Novartis International Bio Camp 2006

06 Oct 2006

By Professor K Satku, Director of Medical Services, MOH

Venue: Shangri-La Hotel

Mr Philip Yeo,

Chairman, A*STAR;

Mr Paul Herrling,

Head, Novartis Corporate Research;

Mr Stefan Ziegler,

Head, Novartis Asia Pacific;

Distinguished guests, colleagues,

Ladies and gentlemen,

INTRODUCTION

I would like to join Chairman A*STAR, Mr Philip Yeo, in extending a very warm welcome to all of you here this morning, particularly to those amongst you who have travelled here from overseas. Singapore is a small but bold country; where multiculturalism and the best of east and west meld together in a tightly knitted social fabric. There are many interesting facts and colourful sights to discover. I hope you will take some time to explore and enjoy Singapore.

Today, I would like to cover three interesting facets about healthcare in Singapore that might be relevant to your work as bioscience students, researchers and scientists. I would like to touch on our Healthcare- "Singapore Style", our venture into clinical and translational research, as well as our regulatory approach for clinical and translational research.

COST-EFFECTIVE HEALTHCARE - SINGAPORE STYLE

Singapore has one of the best healthcare systems in the world. Though borne out of necessity the healthcare system has achieved success through dedication and hard work, particularly in the areas of clinical excellence, access to healthcare and healthcare financing. Indeed, in 2001, WHO ranked the performance of Singapore's healthcare system as number six in the world. Having said that, I would not claim that Singapore provides the most expensive and latest in terms of drugs, medical devices and implants at all times. That would be an unlikely situation. In Singapore, we run an extremely efficient healthcare system. Some would call it a tight ship. But we make sure that every patient has access to healthcare that is appropriate to needs. In fact, I hope that you will agree with me that we should not be too concerned that our healthcare services are not the most expensive or latest - particularly so when the most expensive and latest healthcare services are only marginally better than existing services, and when the marginal difference does not significantly affect the overall health outcome of our patients.This is important because we understand that healthcare must be cost-effective. And we are very cognizant of the fact that there is only a finite amount of resources to deliver healthcare.

Let me illustrate what I mean. I am an orthopaedic surgeon. I specialize in operations of the knee. Not too long ago, a knee prosthesis was introduced locally by implant manufacturers - a porous coated type implant, touted as being much better than the cemented-in type, which we were using in Singapore. The price of the new product was almost 40%  higher! Clinically however, our evaluation of the new implant was that there was no discernable difference as far as patients were concerned; and so we made a conscious effort to continue using the more cost effective of the 2 implants. Our patients continued to enjoy excellent outcomes at a cheaper price. I was told recently that due to this cost-conscious approach of local surgeons, the manufacturers have reduced the price of the newer implant.

Understandably, when a new medical technology provides a quantum leap in terms of patient outcomes, we should embrace it. However, many a time, such improvements are small and clinically insignificant, yet the price increases significantly. If we had adopted the more expensive implant in this case, we would have encouraged the manufacturers to continue selling it. We would have contributed to an unfounded increase in healthcare cost. And our patients would have lost out. Such examples are common in healthcare. Indeed, if we do not follow the principles of cost-effectiveness in healthcare, healthcare will really be a bottomless pit. Before we know it, our healthcare resources will be depleted and people who need it will be left unattended. This is something which happens in some countries but I am glad to say that we have been able to ensure equitable access to healthcare in Singapore.

Having said that, we are constantly improving our healthcare services and processes to ensure that medical excellence and clinical quality is pursued alongside cost-effectiveness. These concurrent efforts will ensure that we continue to foster a high performing healthcare system that is one of the best in the world.

Singapore is also known for one of the most unique healthcare financing mechanisms in the world. Our 3M framework - Medisave, Medishield, Medifund - is built on the basis that Singaporeans must take some personal responsibility for their own health. The Medisave scheme ensures that all working Singaporeans put aside a small percentage of their monthly salary into a personal medical savings account. The money saved can be used to pay for hospitalisations and more recently, for the treatment of chronic diseases such as diabetes, at the primary care level. Savings in a person's Medisave can be extended to defray the cost of healthcare needs of his immediate family. It can also be used to purchase health insurance plans - of which Medishield, also part of the 3M framework, is an example. Health insurance ensures that Singaporeans are able to pay for large medical bills arising from catastrophic illnesses. And to underline the importance of personal responsibility, all payments from Medishield are built around deductibles and co-payments.

Yet, the State provides graduated subsidies for healthcare services according to ward-classes in public hospitals. The subsidy is 80% in C-class, 65% in B2, 20% in B1 and none in A.

Singaporeans are free to choose the class of hospital admission that they desire, with the understanding that differences between ward-classes are primarily material comforts and hotel-type facilities; the level of care is not affected.

Primary care services in polyclinics are also heavily subsidised with consultations costing as low as $4 for the elderly and children. The third M in the 3M framework is Medifund, which provides a healthcare funding safety-net for Singaporeans who are poor and in need. The State continues to strengthen the 3M framework from time to time, adjusting the framework to ensure that the out-of-pocket cash co-payments remain affordable, and that no one is denied basic healthcare in Singapore. And because our doctors are aware of the fact that patients are paying for healthcare out of their own pockets through cash and Medisave, they are less likely to order tests and treatments that are not absolutely beneficial to the patient.

Indeed, we believe that if the State were to underwrite all healthcare costs, the health of Singaporeans would be worse off today, with rampant abuses and wastage in our healthcare system.

VENTURE INTO CLINICAL AND TRANSLATIONAL RESEARCH

In general, our system has been proven to be effective. Singapore spends about 4% of our GDP on health. This is a small amount compared with the 9% of GDP in UK, and 16% of GDP in the US. Yet, our overall healthcare statistics, such as life expectancy at birth, are comparable to the US and UK; and we have lower rates of maternal and infant mortality.

On the other hand, because we have traditionally kept a tight check on costs, we have not spent enough to build up our clinical research capabilities. Of the annual $1.6 billion that the government expends on healthcare, research expenditure accounted for only approximately 3%. And because of our strong focus on clinical services, we have not developed the talents and manpower required to grow clinical and translational research significantly.

This is not to say that no clinical research takes place in Singapore. Quite the contrary, many of our clinicians are reputed in the international arena as experts in their own field; they have published excellent papers in peer-reviewed journals, and have contributed to new knowledge in medicine. Nonetheless, the culture of medical innovation is still in its infancy in Singapore. There is tremendous scope for us to do more in terms of cutting edge clinical and translational research, medical patents, medical spin-offs and enterprises. Adapting in a truly globalized world, we now recognize that it is no longer sufficient to pursue excellence in clinical services only.

The decision to venture into clinical and translational research was an apparent but difficult one. We had to deliberate very hard, and had to convince many people of this. But noting what Mr Philip Yeo has done for basic science in Singapore, it would be foolish if we do not extend that success to clinical and translational research.

This is a golden opportunity. Creating new medical knowledge and technology, and sharing that with the rest of the world has become as important as providing excellent clinical services. And for Singapore and Singaporeans, a thriving medical sector can contribute tremendously to economic development and progress in society.

It is with this view that we sought and obtained the mandate from the government to grow clinical and translational research in a big way. As you may have heard, Singapore has committed close to a billion dollars in the next 5 years to this endeavour. Given that our healthcare services have thus far been kept very lean for good reasons, we will need to scale up our research manpower significantly. There is an urgent need for post-doctoral research fellows, principal investigators, clinician-scientists, masters or doctorate students in the life sciences, biostatisticians, and many others. We will be expending significant resources to build-up our research infrastructure. We will facilitate the growth of research partnerships between the local and international research community.

Research funds will be available through competitive grant calls on an international stage. Clinician scientists and non-medical scientists alike will be invited to apply for these funds. Contrary to popular belief, there are non medical scientists who are currently the lead principal investigators for some of our research projects.

We believe that an equal partnership between clinician and non-clinician scientists will contribute to a more vibrant research culture. All in all, it will be an exciting time for all members of the research community.

REGULATING RESEARCH IN SINGAPORE

In promoting clinical and translational research, we will need to strengthen our understanding and know-how in bioethics. There will be ethical issues concerning consent, patient safety, confidentiality, as well as the use of personal and genetic information. Religious, cultural and personal beliefs may exert selective pressures on what people are willing to accept.The government will work towards stronger legislative support for the protection of our patients and human subjects involved in research. Legislation can be extremely effective, but it can be draconian and cumbersome. Legislation will be introduced to provide a basic level of checks and balances and professionals in research would be encouraged to aspire towards a climate of self-regulation and practice guided by ethics and codes of conduct. Ultimately, a society that is able to freely discuss these ethical concerns and come to an agreement or a working consensus that is based on principles of professionalism, codes of conduct, self-regulation, mutual respect and appreciation - arguably, such a society will be better off in the long run. It will retain the flexibility to selectively embrace controversial research in key pioneering areas and to proceed cautiously while balancing the interests of society with the need to protect individuals. If legislation were meant for keeping the unscrupulous at bay, a research culture based on ethics will promote a more gracious and progressive research community.

In this aspect, we are encouraged by the fact that under the guidance of the Australian National Health and Medical Research Council, Human Research Ethics Committees now play a central role in the ethical oversight of research involving humans in Australia. Down south, more than 200 of these committees are responsible for reviewing proposals for research involving humans to ensure that such research is soundly designed and conducted according to high ethical standards.  The prominence accorded to regulation via ethical review by peers in the Australian system is worthy of our emulation. In this light, my ministry will continue to support and strengthen the work of the Bioethics Advisory Committee, as well as the various ethics committees and institutional review boards that currently deal with clinical and translational research in Singapore.

CONCLUSION

Going ahead, the Singapore government has announced several initiatives to attract talent from overseas. We hope to become a talent magnet; we hope to be home to diverse groups of talented people. If you are prepared to call Singapore your home, we are committed to help you make this transition. We are very confident that working and living here, you will come to appreciate the attractiveness of our small city state, of the Singapore "style". The effectiveness of our healthcare system will convince you that the most expensive care isn't always the best, and that the marginal differences between best and good care are often not worth the additional costs that society as a whole must bear. Our forays into clinical and translational research will be careful but certain. It will be challenging but exciting. This is a golden opportunity, and I hope that some of you will consider taking up this challenge.On this note, I wish all of you the very best in your future endeavours, and an exciting and rewarding learning experience over the next three days.

Thank you.