Keynote Address by Mr Masagos Zulkifli, Minister for Social and Family Development and Second Minister for Health at the Third Temasek Shophouse Conversations 2021, 7 June 2021

Mr Lim Boon Heng, Chairman, Temasek Holdings,

Ms Ho Ching, Executive Director and Chief Executive Officer, Temasek Holdings,

Mr Richard Magnus, Deputy Chairman, Temasek Foundation,

Mr Ng Boon Heong, Chief Executive Officer, Temasek Foundation,

Esteemed speakers and panellists,

Distinguished participants,

Ladies and gentlemen,

Introduction

               A very good morning to all. It is my pleasure to join you for the third series of Temasek Shophouse Conversations. An honour to be in the presence of so many experts and practitioners in the field of child development.

2.            Today’s topic is close to my heart; and I know for many of you too. The formative years of life are a critical window. Not only for the child, but the mother as well. In my keynote address, I will expand on this idea further – first by setting out why this is important – what the science tells us. Before sketching out what we need to do and how to get there.

Appreciation of Strong Support from Temasek Foundation

3.             But first, I would like to acknowledge the strong support and contributions by Temasek Foundation. They have actively championed this cause – spearheading and pioneering many new initiatives and pilots to further the health and wellbeing of children and their mothers.

4.              We have seen some breakthroughs, with good initial outcomes, and new care models emerging.

a) One example is KIDS0-3. It started off as a pilot programme, providing vulnerable children and their mothers with integrated health and social care. Families reported stronger parent-child bonding; with better child health and development outcomes. Today, it has been integrated as a core component of the KidSTART programme.

b) The Integrated Maternal and Child Wellness Hub at Punggol Polyclinic is another example – where the mother-child dyad can receive wrap-around care and services.

c) Temasek Foundation also supported the KK Human Milk Bank, which was recently awarded the National Clinical Excellence Team Award in recognition of its impact. It provides pasteurised donor human milk to support premature and critically ill babies – nutrition that is much needed in order to thrive.

Importance of the Early Years and Intervening Upstream

5.             A common thread that strings together these pilots is their aim to go upstream as early as possible, in providing timely and crucial support to both mother and child.

6.            There is good science behind why we do this. The research tells us that the early years of life are a critical window for development. What happens or doesn’t happen then can influence later life outcomes in many ways.

7.            During the first 1,000 days, tremendous change occurs in a developing child. Neuroscientists argue that the brain grows more quickly at that point than at any other period in one’s life and is extremely plastic. Synapses form; get pruned; shaping the child’s cognitive development. Practitioners and social scientists also warn about the ills of how “toxic stress”, neglect and poor home environments can inflict detrimental harm to a child, should we fail to mitigate them during such sensitive periods of growth. What happens from the point of conception, till a child is two years old has profound implications on the way we design our social policies and services.

8.           The famous Abecedarian Project[1] led by Economist James Heckman found that providing health, early learning and care from birth produced better health outcomes when they became adults. It produced a 13% return on investment per child per annum, even higher than providing only preschool education. These are very significant returns in public policy terms. They argued that the gains are not short-term, but persist throughout life, into adolescence, adulthood and even benefiting the next generation, when the child becomes a parent. These were recorded across numerous domains. The findings are much more detailed and nuanced, and I would encourage you to read them.

9.            More importantly, what we should take away from Heckman’s findings is that the early years provide us with great opportunity to build a strong foundation in our child’s life. And if we want to give them the best start in life, our support must also extend to the mother. Because her health and well-being exert significant influence on her child’s development, even before birth. Finally, it makes good sense for our entire society to be invested into this cause, because it benefits everyone.

10.            The Government understood the implications of these findings and recognised the need to act in this space. We made it a major priority in our national agenda.

11.           But even before that, we had already started investing significantly in building up quality education, healthcare and housing systems since our independence. Key pillars of an enabling environment that we have created in Singapore, raising living standards for all, which in turn provided our children with a good environment to flourish in. A key aspect of our Social Compact.

12.           We took it a step further and invested heavily in the early childhood space in the past decade. We had one goal – to make quality preschools accessible and affordable. We ramped up the number of preschool places. Raised quality through new legislation. Introduced MOE Kindergartens. Professionalised the sector. In fact, this was one of my first assignments when I joined MOE in 2006. It has certainly come a full circle for me. We needed to do this well so that every child can have the best possible start in life. PM Lee even spoke about this in three National Day Rally Speeches – in 2012, 2017 and most recently 2019. Where we outlined plans to provide 8 in 10 pre-schoolers with a place in a government-supported preschool – similar to what we provide for housing and healthcare. And to scale up the KidSTART programme to reach another 5,000 children.

13.          While we have made significant progress in giving our children a good environment to grow up in. For instance, achieving good international rankings in life expectancy and attaining the lowest infant mortality rates. We can do more in some areas. Go even more upstream where we can. Focus our resources on certain developmental pathways which warrant more attention. I would like to highlight three areas from our local data that suggest we can do better.

14.          The first area – low birth weight. We found that 1 in 10 Singaporean babies[2] are born with low birth weight. They are at a higher risk of developing physical and mental health issues later in life, such as obesity and Attention Deficit Hyperactivity Disorder or commonly known as ADHD. Maternal malnutrition and health problems, maternal age and preterm birth are some of the key factors influencing low birth weight. Fortunately, many of these can be addressed if we support couples even before conception. A good opportunity for social-health integration. Where social and healthcare agencies can work alongside each other to provide young couples with support as they plan for parenthood.

15.           Second, Gestational Diabetes Mellitus, or GDM. Earlier this year, I visited Prof Chong Yap Seng and his team leading the ‘Growing Up in Singapore Towards Healthy Outcomes’ or GUSTO study. It’s a remarkable longitudinal study that has expounded many new clinical insights. They shared with me that 1 in 5 pregnant women are at risk of developing GDM during pregnancy. But it doesn’t stop there. Together with their child, they are both at higher risks of metabolic disorders. About 1 in 2 of these women will develop pre-diabetes or diabetes within 5 years of delivery. Similarly, their child is at higher risk of developing obesity. This could lead to higher risk of longer-term health conditions like diabetes and hypertension.

16.             In light of this, KKH initiated the Temasek Foundation GDM Care Programme to provide enhanced care for mothers with GDM. But we should not only see this as a medical issue. This is an area where it takes a whole-of-society effort. An opportunity for healthcare and social agencies, to work alongside community organisations to develop programmes to address the risk factors for GDM. For instance, through physical activities and encouraging a nutritious diet.

17.              Third, maternal mental health and well-being. The GUSTO study found that maternal depression during pregnancy affects the development of brain microstructure in the foetus. This could in turn give rise to vulnerability, such as anxiety and mood disorders in the child’s later life. This underscores the importance of strengthening social support to mothers and mothers-to-be. As early as pre-conception, through pregnancy, and then into motherhood. To enhance the child’s development and learning.

18.            All of us can play a part in supporting maternal mental health.

a) Our healthcare workers actively look out for symptoms of low mood and depression during antenatal and post-natal check-ups through screenings for mothers and mothers-to-be. The idea is to identify those at-risk in order to intervene early. Social agencies and community groups can complement these efforts as well by looking out for others in the community.

b) At the workplace, we can extend more psycho-emotional support to our employees and colleagues who are pregnant or transiting back to work after maternity leave. This could be through providing more flexible work arrangements and being more understanding, should they need to be away from work from time to time.

c) At home and in the community, we can lend our support to our spouse, friends, relatives and neighbours who are pregnant and may be experiencing psycho-emotional stress. You can find some good tips from the HealthHub App and the Baby Bonus Parenting Resources as well.

National Strategy on Child and Maternal Health & Well-Being

19.              At the national level, we will do more. Our people are our greatest resource. The heart and lifeline of our nation. It is therefore our responsibility to provide our children and future generations with an environment that enables them to develop to their fullest potential. A society of opportunities, where every child can get the best possible start in life. Regardless of their family background, resources or their starting point. As we lay the foundations of a healthier next generation. This is our commitment.
20.              If we want to do this well, we need to continue investing in promoting the health and well-being of children, mothers and their families. Our approach has to be grounded in evidence, comprehensive in support, and delivered in an integrated manner, across health and social agencies.

21.            To this end, we have set up an inter-agency Taskforce earlier this year to develop a national Child and Maternal Health and Well-being Strategy to provide comprehensive support to women and their children.

22.          It will be a five-year strategy, adopting a life-course approach – starting as early as pre-conception to adolescents aged 18 years old. As many of the issues extend beyond healthcare, and often cuts across the social domains, we have brought together various agency partners. With this expertise at hand, the taskforce can focus their efforts on issues that are cross-cutting and require a good level of collaboration. We will also prioritise areas with impact that will benefit multiple generations and with clear measurable health, social and education outcomes for our young.

23.         I would broadly group the Taskforce’s efforts into three thrusts:

a) First, translating evidence-based findings into policies and programmes to address upstream risk factors. This includes the pre-conception and pregnancy phases which I mentioned earlier. This will have to be anchored on addressing specific needs at critical life stages and developmental milestones – with both mother and child at the heart of our strategy. For instance, reviewing upstream preventive health efforts for women and children. Another could be to explore how to better prepare and equip young couples for motherhood.

b) Second, we are reviewing our service delivery processes. We want to better integrate our services across the domains. By wrapping services around the mother-child dyad, we not only reap greater efficiencies, but also reduce the opportunity cost to mothers – some may otherwise ignore their own healthcare needs in favour of their child. We will also look at how healthcare agencies can strengthen collaboration with social services and education providers in extending more holistic support to mother and child.

c) Third, boosting awareness and engagement. A big part of the effort involves public education to communicate our key messages to shape positive behaviours. This will require us to continually engage with stakeholders, including parents, grandparents and service providers so that we can triangulate our insights and make our recommendations impactful relevant.

24.         I know that it’s not an easy task. But if we do this well, I am confident that our efforts will go a long way to nurture a healthier next generation.
Closing

25.           In closing, allow me to share with you a quote from a book by the Late Professor David Barker, whom I met many years ago. He was an eminent medical scientist who challenged the conventional wisdom of his time. He published extensively about the “Barker Hypothesis” which drew the connection between foetal and early life conditions with later life outcomes. Laying the academic foundations for much of the research we see today.
26.            He said and I quote “that good paths of growth and development are the greatest gift society can give to the next generation” unquote.

27.          With this, let us work together to give our future generations the greatest gift that we can ever give them. Thank you.

[1] A longitudinal study in North Carolina (US) that traced cohorts of children from birth till when they were 35.

[2] Data from the Registry of Births and Deaths and also referenced in World Bank Data Series for international comparison.