Wednesday 2 October 2013

On healthcare, F1 and politicians

What’s the challenge for Singapore as a medical hub? Is the F1 a “frivolous” use of taxpayers’ money? What do today’s younger politicians lack?

Outspoken former top civil servant Ngiam Tong Dow served as Permanent Secretary in the Prime Minister’s Office under Mr Lee Kuan Yew, as well as in various other ministries.

As Chairman, concurrently, of the Economic Development Board, he had, in the 1980s, championed the idea of developing Singapore as an international medical centre to tap the region’s growing middle-class market. In line with that vision, medical school enrolment was increased.

These are edited excerpts of a wide-ranging interview with Dr Toh Han Chong, Editor of SMA News, published in the September issue of the Singapore Medical Association’s newsletter.

If Singapore becomes an international medical centre, it might create more pressure points, especially in the public sector. What are your thoughts?

In my view, the public sector should compete. If Singapore is to become a medical centre, we have to develop our public hospitals, as they are at the forefront of local Medicine.

If you have a very serious, complex illness, you would probably not go to a private practitioner, but engage an established and experienced medical team who sees a high volume of such a disease, who can get to the problem immediately ... We should develop our public hospitals, instead of running them down, so that doctors will want to stay on and not leave once they get higher qualifications.

The issue is whether our hospitals can cope with the rising number of foreign patients coming into Singapore.

If I may say so, that would be a pleasant problem for us. When you’ve got the demand, it’s up to you to organise to meet the demand. You only need to start worrying when you have no demand, when you pa bang (Hokkien for “swatting flies”, meaning “lack of business”).

The other interesting thing is that when local patients see people from all over the world coming to our hospitals, they will realise that they’re also getting good healthcare services. But now, Singaporeans don’t realise that.


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

Yes, a very influential local health economist in Singapore once said that. He was referring to the backwards sloping supply curve, and thus felt that we needed to restrict the number of doctors ... I completely disagree with him because he has missed the wood for the trees.

The demand for doctors does not come only from our own population, but also from the regional economies. As the middle class becomes richer, they want better medical services, and this is true today! If you look at all the paying patients, the demand is coming from the Indonesian and Vietnamese. In fact, we are very worried about the increase in the costs of Medicine.

My point is there will be greater economies of scale if you serve not just your own people, but also that of the region. With economies of scale, you can restrain the growth of health expenditure. Today, it is 4 per cent of the gross domestic product ... Great credit should be given to our private sector; it consists of businessmen who bring in all the patients who indirectly help us restrain, not add to, the rising costs of Medicine.


We’ve invested so much in biomedical research. There is a strong feeling that in order to bring it to relevant applications and real patient care, there must be more of a connection between such R&D hubs like the Biopolis and the clinical institutions. What are your thoughts?

I’m afraid that so far, we’ve gone for trophy scientists as a key strategy. In the 1970s, when we were building Changi Airport Terminal 1, Mr Ng Pock Too brought the Chinese to the terminal. Of course, as typical Singaporeans, we boasted about being the best in the world. The Chinese leader said: “Mr Ng, who built this terminal?” Alas, we had to say Takenaka Corporation of Japan. He rested his case.

We shouldn’t buy trophies. The best thing is to train our own people and give them the experience.

I wrote an article some time ago on how we were spending over S$6 billion trying to raise productivity. I found out that we have 30,000 trained workers each year, if we took into account the graduates from all our universities, polytechnics and Institutes of Technical Education. Yet, our employers refuse to take them on because they say that while the graduates may have the theories, they may not be able to do the job!

As such, I proposed that the MOF (Ministry of Finance), using the money set aside, pay for the salaries of new graduates that employers hire and train for the first year. If these employers hire them permanently, the training will be free; if not, half of their total salaries must be returned.

I think that’s the best way, as we can reduce a lot of manpower wastage. I have not received a response yet.

After the General Election in 2011, many Singaporeans were angry about the issue of increased foreign talents on local shores. As a result, we have fewer foreign talents in this country now. Since then, our small and medium enterprises have suffered, and our local manpower is insufficient to cope in various industries, including healthcare. What are your views?

My own hospital stay has really opened my eyes. Other than the radiologist, who was a Singaporean, all the hospital technicians were Chinese, Filipinos or Indians. If we send all of them back, the hospitals may have to close down.

I think a lot of these pseudo-economists and pseudo-politicians say Singaporeans should be employed first, but are Singaporeans fit or willing to do some of these job?

For example, the delivery of medical care falls squarely on the shoulders of our nurses, so I was very upset to read that our Population White Paper classified nursing as a “low-skilled” job. (Editor’s note: This reference in a footnote to the White Paper was later deleted, and the Government apologised for its inclusion.) ... Nursing is for the toughest minded, as nurses take care of patients for long hours in the frontlines. Sometimes, the patients get impatient and scream at them. It’s a job I wouldn’t want to do myself, but I respect nurses for it.


How else can Singapore further transform into a global city?

My favourite topic — I’m on public record — is Formula 1 (F1). We’re paying the Englishmen to stage the F1 night race here. Why should we use taxpayers’ money to pay for these races? I have asked this question publicly, but the MOF has never addressed it.

Doesn’t F1 put Singapore on the world map?

What does it mean by putting a country on the world map? I was born in a generation where every cent counts, so I believe we should spend our money wisely, and not on frivolities. Sometimes, I think our present Cabinet spends money on frivolities, and staging the F1 is my “favourite” example.

A Hong Kong delegation asked me what I consider frivolities. In Hong Kong, they have fireworks displays every year. One of the delegates asked me whether I thought it was a waste of public money. If everyone in Hong Kong can see the fireworks, then there is no waste; if only a restricted number of people can see it, then the money spent is wasted.

Since Singapore has been considered a boring country, don’t you think it will increase our soft power?

These are all Hollywood-type dialogue. When you do not have money or there is no food in your stomach, your priority would not be Singapore’s soft power.

For example, one of my favourite topics to show the stark difference in priorities during my younger days and today is work-life balance. During my younger days, we never thought of work-life balance. For me, my first plane ride was for a work conference in Bangkok! It’s a different generation now, as people today travel frequently for leisure from a young age.

I’m not saying we should be miserly, but we should spend our personal money and public funds wisely to benefit most people.


You have said you were worried that some of the politicians today do not have the same qualities as the pioneer generation. What are you hoping to see in the newer and younger politicians today?

In the early days, Lim Kim San and Goh Keng Swee worked night and day, and they were truly dedicated. I don’t know whether Lee Kuan Yew will agree but it started going downhill when we started to raise ministers’ salaries, not even pegging them to the national salary but aligning them with the top 10.

When you raise ministers’ salaries to the point that they’re earning millions of dollar, every minister — no matter how much he wants to turn up and tell Hsien Loong off or whatever — will hesitate when he thinks of his million-dollar salary. Even if he wants to do it, his wife will stop him.

Lim Kim San used to tell me, “Ngiam, if you want to leave your job, make sure you have enough walkaway money.” When the salary is so high, which minister dares to leave, unless they decide to become the Opposition party? As a result, the entire political arena has become a civil service, and I don’t see anyone speaking up any more.

You said that there were many exchanges of ideas and even criticisms in the pioneer years of the Civil Service. Do you see this happening much today?

The Civil Service has definitely become tamer, which is not good because we need a contest of ideas. The difference is that no one wants to make a sacrifice any more. The first generation of PAP was purely grassroots, but the problem today is that PAP is a bit too elitist.

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