testing markets. Veredus Laboratories introduced significant development and breakthroughs that have transformed the quality and efficiency of testing, including the following:
◼ On September 2016, Veredus Laboratories announced the successful development of VereFever™, an application test kit as small as a fingernail that can detect seven major tropical diseases, namely Zika, dengue, malaria, chikungunya, West Nile, Yellow Fever, and Japanese encephalitis. With a drop of blood, the microchip which costs S$ 100.00 (EUR 65) can detect different species of tropical diseases in about two to three hours.
◼ In the previous year, Veredus launched the world’s first application that can detect, differentiate, and identify nine major poultry infectious disease agents in one sample using a single disposable biochip, that include Newcastle Disease virus, Salmonella Pullorum, Salmonella Enteritidis, Campylobacter and Avian Influenza (bird flu) virus. The poultry biochip is called Verevet™, jointly developed by scientists from Agri-Food and Veterinary Authority of Singapore and Veredus Laboratories.
◼ In 2014, the company announced and released the successful development of VereMERS™, an application that can detect from a sequence perspective, the coronavirus that causes Middle East Respiratory Syndrome.
HealthSTATS International, is a Singapore-based technology company that focuses in research & development, sales & marketing of innovative bio-monitoring devices for hypertension and related illnesses. The company’s bio-monitoring devices have obtained US Food and Drug
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Administration approval. HealthSTATS also released a mobile application called AF Detect, that transforms a mobile device into a personal heart-rate monitor and Atrial Fibrillation detector. Through the inbuilt camera of a mobile phone, AF Detect can monitor the person’s heart condition by reporting instances of Atrial Fibrillation. AF Detect comes with data visualisation, result-based recommendations, email export and much more.
3.3.2 EU Entry Opportunities
Singapore offers numerous opportunities to European companies, especially as a manufacturing base for high value medical technology manufacturing. European companies can also tap into Singapore’s R&D ecosystem, comprised of universities, institutions and start-ups to develop next- generation products incorporating digital technologies to meet the need for patient-centric and preventive care models and enable people to take ownership of their health.
Diagnostics is an important area in view of Singapore’s ageing population and rising incidence of chronic diseases. Better and earlier identification of diseases could help in controlling increasing healthcare costs. This is in line with the Ministry of Health’s state strategic shift from healthcare to health. Within the field, use of in-vitro diagnostics (blood, urine or tissue samples to detect infections or diseases) is expected to witness significant growth in the coming years. Singapore is seeking to attract innovative companies to develop investible diagnostic assets.
The Ministry of Health accounts for 70% of local demand. It is setting up a National Healthcare Supply Chain Agency, which will serve as a new national integrated supply chain, bringing together the entire supply chain’s functions, including procurement and resources of the three healthcare clusters.
In addition, the following areas can be highlighted:
◼ Access to South East Asia
◼ Government-led initiatives
◼ Research Opportunities
◼ Singapore as a Manufacturing Base
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Access to South East Asia
Singapore is South East Asia’s trading hub for medical equipment, and European companies interested in expanding in the region can find in Singapore an excellent entry-point. Moreover, in August 2014, the Association of Southeast Asian Nations (ASEAN) signed a formal agreement that harmonised medical device regulations. This agreement, formally called the ASEAN Medical Device Directive (AMDD), provides a more straightforward path to the market for medical device manufacturers. For medical device companies, this means that they will be able to more easily access a common medical device market with a market size of more than 600 million people. In terms of actual AMDD implementation dates, however, no official time frame has yet been set. Current medical device regulatory systems in Singapore and Malaysia, however, provide a good indication of what an ultimate ASEAN framework will look like.56
As of 2018, the Health Sciences Authority (HSA) Singapore has updated its regulatory legislation to facilitate faster access for certain lower-risk medical devices and certain standalone mobile applications. Class A (low risk)57 sterile medical devices, such as sterile examination gloves and sterile intravenous sets, will not need to be registered with HSA. Class B (low-mid risk) and C (mid-high risk) standalone mobile medical applications, such as those for calculation of insulin dosage, or live monitoring of ECG for cardiac patients) that are approved by at least one reference regulatory agency without safety issues globally will be eligible for immediate market access under the immediate registration route. In the same regulatory enhancement exercise, HSA also clarified that telehealth devices intended by their manufacturer for medical purpose will be regulated as medical devices. Those intended by the manufacturer solely for well-being or lifestyle purposes (e.g. smart watch to track heart rate and heart rate measuring devices in smart phones for fitness purposes) and not intended for medical purpose will not be subjected to regulatory controls. The industry is already advancing in healthcare solutions specifically
56 www.emergogroup.com 57 Medical devices are classified into four risk classes in Singapore – class A to D with class A being the lowest risk class. This classification is based on the intended purpose of the medical device, mode of operation and the user, and also the device technologies. The details can be found here: https://www.hsa.gov.sg/content/hsa/en/Health_Products_Regulation/Consumer_Information/Consumer_Guides/Medical_Devices.html
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targeting neighbouring Asian economies, where the market is developing at a rapid pace and the physical, medical, and disease profiles differ considerably from other regions.
Figure 10: The AMDD Creates Opportunities in the ASEAN Market
Government-led initiatives
Government-led initiatives are another lucrative area for European companies. The Singaporean market has seen numerous opportunities over the years arising from the government’s commitment to collaborate with the private sector:
◼ EDB’s Partnerships for Capability Transformation (PACT) – The government set aside S$ 250 million (EUR 163 million) for a five-year period to help pay qualifying expenses of up to 70% on a partnership between locally based manufacturers and suppliers towards development of their competency to meet manufacturing quality and certification requirements. PACT also offers opportunities to both parties to co-develop innovative products or solutions for the industry.
◼ Medical Technology Manufacturing Consortium – A 26-member consortium organised by Singapore Institute of Manufacturing Technology supports local industry capabilities and offers medical technology R&D platforms for technology and knowledge transfer by sharing the results of R&D collaboration with the research institutes, value chain partners, and Multinational Corporations.
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◼ Sector Specific Accelerator programme – This programme, with a S$ 70 million (EUR 46 million) committed budget, aims to encourage the formation and growth of start-ups in medical technology. There are four appointed accelerators, namely Clearbridge BSA, Singapore Medtech Accelerator, Zicom MedTacc and Medtech Alliance that identify and co-invest with qualifying companies in high-potential medical technology start-ups. Besides co-investing, the accelerators take a hands-on approach to help the start-ups build up their management teams, meet regulatory requirements and connect with potential customers.
◼ Biomedical Engineering Programme– The programme was designed to foster Clinician- Engineer collaborations to develop medical devices and solutions to improve patient care and cost-efficiency of the healthcare system. To qualify under this grant, a collaborative research project proposal must have emphasis on devices, procedures, diagnosis, and clinical systems and be driven by needs identified by clinicians that are matched to a potential technological solution.
Research Opportunities
◼ Singapore’s public-sector research institutes have established strong capabilities in various technologies across multiple disciplines such as bio-imaging, cell biology, materials engineering, microelectronics and nanotechnology. These institutes are open for collaboration with private companies and public entities. Some of the successful partnerships are outlined below:
▪ Veredus Laboratories Pte. Ltd. worked together with A*STAR’s Singapore Immunology Network in successfully developing the first biochip in the molecular diagnostics market that can identify 13 different major tropical diseases from a single blood sample. The biochip test kit was officially released in 2013 and was validated successfully on patient samples in the external fields of Northern Thailand, at the Thai-Myanmar border.58
58 ‘A*STAR and Veredus Laboratories Create Market’s First Lab-on-Chip for the Detection of Multiple Tropical Infectious Diseases’, 2013, Veredus Laboratories Pte. Ltd.
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Figure 11: The VereChip Source: A*STAR
▪ A close collaboration between scientists from the Experimental Therapeutics Centre under A*STAR and clinicians from Tan Tock Seng Hospital has enabled the successful development of the most comprehensive and rapid H5N1 bird flu test kit. The license agreement between local SME, AITbiotech, and A*STAR to market the test kit was signed in 2012, which greatly aided the public healthcare sector in the fight against infectious diseases.59
◼ Catalist-listed incubator Trendlines Group, an Israel- and Singapore-based incubator of medical and agricultural technology start-ups, announced in 2018 its participation in i2Start, a new initiative in Singapore that supports clinician or institutional-researcher-led projects, and provides projects with a grant of up to S$ 1.25 million (EUR 814,793) to spin off or commercialise their solutions. The initiative is backed by the Singapore MIT Alliance Research Technology, National Health Innovation Centre and Spring Singapore. Trendlines has also announced in February 2018 its collaboration with Singapore-based venture capital K2 Global. The collaborations come after Trendlines said last year that it had inked a partnership with the National Healthcare Group to build a pipeline of medtech start-ups and solutions for the global market. The Trendlines Group set up four medical technology start-
59 Tan Tock Seng Hospital (2012). Made-in-Singapore H5N1 Bird Flu Diagnostic Kit – Detects All Known Strains of H5N1.
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ups in Singapore in 2018, including tie-ups with the National Healthcare Group and A*ccelerate, the commercialisation arm of the Agency for Science, Technology and Research (A*Star).
◼ In 2017, Australian medical technology start-up Anatomics has signed a 3D printing-related agreement with the Nanyang Technological University (NTU). Working with NTU, Anatomics will seek to advance research in the field of 3D printed medical devices, which will include developing new medical-grade 3D printing materials, as well as designing customised, smart implants. Anatomics has also announced its plans to reach out and collaborate with additional Asia-based healthcare institutions to market and sell their 3D printed products in addition to its plans to explore the potential of smart medical devices and implants that are capable of giving feedback and real-time statistics about the patient’s condition and body.
Singapore as a Manufacturing Base
◼ Singapore is a trusted base for companies to manufacture complex and high-quality instruments and medical devices for global markets, and many big players see Singapore as a strategic regional hub. The country offers key engineering capabilities that would enable healthtech companies to engage in product reengineering and scale up their manufacturing operations. The strong base of high-quality, ISO 13485-certified suppliers in Singapore’s medical technology sector has extensive experience in working with medical technology multinational companies, adhering to strict standards of IP protection and regulatory requirements stipulated by US FDA and European EMEA. Their capabilities include electronic product conception, manufacturing and supply chain management. To facilitate and enhance partnerships between original equipment manufacturers (OEMs) and suppliers, Singapore has also established a number of platforms to ensure that suppliers’ capabilities evolve to meet the needs of the industry, which include:
▪ EDB’s Partnerships for Capability Transformation – which subsumed the Local Industries Upgrading Programme – was initiated to develop the competences of locally-based OEMs and suppliers to meet manufacturing quality and certification requirements.
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The government has also committed funds to help defray part of the qualifying expenses for such partnerships.
▪ Medical Technology Manufacturing Consortium, spearheaded by the Singapore Institute of Manufacturing Technology – a publicly-funded research institute of A*STAR – is a 26-member consortium formed in 2009 to reinforce local industry capabilities and establish medical technology R&D platforms for technology and knowledge transfer by exploiting the results of R&D collaboration with the research institutes, value chain partners and multinationals. This includes optics and fluid dynamics, new materials such as composites and alloys, as well as advanced manufacturing processes comprising micro and large format machining.
European Players
Essilor International
Essilor International S.A. is a French company that produces ophthalmic lenses along with ophthalmic optical equipment. Essilor is responsible for creating Varilux, the world's first progressive lens that corrects presbyopia and allows clear vision in the wearer's near, intermediate and far vision.
The company has been present in Singapore since the 1980s and in 2014 Essilor inaugurated its new facility in the country to house its expanded headquarters for the AMERA (Asia, Middle East, Russia and Africa) region. The facility also houses the group’s Centre for Innovation and Technology and the International Vision Academy. Essilor has established Singapore as one of its 3 Centres for Innovation and Technology to drive product development for the region.
The Singapore team has also partnered the Singapore Eye Research Institute, the largest eye research institute in Asia Pacific, on clinical collaborations to obtain clinical insights in supporting Essilor’s product development efforts. The expansion of the regional hub in Singapore will contribute to the Group’s ambition of generating revenues of S$ 4.6 billion (EUR 3 billion) in fast
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growing markets by 2018. Cross-functional teams working in its Singapore hub will continue to develop tailored products and adapted distribution channels to serve the regional market.
Figure 12: Essilor’s New Facility in Singapore Source: www.edb.gov.sg
Siemens Medical Instrument (SMI)
Siemens Medical Instruments is the Singaporean subsidiary of the German Siemens Audiologische Technik GmbH, one of the leading companies producing medical equipment. It was established in 1974 in the country and is the worldwide manufacturing and logistics Centre for the Siemens Audiology Group. Since its inception in the country, SMI has invested over S$ 110 million (EUR 71 million) in which a significant portion was focused in R&D as 40% of the company’s global R&D is conducted in Singapore. In 2012, SMI launched the Ace hearing aid, a tiny and most discreet hearing aid device in its class. The device, which was jointly developed by Singapore R&D team and its German counterpart, was designed for younger users and first- time customers. Apart from R&D activities, SMI also invested S$ 20 million (EUR 13 million) in launching Singapore’s first degree course related to audiology. The two-year Master of Science in Clinical Audiology is available at the National University of Singapore’s Yong Loo Lin School of Medicine and aims to increase the number of audiologists in Singapore.
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B. Braun Melsungen AG
B. Braun Melsungen AG is a German medical and pharmaceutical device company. Its headquarters are located in the small town of Melsungen, in central Germany. The company was founded in 1839 and is still owned by the Braun family. As the company grew, manufacturing facilities were acquired or established in France, Italy, Spain, Switzerland, Hungary, Slovakia, Czech Republic, the United States, Brazil and Malaysia. B. Braun also acquired Aesculap AG, a Germany-based manufacturer of surgical instruments, and the company currently employs more than 54,000 people in more than 60 countries. B. Braun has been serving the Singaporean market since 1987, carrying an extensive range of products and services for general medical treatment and comprehensive therapy concepts in hospitals, surgery, general practice, home care, as well as dialysis in Singapore. In fiscal 2013, the company reported local sales of EUR 18.9 million employing 48 people.
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3.4 ICT for Healthcare
3.4.1 Market Overview
The Singaporean public healthcare sector was estimated to have spent S$ 300 million (EUR 196 million) in ICT projects during fiscal year 2017.60 The market is projected to grow steadily at a CAGR of 4% between 2016-2019. 61 In South East Asia, which is the fastest growing region for the eHealth market, Singapore attracts key eHealth players for its IT infrastructure reliability and its strategic location. The country leads the other ASEAN members in terms of setting clear guidelines and road maps for improved care through the implementation of ICT and has made significant progress on eHealth development in the past few years.
Figure 13: Evolution of Singapore’s Healthcare IT Source: IHiS
Over the years, Singapore has significantly advanced its digital healthcare ecosystem and it is now moving to solidifying this progress further. The healthcare sector’s IT programmes in Singapore have been guided by a Master Plan (HITMAP) since 2014. Seven new transformation
60 https://www.businesstimes.com.sg/technology/healthcare-sector-to-procure-s300m-of-ict-projects-in-fy2017 61 IDC (2016). Singapore Healthcare IT Spend Market Analysis, Forecasts, and Trends
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programmes have been added to the strategic HITMAP in 2017 to enable the MOH’S three key shifts of moving beyond quality to value, beyond hospital to community, and beyond healthcare to health. In addition, it supports policy formulation and evaluation, systems governance, public health and operations management, as well as strengthens IT resiliency and improves cost effectiveness. There are also new projects in the pipeline such as the admissions prevention predictive model for the Ministry’s Hospital to Home Programme, Health Marketplace and Vital Signs Monitoring.
The seven transformation programmes include:
◼ Population Profiling: to develop common data analytic capabilities to link data across Singapore’s healthcare and other non-healthcare data sources to deliver insights about the population.
◼ Population Enablement: to develop one-stop online health content, information and services portal for Singapore residents. This is also a common channel for them to interact with healthcare providers.
◼ Prevention and Continuity of Care: to develop a platform that allows accessibility and sharing of patients’ health records across the national healthcare network and to promote coordination among clinicians and care providers across the continuum of care and provides care transformation from the traditional doctor-centric model to a team-based, patient-centric model.
◼ Provider Care & Operations Excellence: to enable the primary and intermediate & long- term care sector with basic IT in order to connect them with Public Health Institutions to facilitate the processing of sharing patients’ information
◼ Healthcare Financial Excellence: to ensure patient healthcare affordability and improve visibility in costs and outcome. This will also enhance cost effectiveness in this sector.
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◼ Policy & Public Health Workbench: to identify common information needs and develop common capabilities to collect and analyse the data to support policy formulation and public health management.
◼ IT Foundation & Resiliency: to develop common foundation IT capabilities to improve its scalability and resiliency.
In 2017, the Singapore healthcare sector set plans to procure an estimated S$ 300 million (EUR 196 million) in ICT projects, independent of the government’s intention to call S$ 2.4 billion (EUR 1.6 billion) in ICT tenders. Over the next five years, the Ministry of Health also expects to increase its procurement of ICT services and technologies by at least 25%.62 With a vibrant and quickly developing ICT market in Singapore, the following key trends can be identified:
◼ The government is encouraging the use of eHealth technologies, both by making health-data more accessible, and by promoting innovative solutions in the industry.
▪ The Ministry of Health has been pushing for electronic medical record (EMR) exchange, which enables information sharing among public hospitals in the country since 2004. Some of these hospitals including Tan Tock Seng Hospital and the National Healthcare Group have moved ahead into implementing electronic approaches to communicate with patients, such as deploying SMS-based systems to transmit information to doctors and sending appointment reminders to patients.
▪ In 2011, the government launched the National Electronic Health Record (NEHR) with the motto “One Patient, One Health Record”. NEHR aims to consolidate the medical records of patients into one standardised database accessible to all qualified healthcare providers. However, responses by general practitioners have been muted, with only only 3% of doctors in private practice contributing data in 2018, resulting in a huge gap in records. The government is looking to table legislation to make it compulsory for all doctors to submit data to the NEHR system.
62 Business Times (2017). Healthcare Sector to Procure S$ 300 of ICT Projects in FY 2017.
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▪ In 2015, an on-line platform called HealthHub was unveiled by Singapore’s Health Minister. The platform allows users to access a wide range of health-related mobile apps, and to log in with their account to access localised and citizen-centric health content, as well as various health records.
Figure 14: HealthHub allows Singaporeans to Access a Wide Range of Health Content Source: Ministry of Health
◼ The Ministry of Health has recently deepened its collaboration with Integrated Health Information Systems (IHiS), the public healthcare IT shared services provider that helps integrate IT into health care services and operations across Singapore. Previously a subsidiary of the Ministry of Health Holdings (MOHH), IHiS has, in November 2016, merged with the Information Systems Division of MOHH to form a single health IT organisation for improved efficiency. IHIS hosts a bevy of tech solutions and gadgets, specifically catered to the health industry. There are different solutions created for patients and healthcare staff. These include an Outpatient Pharmacy Automated System, Digital Pathology System, Real-Time Ambulatory Patient Information Deployment Enabler system, Electronic Health Intelligence System, Tele-Geriatics, Mobile Apps, and other such services. The new merged entity, with its broader and deeper skill sets, supports the Ministry of Health in further integration of the healthcare system, and raises the level of IT deployment beyond the public healthcare institutions to public and preventive health, primary care and intermediate and
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long-term care settings. IHiS’ new mission is to digitise, connect and analyse Singapore’s health ecosystem to improve population health and health administrations by integrating intelligent, highly resilient and cost-effective technologies.
◼ Smart hospitals are becoming the standard in Singapore, with more operations being automated. Singapore has the highest density of HIMSS EMRAM Stage 6 hospitals in Asia. The HIMSS EMRAM award is an international benchmark for the use of advanced IT to improve patient care. Tracking their progress in completing eight stages (0-7), hospitals can review the implementation and utilisation of information technology applications with the intent of reaching Stage 7, which represents an advanced electronic patient record environment. Currently, there are 25 acute care facilities in Asia Pacific at Stage 6 and three at Stage 7.63 Automation is seen as a way to optimise constrained hospital resources, especially with the increase in patients and decrease in healthcare personnel. Ng Teng Fong Hospital for instance is already implementing the use of autonomous guided vehicles to deliver food and linen. More hospitals are also utilising automated and robotic pharmacies, in which the entire workflow of medication picking, labelling, assembling, verifying to dispensing is done by automated dispensing machines and scanning devices.
◼ Singapore represents a strong market for introducing more advanced mobile health and telehealth services. Unlike many markets where consumers primarily purchase prepaid mobile phone subscriptions, Singapore has a comparatively high uptake of post-paid subscriptions, which allows users to have larger data plans and ready access to larger, more sophisticated mobile health and telehealth applications.
◼ The combination of chronic health conditions (such as cancer, heart disease and diabetes) and limited hospital bed capacity limitations is a crucial issue in Singapore, and it is leading to a rebalancing of healthcare provision, resulting in strong business opportunities for mobile health and telehealth companies able to provide devices to patients to more effectively manage their conditions at home.
63 HiMSS Analytics (2015). Ng Teng Fong General Hospital Achieves HIMSS Analytics EMRAM Stage 6 Award.
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◼ Local consumers are very receptive to innovative products. In its 2016 Consumer Survey on Patient Engagement, Accenture revealed that Singaporeans are becoming even more open towards digital health, with consumers of health apps increasing from 40% in 2014 to 44% in 2016, and consumers of health wearables increasing from 17% in 2014 to 23% in 2016. Among the population surveyed, 78% agreed that using wearables helps patients to engage in their health. The same sentiment is shared by 81% of doctors. Another finding from the study revealed that 87% of Singaporean patients are willing to share their wearable or app data with their doctor, and another 82% with their nurses or other healthcare professionals.
Figure 15: Reasons Why Technology is Important in Managing Health, Singapore Survey Source: Accenture
Many companies see the potential in digital health and are investing in the future today. For example, the global pharmaceutical group Merck & Co set up its global innovation hub in Singapore in 2015, which focuses on areas such as data science and analytics, cyber security, and software engineering. The hub includes a digital health studio, bioinformatics and cognitive computing – tools and functions that aid the company’s efforts to provide solutions for better healthcare.64 Other companies are following this suit to tap into Singapore’s evolving digital health market.
64 https://www.pharmbiosingapore.com/articles/industry-articles/overview-of-the-singapore-pharmbio-sector
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Local Players
IHiS is a leading Singaporean Healthcare IT company and now a part of Singapore’s Ministry of Health Holdings (MOHH), specialises in patient care through smart technology. Managing highly integrated systems across Singapore's public healthcare sector, its IT professionals support 40,000 healthcare staff at all public hospitals, national specialty centres, polyclinics and many more. IHiS architects and oversees the performance of the clinical, business and healthcare analytics systems of the various healthcare institutions. It has garnered more than 70 awards for its innovations, and played a key role in ten Singapore public healthcare institutions becoming amongst the first public institutions in Asia Pacific to achieve HIMSS EMRAM Stage 6 and Stage 7, an international benchmark for advanced technology used in patient care.
Figure 16: iHIS' GPFirstAide Mobile App Source: IHiS
Together with Changi General Hospital, the company has developed the GPFirst Aide Mobile App. The product is designed for healthcare staff, and provides general practitioners with clinical guidelines and videos, to help them decide if a patient’s condition requires further management.
NCS Group (previously known as National Computer Systems) is a multinational information technology and communications engineering company headquartered in Singapore. NCS has over 8,000 staff located in more than 10 countries across Asia Pacific. The company specialises in ICT solutions in industries ranging from defence, education, financial services, healthcare, homeland security to manufacturing and logistics, telecommunications, transportation and
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utilities. As a leading ICT service provider in Singapore for the past 30 years, NCS has played a part in defining Singapore’s healthcare landscape, and has provided various solutions to Singapore’s Ministry of Health. These include systems to help integrate primary and tertiary care providers through the sharing of essential patient medical information; a public health crisis management system that covers contact tracing, health checking, national referencing and case reporting; a biosafety management system which provides a one-stop informational and transactional website on bio-safety issues, among others.
Attune Technologies is a next-generation healthcare IT company that has pioneered cloud- based products designed to help the entire healthcare ecosystem. Attune’s solutions seamlessly integrate information from laboratories, hospitals, pharmacies, blood banks, radiology, medical devices (IoT), and insurance companies, resulting in increased operational efficiency. Attune’s solutions can be deployed across a spectrum of organisations – starting from single physician clinics to a network of healthcare providers making it the largest cloud- based healthcare IT service provider in the region. Funded by Norwest Venture Partners and Qualcomm Ventures, Attune is headquartered in Singapore and supports customers spread across 15 countries in the Indian Subcontinent, South East Asia, Middle East and Africa. The company’s platform interfaces with over 1,100 devices such as lab analysers and ICU machines to absorb diagnostic laboratories, clinics and hospitals into the health network. In interfacing with them, Attune is bringing to life the concept of ‘Internet of Things’ or a connected universe for the entire healthcare sector.
3.4.2 EU Entry Opportunities
European ICT companies looking for opportunities in the healthcare sector in Singapore will find that the country offers bright prospects in the following areas:
◼ R&D initiatives
◼ Public-private partnerships
◼ ICT Solutions for private clinics
◼ Cloud computing solutions
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◼ Cybersecurity solutions
◼ Analytics and Big Data
R&D Initiatives
In 2016, the Singapore government launched Research Innovation Enterprise 2020 (RIE2020), a S$ 19 billion (EUR 12.4 billion) plan to support the country’s R&D efforts in the next five years, focusing on solutions that can address national challenges, build up innovation and technology adoption in companies, and drive economic growth through value creation.65 The four primary technology domains for the nation’s five-year roadmap are: advanced manufacturing and engineering, health and biomedical sciences, services and digital economy, and urban solutions and sustainability. RIE2020 will also encourage public-private collaborations.
To support the R&D ecosystem, Singapore has built R&D centres such as Biopolis, which focuses on biomedical sciences, and Fusionopolis, which focuses on ICT, media, physical sciences and engineering industries. Both Biopolis and Fusionopolis are located in one-north, a 200-hectare development in the heart of Singapore that is positioned as the city’s technology and innovation centre. It hosts a cluster of world-class research facilities and business park space. To foster collaboration, the development also hosts corporate laboratories and is in close proximity to the National University Hospital, the Singapore Science Park, the National University of Singapore, ESSEC Business School and INSEAD Business School.
In Singapore, notable areas of focus of R&D activities have been healthcare consumer engagement, wearables and biosensors, and personal health tools and tracking. R&D funding activities are also expected to increase particularly in digital therapeutics, data and analytics, and diagnostics.
65 www.channelnewsasia.com
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Public-Private Partnerships
Many companies operate in Singapore in partnership with local agencies and organisations. The close relationship between the public and private sectors in the country is evident by the rise of start-ups funded by local agencies such as the National Research Foundation (NRF), SPRING Singapore, A*STAR and the like. Many of these start-ups are spin-offs from public sector research, which find commercialisation opportunities through partnership with private capital funding, international companies, and large local corporations. The following are examples of start-ups and initiatives developed in partnership with various Singaporean government agencies.
◼ SPRING Singapore has contributed funds for the local start-up 1Rwave. Thanks to the collaboration, the Singaporean company launched its first product in 2012, and is currently rolling out a solution to Tan Tock Seng Hospital to help track the movement of patients within the hospital. Initially developed to monitor high-value assets in the logistics sector, 1Rwave’s device is built on an active radio frequency identification system that gives the user real-time information about the location of goods and personnel in facilities, such as hospitals, manufacturing plants, hotels and airports.
◼ Exploit Technologies Pte Ltd (ETPL) was created by A*STAR and its goal is to support the agency by driving innovation and commercialising its research outcomes. Examples of relevant eHealth innovations supported by the ETPL include technology for automatic assessment of eyelid health and accurate diagnostics for ocular surface; an assistive device for rehabilitation of stroke victims and the physically disabled, in the form of a brain- computer interface that provides a direct communication and interaction channel between the human brain and the computer; and a portable contactless conductivity device for ion analysis.
◼ In partnership with the NRF, local in-vitro diagnostics company Sentec Pte Ltd has developed a connected device that monitors blood glucose levels among diabetics without the need for individual test strips. The device makes it possible for a diabetic to monitor his or her blood sugar discreetly and conveniently, anytime and anywhere, without the hassle of
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carrying a separate meter, lancer and a container of test strips. Glycemic readings can be transferred wirelessly to caregivers and doctors in real-time using blue-tooth technology. The prototype is presently in development stage and will require regulatory clearance. The research received funding from Get2Volume, an incubator under the NRF’s Technological Incubation Scheme.
Figure 17: Sentec’s Blood Glucose Monitoring System Source: The National Research Foundation
The Singapore government is currently going digital, and requires the support from private companies in terms of data and digital services. The ministry has outlined three key shifts – to move care beyond the hospital to community, beyond healthcare to health, and beyond quality to value. The ministry’s three shifts together with the healthcare facilities under development, consolidation of healthcare backend systems and IT resiliency requirements have opened up significant opportunities for the industry for co-creation. The Ministry of Health has also announced future IT projects worth S$ 67 million (EUR 43.7 million) and its intention to increase its procurement of ICT services and technologies by at least 25% in the next five years. An Integrated Disease Outbreak Management System will be developed on a C3 platform to meet new operational demands, streamline end-to-end operations, and tap on latest technologies for improved monitoring and faster response. Other projects include a data analytics platform, new digital e-services for citizens, a new data centre and a Healthcare Claims Portal which will integrate and consolidate multiple claim forms and processes. According to IHiS, co-creation opportunities also include the use of behavioural science to improve population health, disease
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prevention and management programmes, home-diagnostic kits, non-invasive, non-intrusive and ubiquitous monitoring technologies, assistive robots, predictive models and near real-time surveillance of diseases and services.
ICT Solutions for Private Clinics
There is currently low satisfaction and implementation rate for full solutions at private clinics. Implementation of IT-driven solutions and automation has been poor across the sector so far, with existing tools (NHELP, Pulsesync, and Microsoft Office) being limited in use. Based on volume and labour-intensive nature of handling patients with need for dedicated, long-term care with possible need for decentralised support, private clinics stand to benefit from easy-to-use tools to manage day-to-day operations. Poor satisfaction with existing tools at private clinics offers opportunities for European companies to provide more sophisticated products.
Cloud Computing Solutions
Cloud Computing Institutions implementing integration programmes incur significant costs in running their own health IT systems. To lower costs, Singapore’s entire healthcare information exchange system is moving to the cloud. The health cloud, or hCloud, will reportedly cost US$ 50 million (EUR 44 million) over the next ten years – around half of the total spending incurred by Singapore’s facilities for these operations today. The plan is to store healthcare information from different hospitals in the private cloud, which will have enough capacity to host additional applications in the future. Today, more than 40,000 healthcare workers already use H-Cloud to access medical records.66 Technology partners are sought in Singapore to assist with the cloud implementation plans.
Cybersecurity Solutions
In June 2018, Singapore’s health system was targeted with a serious breach of personal data, as 1.5 million SingHealth patients’ records were accessed and copied while 160,000 of those had their outpatient dispensed medicines records taken. The personal data taken from the 1.5 million
66 https://www.edb.gov.sg/en/news-and-resources/insights/innovation/singapore-a-gateway-to-southeast-asias-digital-healthcare-mark.html
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patients included their names, national identity numbers, address, gender, race and date of birth. Investigations by the Cyber Security Agency of Singapore (CSA) and the Integrated Health Information System (IHiS) confirmed that a cyberattack had occurred. It also uncovered that as of November 2018, some ‘high-risk weaknesses’ found in the system during an internal audit in 2016 had not as yet been remedied. Following the breach, Singapore is now beginning to pay greater attention to the security of patients’ personal and medical information, leading to a growing opportunity for cybersecurity experts to provide vulnerability assessments, audits, and penetration tests for regulatory compliance.
Analytics and Big Data
The application of analytics and big data in healthcare is another area that is expected to grow. For instance, Fullerton Healthcare tracks millions of transactions at public hospitals daily, and their analysts flag spikes in cases and craft prompt and targeted interventions. Similarly, RingMD, a healthcare technology start-up, collates medical data, tracking heart rate and body temperature from patients’ wearables. These technologies will allow Singapore to better understand its population’s health needs and provide targeted services. Predictive analytics67 would be especially valuable, enabling Singapore to identify population disease patterns and develop preventative medicine.
European Players
Biotronik
Biotronik is a leading German manufacturer of advanced technologies for vascular intervention, implantable cardiac pacemakers and defibrillators, and the pioneer of wireless remote monitoring technology. The company established its regional headquarters for Asia Pacific in Singapore— emphasising the commitment of the company to build a powerful leadership position in the region. Moreover, in 2016 the German medtech firm opened an expanded production plant in Kaki Bukit. "Singapore's skilled workforce, excellent infrastructure and favourable business environment
67 https://www.elsevier.com/connect/seven-ways-predictive-analytics-can-improve-healthcare
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made it a natural choice for Biotronik as we seek to expand our global footprint," said Mr Erik Trip, Biotronik's managing director for Asia-Pacific manufacturing. "This small nation of 5.5 million people is the fourth-largest exporter of high-tech goods in the world. That success is a reflection of Singapore's highly skilled and professional workforce, its world-class research institutions and education, infrastructure and overall business climate. We will be manufacturing components for Biotronik's latest and most innovative products for distribution around the world."
Figure 18: The Official Inauguration of Biotronik's Production Plant in Singapore Source: The Straits Times
Cryo Life Science Technologies GmbH
Cryo Life Science Technologies GmbH (CLST) is a global expert and producer high-tech modular solutions for freezing, storing and transporting biological materials (plasma, stem cells, tissue etc.) from +4°C to –196°C. The “Cryo Logistics Product Range” consists of cryogenic storage systems for biological materials (to -160°C) and plasma freezers (e.g. for plasma bags). All systems are monitored by specially developed software solutions that comply with all necessary legal GLP/MDD/CE documentation requirements. CLST was founded in 1998. The headquarter is situated in Poggersdorf (Klagenfurt / Austria). All products are CE marked according in accordance with all applicable standards. In addition, the company obtained validation for selling
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its products in Singapore. Today SciMed (Asia) Pte Ltd acts as distributor for CLST in both Singapore and Malaysia.
Technidata
The French Technidata is a major player in the field of software solutions for clinical laboratories and biorepositories. Technidata’s solutions serve organisations from the small single-discipline private laboratory to large multi-site and multi-disciplinary state-owned institutions. Developed in full compliance with the ISO 9001/ISO 13485 quality standards, Technidata software products are distributed in more than 25 countries worldwide and cover all the clinical laboratory disciplines: Biochemistry, Hematology, Immunology, Virology, Microbiology, Blood Banking, Histology/Cytology, Genetics, and Biobanking. The company has over 40 years’ experience in the field of laboratory management, and it sells its products in Singapore through the local distributor Egis Healthcare Technologies Pte. Ltd.
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3.5 Telemedicine and Remote Health Monitoring
3.5.1 Market Overview
The Telemedicine market in the Asia-Pacific region earned revenues worth US$ 239.1 million (EUR 212 million) in 2014, and it is estimated this will reach US$ 421.6 million (EUR 373 million) in 2019.68 The region is also poised to record the fastest growth in the global telemedicine market until 2024.69 Unlike larger countries which may face difficulties in providing healthcare coverage in remote regions, Singapore has a well-developed "The telehealth market in Singapore is still very healthcare infrastructure that is accessible much in its infancy, with no industry-dominant island wide. However, the country has to deal players and no single 'killer app'," with a rapidly ageing population as well as Mr William Chew, Managing Director of myHealth Sentinel, Singapore decreasing number of health professionals due to retiring personnel. These two issues compel the government to focus on enabling greater access to care for every Singaporean by encouraging the development and implementation of telemedicine and remote health monitoring. Singapore is moving towards a healthcare model that is centred around delivering services that empower patients: online consultations, eHealth and remote monitoring are creating a new healthcare framework and extending care beyond the hospitals, allowing patients to have more information and control.
As a technologically-advanced country, 70% of all Singaporeans aged 50 and above have already engaged in the use of mobile health or mHealth, where the practice of medicine and public health is supported by mobile devices. mHealth users in Singapore utilise mobile devices to track their fitness, analyse sleep patterns, engage in live chats with their medical providers and obtain medication updates, among others.
Although patients in Singapore see the benefits of technology for managing their health, virtual or remote health engagement is in an explorative phase.70 Traditional, in-person visits remain the
68 First Post (2015). Telemedicine Market Growing in APAC; To Touch US$ 421.6 million in 2019. 69 Research Nester (2018). Global Telemedicine Market Analysis & Opportunity Outlook 2024. 70 Accenture, 2016 Consumer Survey on Patient Engagement
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standard for most consumers, with 72% of Singaporeans preferring traditional over remote visits. Quality care is still associated with in-person visits, which is likely a barrier to increasing virtual visits further. Telemedicine is likely to gain greater acceptance as Singaporeans realise the benefits of virtual care - reduced medical costs, timely medical care, as well as the added convenience of not having to commute to a clinic or hospital and to wait for hours to see a doctor.
Figure 19: Perceived Advantages of Virtual or In-Person Visits, Singapore Survey Source: Accenture
Singaporeans, however, appear to readily embrace new telemedicine solutions and products. A study by McKinsey in 2014 revealed that more than 75% of patients in Germany, the UK and Singapore expect to use digital services related to healthcare in the future, while a 2016 Accenture study found that 83% of consumers said that technology is important to managing their The Singapore telemedicine market is still very health. The McKinsey study also disclosed much in its infancy, with no industry-dominant actors. There is room for multiple players, both that, on average, Singaporeans are more large and small. responsive to innovative telemedicine products than Britons and Germans are. For example, barely 8% of Singaporean patients had never used website/online portals, compared with 23% in Germany and 22% in the UK. Only 11% of Singaporean patients had never used email compared to 23% in Germany and 34% in the UK. Just 13% of Singaporean patients had never used smartphone apps, compared to a substantial
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76% in Germany and 58% in the UK, and another 21% of Singaporean patients had never used social media for telemedicine, compared to 90% in Germany and 84% in the UK. All these data illustrate that Singaporean patients appear to be much more prepared to experience digital healthcare compared to those in Germany and the UK, with more frequent usage of digital channels to meet their healthcare needs.
With Singaporeans being increasingly accepting of the new healthcare innovations, telemedicine has been steadily gaining more ground in Singapore, from progress seen in hospital programmes to new platforms coming online for patients to seek out and book healthcare professionals. Some of the latest developments in Singapore include:
◼ Telehealth programmes at the National University Hospital have been rolled out to help medical professionals to monitor patients and their conditions remotely; over 3,000 patients have participated in the programme so far. It should be noted that the video consultations are not used to diagnose medical conditions. Instead, doctors typically use them to monitor patients whose conditions are relatively stable.
◼ The National University of Singapore has also started offering tele-rehabilitation programmes in order to help patients undergoing physical rehabilitation to recover more quickly.71
◼ In 2017, the public sector health technology agency Integrated Health Information Systems (IHiS) announced the new video call system, which provides a common platform for public healthcare institutions to speak with their patients virtually. The new system is available at six institutions so far, comprising four hospitals, the Institute of Mental Health and the National University Cancer Institute, Singapore. It will be rolled out to the rest later, and possibly even to the private sector. Video consultations are currently available for only select group of patients who require certain specific services, for example, speech therapy or psychiatric counselling.72
71 CNN (2016). Doctor Will Not See You Now: How Singapore is Pioneering Telemedicine. 72 Straits Times (2017). E-Consultations a Boon for Patients.
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Over the past few years, Singapore has seen a growth in the telemedicine sector, with public and private players such as Doctor Anywhere, MyDoc, RingMD, myHealth Sentinel, SoundEye, BookDoc emerging to offer a variety of services to patients. With telemedicine set to become a key feature of Singapore’s healthcare landscape, the Singapore government has stepped in to ensure that Singapore avoids the potential pitfalls of telemedicine.
In April 2018, the Ministry of Health (MoH) launched a Licensing Experimentation and Adaptation Programme (LEAP), which is a regulatory sandbox initiative that allows the safe development of new and innovative healthcare models to be piloted in a controlled environment. The MoH will be inviting telemedicine and mobile medicine providers to participate in the regulatory sandbox. The sandbox encourages innovation but keeps patient safety and welfare as the paramount consideration. In addition, the MoH will work with providers to set clear boundary conditions, undertake clinical and data governance, and patient risk mitigation strategies. It will focus on regulating Medical Practitioner-led tele-consultation and mobile medicine (house call) services that provide direct clinical care, for example, triage, history taking, diagnosis and treatment.
Various medical service providers have joined the MOH’s regulatory sandbox for telemedicine, allowing them to offer services to patients in Singapore while staying within specified patient safety and welfare parameters. These include:
◼ WhiteCoat - www.whitecoat.com.sg
◼ MyDoc Private Limited - www.my-doc.com
◼ Doctor Anywhere Pte Ltd - https://doctoranywhere.com
◼ Speedoc Pte Ltd - www.speedoc.com
◼ MaNaDr - www.manadr.com
◼ SATA CommHealth - www.sata.com.sg/tele-consultation/
◼ Doctor World Pte Ltd - https://doctorworld.co
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◼ Parkway Shenton Pte Ltd - www.parkwayshenton.com
◼ MHC Healthcare Pte Ltd - https://mhcasia.com
◼ HiDoc Pte Ltd - www.hidoc.sg
◼ Rescu Pte Ltd - www.rescu.sg/
The sandbox will exist up until the point when telemedicine and mobile medicine services are licensed under the Healthcare Services Act (HCSA)73, thereby facilitating a seamless transition for telemedicine and mobile medicine providers as the new Act is introduced.
For telemedicine providers based overseas who wish to provide services to patients in Singapore, the Ministry of Health is expected to explore requirements for them to tie up with a local licensed doctor or provider.74
Local Players myHealth Sentinel is a leading cloud-based telehealth service provider. The company was formed to answer the government’s call for public-private partnerships to develop innovative new solutions to address the healthcare needs of its rapidly ageing society. It developed TeleMetrix +, which is a locally developed, cloud-based remote patient monitoring system which is offered as a simple B2B2C subscription service to hospitals, GP clinics, nursing homes and corporations. It is the first commercial telehealth service to be clinically approved by a major Singapore public hospital for mainstream deployment to outpatients suffering from chronic conditions such as hypertension, diabetes and heart failure. Since 2014, TM+ has been successfully deployed by a number of major Singapore public hospitals to over 1,500 outpatients for remote monitoring of their blood pressure, blood glucose and body weight.
Additionally, myHealth Sentinel is an exclusive distributor in Singapore, for the range of innovative, contact-free, continuous monitoring solutions developed by innovative Israeli
73 http://www.hcsa.sg/ 74 Today Online (2018). Telemedicine to be Regulated: Health Ministry.
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company EarlySense, which consists of a proprietary, pressure sensitive sensor placed under a patient’s bed mattress.
RingMD is a Singaporean company that is specialised in the telemedicine industry. In 2014, the company launched an Android app designed to connect patients anywhere in the world to doctors anywhere in the world - although mostly based in Singapore. The platform currently has about 100 doctors, who mostly see patients from the surrounding countries in South East Asia. RingMD has been launched in beta as a web application for a few months, and is now doing a mobile rollout, starting on Android. Besides the international focus, what sets RingMD apart from other telemedicine services is a marketplace approach to facilitating virtual care, wherein doctors can sign up for the service individually, through a practice, or via an insurer.
SoundEye is a Singaporean company specialising in technologies for remote monitoring. Their flagship product, SoundEye ARK, is an innovative monitoring system capable of home monitoring, surveillance and emergency monitoring. SoundEye ARK was developed in collaboration with A*STAR, and it is the world’s first sensor that combines emergency monitoring with home monitoring and surveillance. The features include an emergency monitoring capability which triggers an alert to the caregiver by detecting a scream or shout for help. Neither a wearable nor a physical action to activate an alarm is required. Home monitoring provides a report of the home environment: motion level, sound activity level and temperature. Therefore, it detects the movement of the elderly person being monitored, including the sounds made. SoundEye ARK works differently from CCTV cameras as there is little or no intrusion on the privacy of the elderly. Although there is a camera function embedded in the device, the user can choose to turn it off while using just the sound recorder and motion sensor.
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Figure 20: The SoundEye ARK Monitoring System Source: SoundEye
3.5.2 EU Entry Opportunities
The Singaporean telemedicine market is still very much in its infancy, with no industry-dominant actors. Therefore, there is room for multiple players, both large and small. The following areas present interesting opportunities for European companies:
◼ Test-bedding
◼ Public Private Partnerships and Government-led Initiatives
Test-bedding
Singapore does not face the problem of providing healthcare to remote communities. However, a rapidly ageing population, creates the dual problem of increasing need for healthcare for the elderly (many of whom may have mobility issues) and decline in the number of healthcare problems. The Government considers telemedicine to be a key tool to provide timely and regular quality care, enabling the elderly to age-in-place, while addressing the problem of manpower shortage. Video consultations, tele-rehabilitation and monitoring of vital signs are three key areas of focus.
The Government ultimately plans to regulate telemedicine as a licensed healthcare service following completion of the sandbox. The Government is working on a new Bill for regulation of
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healthcare services, which will replace the Private Hospitals and Medical Clinics Act (PHMCA) and shift the regulatory basis from ‘premises-based’ licensing to ‘services-based’ licensing. The Healthcare Services Bill is expected to be enacted in the second half of 2018. This licensing regime will include telemedicine which was not regulated under the PHMCA. This presents opportunities for European companies to participate in the regulated trials and seamlessly transition to the wider market.
The country is also a suitable testbed and launch-pad to reach the greater South East Asian region, where the market is less advanced than in Singapore. Testbeds are done by engaging scientists from Singapore’s technology agencies and clinical staff in order to produce cost- effective solutions that meet the clinical needs for patients in Singapore. New product solutions developed by the likes of A*STAR’s Institute of Microelectronics (IME), Institute for Infocomm Research, and the Centre for Integration of Medicine and Innovative Technology, are tested in various public healthcare entities.
◼ For example, in 2014, Changi General Hospital (CGH) started piloting a new telehealth programme, touted as the first of its kind in Singapore, which allows healthcare professionals to remotely monitor the recovery of heart failure patients. Patients enrolled in the programme are equipped with devices such as a tablet computer and blood pressure monitor, allowing them to measure their weight, pulse and blood pressure daily. The programme also allows healthcare professionals to monitor and provide assistance to patients after they are discharged.
◼ The National University of Singapore (NUS) is testing iPads for remote rehabilitation of stroke patients, removing the need to visit their clinic. The new treatment is part of a tele- rehabilitation programme currently being trialled by the university. It uses tablets to guide patients through exercises on videos, whilst motion sensors capture data about their progress.
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Figure 21: Remote Rehabilitation Solutions by NUS Source: NUS
Public Private Partnerships and Government-led Initiatives
There are also multiple opportunities for European companies to tap into the public-private partnerships and government-led initiatives. Some of the recent developments in the area include:
◼ In April 2018, Singapore’s Ministry of Health launched the city-state’s first healthcare regulatory sandbox for telemedicine services. This is part of the Ministry’s new Licensing Experimentation and Adaptation Programme, which seeks to provide regulatory sandboxes for enabling innovative healthcare models and services to be developed, tested and refined in a safe and controlled environment. The Ministry of Health will impose clear boundary conditions, implement risk governance measures and adopt risk management strategies for the sandboxes.
◼ Singapore-based tele-consultation service providers, RingMD and WhiteCoat are the first two providers participating in the programme and more service providers may join later after working to meet the requirements.
◼ In 2016, Singapore’s Economic Development Board (EDB) entered into a 3-year partnership with the Dutch company Philips in 2016 to help local digital healthcare companies expand into the rest of South East Asia. The partnership seeks to invest in “disruptive technological
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companies” in the areas of population health management, including telehealth, tele- monitoring, and healthcare informatics tools. Selected companies will gain access to Philips' cloud-based HealthSuite Digital Platform, which collects and analyses healthcare data, as well as receive mentorship from Philips' healthcare experts to help scale their businesses. They will also be able to utilise Philip’s telehealth and healthcare informatics facilities in Singapore for the development of their innovations.
◼ As part of the Infocomm Media 2025 Masterplan, which was launched in 2015, the Singaporean government initiated the Smart Health-Assist project, which was piloted in the Jurong Lake District, a residential-business estate designated as a testbed for the country's future technologies and services. The initiative focuses on promoting the use of products that allow patients to better manage their conditions from the comfort of home while allowing them to remain independent and active in the community. Such initiatives are particularly welcomed in the country, as Singapore may not be able to provide enough hospital beds for its whole ageing population in the future. Turning to telehealth services would allow patients to receive healthcare from their homes, monitor their health conditions and receive medical attention when required.
◼ In January 2010, Singapore’s Agency for Science, Technology and Research (A*STAR) and Tekes, the Finnish Funding Agency for Technology and Innovation, entered a partnership allocating more than S$ 1.4 million (EUR 0.9 million) each to fund two joint projects. One of the projects under the A*STAR-Finland research collaboration is the online health monitoring platform which can remotely track sleep activity of elderly patients. This has seen a successful trial at a Singapore nursing home, allowing caregivers to monitor and advise their patients from anywhere in the world as long as they have an internet connection. The second project is a scalable multimedia content management and delivery system for different devices to improve the quality of streamed mobile content for a spectrum of mobile networks and systems.
◼ In May 2018, GE Healthcare and A*STAR jointly developed new solutions that improve the PET scan procedure using high performance computing, enabling quicker scans and shorter waiting time for patients at hospitals and clinics. The feature involves a more streamlined
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digital PET image reconstruction, which results in a reduction of approximately 15 minutes off the existing workflow that typically takes 40 minutes to complete. As part of the collaboration, GE Healthcare and A*STAR are developing a pipeline of digital solutions, including a diagnostic imaging system for Parkinson’s Disease and advanced capabilities for surgery motion tracking. Other innovations with implementation ongoing under the GE Healthcare and A*STAR partnership are:
▪ A new technological platform for stroke treatment decision-making. The innovation behind the platform features the use of data analytics to analyse CT scans of stroke patients, alongside other data such as vital signs and cognitive tests. The insights derived will enable a holistic approach towards decision-making for treatments that improve stroke care and patient outcomes.
▪ Remote patient monitoring allows doctors to collect digital data, in the form of patients’ medical and health information, outside of conventional healthcare settings like hospitals. Remote patient monitoring is becoming increasingly important in ambulatory patient care. GE Healthcare and A*STAR improved the adaptability of GE Healthcare’s wireless docking systems to connect to a wide spectrum of portable electronic devices, and also strengthened the robustness of its devices to allow seamless and secure roaming of the wireless local area network.
▪ Inclusion of a feasibility study on automated graphical prescriptions for MRI scans. The innovative solution uses high performance computing to reduce the need for technologists with high levels of experience or in-depth anatomical knowledge, and as a result reduces the need for rescans while ensuring high quality data and a clear differentiation of diseased and healthy tissue, enabling doctors to diagnose with greater confidence.
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European Players
Philips
Philips is a Dutch technology company headquartered in Amsterdam with primary divisions focused in the areas of electronics, healthcare and lighting. It was founded in Eindhoven in 1891 and is one of the largest electronics companies in the world and employs around 105,000 people across more than 60 countries. Philips officially opened its new Asia Pacific headquarters in Singapore 2016. Located in Toa Payoh, where Philips has been based since 1972, the 38,000 square-metre office building is designed to foster collaboration and co-creation with healthcare stakeholders. Aside from serving as the company's HQ, it also contains spaces designed to simulate medical scenarios, provide technology training on healthcare equipment.
Figure 22: Philips’ New Facility Includes a Tele-healthcare Centre Source: Today Online
In the same year, Philips and EDBI, the corporate investment arm of the Singapore Economic Development Board, have agreed to jointly invest in a new tele-healthcare centre that will enable hospitals to remotely monitor and treat patients at home. “With the new centre, we aim to improve patient health and lower treatment costs by monitoring patient conditions and reducing the need to hospitalise them,” group chief executive Frans van Houten said.
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Mdoloris Medical Systems
After more than 23 years of academic research conducted in the Lille University Hospital, Mdoloris Medical Systems is an innovative French start-up created in June 2010. Mdoloris Medical Systems is the first worldwide company to be able to provide clinicians continuous and non- invasive pain monitoring systems. With its technology for monitoring, Mdoloris allows clinicians to objectify the pain felt by the patient and thus to administer individually adequate amount of pain killer drugs. Today, Mdoloris’ products are distributed in Singapore by its authorised partner in the country, Gold Lite Pte Ltd.
Enovacom
Enovacom is a French company founded in 2002. The company specialises in the development of software for healthcare, including software for telehealth and remote monitoring. Enovacom provides healthcare organisations and care providers with interoperable data integration and security solutions. Enovacom technology can create integrated environments that enable the efficient and safe sharing of information between healthcare professionals and across care organisations. With over 1,500 customers worldwide, partnerships with major eHealth players, Enovacom is now present in France, Belgium and Switzerland, UK, Canada and Singapore.
In August 2016, Enovacom announced its partnership with myHealth Sentinel (mHS), a young and fast-growing Singapore-based health-tech company focusing on providing healthcare connectivity solutions. Through myHealth Sentinel, Enovacom hopes to introduce its suite of advanced software-based solutions into the South East Asia hospital IT marketplace.
Enovacom’s advanced ‘Integration Engine Technology’ – based on its core solution Enovacom Suite - enables the secure, seamless sharing of information between new and legacy healthcare IT systems, which is essential to the creation and scaling-up of the extended medical ecosystems, required to meet the soaring demand for long term chronic care. Enovacom’s interoperability solutions are cost-effective and can be implemented in months rather than years, providing rapid improvements in operating efficiency.
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3.6 Nanotechnology Healthcare
3.6.1 Market Overview
Nanomedicine and drug delivery will account for 40% of a $136 billion nanotechnology-enabled drug delivery market by 2021.75 In particular, the Asia-Pacific region is expected to grow at a fast rate, owing to presence of high unmet healthcare needs, research collaborations and increase in nanomedicine research funding in emerging economies.
However, nanotechnology for healthcare is a comparatively new field of medical technologies in Singapore, where most nanotechnology companies are focused in the petroleum, automotive and construction industries.76 Overall, developments in the Singaporean market are being driven by public initiatives funding research in the sector. Much of nanotechnology development in the country is thus focused on R&D, with emphasis given to educate students and attract talents. This is done by establishing research and development units in education institutions such as the Nanotechnology cluster at Nanyang Technological University (NTU) and the National University of Singapore Nanoscience and Nanotechnology Institute. Another outreach programme was initiated by A*STAR’s Institute of Bioengineering and Nanotechnology (IBN), which has hosted over 2,300 students and teachers to do at least one-month full time research at IBN with a one- to-one mentoring approach in its Youth Research Programme.
Through the establishment of these units, Singapore laid the basis for the development of the local industry. A reliable indication of its development is the number of nano-articles produced in Singapore between 2011 and 2016.77 This development is equal to countries like South Korea and Japan, both of which have been experimenting with nanotechnology for many years. A number of PhD graduates in the nanotechnology field at the NTU are reported to be working on projects related to the energy, pharmaceutical and drug sectors,78 signalling a potential for the development of nanotechnology healthcare applications in the country. Entrepreneurs recognise that Singapore has state-of-the-art infrastructure for R&D in nanoscience and technology.79
75 https://nanomedicine.pharmaceuticalconferences.com/2018 76 StatNano (Accessed in April 2018). Singapore. 77 StatNano (Accessed in April 2018). Singapore. 78 Straits Times (2016). Nano, Nano, Jobs for the Future. 79 Straits Times (2016). The Invisible Disruption of Nano-Scale.
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For example, there is the Centre for Advanced 2D Materials, into which the National Research Foundation poured S$ 50 million (EUR 32.6 million) in 2014. Singapore also has the A*STAR Nanoimprint Foundry, launched in 2013, which helps companies develop industrial-scale applications. At NTU, researchers are also designing nanorobots which could eventually be deployed in nanosurgery and drug delivery. The A*STAR’s Institute of Materials Research and Engineering is also working on using nanotech for various applications. In the biological realm, researchers at the Institute of Bioengineering and Nanotechnology at A*STAR have managed to incorporate substances from green tea into nanoparticles for targeted cancer drug delivery. A spin-off company, GreeT Biomed, has been set up to commercialise the product.
Although academic institutions are doing much of the heavy lifting, nanotech start-ups are also receiving support in Singapore. For example, Salus Nanotechnologies has an investment offer from local venture capital firm Red Dot Ventures under the NRF Technology Incubation Scheme, which is Red Dot Venture’s first proposed investment in the nanotech sector. In 2018, Singapore- based Vickers Venture Partners has also announced that it was seeking to raise its largest fund yet of up to US$ 500 million (EUR 442 million) as it seeks to increase investment in biotechnology, nanotechnology and artificial intelligence.80
Even though there is agreement that the future of the nanotechnology industry in Singapore is bright, local investors are often still deterred by the initial high R&D costs of developing new nanomaterials, securing or licensing existing nanotechnology intellectual property and capitalisation of nanotechnology.81
Singapore is also a member of the Asia Nano Forum (ANF), a network organisation, founded in May 2004 and now a registered society in Singapore with the aim to promote responsible development of nanotechnology that educationally, socially, environmentally and economically benefits each economy by fostering international network collaboration. Among the key goals of the organisation are coordinating joint investment in, and mutual access to, major infrastructure by member economies; and promoting and coordinating standardisation and safety of
80 World Finance Markets (2018). Singapore’s Vickers Venture Targets US$ 500 Million Fund, Eyes Biotech, Nanotech, AI. 81 Straits Times (2016). The Invisible Disruption of Nano-Scale.
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nanotechnology concepts and measurements. Singapore is among the most active members of the organisation and the country also chairs the standardisation working group in the ANF.
Figure 23: Map Showing ANF’s Member States Source: Asia Nano Forum
The ANF also organises the Asia Nano Forum Summit, which is held annually hosted by one of its member organisations where high level invited delegates from government, academia and industry gather to report on the latest developments of nanotechnology in ANF member economies. The ANF summit is a flagship event of great significance to the hosting member economy, which receives strategic support from ANF for its nanotechnology development.
Local Players
Omniyo - Omniyo Pte Ltd was established in 2011 to bring together the latest advancements in nanoscience technology for the masses as a product and/or service that is affordable and practical. One of the most immediate aims of Omniyo is to make the environment a safer and healthier place through the propagation of breakthrough healthcare technologies that transform surfaces to become "self-sanitising" in which deleterious bacteria and viruses are eliminated upon contact so as to reduce the risk of infections and promote greater hygiene throughout the world. An example of an innovative nanotechnology product developed by the company is Omniyo Nano 223, which is able to prevent the formation of biofilms through actively killing all organic
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compounds such as bacteria, viruses, fungi and dirt that come into contact with the coated surface, particularly useful to prevent hospital-acquired infections. The company is headquartered in Singapore, and has also offices in Malaysia.
NanoMaterials Technology Pte Ltd (NMT) is a technology-based company founded and incorporated in Singapore in 2000. NMT specialises in the development, manufacturing, commercialisation, and licensing of nano-material products for various markets. It is one of the leading companies that can produce nano-materials commercially, and its products are particularly suited for pharmaceutical and medical applications. NMT is headquartered in Singapore, which houses its corporate office and R&D laboratories. The company also has manufacturing operations in Singapore and China, and is expanding in Asia Pacific, South Africa and South America. NMT works with worldwide partners to market and distribute its nano-material products. NMT has more than 30 worldwide granted patents and patent applications.
Curiox Biosystems is a Singapore-based bio-instrumentation company, with a range of patent- pending technologies. Curiox aims to accelerate the progress of research in life sciences, diagnostics and drug discovery through its innovative “wall-less” DropArray™platform, developed by a research group led by Dr. Namyong Kim at the Agency for Science, Technology, and Research (A*STAR)’s Institute of Bioengineering and Nanotechnology (IBN). Curiox subsequently spun out from the IBN, backed primarily by Nanostart AG, a renowned venture capital firm in Germany, and Exploit Technologies, the commercialising arm of A*STAR. In 2010, Curiox received a large corporate investment by the Zicom Group, a Singaporean / Australian conglomerate listed on the Australian Stock Exchange. Curiox’s DropArray platform enables miniaturisation of samples and reagents down to nano-microlitre levels, without the current liquid handling limitations faced by traditional microtiter plate. Its patented miniaturisation platform provides up to 1,000 times savings in sample and reagent consumption, and up to 10 times reduction in assay time. The company is presently collaborating with research groups at the Institute of Molecular and Cell Biology, Singapore Eye Research Institute, and Experimental Therapeutic Centre. It is currently in R&D and pre-scale up phase. Having completed products
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for its low throughput customers, it is now focusing on completing its high throughput prototype, before launching aggressive sales and marketing efforts.
3.6.2 EU Entry Opportunities
The Nanotechnology Healthcare sub-sector is still very young in Singapore. However, the industry presents interesting opportunities as the government is heavily investing in the development of nano-medicine and nanotechnology.82
One of the areas presenting opportunities for European companies is nanotechnology applications in the area of cancer. Today, cancer is the leading cause of death in Singapore, accounting for about 30% of deaths.83 With an ageing population, the number of people being diagnosed and living with cancer is expected to continue rising. Nanotechnology has demonstrated significant potential in simpler, faster, possibly point-of-care diagnostics, testing of drug efficacy to enable personalised treatment and targeted drug delivery.
Another area with potential for entry and growth is the use of nanotechnology-based implantables or wearables for real-time monitoring of physiological variables for chronic diseases such as blood glucose levels for patients suffering from diabetes, or cholesterol levels for heart disease. Nano- size devices can also administer treatment if required. Incidence of chronic diseases is on the rise in the country and they are a key focus area in Singapore’s RIE2020 plan. Diabetes affects 400,000 Singapore residents and one in three Singaporeans84 is at risk of developing it over his/her lifetime. Cardiovascular disease is a leading cause of death, accounting for 29.5% of all deaths in 2016.
As a research-intensive economy, Singapore also presents a suitable platform for nanotechnology companies to conduct R&D activities by collaborating with local institutes. Some of the key collaboration opportunities exist with:
82 https://www.moh.gov.sg/news-highlights/details/speech-by-mr-edwin-tong-senior-minister-of-state-for-health-at-the-singapore-cancer-society- charity-golf-dinner-2018-2-november-2018 83 National Registry of Diseases Office, Ministry of Health, Singapore 84 Ministry of Health, Singapore
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◼ The A*STAR’s Institute of Bioengineering and Nanotechnology (IBN). Founded in 2003, IBN has carved out a unique niche at the interface of bioengineering and nanotechnology, as it conducts interdisciplinary research bridging science, engineering and medicine. IBN is focused on generating new knowledge and creating innovative technology platforms that combine novel catalytic chemistry, biomaterials, nanofabricated devices, and microfluidic systems with biological and biomedical engineering.
▪ A particular strength of the Institute of Bioengineering & Nanotechnology is the research area that involves nanotechnology and microfabricated platforms for high-throughput biomarker and drug screening, automated biologics synthesis, and rapid disease diagnosis. The portfolio of innovations includes, amongst others, the miniaturised DropArray for faster drug screening developed with Curiox Biosystems; quantum dots for cell imaging applications; a digital pathology software; and a virtual reaction chamber. IBN has left its footprint in the devices and diagnostics market with its technologies being spun out into companies like Curiox Biosystems, HistoIndex, Baldr Biosystems and InvitroCue.
▪ IBN has also collaborated with MP Biomedicals LLC, a global life science and diagnostics product manufacturer and supplier, to develop an affordable microfluidics real time machine. After the trials, the company brought the new product to the market.
▪ After collaborating with IBM Research, IBN announced the discovery of a new breakthrough macromolecule that could help prevent deadly virus infections with a unique triple-play mechanism that can also help prevent viral drug resistance. The short-term potential could be for applications such as an anti-viral wipe or detergent, which would require a small amount of the macromolecule dispersed in water to potentially neutralise an entire room infected with Ebola, for example. Potential longer-term applications may include the development of a new mode of vaccination that could help prevent a whole category of viral infections.
◼ The Nanoscience & Nanotechnology Cluster (NanoCluster), which is an NTU-wide network of research centres that includes shared facilities for nanofabrication,
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nanocharacterisation, and exploitation of nanotechnology applications. The NanoCluster seeks to coordinate, facilitate, and stimulate research in nanotechnology in NTU.
▪ Within the Cluster, the Nanoscale Initiatives bring together researchers concerned with the development of nanomaterials, including nano-magnetic carriers, for bioengineering and life science applications. Other areas of interest include biosensors, bio-mimetics, bio-photonics and bio-imaging. These studies are expected to lead to significant improvements in a wide variety of products and processes in the biotechnology space. Specific projects include nano-magnetic particles for cancer treatment and photonic devices for biomedical applications.
▪ NTU has also established a S$ 60 million (EUR 39 million) research institute in nano- medicine that will focus on developing solutions in diabetes, cardiovascular diseases, ophthalmology and skin therapeutics. The Institute for Nanomedicine is the first of its kind in South East Asia.
◼ The Nanoscience and Nanotechnology Initiative (NUSNNI) was launched in July 2001 by the National University of Singapore (NUS). NUSNNI provides the necessary support to facilitate the efforts by NUS faculties, researchers and students interested in pursuing this area of research, and encourages collaborative efforts between various disciplines within the university faculties and interested research partners.
European Players
Innova Biosciences Ltd
Innova Biosciences are world-leading experts in easy-to-use, cutting-edge bio-conjugation technologies and services based on nanotechnology. The company has the flexibility to support scientists from academia through to commercial manufacturing. Innova Biosciences develops antibody labelling and bio-conjugation kits for the life science sector. It offers antibody-labelling kits, such as enzyme, fluorescent protein, biotin/streptavidin, tandem, and fluorescent dye labelling kits. The company also provides rapid antibody labelling kits, rapid fluorescent dye labelling kits, antibody purification kits, gold conjugation kits, immunogenic kits, activated labels,
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substrates and stabilisers, phosphate detection assays, and affinity resins. Its products are used in hospital, research, and pharmaceutical research and development laboratories; immunodiagnostic applications; and consumer items, such as pregnancy test kits. The company offers its products through a distributor network globally, as well as online. Innova Biosciences Ltd. was founded in 2002 and is based in Cambridge, United Kingdom. The company’s products are sold in Singapore by its official distributor in the country, Precision Technologies Pte Ltd.
NanoTools
NanoTools is a German company providing monoclonal and polyclonal antibody development services and products. Founded and based in Munich in 1997, NanoTools has constantly extended its core competences in the field of nanofabrication and has achieved scale as one of the leading experts in the production of atomic force microscopy. For more than 15 years, NanoTools has been supplying the world's leading semiconductor and nano-electronics manufacturers with cutting-edge CD metrology and high aspect ratio AFM tips. Besides providing individually tailored custom solutions, the company develops, manufactures and markets phosphorylation and modification - state specific monoclonal antibodies and other innovative reagents for Signal Transduction and Alzheimer research, high throughput screening (HTS) and proteomics. The company has a network of resellers distributed all over the world. In Singapore, NanoTools’ products are available through its official reseller, Advano Technologies Pte Ltd.
Obducat
Obducat is one of the world-leading suppliers of lithography solutions enabling advanced micro- and nano-patterning of surfaces for various industries, including the biomedical industry. Obducat develops and delivers innovative products and technologies focused on processes used in production and replication of advanced micro- and nanostructures. Obducat supplies its customers with process equipment as well as process know-how applied in both high-volume production and R&D. Obducat's head office is located in Lund, Sweden, with production, R&D and sales. In Singapore, Nano Imprint Lithography System distributes Nano Imprint Lithography (NIL) from Obducat provides solution that allows fabrication of features down to sub 30nm. Using
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their patented Soft Press Technology, all NIL models enable thermal imprint as standard as well as offering UV upgrade if required. In addition, Nano Imprint Lithography System also sells Obducat’s Intermediate Polymer Stamp to enhance the lifespan of the master stamp thereby reducing cost of manufacturing.
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3.7 Life Sciences / Biotechnology for Health
3.7.1 Market Overview
Over the past 15 years, Singapore has grown its life sciences and biotechnology industry to become the fourth pillar of the manufacturing sector and the second largest contributor to the manufacturing output, contributing roughly 3.5-4% to the country’s GDP. From manufacturing, research and development (R&D), to commercial operations, Singapore is now the region’s leading biotechnology cluster, home to more than 50 biomedical science manufacturing plants,85 and a key hub for life sciences and biotechnology R&D. It is also the Asia’s fastest growing bio- cluster. In 2018, 19.4% of the overall growth of manufacturing output came from Singapore’s biomedical sector.86 Business expenditure on biomedical manufacturing stood at S$ 377 million (EUR 245 million) in 201787, compared to around S$ 200 million (EUR 130 million) five years earlier in 201388, while the biomedical R&D expenditure grew at 5.7% CAGR during 2006-2016 to reach S$ 1.8 billion (EUR 1.2 billion) in 201689. Of the research expenditure, around 33.1% was directed towards basic research, while 37.2% and 29.7% of funds were spent on applied research and experimental development respectively.
In addition to private investments, the government has committed over US$ 3.7 billion (EUR 3.27 billion) in life science funding over the next five years, which will offer additional opportunities for companies to serve the needs of the regional market and beyond.
Today, more than 100 global biomedical sciences companies are carrying out a variety of business operations in Singapore, including cutting-edge research and manufacturing. Several major bio-pharmaceutical companies, including Abbott, Lonza, MSD, Novartis, Pfizer and Sanofi, have made Singapore their global manufacturing base. The country also serves as the
85 http://www.straitstimes.com/opinion/biotech-sector-poised-to-deliver-more-health-and-wealth 86 https://epsi-global.com/locations/singapore/article01.html 87 Economic Development Board (2018). Annual Report 2017/18 88 Economic Development Board (2018). Annual Report 2013/14 89 Department of Statistics, Singapore (Accessed in March 2019). Annual Research and Development Expenditure by Area of Research
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manufacturing base for biologics manufacturing with Baxter, Roche, Lonza and GlaxoSmithKline (GSK) having their facilities here.
In September 2018, global pharmaceutical company Merck announced the opening of a new 3,800-square-meter laboratory in Singapore. The new S$ 20 million (EUR 13 million) laboratory is the first of its kind outside of the U.S. and U.K., and the first in Singapore. The biosafety testing lab will offer services such as lot release testing, which ensures clients' products are safe for release, and viral clearance, which validates the ability of clients' manufacturing processes to remove viral contamination. It also provides biorepository cell banking: helping clients store copies of the cell lines used in their production, to mitigate risks and provide greater convenience. Previously, Asia-based customers would have had to work with Merck's two other BioReliance labs, located in the U.S. and U.K. The new Singapore lab allows for a faster turnaround as it shares a similar time zone with Asia-based customers. Customers will also save on travel costs when visiting Merck's facilities for viral clearance services.
The domestic biotechnology ecosystem is also rapidly evolving. According to A*STAR, the number of local biotechnology start-ups has more than doubled in the last six years to about 50, with between three and four formed annually in recent years.90 Several of these companies have become success stories, including Aslan Pharmaceuticals, which was listed on the Taipei Stock Exchange in June 2017.
Figure 24: Biomedical Research Highlights Source: A*STAR (2017). National Survey on R&D in Singapore 2016
90 https://www.todayonline.com/singapore/surge-local-biotech-scene-public-investments-pay
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Figure 25: Biomedical R&D ecosystem in Singapore Source: Holland Innovation Network
Figure 26: Biomedical Corporate Presence in Singapore Source: Economic Development Board (2018). Singapore’s industry-friendly landscape for businesses
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The reasons behind the biotechnology’s strong growth in Singapore are multi-fold. Firstly, the country has provided conducive environment for biotechs to set up and commercialise their innovations, including government initiatives and friendly policies, enabling public-private partnerships and incentives as well as world-class intellectual property protection. Compared with regional clusters, Singapore also enjoys an enviable position as a hub for commerce, finance, logistics and distribution, with world-class infrastructure as well as skilled and diverse talent, which make it an ideal place for the biotechnology sub-sector.
Much of the current life sciences and biotechnology cluster has taken shape as a result of a top- down effort to develop excellence in R&D, manufacturing and healthcare delivery. Three government agencies – the Biomedical Research Council of A*STAR, the Biomedical Sciences Group of the Economic Development Board (EDB), and the National Medical Research Council of the Ministry of Health – have led sector development thus far. However, the private sector has been given a boost with increased funding from both private investors and the public sector.
In November 2018, pan-European alternative asset manager Tikehau Capital and global healthcare consultancy company Sprim launched a venture capital fund, TKS1, which will focus on early stage investments in med-tech and life science companies. The total committed capital for the fund as of its initial closing is US$ 50 million (EUR 44.2 million). Administered out of Singapore and with investment sizes ranging between US$ 500,000 (EUR 442,450) and US$ 5 million (EUR 4.4 million), TKS1 provides early stage capital to innovative life-sciences companies and has already seeded four Singapore-based companies namely ObvioHealth, Fibronostics, Travecta Therapeutics and Babynostics.
The country is currently entering the fourth phase of its bioscience sector development. Phase 1, launched in 2000, focused on building the foundations – putting in the core scientific capabilities, establishing the bio-clusters and fundamental pillars to build the biotech ecosystem. Phase 2 was about moving into translational and clinical research whereas Phase 3, which culminated in 2015, centred on integrating all these capabilities and forging industry partnerships. The current phase now focuses on driving health outcomes for Singapore, emphasising five therapeutic areas under the RIE2020 plan, namely, cancers, cardiovascular diseases, diabetes mellitus and other
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metabolic/endocrine conditions, infectious diseases, and neurological and sense disorders. Health and Biomedical Sciences agencies are expected to develop research roadmaps to translate research discoveries into healthcare solutions, innovative medicines and medical devices.91
Figure 27: First Three Stages of Biotechnology Development in Singapore Source: Economist Intelligence Unit (2015). The Next Lap: Biosciences in Singapore 2025
Over the years, Singapore has developed a dedicated state-of-the-art infrastructure to support the growth of the life sciences and biotechnology sub-sector. Currently, the country has over 50 R&D centres and bio-hubs, which co-locate public sector research institutes with corporate labs, giving biotechnology companies easy access to multidisciplinary capabilities. The most prominent hubs are Biopolis and Tuas Biomedical Park, which provide infrastructure, tax breaks and other incentives to foreign companies, encouraging them to build factories and manufacture biotechnology products in Singapore.
◼ Biopolis, located at One North, was launched in 2003 as an integrated cluster of research facilities for basic and applied research for biomedical and molecular biotechnology. It is one of the leading biotechnology clusters in the Asian market. The hub has provided a fertile ground for the biotech ecosystem to take root in Singapore. A mix of global pharma, local biotechnology and service companies inhabit the cluster. Budding biotechs also capitalise on the co-location
91 https://www.nrf.gov.sg/rie2020/health-and-biomedical-sciences
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with A*STAR and other research entities to jump-start their operations and initiate partnerships. The presence of international biopharmaceutical and bioscience companies in Biopolis, such as Novartis and GSK, has also enabled the country to build up a critical mass of excellent scientists with training in drug discovery and other biotechnology fields.
◼ Tuas Biomedical Park (TBP) is a 360-hectare stretch of ready-prepared and specifically- zoned land set aside by the government for pharmaceutical and biologics manufacturing. TBP is an integrated development comprising industrial units, laboratories and shared meeting and training rooms. TBP is currently home to leading pharmaceutical, biotechnology and medical technology companies, including Abbott, Roche, GSK, Lonza, Merck, Novartis, Wyeth and Alcon.
Encouraged by government focus on co-location, a number of global companies have taken the lead in leveraging this opportunity for private-public partnerships by making investments or financial commitments towards establishing and growing their centres of excellence for R&D. Some of the prominent examples are:
◼ Roche established its CHF 100 million (EUR 88 million) Singapore Hub for Translational Medicine, comprising of a multi-disciplinary team, to partner with scientific and medical institutions in Singapore on disease biology for accelerating drug discovery and development.
◼ Bayer Healthcare invested S$ 14.5 million (EUR 9.5 million) in five projects with local academic institutions to advance R&D towards oncology diagnosis and treatment.
◼ GSK established its first Academic Centre of Excellence in Singapore, with an initial focus on early-stage research in ophthalmology, regenerative medicine and neuro-degeneration.
◼ Maccine had earlier started a joint initiative with A*STAR Singapore Bioimaging Consortium to form the Translational Imaging Industrial Lab, which aims to be a state-of-the-art imaging facility for drug development.
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◼ Siena Biotech is also partnering with A*STAR’s Experimental Therapeutics Centre for developing molecular inhibitors of a major signalling pathway in oncology that will target difficult-to-treat cancers, such as gastric cancer, leukaemia and brain tumours.
◼ Humalys SAS and Cytos Biotechnology are working with Singapore Immunology Network to develop antibody-based therapies for infectious diseases that are relevant in the Asian context.
◼ GSK Biologicals and A*STAR Bioprocessing Technology Institute are partnering on vaccine and adjuvant system-related research projects.
◼ Novartis has also collaborated with the Swiss Tropical and Public Health Institute, and the Scripps Research Institute to discover new drug against malaria called spiroindolone NITD609.
With the rapidly evolving biotechnology and life sciences sector in Singapore, the country has also had several early domestic commercial successes, which include: the first novel drug from Singapore company to achieve FDA approval (MerLion Pharma’s antibiotic – finalfloxacin); a pipeline relevant to local disease burden, including gastric cancer, cardiovascular and metabolic diseases; and a slew of start-ups in biopharma, medical device, diagnostics and health technology segments, including Aslan Pharmaceuticals, Endomaster, Veredus Diagnostics, ConneXionnAsia, Healint, and many others. With these early successes, the government continues to actively encourage the growth of the sector through financial support. Most recent examples include:
◼ In March 2018, the Ministry of Health awarded US$ 60 million (EUR 53 million) to three new research projects in the health and biomedical fields, which target areas of lung cancer, virus-induced cancer and age-related macular degeneration (AMD).
◼ Earlier in 2018, EDBI, the investment arm of the Economic Development Board, has joined a group of investors in a US$ 500 million (EUR 442 million) funding round of Moderna
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Therapeutics, which gave it a valuation of around US$ 7 billion (EUR 6.2 billion), making it one of the biggest unicorns in the biotechnology sector.
Although the country has succeeded in building a reputation as a regional biotechnology cluster, challenges remain. With limited resources and rising costs, and growing competition from regional markets, there is a need to focus on R&D on areas where Singapore has a distinctive advantage. Commercialisation also remains at an early stage, with gaps in venture capital and a complex skillset required to bring healthcare products and services to the market.
Local Players
Aslan Pharmaceuticals is an oncology-focused biotechnology company developing a portfolio of immune-oncology agents and targeted therapies. The company was incorporated in 2010 and is based in Singapore. Aslan offers ASLAN001, a pan-HER inhibitor for solid tumours; and ASLAN002, a cMET inhibitor for solid tumours. It also in-licenses preclinical and early clinical/development compounds and candidate drugs from pharmaceutical companies focusing on oncology, respiratory and inflammation diseases; gets proof of concept (PoC) for the partnered compounds in Asia; and out-licenses PoC compounds back to the partner for development and launch. The company sells its products in Asia and internationally.
ESCO Group is a renowned Singapore-based life science company with a diversified portfolio and sales in over 100 countries. It is one of the world’s leading manufacturers of laboratory and biopharma equipment, and IVF medical devices. ESCO operates its business through three divisions, namely, Life Sciences, Medical, and Healthcare. ESCO Life Sciences has a strong position in laboratory equipment technology with one of the most extensive produce lines in the industry. Among others, its key product line includes a complete range of controlled environment equipment solutions, such as Biological Safety Cabinets, Hume Hoods, General Purpose Ovens and Incubators, CO2 Incubators, and ULT Freezers. ESCO Medical is the IVF Medtech Company of Esco Group, manufacturing and innovating high-quality equipment, such as long-term embryo incubators, ART workstations, and vibration table, and time lapse incubator, and others. ESCO Healthcare, comprised of 3 divisions – ESCO Pharma, VacciXcell and TaPestle Rx – enables a
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complete translational discovery to delivery within the healthcare industry from research and development to clinical trials, final commercial production, and pharmacy compounding or stem cell therapy. In recent years, the Group has further extended its business into faster growing market segments by establishing a strategic investment arm, ESCO Ventures, which invests in biomedical start-ups. Some of its investments are in the fields of cancer, precision medical diagnostics for predicting and preventing pregnancy complications, novel life sciences tools and diagnostic platforms, and regenerative medicine. i-DNA Biotechnology Pte Ltd is a product- and service-oriented biotechnology and life sciences company, with headquarters and R&D laboratory facilities in Singapore. The primary focus of i- DNA is to develop, manufacture, market and distribute innovative products and services for applications in areas of life science, biotechnology and laboratory testing. The company currently has an established range of life science research products, which are categorised by different research applications. It provides reagents, lab services, instruments and lab animals. In addition, it also distributes research products from many leading international brands, with the aim of bringing more diverse research tools and solutions to its customers. In its laboratory services, the company also offers specialised and contract research services catered to the client’s specific requirements. In addition to its operations in Singapore, i-DNA has a strong business network across the South East Asian region.
Singapore Biosciences Pte Ltd is a Singapore-based company engaged in manufacture and marketing of in-vitro diagnostic reagents and kits. It offers products ranging from rapid diagnostic tests for cardiac markers and cancer markers to reagents for infectious diseases, immunohematology, immunology, microbiology, haematology, general pathology and clinical biochemistry. The company has major expansion plans and intends to add innovative ranges of other diagnostic kits and instruments in the near future. It is an ISO 12845:2016 certified company.
Maccine Pte Ltd is a preclinical contract research company, which provides discovery support and regulatory safety assessment services. The company develops in-vivo assays in therapeutic areas, including neurology, psychiatry, metabolic disorders, pain and inflammation, oncology, musculoskeletal disorders, and women’s health. It offers pharmaceutical and biotechnology
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companies a preclinical outsourcing alternative in Asia and delivers new drug discovery and drug safety assessment services to the pharmaceutical and biotechnology industry worldwide. It also provides technology platforms for preclinical use in clinical pathology, ELISA, western blot, DEXA, flow cytometry, analytical chemistry-HPLC, multiplex reader-Luminex, necropsy and histology, tissue culture, micro dialysis, EEG and ECG, operant self-administration, PET, CT, MRI, radiochemistry, and automated activity assessment. The company was incorporated in 2003 and is based in Singapore. It has operations in Singapore, Indonesia, the US and Canada.
3.7.2 EU Entry Opportunities
As a leading biomedical sciences hub in the heart of Asia, Singapore is the choice location for many companies to develop and produce new products that better meet Asia’s healthcare needs. Companies benefit from Singapore’s pro-business environment, infrastructure, talent and innovation ecosystem, as well as its proximity to the rest of Asia. There are numerous opportunities for EU companies interested in tapping into Singapore’s life sciences and biotechnology sub-sector. Some of the key relevant opportunities include:
◼ Test-Bedding Precision Medicine for Asian Phenotypes
◼ Addressing Local Disease Burden
◼ Innovation Opportunities in R&D
◼ Creating Value through Complex Production
◼ Public-Private Partnerships
◼ Opportunities for Biosimilars
◼ Industry Alignment Fund Pre-Positioning (IAF-PP)
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Test-Bedding Precision Medicine for Asian Phenotypes
There is a distinct opportunity for European companies to leverage on Singapore’s location and developed biotechnology infrastructure for focusing on specific diseases with Asian distinctiveness, whether in presentation, pathology, genome make-up, response to treatment, or the propensity to adverse drug reactions. Singapore’s small size and integrated health system make it a good test hub for new health technologies and innovations in the continuum of care. For example, a centralised population genomic database and regulatory framework for data privacy and security, in addition to electronic health records, can facilitate cost-effective research and analytics for personalised therapies for the local population, with extrapolation potential to other markets.
Addressing Local Disease Burden
To maximise relevance and return on investment, EU companies wishing to enter the biotechnology and life science market should clearly articulate local relevance in their R&D and commercialisation efforts. Given the local and regional needs and capabilities, companies have found success so far by aligning with local disease burden and converging with local institutes as well as government agencies on strategic health challenges. Currently, the government has identified five strategic priorities, which should open up investment opportunities for EU companies: cancers, cardiovascular diseases, diabetes mellitus and other metabolic/endocrine conditions, infectious diseases, and neurological and sense disorders. As the Health and Biomedical Sciences agencies are preparing research roadmaps to translate research into healthcare solutions, innovative medicines and medical devices, opportunities are likely to open up for companies with relevant expertise in the five strategic health priorities.
Innovation Opportunities in R&D
Public funding is being offered for product innovation and research in the biotech sector. As a result, the private sector has been aggressively pursuing focused R&D innovation. Currently, innovations in vaccines and recombinant therapeutics are the sectors driving the biotechnology industry’s growth. Newer therapies, including stem cell therapy, are expected to be launched in the next few years. Bioactive therapeutic proteins, protein and antibody production and fabrication
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of diagnostic protein chips are also promising areas for investment. Finally, stem cell research, cell engineering and cell-based therapies are further areas where companies can find demand for their expertise in the short-to-medium term.
Creating Value through Complex Production
Singapore is also interested to stay competitive as a manufacturing location, despite rising costs and growing sophistication of regional alternatives like China. The country’s desire to stay competitive can be satisfied by selecting complex manufacturing projects that need skilled talent and cutting-edge technology, such as biologics. As a result, the country is expected to continue its investment in the next-generation platforms to help bioscience companies make dramatic improvements in productivity and costs. Economic Investment Board (EDB) has also reported that it is on the lookout for untapped market segments, especially greenfield projects from companies that are not there. In recent years, EDB has approved investments in bioprocess development, next-generation facilities and new modality investments in cell therapies. Some companies have already recognised the potential of complex production investments. For instance, Amgen has developed a next-gen manufacturing plant that utilises single-use, disposable technologies to improve its complex manufacturing processes. AbbVie has also invested in two manufacturing facilities with capabilities for both small molecule APIs and biologics.
Public-Private Partnerships
Singapore’s biotech sector has attracted many international companies and its institutions work with many of them to address local health concerns. These public-private partnerships also help companies connect with Singaporean academics and researchers. There are diverse partnership opportunities with the public-sector research institutes. Major companies, such as Roche, GSK, Bayer Healthcare, Maccine, Siena Biotech, Novartis, and others (see market overview for more details), have already tapped such opportunities. With two prominent co-location hubs (Biopolis and Tuas Biomedical Park) and over 50 R&D centres, there are numerous venues for European companies to collaborate with the public sector on R&D activities.
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Opportunities for Biosimilars
One of the emerging trends in biotechnology and life sciences is the growing interest in biosimilars, with both Western and Asian firms racing against each other to be the first to supply them to Asian patients. Biosimilars are essentially less expensive, highly similar versions of drugs, called biologics, which are derived from natural sources, such as plant, animal or human cells, and bacteria. In the next few years, patents for more than 10 top-selling biologics will expire in the US and Europe, opening up the field to cheaper, biosimilar versions of them. According to Allied Market Research, the global biosimilars market could soar from US$ 2.6 billion (EUR 2.3 billion) in 2014 to US$ 26.5 billion (EUR 23.4 billion) by 2020. With Asia set to be a key growth market – and the Asia Pacific region estimated to be the second largest market after Europe for biosimilars – both new and established companies are likely to find demand for biosimilars, and biosimilar production, in Singapore.
The interest to tap Singapore as a hub for biosimilar production and regional distribution has already shown traction with various companies expanding their operations to cover biosimilars. For example, Novartis opened a US$ 500 million (EUR 442 million) manufacturing plant in Singapore which could produce both biologics and biosimilars. It also located the Asia-Pacific headquarters of its Sandoz division, which concentrates on biosimilars and generic pharmaceuticals, in Singapore. Amgen, one of the leading biotechnology companies, has also opened in 2014 the S$ 200 million (EUR 130.4 million) biologics and biosimilars manufacturing plant in Singapore. In May 2018, Chinese contract development and manufacturing organisation WuXi Biologics, announced an investment of S$ 80 million (EUR 52.45 million) into a new biologics manufacturing facility in Singapore.
To bolster their position in Asia’s biosimilars market, Amgen and other Western companies are also inking collaborations with Asian firms. In July 2016, Amgen signed agreement with Japanese pharmaceutical company Daiichi Sankyo to commercialise nine biosimilars in Japan.
In December 2018, Prestige BioPharma also announced that it has reached a licensing agreement with pharmaceutical company Cipla Ltd for trastuzumab biosimilar (HD201) under
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which Cipla will have exclusive rights to distribute and market the drug in selected emerging markets. Prestige BioPharma is a Singapore-based biopharmaceutical company focusing on the development of biosimilars and new antibody therapeutics. Its lead program, HD201 Trastuzumab biosimilar, is under Phase 3 clinical development and will be filed with EMA and USFDA in 2019.
Leading Asian companies themselves are ramping up efforts in biosimilars R&D. In 2012, the South Korean electronics and healthcare giant Samsung Group joined forces with American biotechnology company Biogen to form a joint venture focused on biopharmaceuticals, called Samsung Bioepis.
While the giants in the pharmaceutical industry are staking their claims to the Asian biosimilars market, smaller and newer players are also finding creative ways to carve out niches in the field as well. For example, Primetrics, a contract research organisation based in Singapore, started offering biosimilar testing services to other pharmaceutical companies. SGS, a Swiss-based company, also started providing such services in Singapore.
With biologics still greatly underused in Asia due to their high costs, the demand for their biosimilars is set to skyrocket in the near future. The opportunity for European companies – and their investors – is one that is not to be missed.
Industry Alignment Fund Pre-Positioning (IAF-PP)
One of the interesting opportunities for European companies is the IAF-PP Fund, which supports public sector research aligned with industry outcomes for Singapore through the development of integrated capabilities and programmes, which address major challenges faced by the industry. IAF-PP allows A*STAR and EDB to catalyse and orchestrate R&D activities across companies, research and academic institutes, hospitals and public institutions, towards industry development outcomes. European companies can tap into this opportunity by collaborating with various domestic stakeholders and providing industry transforming solutions.
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European Players
GlaxoSmithKline (GSK)
GlaxoSmithKline (GSK) is a British pharmaceutical company headquartered in Brendford, UK. Established in 2000, GSK is one of the six largest pharmaceutical companies in the world. The company was the first global healthcare firm to establish presence in Singapore, opening an outlet in 1959. Since then, it has invested more than US$ 2.5 billion (EUR 2.2 billion) to expand its operations in the country. The company currently employs around 1,600 people in Singapore and has manufacturing sites in Quality Road and Jurong as well as a vaccine manufacturing facility in Tuas. In 2017, GSK has also opened its Asia headquarters in Singapore, called GSK Asia House. The facility in Rochester Park functions as the commercial hub for more than half of the company’s global healthcare operations. To further solidify its position in Singapore, it has also established the Academic Centre of Excellence, which focuses on research in ophthalmology, regenerative medicine and neuro-degeneration.
Sanofi S.A.
Sanofi is a French multinational pharmaceutical company headquartered in Gentilly, France. It is one of the world’s five largest pharmaceutical companies by prescription sales. Sanofi principally engages in research and development, manufacturing and marketing of pharmaceutical drugs, covering seven major therapeutic areas: cardiovascular, central nervous system, diabetes, internal medicine, oncology, thrombosis, and vaccines. It is the world’s largest producer of vaccines through its subsidiary Sanofi Pasteur.
Sanofi operates in Singapore through its subsidiary, Sanofi-Aventis Singapore Pte Ltd., which manufactures consumer healthcare products, generics, and animal health products to patients and residents in Singapore. It offers therapeutic solutions in areas of cardiovascular diseases, thrombosis, oncology, central nervous system, metabolic disorders, internal medicine for prostatic hyperplasia, osteoporosis, and rheumatoid arthritis as well as vaccines for bacterial and viral diseases. The company was incorporated in 1997 and is based in Singapore.
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Siena Biotech
Siena Biotech is a privately held Italian biotechnology company operating in the biomedical field of oncology and neurodegenerative diseases, including rare diseases. It is a clinical-stage drug discovery company whose R&D efforts are mainly focused on discovering new drugs for therapeutic intervention. In order to support the drug discovery process from exploratory target identification to clinical studies, the company applies advanced technologies in the biomedical and biotechnology fields ranging from target identification and validation molecule identification, to optimisation and validation in clinical studies. Siena has developed an internal portfolio of several innovative R&D projects in three therapeutic areas: Alzheimer’s disease, Huntington’s disease, and oncology. In addition to partnerships with major pharmaceutical companies, Siena has built a wide network of external collaborations, in both academic and business communities. In 2010, it has inked a deal with A*STAR to develop small- and large-molecule therapies for cancer and bone loss diseases.
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3.8 Research & Development Technologies & Services
3.8.1 Market Overview
The Singaporean government is highly committed to promoting R&D in the country, having sustained its spending in research and development (R&D) at about 1% of the country's GDP over the past few years, a proportion that is similar to R&D spending in the US.
The National Research Foundation (NRF) through its sixth science and technology plan, RIE2020, has been given a budget of S$ 19 billion (EUR 12.4 billion) to fund research, innovation and enterprise (RIE) activities in Singapore, of which S$ 4 billion (EUR 2.6 billion) has been allocated to health and biomedical sciences research.
Figure 28: Allocation of R&D budget under RIE2020 Source: National Research Foundation
Aligned with the country’s growing disease burden, Singapore is emphasising five key therapeutic areas; cancer, diabetes and other metabolic/endocrine conditions, cardiovascular diseases, infectious diseases and neurological and sense disorders.
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The country has successfully established an R&D ecosystem that promotes close partnerships between the private sector, government ministries, public and private research institutes, start- ups and regulatory agencies.
Figure 29: The R&D Ecosystem in Singapore Source: The National Research Foundation (NRF)
Singapore has built strong translational research capabilities through institutes under the Agency for Science, Technology and Research (A*STAR) as well as those associated with the universities and healthcare organisations. A*STAR’S Biomedical Research Council (BMRC) hosts the country’s main biomedical research institutes in this area and supports, monitors and coordinates public sector biomedical R&D activities. The BMRC research institutes focus on building up core biomedical capabilities in the fields of bioprocessing; chemical synthesis; genomics and proteomics; molecular and cell biology; bioengineering and nanotechnology; and computational biology.
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BTI (Bioprocessing)
GIS (Genome studies)
IBN (Bionanotech)
IMB (Medical Biology)
IMCB (Molecular & Cell) BMRC (Biomedical) SICS EDB (Clinical Sciences) Ministry of Trade and SERC Industry (Science) BII A*STAR (Bioinformatics) A*GA (Graduate academy) SBIC (Bio-imaging) A*ccelerate (Commercialisation) SIgN (Immunology)
SRIS (Skin research)
Figure 30: Main Public Biomedical Research Institutes in Singapore Source: Adapted from the Singapore Economic Development Board (EDB)
To support the R&D ecoystem, the Singaporean government has invested in large R&D hubs such as Fusionopolis, focused on ICT, physical sciences and engineering and Biopolis, a biomedical science R&D and innovation hub. Biopolis, as the dedicated biomedical sciences R&D hub, hosts nine research centres under A*STAR (see figure above) and nearly 40 corporate research labs for companies such as Novartis, Danone, Abbott and Procter & Gamble. The hub hosts nearly 3,000 researchers and boasts nearly 230,000 sqm of dedicated research space. It
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is close to the Singapore Science Park, the National University of Singapore, the technology start up community and the National University Hospital.
Singapore has established several clinical research platforms in partnership with the three main healthcare providers, academia and government-led research institutes. Public R&D technologies and services are mainly provided by academic medical centres and partnership-based platforms between the private sector, public healthcare providers and academia. Furthermore, the various public hospitals and specialist clinics in Singapore have established Clinical Research/Trials Units within their walls to coordinate clinical trial activities carried out by their clinician researchers. By providing grants and incentives to attract international talent, Singapore has established an impressive pool of expert researchers.
The governmental body responsible for regulating clinical trials is the Health Sciences Authority (HSA). The HSA is responsible for regulating clinical trials as a statutory board under the Ministry of Health (MoH). Apart from clinical trial approval from the HSA, trial sponsors and the Principal Investigator (PI) are also required to comply with the Singapore Guideline for Good Clinical Practice (GCP) to ensure protection of trial participants’ rights and interests. The clinical trial application review period generally spans 4-6 weeks and each certificate of approval is valid for a maximum of 2 years.
Singapore set up academic medical centres (AMCs) to further translational and clinical research activities within the local training hospitals. These AMCs focus on combining training and medical education with research to deliver research-proven new treatments and applications that can benefit patients. These include:
◼ SingHealth Duke-NUS Academic Medical Centre (AMC) is dedicated to clinical and translational research that brings new treatments and enhanced diagnostic tools. It has a ready platform for Phase I and II clinical trials and regional networks enable large phase III clinical trials. Its core research platforms include advanced bioimaging, advanced molecular pathology, clinical pharmacology, flow cytometry, and its facilities include a health services research centre, an investigational medicine unit, a medical technology office, an
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experimental medicine centre, a tissue repository and a large animal research facility. In terms of physical infrastructure, the National Cancer Centre (NCC), National Heart Centre (NHC), Singapore National Eye Centre (SNEC) and part of the National Neuroscience Institute (NNI) are all located in the Outram campus, an area which is also home to the Health Sciences Authority.
◼ National University Health System (NUHS) offers a variety of research facilities that enhance basic, clinical and translational research conducted by its staff and students. It provides 13 research facilities and 3 institutes, a cancer institute, a heart centre and a centre for oral health.
There is a similar focus on clinical research in academia. In 2007, the National Research Foundation (NRF) and the Ministry of Education (MoE) established various Research Centres of Excellence (RCE) to promote excellence in research in local universities. In line with this initiative, a dedicated campus for research excellence was opened in 2012. Relevant RCEs and academic research organisations are outlined below.
◼ Cancer Science Institute of Singapore (CSI) conducts basic and translational cancer studies under two multidisciplinary research programmes: Cancer Biology & Stem Cell and Experimental Therapeutics. They span the spectrum from laboratory-based studies to targeted therapies in humans. CSI, hosted at the National University of Singapore (NUS) works closely with basic scientists and clinicians across Singapore in various institutes, including the NUS, National University Hospital (NUH), National Cancer Institute Singapore (NCIS), Duke-NUS Graduate Medical School and Institute of Molecular and Cell Biology (IMCB).
◼ Mechanobiology Institute (MBI Singapore) aims to develop a new paradigm for studying living systems and diseases by focusing on cell and tissue mechanics. Working from the NUS, It hopes to create a common international standard for defining new computational models, experimental reagents and tools for studying diseases of cells and tissues.
◼ Singapore Centre for Environmental Life Sciences Engineering (SCELSE) is a joint venture between NTU and NUS, and is hosted in NTU. It aims to take a multidisciplinary
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approach to discover, control and direct the behaviour of biofilm communities for sustainable environmental, engineering, public health and medical applications.
◼ Campus for Research Excellence and Technological Enterprise (CREATE) is an international research campus and innovation hub. It hosts the National Research Foundation and nine cross-disciplinary research centres of excellence from multiple top-tier universities. Relevant projects include:
▪ Singapore-MIT Alliance for Research and Technology (SMART) is a leading research centre established by MIT and the National Research Foundation. SMART hosts seven interdisciplinary research groups including Infectious Diseases (SMART-ID), Biosystems and micromechanics (SMART-BioSyM) and Antimicrobial Resistance (SMART-AMR)92. It engages around 800 MIT and Singapore researchers, fosters collaboration with other universities, research institutes and industry and offers innovation grants to promote commercialisation.
▪ Singapore-HUJ Alliance for Research and Enterprise (SHARE) was established to strengthen R&D collaborations between Israel and Singapore. It serves as hub for interactions between the Hebrew University of Jerusalem (HUJ) researchers and their counterparts from NTU and NUS. The research centre has two major research projects, among which is a project investigating molecular mechanisms underlying Inflammatory diseases93.
◼ Singapore Clinical Research Institute (SCRI) is a national academic research organisation dedicated to enhancing the standards of human clinical research. The SCRI designs and conducts clinical research including multi-centre clinical and procedural trials, as well as clinical research training programmes for research professionals. SCRI collaborates with clinicians to develop specific disease and practice-focused Clinical Research Networks. Relying on funding from the National Medical Research Council
92 The remaining four research groups are Disruptive & Sustainable Technologies for Agricultural Precision, Future Urban Mobility, Low Energy Electronic Systems and Center for Environmental Sensing and Modeling. 93 The other project is on “Nanomaterials for Energy and Water Management”.
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(NRMC) of Singapore, it provides services in study design, project management, statistical analysis and reporting and is seen as a one-stop shop for multi-centre research projects.
Given the strength of public sector research facilities and physical infrastructure available for R&D, it is no surprise that the number of clinical trials in Singapore has greatly increased. According to the latest available data from the Health Sciences Authority (HSA), the total number of clinical trial certificates issued has increased from 157 in 2000 to a total of 268 in 2015.
The Singaporean government has invested heavily in universities and public research institutions which has led to significant private sector investments. Despite growth in intensity and quality in public sector research, that of enterprises – particularly local enterprises – has not followed suit. Multinational Corporations (MNCs) largely dominate R&D intensive industries such as pharmaceuticals and biomedical sciences. According to the Singapore Economic Development Board, there are currently over 50 Singapore-incorporated companies that are focusing on biomedical sciences R&D, including drug discovery, translational and clinical research.
Although many MNCs have manufacturing facilities in Singapore (including Amgen, Pfizer, GSK, Roche, Pfizer) not all of them have moved their R&D activities to Singapore as some prefer to outsource to start-ups or Contract Research Organisations (CROs).
◼ Eli Lilly Centre for Clinical Pharmacology (LCCP), a subsidiary of US-based Eli Lilly and Company, has opened a 40,600 square foot, $30 million research facility in Biopolis last year. LCCP conducts clinical trials in healthy participants and patients, with a primary focus on first human dose studies and the development of new medicines for diabetes. The new research facility includes nurse stations, wards, a pharmacy, a laboratory and a recreation room.
◼ Chugai Pharmabody Research utilises Chugai’s proprietary antibody engineering technologies to quickly and efficiently generate innovative therapeutic antibody candidates. According to Nikkei Asian Review, in 2017 the Japanese giant announced a 25 billion yen (EUR 200 million) investment in a Singapore R&D centre for biopharmaceuticals by 2021, including investments in sophisticated automation and artificial intelligence technologies to increase the efficiency of the sifting process.
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◼ MSD Translational Medicine Research Centre (TMRC) is a research centre focused on drug discovery and development, with the aim to identify and validate novel therapeutic targets, discover drug candidates and biomarkers to aid clinical proof-of-concept and deliver new therapeutic offerings. MSD TMRC collaborates with academic and clinical researchers in the country to drive innovation to their drug pipeline and promote scientific discoveries.
Private hospitals and healthcare organisations in Singapore have embraced the importance of clinic research as well. Raffles Medical Group, a private healthcare provider with 74 medical clinics and a tertiary care hospital, hosts a Clinical Trials Unit (CTU) in Raffles Hospital to coordinate clinical trial activities within the organisation, and has experience in over 50 clinical trials (phase I, II and III). Parkway Pantai, one of Asia’s largest healthcare providers, set up GleneaglesCRC, a joint venture between ParkwayHealth and Mitsui Co. that offers comprehensive contract research solutions and enjoys privileged access to all of ParkwayHealth’s doctors and hospitals. GleneaglesCRC is now part of EPS Global Research Pte Ltd.
In line with the global R&D restructuring of large pharmaceutical companies, some pharma companies are finding it increasingly cost-effective to outsource their R&D to start-ups that are able to take a drug candidate from the discovery stage to the early clinical trial phase, as well as start-ups that focus on diagnostics. Pharma is directing more resources to the growth of start-ups and facilitating collaboration between companies and academic researchers, rather than keeping R&D in-house.
◼ HistoIndex was originally a spin-off from A*STAR’s Institute of Bioengineering and Nanotechnology (IBN). It has since formed partnerships with 17 partners around Europe, the US, China, Malaysia, Australia and Singapore. It is also working on drug development in collaboration with six pharma companies, predominantly based in the US. Their focus is particularly on non-alcoholic steatohepatitis, an increasingly common liver disease.
◼ ObvioHealth, a Singapore and US-based start-up created an app called ClaimIt™, which removes the overhead costs for researchers and participants of physical site visits (if
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desired) and brings the trial directly to the participant’s mobile device. This open-ended communication also allows the study team to be continually connected to study participants.
◼ Engine Biosciences is a Singaporean start-up that is using artificial intelligence to make drug discovery more efficient. The company’s technology uses machine learning to comprehend genetic interactions that underlie diseases. This information is crucial to help scientists with drug discovery. The AI based platform is designed to significantly increase the efficacy and speed of the discovery process.
Large pharmaceutical manufacturers are struggling to renew their pipelines and face challenges speeding up and de-risking R&D processes such as drug discovery because of their high cost. These factors have given a major push to the growth of the contract research outsourcing industry in Singapore. Government support, IP protection, research infrastructure and a highly-educated workforce further sustain the growth of the sector.
The CRO market includes Phase I – IV clinical trials, pre-clinical studies, data management, biostatistics and laboratory services, pharmacovigilance and bio-analytics. Because of the government focus on translational research within pharmaceutical R&D, the preclinical market is large. Similarly, because of government emphasis on the oncology segment of clinical trials, this therapeutic area is also well developed. Aligned to the pharmaceutical manufacturing industry, the CRO market remains dominated by MNCs utilising government incentives and support for clinical research and foreign funding.
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Figure 31: Top 10 global CROs in 2018 Source: IGEA Hub
An analysis of the top 10 global CRO organisations reveals that nearly all have global headquarters in the US and have a presence in Singapore. These top players are estimated to occupy more than 60% of the CRO market. Medpace, ICON, PPD, Iqvia, Covance, Charles River have R&D facilities and/or central laboratories located in the country. PRA health services’ location in Singapore serves as its regional hub, including clinical operations teams. The top two companies, Iqvia and Covance both have an extensive presence in Singapore:
◼ IQVIA Singapore, formed through a merger of IMS Health and Quintiles is a multinational healthcare company. Its Asia-Pacific operations are headquartered in Singapore, as well as one of its five central labs in the region. The company employs more than 400 people providing services, healthcare solutions and market insights. It offers full CRO capabilities, including clinical trial design, commercialisation, early clinical development, global laboratory services and R&D management consulting.
◼ Covance is the drug development arm of LabCorp and a global contract research organisation. From its regional headquarters in Singapore, it hosts clinical development
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services and central laboratories offering clinical trial management and biomarkers, and a food solutions lab offering food and dietary supplement testing.
Local Players
DeNova Sciences is a Nanyang Technological University spin-off company founded in 2012. It offers artificial skin models as well as tissue scaffolding. Additionally, it offers services for product testing, validation or co-development.
ClinActis Pte Ltd is a full service CRO providing clinical trial services to the pharmaceutical, medical device, medical nutrition and biotech companies in Asia Pacific. Established in 2009, ClinActis Pte Ltd is headquartered in Singapore. It has more than 33 years of experience in clinical research.
Genomax Technologies, a company founded in 2003, offers life science research products and services. Core products cover 4 major categories of applications: bioinformatics, genomics, molecular cell biology and proteomics. The company is headquartered in Singapore and has local offices in Malaysia and Thailand.
1st Base Laboratories is a life sciences research and services provider specialising in DNA sequencing, molecular biology, peptide synthesis, antibody production, biochemicals and metabolomics services.
Analisa Scientific Resources is a laboratory and scientific equipment supplier with offices in Malaysia and Singapore. Their core industries are life sciences, analytical chemistry and diagnostic markets for which they offer comprehensive product suits ranging from instruments, chemistries, consumables, software and technical services.
3.8.2 EU Entry Opportunities
◼ Singapore is a nexus for international R&D collaborations as evidenced by the CREATE campus, which has over 15 joint research programmes with foreign institutions. Additionally, EU companies can partner with A*STAR for their R&D initiatives, benefiting from their
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facilities, work force and commercialisation infrastructure. A*STAR offers various collaboration models that European companies could benefit from.
◼ Market areas that will see sustained need for equipment are institutional R&D laboratories and the biomedical sciences, particularly in product testing, certification and consulting services, as they continue to attract investment by the Singaporean government. Large private healthcare providers such as Raffles Medical Group and ParkwayHealth are large buyers of medical equipment, as well as public providers. Because of the strong focus on translational research to benefit the population, European companies who are able to provide innovative technologies, laboratory and testing equipment supporting this aim are well-placed to enter the market.
◼ The CRO market is dominated by large top-10 companies. Early phase clinical trials are increasing rapidly through fast recruitment, worldwide data acceptability and cost- effectiveness. Additionally, Singapore disease patterns are not dissimilar from the western market and the regulatory process for the approval of conducting trials is short compared to other countries in the region. European companies looking to provide R&D services should consider specialising in diagnostics, the government’s therapeutic focus areas and advanced capabilities that bring added value to the local context.
European Players
ICON Clinical Research
ICON Clinical Research is a large global CRO headquartered in Dublin, Ireland. ICON provides full clinical trial services for Phases I to IV. The company specialises in the strategic development, management and analysis of programmes and clinical trial support services for all stages of the clinical development process, including data management, quality control, quality assurance and biometrics. ICON currently operates from 93 offices in 37 countries and has approximately 13,650 employees. Its operations in the Asia-Pacific began in 1996 with a team of five people and opened an office in Singapore in 1998. It now employs over 3,000 people in the region. In 2009, ICON
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moved its central laboratory in Singapore to a larger facility after it saw an increased demand of 149% for its services.
In 2017, ICON continued organic growth expansion through acquisition of MAPI, a health outcomes consultancy that specialises in late-phase research, making the company the second largest late-phase CRO in the world. In 2018 it won the award ‘Pharma Contract Services Company of the Year’ for the second time in a row.
LONZA
Lonza was founded in Switzerland in 1897, where it still hosts its headquarters. Today, Lonza employs approximately 14,500 people around the world. Lonza is one of the world's leading suppliers to the pharmaceutical, healthcare and life science industries. It is the global leader in the production and support of active pharmaceutical ingredients, both chemically as well as biotechnologically. Biopharmaceuticals are one of the key drivers of the pharmaceutical and biotechnology industries. Lonza has strong capabilities in large and small molecules, peptides, amino acids and niche bioproducts, which are important for the development of novel medicines and healthcare products. Lonza is a leader in cell-based research, endotoxin detection and cell therapy manufacturing.
Lonza’s Singapore operations were set up in 2007 as a joint venture between Lonza and the EDB of Singapore with the opening of a large cell culture manufacturing location for the production of biopharmaceutical products (such as antibodies). It became a wholly owned subsidiary of the Lonza Group in 2009. In 2011 it expanded its operations with a CHF 10 million (EUR 8.8 million) investment and a second cell therapy production facility. In 2018, it consistently recorded sales growth, particularly in the pharmaceutical and biotech sectors.
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3.9 Dental Products
3.9.1 Market Overview
The dental market in Singapore has seen steady growth, driven by a growth in disposable income, an increased desire for aesthetics, a demographic shift towards an ageing population, as well as a greater utilisation of dental preventive care. The oral care market in Singapore stood at US$ 87.3 million (EUR 77 million) in 2018 and it is expected to grow at CAGR of 2.6% between 2019-2023 to US$ 99.7 million (EUR 87.7 million in 2023.94
Business Monitor International forecasts positive growth for the dental products market in Singapore95:
◼ The Singaporean dental instruments and supplies market (dental cements; dental instruments; teeth and other fittings) is expected to grow by an average of 7% each year, to reach a value of approximately US$ 50 million (EUR 44 million) by 2022.
◼ The market for capital equipment (dental drills; dental chairs; dental x-rays), is projected to grow to just under US$ 4 million (EUR 3.5 million) by 2022.
Imports supply the majority of the dental market. Over half of all imports come from the EU-28 with Germany leading European dental exports (18% share). Other leading suppliers include South Korea (14%) and Japan (13%). Between 45%-50% of dental equipment and supplies imported are re-exported to the region.
The number of dentists in Singapore has increased in tandem with the growing demand for dental services, with 2,293 dentists in 2017, a 4.3% growth compared to the previous year.96 According to the statistics published by the Ministry of Health (MOH), nearly 85% are General Dental Practitioners and the rest are Dental Specialists. Around 75% of dentists in the country work in
94 Statista (Accessed in March 2019). Oral care, Singapore 95 Business Monitor International (2018). Singapore Medical Devices Report, Q2 2018 96 Ministry of Health (Accessed in March 2019). Health Manpower.
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the private sector. Attendance at public sector dental clinics also increased to 1,051,500 in 2017, and has been averaging at 1,032,167 annually over the past three years.
Table 4: Dentists in Singapore Source: Ministry of Health
The Health Promotion Board (HPB) promotes good oral hygiene through events like the annual Oral Health Month in partnership with specialised professionals and industry cohorts. The government provides subsidised dental services to eligible patients at the National Dental Centre (NDC) and runs a Primary Care Partnership Scheme that provide subsidised treatments for eligible patients in private dental clinics. The HPB targets specific groups of people in Singapore. It runs the School Dental Service programme for all Singaporean students aged 7 to 18 years old, which provides free basic dental care including cleaning, screening and fillings, as well as dental health education to promote good oral hygiene among students.
Generally, Singaporeans have a strong dental and oral hygiene culture. Nielsen’s survey in 2011 showed that 70% of the population go for check-up at least once every 12 months, which complies with the current recommended frequency for check-ups.97 Demand for subsidised dental treatments has been rising significantly. Dental attendances at polyclinics have gone up from
97 www.polyclinic.singhealth.com.sg
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149,000 in 2013 to 179,000 in 2016. On top of that, in 2016, there were more than half a million subsidised attendances at the 700 dental clinics under the Community Health Assist Scheme, where the Government pays part of the bill for cardholders and pioneers.
Average fees for dental procedures are as follows:
Table 5: Dental fees for selected procedures at public institutions and private clinics Source: Ministry of Health
Dental practitioners in Singapore have shifted to an approach that focuses on enhancing the patient’s aesthetic appearance. Being a wealthy nation, Singaporeans tend to go for restorative treatment when tooth decay or loss occurs, or go for aesthetics/cosmetic teeth treatment for severe cases. Parents usually bring their children to see orthodontists before they lose their baby teeth while teenagers are seeking corrective treatments to improve their teeth alignment. Cosmetic dentistry has seen continuous growth over “The dental market in Singapore is the last few years, fuelled by increased media hype, currently fragmented with a few group practices and many individual desire to have a “perfect” smile, and increasing operators. It is large and varied awareness among Singaporeans about oral hygiene. enough to allow for healthy competition, and to offer greater To this end, Singapore continues to strive to meet the choice and better value.” needs of the more discerning clientele as well as Patrick Wong, provide first class healthcare systems and facilities to Head, Unity Denticare, NTUC Health its residents and the international patient market.
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Besides serving a more affluent and demanding resident population, dental practitioners have also seen a marked increase in foreign patients seeking dental treatment in Singapore. Wealthy patients from Indonesia, Brunei, Thailand, Malaysia, Philippines, Hong Kong, Cambodia, China and Vietnam are frequent visitors for medical care. These patients are not looking for a quick clean or check-up but come for treatments that include cosmetic dentistry that arrest problems of discoloured teeth, gaps between teeth, unsightly old crowns and reconstructive work which can cost up to US$ 60,000 (EUR 53,094).
Competition and technological innovations have brought treatment costs down, and decades of research and clinical success have minimised the risk elements. In past years, missing teeth or extracted teeth were commonly replaced with either removable prosthesis (dentures) or non- removable prosthesis (dental bridges), but now dental implants are gaining popularity. Before, there were only few dentists with expertise in dental implants, and the procedure had to be done by specialist teams led by an oral surgeon and a prosthodontist. Today, dental implants have become a common procedure as more dentists (not just specialists) have undergone training to do implant dentistry, and a lot of brands and treatment options are available.
The dental implant market in Singapore is categorised into two broad categories, the premium dental implant and discount dental implant. Due to the stringent laws governing medical devices, the common implants used in Singapore are either from Europe or the US (by companies such as Straumann and Neobel Biocare), which dominate the premium dental implants category. Recently, however, Korean brands such as Osstem Implant have been gaining traction due to their price competitiveness.
A key industry event in Singapore is the International Dental Exhibition and Meeting (IDEM), which is a highly targeted biennial trade exhibition and conference for the dental industry that offers exhibitors interesting prospects to meet and do business within the dental industry in the Asia- Pacific region. In its 2018 edition, IDEM drew 8,571 trade visitors, of which 1,894 were conference delegates, from across 71 countries. A sizeable proportion was dental professionals, dentists, traders and manufacturers or dental hygienists and therapists. Around 51% of visitors revealed that they possess either significant influence on the purchasing outcome or are the decision-
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makers. Survey results were also markedly positive, with 96% of visitors saying they were satisfied or very satisfied with their visit. Around 88% of exhibitors were satisfied with visitor quality. 95% of exhibitors and 91% of visitors disclosed their intentions to return for IDEM 2020.
Figure 32: IDEM 2018 - Breakdown by Profile of Attendees Source: IDEM
Startups like Zenyum is also entering the Singapore dental market. Zenyum, headed by Julian Artope from Germany, provides invisible orthodontic braces for minor dental corrections that are priced at just a fraction of other brands in the market. While the costs of invisible braces in Singapore typically ranges for S$ 6,000 (EUR 3,911) to S$ 10,000 (EUR 6,518), Zenyum says its invisible braces cost only around S$ 2,200 (EUR 1,434) on average. By qualifying potential customers and only accepting cases which it is confident in treating, variability is reduced and Zenyum is able to give a standard fair price of S$ 2,200 (EUR 1,434) per treatment. Zenyum is already being used by dentists and the company has so far partnered with nine clinics across Singapore.
Local Players
Dental products in Singapore arrive mostly either from Europe, the United States or in recent years, South Korea; at the 2018 IDEM edition, 37% of the exhibitors were from Europe. In general,
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local Singaporean companies do not manufacture dental products, but distribute them in the country.
Established in 1980, Eastland Dental Supplies Pte Ltd specialises in the provision of service and high-quality dental products to the Singaporean public. Being one of the leading dental suppliers in the country, this company carries over 40 renowned brands, mostly from Germany, Italy, and the United States. Products range from the most economical top-quality disposables and consumables to essential equipment, from unique dental art to dependable dental units. This company is the only dental supplier in Singapore with two qualified dentists in its team as product specialists.
Raydent is a Singaporean company established in March 1991. The company has grown steadily to a team of more than 25. It specialises in the distribution of dental products in Singapore. Raydent’s business is divided into three strategic business units: Dental Clinical, Implants and Laboratory products. The company offers products for Dental Implants, Tooth Extraction Management, and Tooth Whitening. Raydent sources its products from North America, and Europe, in particular from Germany. Examples of brands distributed in Singapore include Bausch, Horico, Zhermack, Aesculap.
Chee Sang Dental Supply Pte Ltd, established in 1953, is one of the early foremost dental suppliers and distributors of dental medical devices in Singapore. In September 2009, AK Dental Supply Pte Ltd merged with Chee Sang Dental Supply and incorporated in Singapore as Chee Sang Dental Supply Pte Ltd. The company is the sole representative for NSK and the German Komet brands with a close working relationship over the span of almost 30 years. It is also a distributor for some 30 other brands from the leading dental manufacturers and principals from Japan, Europe, the US, Canada, and other countries.
3.9.2 EU Entry Opportunities
The dental products sub-sector is well developed in Singapore, and the country offers considerable opportunities to European companies. Some of the key sales prospects include cosmetic dentistry, oral and maxillofacial surgery, orthodontics, periodontics and prosthodontics.
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There is also demand for services in the endodontics and paediatric dentistry as well as dental imaging systems, dental waste disposal systems and infection control products. Some of the procedures most sought at dental clinics include implant tooth surgery, wisdom tooth removal, dento-alvelar surgery and aesthetic dental treatment. These segments offer various opportunities for European companies to export products, which cater to such regional trends. In addition, with a significant re-export market, companies can find good prospects to tap not only Singaporean, but also the wider ASEAN market. Further to exporting the aforementioned product groups, there are several emerging trends that additionally fuel dental market opportunities in Singapore:
◼ Dental Implants & Technologies
◼ Products & Services Catering to the Elderly
◼ Orthodontics Products & Services
Dental Implants & Technologies
There is a growing popularity and demand for dental implants, particularly among the ageing population. Although dental implants remain very expensive, demand for dental implants as a tooth replacement option for older adults has increased due to greater awareness, growing affluence and changing lifestyles of the Singaporean population. In 2017, more than half (200) of the 369 cases of dental implants carried out at the National Dental Centre Singapore were for adults aged 50 and above. Among them, 46 patients were aged 65 and above. After braces, dental implants were the most sought-after treatment in the local private dentistry market from April 2016 to April 2017, according to a clinic comparison website that looked at its data across 1,319 clinics in Singapore. In addition, according to Dr Wonf Keng Mun, the managing director of T32 Dental Group, almost 9 in 10 of his patients above 50 who require a tooth replacement now request for dental implants, compared to less than 10% 15 years ago.98
The increasing use of latest technologies in dental implants allows more specialised interventions. Various technological advancements in dental implants such as Computer Aided Design (CAD),
98 Today Online (2018). Dental Implants Costly, but gaining Popularity Among Baby Boomers.
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3D imaging, mini dental implants, laser dentistry, sedation dentistry, and applications of nanotechnology have improved dental surgical procedures in Singapore. Demand for such technologies remains high in Singapore with various initiatives springing up to improve dental implant technologies through research & development.
For example, researchers at the National Dental Centre Singapore and bioengineers from Nanyang Technological University have invented a 3D-printed scaffold to grow bone for placing dental implants after a tooth has been extracted. This could eliminate the need for painful bone grafting, in which bone is taken from other parts of the patient's body. Researchers say it is the first of its kind in the world in terms of design and material and plan to roll it out in the near future, after a second trial involving 132 patients is completed. The invention will be particularly helpful, given that the number of tooth decay and gum disease cases in Singapore is likely to increase because of an ageing population.
Products & Services Catering to the Elderly
There is also a growing demand for products and services catering to the elderly population, as its numbers and their affluence increase continuously in Singapore. Some of the latest initiatives that cater to this growing market segment include:
◼ Opened in 2016, the Geriatric Special Care Dentistry Clinic at the National Dental Centre Singapore has been the first dental clinic in the country catering to the elderly and patients with special needs, offering a full range of oral health services customised for patients with complex medical needs as well as those with intellectual or physical disabilities. A wheelchair-friendly dental chair has also been installed to allow patients to remain in the wheelchair during dental treatment. The clinic is one of the first answers to meet the growing demand in Singapore for specialised dental care.
◼ The opening of the new National University Centre for Oral Health is planned for 2019. The Centre for Oral Health’s patient-centric facilities will be tailored to serve the oral health needs of the elderly, and those who have special needs and co-existing medical conditions rendering routine dental treatment more complex. These include hoisting aids to move
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patients onto dental chairs and wheelchair-accessible treatment rooms. At the moment, new specialised doctors are being trained to enlarge the pool of trained geriatric dentists in Singapore, as part of the “software” necessary to effectively address the needs of the country’s ageing population.
◼ The Health Promotion Board has also started a Community Functional Screening Programme for seniors 60 years old and above, to detect early signs of functional decline, including poor oral health, and to institute the appropriate follow-up measures.
Orthodontics Products & Services
According to the National Dental Centre, there is a growing demand for braces in Singapore. Since 2012, it has seen a 6% rise in adult patients seeking braces every year. In the private sector, slightly more than half of those getting braces are adults. Dentists cite an increase in awareness and social acceptance as reasons for the spike. Singapore is also seeing a surge in specialist dentists, who are trained to fit braces. Additionally, Singapore is seeing more cases of children requiring jaw alignment, which cannot be solved with regular braces, to resolve malocclusion or misalignment of teeth where the upper teeth are positioned too far forward compared to the lower. In 2015, it saw 120 such children aged 12 and below. In 2017, the number more than doubled to 259.
European Players
Global Medical Implants
Global Medical Implants is a Spanish manufacturer of dental implants founded in 1972. The company is one of the latest players to announce its upcoming market entry in Singapore. Operating from a new office in the country, Global Medical Implants intends to fill a gap with its moderately priced and scientifically supported range of dental implants. “South East Asia is a very price-sensitive region. While dentists in Western Europe commonly go for brand names, people here tend to look at every single dollar,” the Director of Global Medical Implants Asia, Javier Gamboa, told Dental Tribune Asia Pacific recently in Singapore. “Our advantage is that we can
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position ourselves as a quality European brand, while at the same time being able to offer prices that are competitive with those commonly charged by manufacturers from South Korea.” Gamboa commented that Singapore was considered a good testing ground for the company’s expansion into South East Asia owing to its favourable market environment, which promotes medical research and innovation. GMI next intends to expand into Hong Kong and the Philippines.
Swann-Morton
Founded in Sheffield (United Kingdom) in 1932, Swann-Morton is a manufacturer of surgical blades, scalpels and handles. Swann-Morton targets the Dental industry offering various products and solutions. The wide and varied range of products consisting of around 70 individual blades shapes and 30 different handles is used extensively by healthcare professionals such nurses and paramedics along with practitioners in the associated fields of dentistry, podiatry and veterinary surgery. Swann-Morton is accredited to ISO 13485, the International Standard for Quality Management Systems for medical devices companies. The company offers its dental products in Singapore through its only official distributor in the country, DS Medical Systems.
Sirona
Sirona is a leading German manufacturer of dental technology and is one of the innovation leaders in dentistry. Sirona partners with dental practices, clinics, dental laboratories and authorised distributors worldwide. The company develops, manufactures and markets a complete line of dental products, including, CAD/CAM restoration systems (CEREC), digital intra-oral, panoramic and 3D imaging systems, dental treatment centres, hand pieces and hygiene systems. In 2013, the company opened a new office in Singapore. In an interview following the inauguration of the office, its Executive Vice-President of Sales, Walter Petersohn explained that the main reason for establishing a facility in Singapore is the increasing significance of the ASEAN region as a core growth market with significant potential. “We have had particular growth in the Asia Pacific region in recent years and see even more potential for growth,” he said. “Dentists in these countries have high standards, are open to new products and are willing to invest in quality that is made in Germany. With our new office, customers from the entire region can now easily
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contact Sirona representatives at any time and take advantage of the personal service, training and seminars. There are many sales specialists to take care of their needs.” According to Petersohn, the new facility is expected to expand quickly in the near future to offer customers Sirona’s entire product portfolio, which includes dental CAD/CAM, such as the recently introduced CEREC Omnicam intra-oral camera, treatment centres, as well as dental instruments and materials. The recently launched APOLLO DI scanner for digital impressions, for example, is intended to make digital impressions more economical.
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4. Regulations
4.1 General Import Procedures
As an open market, products and services can enter and exit Singapore relatively freely. All goods imported into Singapore are regulated under the Customs Act, the Goods and Services Tax (GST) Act and the Regulation of Imports and Exports Act. Imported goods are subject to GST and/or duty payment. A Customs permit is required to account for the import and tax payment of the goods. The current GST rate is 7%. GST is calculated based on customs value of the goods, plus all duties. Before the actual importation, the importer is required to obtain a Customs permit, to account for the import and the tax payment of the goods.
Importing Trade Samples
The Singapore Customs defines trade samples99 as the goods imported solely:
◼ For the purpose of being shown or demonstrated in Singapore to enable manufacturers in Singapore to produce these goods to fulfil orders from abroad or to solicit orders for goods to be supplied from abroad, or
◼ By a manufacturer for the purposes of copying, testing or experimenting before producing these goods in Singapore.
Trade samples should not be sold, consumed, put to normal use, or used for hire or reward in Singapore. Importers of trade samples that are supplied without cost or free of charge must pay GST and/or duty. The relevant import permit (if required) and supporting documents (for example, commercial invoice, packing list, Bill of Lading/Airway Bill) for the trade samples must be produced to the checkpoint officers for verification at the time of cargo clearance. Importers must also check if their trade samples fall under controlled or non-controlled items before importation.
99 For more info on this topic, please visit http://www.customs.gov.sg/businesses/importing-goods/import-procedures/importing-trade-samples
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4.2 Medical Device Import Licence
A company importing medical devices into Singapore is required to hold an importer’s licence. Applications for Importer’s Licences are to be submitted via the online system, MEDICS@HSA.
A key contact person appointed by the company would be the person who will liaise with the Authority on all issues regarding applications submitted by the company, including input request on applications.
Applications must be accompanied by a certificate of Good Distribution Practice for Medical Devices in Singapore (GDPMDS) or ISO 13485 certificate, with scope of storage and distribution including a list of exempted Class A medical devices imported. For companies that do not manufacture or import class A exempted medical devices, a letter of declaration made on company letterhead should be provided. Certification to GDPMDS is to be performed by recognised certification bodies that are accredited by the Singapore Accreditation Council.
GDPMDS certification is not required for the following activities:
◼ Import for re-export only
◼ Import for non-clinical use only
In the case of the abovementioned exceptions, a declaration should be submitted in place of the certificate.
Every licensee is required to notify the Authority whenever there is a change to any particulars formerly declared.
A licence is valid for 12 calendar months and an email notification reminder for licence renewal will be sent from the Authority to the licensee 60 calendar days before the expiry of licence. Application for renewal must be submitted 40 calendar days prior to the expiry date of licence.
Companies that only conduct trans-shipment of medical devices activity, within the FTZ of the air or seaports, are not required to be licensed by the Health Sciences Authority (HSA).
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4.3 Medical Device Regulations
The Medical Device Branch of the Health Sciences Authority (HSA) is entrusted with the responsibility of regulating medical device products in Singapore. It implements regulatory controls through a programme of pre-market assessment of devices, manufacturing controls and post-market vigilance. It also carries out a range of assessment and monitoring activities to ensure medical devices available in Singapore are of an acceptable standard in accordance to the Health Products Act and Health Products (Medical Devices) Regulations.
A Medical Device is understood as “Any instrument, apparatus, implement, machine, appliance, implant, in vitro reagent or calibrator, software, material or other similar or related articles used for achieving a medical function, that is diagnostic, preventive or therapeutic in nature but without involving pharmacological, immunological or metabolic action.”
The Health Products Act (HPA) classifies the medical devices into four classes depending on the risk involved, which is assessed based on factors including duration of use, invasive or implantable, involves any drug or biological compound etc. The HPA has developed the Medical Device Risk Classification Tool, a query tool to identifying the risk classification of a medical device. The tool can be accessed here: http://www.hsa.gov.sg/content/hsa/en/Health_Products_Regulation/Medical_Devices/risk- classification-tool.html
Class Risk Level Device examples
A Low Risk Surgical retractors / tongue depressors
B Low-moderate Risk Hypodermic Needles / suction equipment
C Moderate-high Risk Lung ventilator / bone fixation plate
D High Risk Heart valves / implantable defibrillator
Table 6: HPA's Risk Classification
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Since August 2011 according to the Health Products Act, all medical devices will need to be registered with HSA before supply unless they are for clinical trials, are “custom made” medical devices, and/or are class A devices on the exemption list.
4.4 Government Tenders
Singapore government tenders are open to international companies. A foreign company is required to register on GeBIZ (www.gebiz.gov.sg), which is the procurement portal for the government, as a GeBIZ trading partner before they can participate in any electronic tenders and quotations. Information on contracts and tenders available in Singapore can be found on the GeBIZ portal, as well as at industry briefings.
With many international companies already present in the country, European companies that are new to the market may want to look for potential partners readily established in Singapore that can contribute to the local knowledge to license their technology or form an alliance/consortium to jointly bid for projects.
GeBIZ Trading Partners
All local and foreign suppliers are required to register on GeBIZ as a GeBIZ trading partner prior to responding to electronic tenders and quotations. A supplier that is registered with the Accounting and Corporate Regulatory Authority (ACRA) will be approved immediately. Registration is free for the first account, while each additional account costs S$ 280 (EUR 183) per year (inclusive of GST). Apart from enabling partners to bid and tender for projects on GeBIZ, the account will also give access to archives of tender and quotation awards.
Government Procurement
Each ministry, statutory board or department is in charge of procuring its own goods and services. Some agencies also purchase common goods and services used by the entire public sector such as IT security services, courier services and paper. These agencies are the Expenditure and Procurement Policies Unit, Defence Science and Technology Agency, and Infocomm
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Development Authority of Singapore. The Ministry of Health is setting up a National Healthcare Supply Chain Agency, which will serve as a new national integrated supply chain, bringing together the entire supply chain’s functions, including procurement and resources of the three healthcare clusters.
In the financial year 2018 the government planned to call for ICT tenders worth S$ 2.6 billion (EUR 1.7 billion), up from S$ 2.4 billion in the previous year (EUR 1.56 billion). Over two-third of projects were available for SMEs, in line with previous years. Examples of previous tender procedures include the one won by the Irish medical device company in June 2016. The company won the bid supply the National Heart Centre in Singapore with diagnostic angiographic equipment.
For what concerns private procurement, private tenders and quotations are advertised through the companies’ and organisations' websites. Otherwise, some portals such as Singtel myBusiness Trading Board (https://mybusiness.singtel.com/trading-board), which is an e- procurement portal for businesses, serve as a source for daily postings of tenders and request for quotations. Partnered with SESAMi (https://www.sesami.com/), the portal offers products and services from the largest enterprises in Singapore, including Singtel, Singapore Airlines, ST Electronics and OCBC bank.
The government procures goods and services through three procedures:
Small Value Purchases (Up to S$ 3,000 or EUR 1,955)
The government will buy directly from suitable suppliers with prices reflecting fair market value. The agency requiring the product or service would normally ask around for quotations and undertake direct purchase. These small value purchases are not publicised on GeBIZ. Sourcing methods include verbal or written quotes, off-the-shelf purchase, and the GeBIZ Mall Catalogue.
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Invitation to Quote (S$ 3,001 to S$ 70,000 or EUR 1,956 to EUR 45,628)
The government will publish an online quote on GeBIZ to invite suppliers to quote. All suppliers registered with GeBIZ can submit a quote on GeBIZ. Sourcing methods include Invitation to Quote (ITQ), Request for Quotation (RFQ), Period Contracts and Framework Agreements.
Invitation to Tender (Above S$ 70,000 or EUR 45,628)
Only GeBIZ trading partners can tender for projects. Tenders are categorised into three:
◼ Open – all interested parties can bid, with tenders posted on GeBIZ.
◼ Selective – Applicants are shortlisted through a pre-qualification exercise, with tenders posted on GeBIZ.
◼ Limited – tenders are by invitation only as they concern national security or are impractical for open tenders.
4.5 Singapore Consumer Protection (Safety Requirements) Registration Scheme (CPS)
The objective of the Singapore Consumer Protection (Safety Requirements) Registration Scheme or CPS Scheme is to safeguard consumers’ interest by ensuring household products, designated as Controlled Goods, meet the specified safety standards.100
Undoubtedly, consumers today are prepared to pay for products that are safe and of high quality. The development of the CPS Scheme is therefore consistent with the growing sophistication of consumers in Singapore.
The CPS Scheme is administered by SPRING Singapore as the Safety Authority since 1991 by Ministry of Trade and Industry (MTI) under the Consumer Protection (Safety Requirements) Regulations. One of the roles of the Safety Authority under the Regulations is to ensure
100 Source: www.spring.gov.sg/Building-Trust/Raising-Confidence/Consumer-Product-Safety/CPS-Scheme/Documents/CPS_InfoBooklet.pdf
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compliance by industry on the registration of forty-five categories of Controlled Goods. The definitions and applicable safety standards of the Controlled Goods can be found here: http://www.customs.gov.sg/businesses/importing-goods/controlled-and-prohibited-goods-for-import
Registration of Controlled Goods under the Consumer Protection (Safety Requirements) Regulations is based on a Certificate of Conformity (CoC) issued by designated third party Conformity Assessment Bodies (CABs).
All suppliers of Controlled Goods for consumers in Singapore must first be registered with the Safety Authority as Registered Supplier. Registered Suppliers are required to register each model of Controlled Goods with the Safety Authority. The registration must be supported with COC issued by designated CABs located in Singapore or MRA partners, i.e. CABs (Local) or CABs (Foreign - MRA) respectively.
Controlled Goods and their Applicable Safety Standards
Controlled Goods are required to be tested to the minimum edition of the safety standards. In addition to the specified safety standards, Controlled Goods are required to fulfil the Safety Authority’s Requirements. The table below shows the definition and safety standards for controlled goods related to the Healthcare & Medical Technologies sector, particularly relevant for ICT and remote-monitoring equipment.
Controlled Goods Definitions Safety Standards
Adaptor A device designed to supply a.c. or d.c. (applicable for electrical power from an a.c. or d.c. source, either 101 by itself or as part of an accessory, for appliances ) applications such as computers, IEC 61558-2-6: 1997 telecommunication equipment, home or IEC 61558-2-16: 2009 entertainment equipment or toys
101 For other applications there are different standards. For a complete list, please visit http://www.spring.gov.sg/Building-Trust/Raising- Confidence/Consumer-Product-Safety/CPS-Scheme/Documents/CPS_InfoBooklet.pdf
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Controlled Goods Definitions Safety Standards
Audio products An electronic device (other than High- IEC 60065: fidelity set) for the reproduction of 2001 sound, connected to the supply mains, either directly or indirectly.
Computer system (inclusive A microprocessor based data system of monitor, printer, speaker with compact, local computing and IEC 60950-1: 2001 and other mains operated calculating power on high definition accessories) graphics and with flexible data communication interfacing.
High-fidelity set An electronic device for reproduction of sound, with little distortion, IEC 60065: 2001 connected to the supply mains as the only energy source intended for domestic and similar general indoor use with a rated supply voltage not exceeding 250 volts rms.
Laser disc set An electronic device for video recording and playback or laser disc IEC 60065: 2001 for play-back only connected to the supply mains, either directly or indirectly, and intended for domestic and similar general indoor use.
Television / video display unit Namely an electronic device for receiving and displaying information IEC 60065: 2001 from a transmitting station or local source. The device is to be connected to the supply mains either directly or indirectly, and intended for domestic and similar general indoor use.
Table 7: Definitions of Controlled Goods and Safety Standards
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Safety Authority’s Requirements
The Safety Authority monitors the safety of the Controlled Goods sold in Singapore by investigating all complaints, incidents and accidents reported to the authority. Acquired information will be leveraged upon to develop the operational interventions within the Safety Authority’s Requirements. These requirements are to be fulfilled in addition to the applicable safety standards. The table below presents the Safety Authority’s Requirements for each controlled good related to the Healthcare & Medical Technologies sector, particularly relevant for ICT and remote-monitoring equipment.
No Items Requirements Applicable to all products 1 Test report and test Test report including its test certificate (if applicable) more than certificate three (3) years shall be rejected.
2 Controlled Goods The additional function must be tested to its applicable safety incorporated with standard. additional function
Applicable to AC adaptor
17 Detachable power supply a) Registered Supplier who is not supplying the detachable power supply cord set not supplied by cord set together with the AC Adaptor must provide written instruction to Registered Supplier its customer on the type of approved detachable power cord set to use and declare to Conformity Assessment Body when applying for Certificate of Conformity. b) This requirement is only applicable to Register Supplier whose core business is supplying AC Adaptor or its Registered Supplier name is affiliated with the AC Adaptor’s manufacturer.
18 AC Adaptor incorporated Additional tests would be required. with 13A socket-outlet Applicable to computer products
19 CD/DVD ROM (used Test certificate showing that CD/DVD ROM has complied with IEC in personal computer) 60825-1 must be provided.
20 Modem Card (used in Modem card incorporated in the personal computer must be tested at personal computer) set level (sub-clauses 5.1 & 6 of IEC 60950) or at component level.
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No Items Requirements
21 Powerline Ethernet Additional tests would be required. Adaptor incorporate with 13A socket- outlet Applicable to plasma/LCD display monitor
45 Plasma/LCD display Plasma/LCD display monitor tested to IEC 60950 would require additional monitor with TV tune test to clauses 9 (related to antenna only), 10.1, 10.2, 10.3 and 12.5 of IEC 60065.
Table 8: Requirements for Controlled Goods
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5. Annex
5.1 List of Useful Contacts
Academy of Medicine 81 Kim Keat Road #11-00 & #12-00, NKF Centre Singapore 328836 Tel: +65 6593 7800 Fax: +65 6593 7880 Email: [email protected] Website: www.ams.edu.sg
Agency for Integrated Care No. 5 Maxwell Road #10-00 Tower Block, MND Complex Singapore 069110 Tel: +65 6603 6800 Fax: +65 6820 0728 Email: [email protected] Website: www.aic.sg
Agency for Science, Technology and Research (A*STAR) 1 Fusionpolis Way #20-10 Connexis North Tower Singapore 138632 Tel: +65 6826 6111 Fax: +65 6777 1711 Email: [email protected] Website: www.a-star.edu.sg
Asia Pacific Medical Technology Association 2 Science Park Drive Ascent Tower A #02-03, Science Park 1 Singapore 118222 Tel: +65 6816 3180 Email: [email protected] Website: www.apacmed.org
Economic Development Board 250 North Bridge Road, #28-00 Raffles City Tower
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Singapore 179101 Tel: +65 6832-6832 Email: [email protected] Website: www.edb.gov.sg
Enterprise Singapore 230 Victoria Street Level 10, Bugis Junction Office Tower Singapore 188024 Tel: +65 6898 1800 Email: [email protected] Website: www.enterprisesg.gov.sg
Government Technology Agency of Singapore (GovTech) 10 Pasir Panjang Road #10-01 Mapletree Business City Singapore 117438 Tel: +65 6211 2100 Fax: +65 6211 2222 Email: [email protected] Website: www.tech.gov.sg
Health Promotion Board 3 Second Hospital Avenue, Singapore 168937 Tel: +65 6435 3500 Fax: +65 6438 3848 Email: [email protected] Website: www.hpb.gov.sg
Health Sciences Authority 11 Outram Road, Singapore 169078 Tel: +65 6213 0838 Fax: +65 6213 0749 Email: [email protected] Website: www.hsa.gov.sg
Infocomm Media Development Authority of Singapore (IMDA) 10 Pasir Panjang Road #10-01 Mapletree Business City Singapore 117438 Tel: +65 6377 3800 Fax: +65 6577 3888
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Email: [email protected] Website: www.imda.gov.sg
Integrated Health Information Systems Pte Ltd 6 Serangoon North Avenue 5 #01-01/02 Singapore 554910 Tel: +65 6594 1800 Fax: +65 6594 1900 Email: [email protected] Website: www.ihis.com.sg
Medical Device Manufacturers Association 318 Tanglin Road #01-35/36 Phoenix Park Singapore 247979 Tel: +65 6733 2230 Fax: +65 6733 2239 Email: [email protected] Website: www.amdi.org.sg
Ministry of Health 16 College Road College of Medicine Building Singapore 169854 Tel: +65 6325 9220 Email: [email protected] Website: www.moh.gov.sg
Ministry of Trade and Industry 100 High Street #09-01 The Treasury Singapore 179434 Tel: +65 6225 9911 Fax: +65 6332 7260 Email: [email protected] Website: www.mti.gov.sg
National Cancer Centre Singapore 11 Hospital Drive Singapore 169610 Tel: +65 6436 8000 Fax: +65 6225 6283 Email: [email protected] Website: www.nccs.com.sg
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National Dental Centre Singapore 5 Second Hospital Avenue Singapore 168938 Tel: +65 6324 8802 Email: [email protected] Website: www.ndcs.com.sg
National Heart Centre Singapore 5 Hospital Drive Singapore 169609 Tel: +65 6704 8000 Fax: +65 6844 9030 Email: [email protected] Website: www.nhcs.com.sg
National Research Foundation 1 CREATE Way #12-02 CREATE Tower Singapore 138602 Tel: 65 6684 2900 Fax: +65 6684 0384 Email: [email protected] Website: www.nrf.gov.sg
Singapore Medical Association 2 College Road, Level 2 Singapore 169850 Tel: +65 6223 1264 Fax: +65 6224 7827 Email: [email protected] Website: www.sma.org.sg
Singapore Medical Council 16 College Road #01-01 College of Medicine Building Singapore 169854 Tel: +65 6372 3093 Fax: +65 62210558 Email: [email protected] Website: www.smc.gov.sg
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5.2 Starting a Business in Singapore
Why Singapore?
Singapore’s high ranking as the world’s easiest place to do business makes it an attractive investment destination. Its high standard of living, high quality education, advanced infrastructure and technology and low crime rates make it a popular global city in which to work and live.
Singapore welcomes individuals and corporations that are interested in doing business in Singapore. Many global corporations chose to locate their headquarters in Singapore because of its political stability, attractive corporate tax rates, as well as the strength of its legal and financial system. Due to its strategic geographical location, there is an unwavering preference for Singapore as a location for business expansion efforts.
Registering your business
It is easy to register a business, including foreign branch offices, online at Bizfile102 by the Accounting and Corporate Regulatory Authority103.
Generally, European companies have the following options for business formation:
◼ Singapore Subsidiary - a locally incorporated company with the foreign parent company as a shareholder. Singapore allows 100% foreign shareholding. The company is entitled to local government incentives and privileges of tax treaties, which satisfies the qualifying conditions. It will be subjected to local corporate tax rates, has a separate legal identity and its liabilities do not impact the foreign parent company.
◼ Branch Office – a locally registered entity that acts as an extension of the foreign parent. Therefore, its liabilities are extended to the parent company. The revenue generated locally
102 https://www.bizfile.gov.sg/ngbbizfileinternet/faces/oracle/webcenter/portalapp/pages/BizfileHomepage.jspx 103 https://www.acra.gov.sg/Home/
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will be subjected to tax. It will be taxed at the prevailing local tax rate although it is a non- resident for tax purposes.
◼ Representative Office – This type of entity is for the purpose of market research, administrative or liaison purposes only. It cannot engage in revenue generating activities. This entity is a transitory arrangement only because the registration is valid for one year, renewable for up to 3 years maximum; thereafter it must graduate to a subsidiary or branch office to continue its operations in Singapore.
Business Registration Procedure
All businesses must be registered with the Accounting & Corporate Regulatory Authority (ACRA). This includes any individual, firm or corporation that carries out business for a foreign company. The first step is to seek the ACRA’s approval of the name of the corporation, which can be done online.
Once the name is approved, the registration papers and information can be e-filled with ACRA for the registration of the foreign company. The following documents have to be submitted as well for registration:
◼ A certified copy of the corporation’s certificate of incorporation in its place of incorporation or origin, or a document of similar effect
◼ A certified copy of the corporation’s certificate of change of name or a document of similar effect (if applicable)
◼ A certified copy of its charter, statues, or memorandum and articles of association or other instrument constituting or defining its structure
◼ A list of its directors stating their names, residential addresses, nationalities, passport numbers, occupations and dates of appointment as directors
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◼ A memorandum of appointment of agents together with an affidavit. There must be at least two agents who must be Singapore citizens, permanent residents or holders of valid Employment Passes.
◼ Notice of the location of the corporation’s registered office in Singapore to which all communications and notices may be addressed.
A Singapore address for the business will be needed during the business registration. Businesses that do not require a physical premise can provide virtual addresses, which are offered by many professional service providers. As for businesses that require a physical premise, the individual or company can choose to operate from a home office, retail outlets or flatted factories depending on the nature of the business. Premises must be operated in accordance to the approved business use by the relevant authorities. The body monitoring the requirements of the Companies Act (CA) is ACRA.
Government Agencies
The Singapore government provides support and assistance in all kinds of aspects to help businesses grow in Singapore. European companies looking to set up, operate and establish a business in Singapore will find it easier with assistance from the following government agencies:
◼ Economic Development Board (EDB) – Provides comprehensive investor support and ensures a first-rate pro-business environment in Singapore. It initiated the Global Investor Programme to help international corporations set up and operate businesses in Singapore. Contact Singapore, an alliance of the EDB assists in this programme by linking up entrepreneurs and investors with local business networks as well as facilitating a range of immigration processes for their entry and stay in Singapore. Further information regarding the business opportunities of the programme as well as the application process and requirements is on the EDB’s page or Contact Singapore’s webpage.
◼ Standards, Productivity and Innovation Board (SPRING) – An agency under the Ministry of Trade and Industry which is the enterprise development agency for growing innovative
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companies. SPRING aids enterprises in financing, capabilities and management development, technology and innovation and access to markets for small and medium enterprises to become more established and competitive. SPRING is also the national standards and accreditation body.
◼ Accounting and Corporate Regulatory Authority (ACRA) – ACRA oversees the registration and regulation of business entities and public accountants, and also provides information on new business structures, compliance requirements and corporate governance practices.
◼ SMEPortal.sg (by SPRING) – An EnterpriseOne portal that makes an ideal one-stop site for enterprises looking to start, sustain and grow their businesses. It features links to government information and services as well as industry help and how-to guides.
◼ Ministry of Manpower – Ministry of government of Singapore which provides the formulation and implementation of labour policies related to the workforce in Singapore. The ministry oversees matters related to immigration, issue of Employment Pass (EP) or working visas to foreign talent and work permit transactions. Its website also contains information pertaining to labour, wages and employment in Singapore.
Business Locations
Businesses have a variety of options to find a commercial premise that best meets one’s needs. This includes the heart of Singapore’s latest financial and business district in the Marina Bay Financial Centre to suburban offices in Jurong Lake District, Tampines and Paya Lebar.
In the industrial space market, there are developers like Ascendas, Mapletree and Soilbuild that offer many contemporary space options, from stack-up factories with dedicated loading and unloading bays to spaces for wet laboratories and research activities. Government bodies like HDB and JTC Corporation also provide industrial land and space options for industrialists engaging in high value added industrial activities in Singapore. An example of an innovative and environmentally-friendly industrial space concept is JTC’s multi-tenanted Surface Engineering
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Hub, which aims to minimise water and carbon footprint for companies engaging in electroplating and other similar processes.
JTC also develops specialised industrial parks in Singapore like the Seletar Aerospace Park, Tuas Biomedical Park and Jurong Island to support the growth and development of key manufacturing sectors. Such specialised industrial parks provide industrialists with the necessary supporting infrastructure and allow industrialists to leverage the potential synergies by being clustered together. These specialised industrial parks in Singapore have proven to be attractive to companies and remain a cornerstone of Singapore’s industrial development.
Finding a Distributor in Singapore
One good way to establish a local presence is by working with agents and distributors in Singapore. Qualified agents and distributors can be found for nearly all kinds of products. A number of Singapore-based agents cover the ASEAN region as well as Singapore.
Singapore-based trade associations, chambers of commerce, and foreign commercial offices within EU Member State embassies are all good places to start the search for a distributor in Singapore. International business consultants with experience in helping foreign companies can also prove invaluable by facilitating introductions to qualified distributors. It is always best to meet a prospective distributor in person, and to check references.
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5.3 Useful Statistics
Government Health Expenditure 2013 2014 2015
Operating Expenditure (S$ million) 5,044 5,872 7,520
Development Expenditure (S$ million) 723 1,147 1,413
Government Health Expenditure (S$ million) 5,938.0 7,221.3 8,610.4
Government Health Expenditure (as % of GDP) 1.6 1.8 2.1 Table 9: Government Health Expenditure Source: Singapore’s Ministry of Health
Health Financing 2014 2015 2016 Medisave No. of Accounts (million) 3.2 3.3 3.4 Total Medisave Balance (S$ billion) 70.5 75.9 82.1 Average Balance per Account (S$) 21,800 22,700 24,200 Amount Withdrawn for Direct Medical Expenses (S$ million) 853 900 931 MediShield Life & Integrated Shield Plans No. of MediShield Life Policyholders (‘000) 3,656 ALL SC/PR All SC/PR No. of Policyholders with Private Integrated Shield plans (‘000) 2,485 2,548 2,619 ElderShield No. of ElderShield Policyholders (‘000) 1,167 1,220 1,279 No. of ElderShield Policyholders with Supplements (‘000) 357 398 437 Medifund No. of Applications Approved (‘000) 1,006 1,087 1,136 Grants Disbursed to Institutions (S$ million) 157.5 162.6 161.1 Table 10: Healthcare Financing, 2014-2016 Source: Singapore’s Ministry of Health
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Health Facilities 2014 2015 2016 HOSPITALS Acute Hospitals 18 19 19 Public 8 9 9 Not-for-profit 1 1 1 Private 9 9 9 Psychiatric Hospitals 1 1 1 Public 1 1 1 Community Hospitals 6 7 8 Public 1 3 3 Not-for-profit 4 4 4 Private 1 - 1 RESIDENITIAL LONG-TERM CARE FACILITIES Nursing Homes 65 71 69 Public 6 11 13 Not-for-profit 27 26 26 Private 32 34 30 Inpatient Hospices 2 2 2 NON-RESIDENTIAL LONG-TERM CARE FACILITIES Centre-based care facilities 68 81 88 Home Care Providers 14 17 21 Home Palliative Care Providers 5 7 7 Primary Care Facilities 1886 1951 2035 Public – Polyclinics 18 18 18 Private – General Practitioner Clinics 1868 1933 2017 DENTAL CLINICS 970 1039 1073 Public 248 247 251 Private 722 792 822 PHARMACIES 253 232 235 Public Sector 63 62 62 Private Sector 190 170 173 Table 11: Health Facilities in Singapore, 2014-2016 Source: Singapore’s Ministry of Health
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Beds in Inpatient Facilities 2014 2015 2016 HOSPITALS Acute Hospitals 9,262 9,844 10,318 Public 7,652 8,128 8,561 Not-for-profit 283 316 316 Private 1,327 1,400 1,441 Psychiatric Hospitals 1,950 1,950 1,950 Public 1,950 1,950 1,950 Community Hospitals 1,065 1,464 1,663 Public 142 503 690 Not-for-profit 905 961 961 Private 18 - 12 RESIDENITIAL LONG-TERM CARE FACILITIES Nursing Homes 10,968 12,185 13,022 Public 1,372 2,488 3,110 Not-for-profit 6,021 5,802 6,058 Private 3,575 3,895 3,854 Inpatient Hospices 141 141 173 NON-RESIDENTIAL LONG-TERM CARE FACILITIES Total No. of Day Places 3,100 3,500 4,000 Total No. of Home Care Places 6,500 6,900 7,500 Total No. of Home Palliative Care Places 5,000 5,150 5,500 Table 12: Beds in Inpatient Facilities, 2014-2016 Source: Singapore’s Ministry of Health
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Health Manpower 2014 2015 2016 TOTAL NO. OF DOCTORS 11,733 12,459 12,967 Public Sector 7,330 7,909 8,358 Private Sector 3,790 3,914 3,979 Not in Active Practice 613 636 630 Doctors to Population Ratio 1:470 1:440 1:430 Doctors per 1,000 Population 2.1 2.3 2.3 TOTAL NO. OF NURSES/MIDWIVES 37,618 39,005 40,561 Public Sector 22,744 23,942 24,829 Private Sector 9,002 9,784 9,985 Not in Active Practice 5,872 5,279 5,747 Nurse to Population Ratio 1:150 1:140 1:140 Nurse per 1,000 Population 6.9 7.0 7.2 TOTAL NO. OF DENTISTS 1,905 2,060 2,198 Public Sector 444 449 486 Private Sector 1,435 1,541 1,644 Not in Active Practice 26 70 68 Dentist to Population Ratio 1:2,870 1:2,690 1:2,550 Dentist per 1,000 Population 0.3 0.4 0.4 Table 13: Health Manpower Key Statistics, 2014-2016 Source: Singapore’s Ministry of Health
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Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017
World 30,171 28,782 26,662 40,258 38,949
United States of America 16,238 14,935 13,540 21,108 20,339
United Kingdom 1,326 874 712 667 3,720
Germany 2,372 2,008 4,068 8,719 3,692
Korea, Republic of 1,746 2,066 1,712 2,407 2,908
China 1,098 1,337 1,095 1,346 2,057
Taipei, Chinese 1,608 1,438 1,731 1,614 1,413
Japan 1,915 1,209 788 961 1,171
Viet Nam 461 427 705 961 868
Dominican Republic 0 8 0 0 839
Thailand 449 782 823 732 511 Table 14: Imports of Wadding, gauze, bandages and the like (adhesive) Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017
World 29,777 29,265 28,940 27,586 32,729
Malaysia 4,376 7,152 3,682 4,596 4,658
Australia 1,704 3,267 3,498 5,124 4,631
Taipei, Chinese 2,812 2,334 2,770 2,055 3,714
Korea, Republic of 2,512 272 2,494 501 3,661
Thailand 5,252 2,664 3,240 4,030 3,234
Hong Kong, China 3,315 3,125 3,214 2,573 2,394
Viet Nam 723 512 798 829 2,362
Philippines 1,508 1,687 1,351 1,680 2,018
China 1,098 2,945 795 277 1,863
Indonesia 1,152 1,029 3,321 1,865 1,839 Table 15: Exports of Wadding, gauze, bandages and the like (Adhesive) Source: Trade Map Unit: US Dollar thousand
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Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017
World 22,692 23,284 20,865 21,655 29,055
United States of America 4,023 5,168 5,698 5,269 6,589
United Kingdom 5,410 4,928 3,177 2,276 5,219
China 5,168 5,254 4,196 4,025 5,108
Germany 602 618 619 1,457 2,326
Korea, Republic of 542 668 958 1,277 1,927
Malaysia 2,021 1,624 1,556 1,708 1,440
Taipei, Chinese 1,185 1,224 1,370 1,455 1,399
Japan 536 484 444 1,134 1,203
Dominican Republic 9 3 55 94 534
Finland 543 589 176 492 520 Table 16: : Imports of Wadding, gauze, bandages and the like (non-adhesive) Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017
World 36,692 27,001 35,509 47,316 61,191
Thailand 11,009 5,974 9,679 23,559 20,874
Hong Kong, China 3,887 6,514 9,607 10,422 13,002
Malaysia 3,824 3,538 3,342 2,666 5,057
China 2,046 1,926 1,582 555 4,647
United States of America 3,640 2,878 3,179 3,137 3,450
Viet Nam 145 160 609 1,732 2,646
Taipei, Chinese 2,084 1,027 2,187 848 2,246
Australia 581 588 563 725 1,649
Korea, Republic of 1,582 57 487 140 1,459
Indonesia 560 242 616 242 1,100 Table 17: Exports of Wadding, gauze, bandages and the like (non-adhesive) Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 168 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 38,682 53,519 40,548 34,753 37,912
United States of America 20,176 38,634 26,363 23,066 22,752
Mexico 4,576 5,138 5,567 4,922 4,920
Spain 556 1,328 1,053 1,788 2,602
Japan 1,960 1,230 237 388 1,096
Philippines 772 107 46 402 990
United Kingdom 146 336 512 166 855
Indonesia 79 278 85 218 806
China 549 1,095 1,127 371 762
Belgium 5,883 1,751 452 1,305 701
Denmark 28 8 7 1 346 Table 18: Imports of Syringes, with or without needles, used in medical, surgical, dental or veterinary sciences Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 80,321 99,949 82,658 81,865 69,404
India 13,335 19,767 21,078 18,642 14,735
Australia 12,953 11,663 12,468 14,017 9,860
United States of America 10,159 7,130 13,136 8,696 7,347
Taipei, Chinese 7,022 5,941 6,866 6,885 5,317
Pakistan 1,882 2,806 3,263 3,639 5,059
China 4,487 29,659 3,545 4,861 4,598
Indonesia 8,122 4,803 5,100 5,766 4,226
Philippines 3,537 3,367 3,760 3,787 3,916
New Zealand 4,187 4,814 4,889 4,537 2,809
Thailand 1,764 1,629 2,322 2,742 2,682 Table 19: Exports of Syringes, with or without needles, used in medical, surgical, dental or veterinary sciences Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 169 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 9,051 9,123 7,107 12,174 13,870
Japan 1,539 1,230 857 3,194 3,789
United States of America 1,418 1,072 1,393 2,878 3,526
Australia 0 0 0 1,110 2,745
Ireland 16 36 2,542 935 1,192
Belgium 2,956 3,227 643 1,948 823
United Kingdom 2 23 8 78 344
Switzerland 103 212 141 83 225
Denmark 0 2 0 480 175
Dominican Republic 0 0 0 0 157
Spain 6 5 3 77 149 Table 20: Imports of Tubular metal needles and needles for sutures, used in medical, surgical, dental or veterinary sciences Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 43,637 64,783 87,569 78,231 75,112
China 2,770 6,022 8,613 8,429 11,126
India 8,351 9,064 8,540 8,579 10,773
Australia 2,767 6,320 9,410 10,175 9,386
United States of America 9,111 8,981 14,092 8,694 8,335
Taipei, Chinese 348 1,639 7,072 7,921 5,775
United Kingdom 2,246 5,155 6,896 5,107 4,919
Korea, Republic of 469 2,018 1,274 2,497 3,998
Malaysia 804 962 903 1,655 2,773
Philippines 800 1,615 2,439 2,222 2,667
Belgium 6,303 5,805 7,339 3,330 2,415 Table 21: Exports of Tubular metal needles and needles for sutures, used in medical, surgical, dental or veterinary sciences Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 170 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 365,278 327,984 309,923 371,472 323,259
United States of America 128,217 90,781 64,933 80,025 89,662
Malaysia 67,919 72,094 44,640 48,807 63,943
Ireland 9,331 35,254 56,867 79,419 52,925
Mexico 20,346 22,313 51,701 56,376 42,576
Japan 10,434 12,284 12,536 15,077 14,493
Costa Rica 1,146 1,514 7,953 15,904 12,802
Switzerland 3,172 9,079 3,362 2,205 7,899
China 5,949 1,806 2,487 3,433 6,700
Czech Republic 13,164 10,383 4,163 2,714 4,948
Indonesia 48,206 43,810 38,661 37,391 3,820 Table 22: Imports of Needles, catheters, cannulae and the like, used in medical, surgical, dental or veterinary sciences (excluding syringes, tubular metal needles and needles for sutures) Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017
World 667,658 660,326 559,983 498,502 478,528
Malaysia 49,770 91,738 91,023 110,425 100,881
Belgium 62,064 62,159 44,767 39,735 44,573
Korea, Republic of 68,003 38,667 22,047 30,045 32,451
Taipei, Chinese 52,276 71,145 54,505 45,010 30,761
United States of America 18,858 24,011 54,536 39,292 29,784
Japan 49,342 29,513 31,182 31,082 29,519
China 146,729 64,496 100,323 45,457 26,826
Australia 18,263 14,574 20,082 27,665 18,794
Hong Kong, China 13,243 38,748 14,186 14,528 16,881
India 12,393 12,724 6,835 9,614 16,808 Table 23: Exports of Needles, catheters, cannulae and the like, used in medical, surgical, dental or veterinary sciences (excluding syringes, tubular metal needles and needles for sutures) Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 171 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 12,040 11,797 10,794 15,312 16,651
Canada 5,378 4,549 5,069 6,387 7,740
United States of America 2,933 3,339 2,394 4,906 4,426
Germany 1,714 1,407 1,607 1,749 1,944
India 222 320 255 575 717
China 278 250 305 362 486
Mexico 340 430 329 394 435
Israel 103 16 7 88 195
Switzerland 90 178 48 22 132
Korea, Republic of 80 192 100 206 117
Japan 295 185 221 117 81 Table 24: Imports of Electro-cardiographs Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 8,885 11,362 11,487 11,055 12,132
Australia 2,628 4,050 3,348 3,291 3,474
Thailand 967 1,116 1,318 2,770 2,406
Viet Nam 257 109 446 469 908
Hong Kong, China 262 368 549 776 828
Indonesia 426 1,154 409 569 651
United States of America 1,256 1,571 2,405 653 626
Malaysia 220 799 561 795 495
Pakistan 236 26 19 0 463
France 11 131 269 303 403
New Zealand 137 200 247 249 275 Table 25: Exports of Electro-cardiographs Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 172 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 33,468 33,721 25,022 23,348 34,804
Japan 14,213 11,456 9,276 9,529 9,591
United States of America 9,491 10,170 7,637 6,834 9,308
China 2,389 2,525 1,405 1,141 5,036
Korea, Republic of 1,014 3,197 2,825 2,349 3,403
Austria 1,055 1,015 528 496 1,740
Malaysia 258 579 357 423 1,434
Norway 793 1,154 553 517 747
India 99 229 304 228 540
France 1,149 786 210 108 446
Australia 289 393 127 64 347 Table 26: Imports of Ultrasonic scanning apparatus Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 133,737 35,562 37,004 51,999 43,426
United States of America 103,940 2,662 4,614 10,319 8,155
China 856 6,207 7,639 11,199 6,111
Thailand 4,050 2,479 4,204 3,797 5,316
India 891 1,859 1,240 3,899 3,533
Japan 1,836 646 984 1,653 2,786
Viet Nam 1,389 2,258 2,031 1,672 2,289
Malaysia 5,064 3,603 1,162 1,889 2,111
Australia 2,299 5,918 4,108 3,466 1,698
Indonesia 1,265 1,141 934 1,627 1,503
Philippines 627 966 661 865 1,296 Table 27: Exports of Ultrasonic scanning apparatus Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 173 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 30,969 32,831 27,993 40,077 40,406
United States of America 12,887 9,914 7,389 11,495 15,405
Netherlands 5,421 5,682 8,724 6,463 7,296
Germany 6,207 6,656 3,633 8,098 6,146
China 4,069 6,918 4,912 9,750 5,668
India 52 397 248 479 2,713
Japan 1,166 1,438 2,061 2,480 1,601
United Kingdom 75 503 413 369 405
Switzerland 652 160 84 50 205
Italy 30 554 30 125 126
Mexico 9 43 14 27 124 Table 28: Imports of Magnetic resonance imaging apparatus Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 26,306 61,664 33,245 54,989 56,110
United States of America 6,155 5,708 5,447 13,414 12,780
Japan 2,683 2,243 3,435 7,568 10,123
Myanmar 0 1,385 3,866 2,666 7,774
Australia 3,532 6,161 2,049 2,759 3,442
Thailand 2,074 3,793 4,363 4,445 2,874
Korea, Republic of 1,021 101 265 2,029 2,780
India 1,604 3,276 2,375 4,242 2,629
Malaysia 1,974 1,603 648 997 2,298
China 1,216 27,019 4,667 3,300 1,306
Taipei, Chinese 279 406 856 610 1,275 Table 29: Exports of Magnetic resonance imaging apparatus Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 174 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 2,056 1,478 1,694 2,045 1,582
United States of America 113 524 591 514 686
Hungary 1 10 0 556 472
Israel 1,145 586 574 776 142
China 26 38 50 19 86
Japan 0 0 0 0 69
Germany 3 106 20 16 43
Mexico 0 43 13 31 35
Netherlands 17 25 65 53 33
Turkey 0 0 0 0 7
Sweden 9 68 17 53 5 Table 30: Imports of Scintigraphic apparatus Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 1,306 1,386 1,538 2,357 3,188
United States of America 350 205 221 710 966
Japan 152 177 154 492 712
Viet Nam 0 38 4 0 239
Australia 257 219 131 233 222
India 67 183 183 133 212
Korea, Republic of 2 3 98 91 164
Italy 36 35 1 30 130
Germany 34 121 146 78 76
Hong Kong, China 15 63 235 181 66
Malaysia 45 83 28 155 59 Table 31: Exports of Scintigraphic apparatus Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 175 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 152,644 156,946 140,783 149,580 155,316 United States of America 63,874 67,043 61,289 63,467 80,209 China 15,625 16,037 19,291 18,295 13,817 Mexico 4,139 5,685 4,897 10,130 10,406 Japan 11,942 8,865 5,972 7,614 9,882 Germany 12,113 17,525 13,137 8,457 6,341 Korea, Republic of 4,578 5,516 3,894 5,271 5,889 Viet Nam 11,270 8,922 8,997 9,149 5,698 Dominican Republic 4,727 5,633 5,447 4,164 5,107 Finland 2,094 3,342 3,075 10,116 3,246 Israel 941 1,595 1,399 1,470 2,052 Table 32: Imports of Electro-diagnostic apparatus, incl. apparatus for functional exploratory examination or for checking physiological parameters (excluding electro-cardiographs, ultrasonic scanning apparatus, magnetic resonance imaging apparatus and scintigraphic apparatus) Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 195,961 264,463 319,266 257,401 285,538 United States of America 56,635 111,014 139,791 121,943 132,825 China 14,829 37,555 53,661 31,953 41,649 India 10,817 8,851 13,020 13,831 17,418 Belgium 684 1,986 9,483 9,310 11,268 Thailand 13,707 6,592 23,224 7,298 8,622 Australia 9,152 7,284 5,141 5,288 7,501 Viet Nam 7,797 9,395 10,503 8,813 7,465 Korea, Republic of 6,876 3,231 4,283 4,584 6,616 Germany 3,093 10,959 12,382 12,382 6,551 Indonesia 9,722 10,041 6,978 4,624 6,523 Table 33: Exports of Electro-diagnostic apparatus, incl. apparatus for functional exploratory examination or for checking physiological parameters (excluding electro-cardiographs, ultrasonic scanning apparatus, magnetic resonance imaging apparatus and scintigraphic apparatus) Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 176 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017
World 2,800 3,349 2,912 1,619 2,031
United States of America 563 931 740 307 447
Germany 495 57 140 254 443
Slovenia 0 285 70 41 428
Hong Kong, China 0 237 127 323 314
United Kingdom 101 23 145 53 85
Italy 148 78 303 106 68
Korea, Republic of 195 1,073 484 140 60
China 346 29 28 26 41
New Zealand 0 0 0 59 28
Poland 96 0 0 1 28 Table 34: Imports of Ultraviolet or infra-red ray apparatus used in medical, surgical, dental or veterinary sciences Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017
World 2,687 1,430 2,280 1,162 935
Indonesia 1,127 225 434 181 364
Malaysia 79 201 205 104 117
India 22 5 17 23 98
Korea, Republic of 6 1 0 20 91
United States of America 5 20 26 140 51
China 27 30 487 16 40
Slovenia 0 0 0 0 39
Thailand 2 188 307 23 39
Italy 0 2 35 14 30
Philippines 0 25 7 167 19 Table 35: Exports of Ultraviolet or infra-red ray apparatus used in medical, surgical, dental or veterinary sciences Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 177 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017
World 357,228 356,061 348,263 393,088 465,309 Germany 73,842 91,458 76,191 81,958 102,912 United States of America 91,110 83,363 94,918 82,138 89,513 China 26,714 41,738 66,723 55,918 67,274 India 52,020 29,228 3,702 45,274 55,415 Japan 51,133 36,623 37,096 41,838 45,993 Malaysia 7,792 12,396 7,450 29,472 38,004 France 9,447 13,287 11,732 12,910 20,032 Netherlands 13,366 9,710 9,495 7,334 8,041 United Kingdom 3,929 7,559 5,859 6,047 5,962 Thailand 1,055 2,082 2,396 4,046 4,381 Table 36: Imports of Apparatus based on the use of X-rays or of alpha, beta or gamma radiations, whether or not for medical, surgical, dental or veterinary uses Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017
World 541,762 704,571 539,429 581,775 718,398 China 20,151 107,577 73,973 80,408 100,811 Japan 57,711 72,897 62,656 60,978 88,456 United States of America 145,251 63,498 67,558 61,032 72,552 Thailand 36,210 42,371 40,930 43,559 60,427 Taipei, Chinese 19,652 40,561 36,760 49,958 56,914 Malaysia 37,663 50,306 45,949 39,925 52,618 Indonesia 12,693 12,300 14,730 46,185 46,695 Australia 20,705 28,406 19,277 17,082 37,988 Viet Nam 13,671 13,796 15,678 24,542 32,365 India 39,237 42,788 32,456 31,479 25,005 Table 37: Exports of Apparatus based on the use of X-rays or of alpha, beta or gamma radiations, whether or not for medical, surgical, dental or veterinary uses Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 178 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 22,661 29,932 19,307 18,654 37,250
Japan 16,148 12,256 11,291 11,412 16,158
United States of America 2,564 1,956 2,110 496 6,934
France 131 157 0 47 6,331
Germany 2,922 5,930 1,371 4,057 4,320
Israel 76 2,359 1,190 192 1,381
China 809 4,604 1,080 1,034 1,132
India 0 0 0 320 576
Thailand 0 0 0 0 257
Belgium 0 282 211 309 116
Korea, Republic of 0 30 0 0 39 Table 38: Imports of Computer tomography apparatus Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017
World 22,654 16,834 18,171 20,446 25,288 Thailand 5,447 4,284 4,562 5,767 9,035 Viet Nam 5,213 2,359 6,970 9,110 5,884 Myanmar 2,465 5,612 1,713 827 3,505 Pakistan 0 0 0 0 2,379 Indonesia 279 407 855 800 1,887 Cambodia 0 1,034 882 1,165 1,189 India 427 227 1,637 218 430 Maldives 0 0 0 0 410 Australia 1,128 53 6 880 278 United States of America 0 37 415 89 233 Table 39: Exports of Computer tomography apparatus Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 179 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 4,081 4,455 3,874 3,158 2,767
France 623 922 618 650 724
Korea, Republic of 1,694 1,214 1,088 893 670
Finland 919 1,613 807 683 542
Germany 93 237 781 550 505
Japan 274 289 496 68 213
Italy 108 147 33 216 113
China 78 0 0 0 0
Estonia 0 0 2 0 0
Hong Kong, China 0 0 35 0 0
Malaysia 0 0 0 0 0 Table 40: Imports of Apparatus based on the use of X-rays for dental uses Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017
World 1,357 1,480 282 678 165 Viet Nam 33 9 0 0 115 France 0 0 0 0 26 Myanmar 67 30 0 0 15 Australia 14 3 0 48 5 Korea, Republic of 58 38 0 40 2 Hong Kong, China 7 43 0 0 1 South Africa 0 0 0 0 1 British Indian Ocean 0 0 0 27 0 Territory Cambodia 0 872 0 0 0 China 6 0 0 86 0 Table 41: Exports of Apparatus based on the use of X-rays for dental uses Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 180 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 36,544 30,422 17,859 18,914 19,695
Japan 16,565 6,993 6,492 8,857 5,766
Germany 5,838 7,979 3,022 2,141 4,490
United States of America 5,150 6,857 2,151 3,400 4,141
Netherlands 4,197 2,392 2,161 767 2,109
France 433 1,246 1,325 534 956
China 633 1,626 1,363 1,263 767
Korea, Republic of 803 531 512 747 542
Mexico 0 25 0 0 288
Spain 530 800 15 404 221
Italy 61 28 28 208 180 Table 42: Imports of Apparatus based on the use of X-rays, for medical, surgical or veterinary uses (excluding for dental purposes and computer tomography apparatus) Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 24,337 24,025 12,007 15,710 15,794
Viet Nam 1,015 1,002 546 2,249 6,042
Thailand 11,201 3,992 6,029 2,941 3,814
Myanmar 2,992 1,152 2,081 1,206 1,505
Indonesia 490 1,426 916 3,018 1,193
Malaysia 4,343 1,872 194 65 756
Pakistan 773 83 254 2,136 623
India 699 10,174 248 1,012 299
Brunei Darussalam 167 22 0 120 278
Cambodia 73 180 16 817 229
Maldives 0 0 0 0 199 Table 43: Exports of Apparatus based on the use of X-rays, for medical, surgical or veterinary uses (excluding for dental purposes and computer tomography apparatus) Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 181 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 85,052 84,878 80,106 107,488 136,261
Germany 36,917 40,580 44,511 49,286 62,629
India 19,773 9,975 1,063 27,187 39,866
United States of America 21,744 27,588 26,761 22,675 22,528
Japan 2,976 2,384 2,927 3,218 3,103
France 1,105 1,618 2,268 1,937 2,426
China 507 469 1,519 854 1,746
Mexico 190 585 356 1,017 979
Canada 0 0 47 288 961
Thailand 110 67 115 412 617
Korea, Republic of 0 429 187 58 434 Table 44: Imports of X-ray tubes Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 33,531 43,041 80,618 100,452 125,070
China 1,569 11,206 34,332 46,807 59,441
United States of America 1,458 2,016 6,576 11,922 13,143
Japan 3,450 2,909 5,824 5,727 10,037
France 5,884 8,699 6,747 8,005 9,332
India 2,572 2,935 4,592 6,609 8,116
Australia 1,672 4,044 6,201 2,732 3,458
Indonesia 1,558 642 180 1,373 3,250
Germany 1,135 879 791 631 3,022
Thailand 2,127 2,047 3,439 3,071 2,704
Viet Nam 444 1,206 1,327 1,560 2,033 Table 45: Exports of X-ray tubes Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 182 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017
World 2,147 1,825 1,344 1,598 1,081
Japan 694 582 415 611 235
France 79 34 13 53 129
Germany 473 294 161 246 107
Poland 0 0 0 0 96
Austria 27 172 59 182 83
Switzerland 121 199 125 198 80
Indonesia 0 0 0 0 76
United States of America 350 315 116 109 72
China 6 5 3 5 52
India 0 0 0 0 45 Table 46: Imports of Dental drill engines, whether or not combined on a single base with other dental equipment Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 155 322 183 533 308
Indonesia 84 165 65 143 231
Malaysia 4 41 13 22 34
Viet Nam 23 0 56 87 28
Thailand 2 19 0 0 7
Belgium 0 0 0 0 4
China 0 32 0 0 1
Pakistan 0 0 0 0 1
United States of America 1 27 0 13 1
Korea, Republic of 0 0 0 0 0
Australia 3 0 43 0 0 Table 47: Exports of Dental drill engines, whether or not combined on a single base with other dental equipment Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 183 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 27,217 25,580 25,657 25,634 22,865
Germany 8,020 7,859 9,536 8,203 9,416
United States of America 6,913 6,837 4,074 4,028 2,989
Japan 3,825 2,801 3,630 4,396 2,886
Switzerland 1,434 1,403 1,448 1,449 1,404
China 571 583 830 561 742
Italy 1,128 763 1,197 1,204 654
Israel 136 123 210 582 642
Mexico 56 404 510 890 487
Poland 0 57 12 204 436
Denmark 86 65 14 33 338 Table 48: Imports of Instruments and appliances used in dental sciences, n.e.s. Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 18,557 17,012 15,296 15,879 10,721
Indonesia 12,654 9,463 9,047 9,189 5,889
Thailand 389 715 855 895 1,026
Australia 217 1,612 1,659 1,361 921
China 370 317 141 311 478
Hong Kong, China 274 859 703 408 459
Malaysia 1,331 963 835 531 397
Viet Nam 322 235 141 142 259
Japan 163 187 281 797 235
United States of America 613 263 149 172 211
United Arab Emirates 35 119 186 160 157 Table 49: Exports of Instruments and appliances used in dental sciences, n.e.s. Source: Trade Map Unit: US Dollar thousand
Healthcare & Medical Technologies - Singapore Market Study - Page 184 of 193
Imported Imported Imported Imported Imported Exporters value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 1,446,556 1,524,900 1,375,796 1,396,659 1,327,694
United States of America 666,114 729,836 495,339 443,897 488,374
Mexico 220,854 187,974 340,227 412,622 323,877
Japan 99,485 104,805 83,707 94,559 90,517
Germany 93,567 92,370 82,658 76,278 70,713
China 32,811 46,156 46,551 54,020 53,694
United Kingdom 28,963 52,801 31,948 34,131 38,526
Malaysia 36,532 27,306 19,686 50,657 34,849
Indonesia 47,111 52,093 47,734 42,184 27,888
Switzerland 23,515 25,341 31,354 30,584 25,272
Australia 7,082 25,411 15,427 24,442 22,909 Table 50: Imports of Instruments and appliances used in medical, surgical or veterinary sciences, n.e.s. Source: Trade Map Unit: US Dollar thousand
Exported Exported Exported Exported Exported Importers value in 2013 value in 2014 value in 2015 value in 2016 value in 2017 World 2,119,294 2,055,126 1,596,487 1,518,073 1,805,536
China 460,342 572,767 416,215 331,251 371,697
Korea, Republic of 129,112 186,406 140,651 128,955 141,726
Australia 182,021 177,374 117,240 103,164 130,882
Japan 77,646 55,950 65,246 80,826 129,497
Indonesia 124,058 116,708 138,431 116,778 126,073
India 156,051 92,375 77,831 145,503 119,536
United States of America 250,984 200,463 138,925 112,806 113,533
Taipei, Chinese 92,517 67,859 59,120 57,973 95,550
Thailand 87,162 88,602 74,968 82,145 91,145
Germany 38,924 27,424 22,078 47,095 64,272 Table 51: Exports of Instruments and appliances used in medical, surgical or veterinary sciences, n.e.s. Source: Trade Map Unit: US Dollar thousand
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5.3 Bibliography
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Straits Times (2017). E-Consultations a Boon for Patients. https://www.straitstimes.com/opinion/e- consultations-a-boon-for-patients
Straits Times (2017). Singapore Trials Its First Self-Driving Wheelchair at Changi General Hospital. https://www.straitstimes.com/singapore/singapore-trials-its-first-self-driving-wheelchair-at-changi- general-hospital
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