Following AWARE’s call for an inclusive budget to support a caring society, we organised a Roundtable event on March 24 to discuss Budget 2012 in greater detail.

The discussion was attended by more than 60 members of the public, and featured the following speakers:

• Economist Yeoh Lam Keong
• Judy Wee, an advocate for rights for persons with disabilities
• Teo You Yenn, sociologist and AWARE board member
• Vivienne Wee, anthropologist and AWARE’s Research & Advocacy Director

The following are some excerpts of the topics that were discussed during this session.

HEALTHCARE  AND SOCIAL SAFETY NETS

Mr Yeoh Lam Keong pointed out that while Budget 2012 did a good job of improving on social policies, the initiatives announced remained “underwhelming” if assessed by the degree to which they begin to meet the needs of underprivileged people on a structured, ongoing basis.

For instance, healthcare expenditure is slated to increase from 1.4 percent of Singapore’s GDP to 2.1 percent. Mr Yeoh compared this figure to that of public healthcare expenditure in Hong Kong, South Korea and Taiwan, where healthcare took up 3 to 4 per cent of the GDP – six years ago. “That is more like what Singapore needs. We need to be more aggressive in this area.”

Another area of concern is the out-of-pocket expenditure taken on by individual citizens for their healthcare costs. In Singapore, this amounts to 55 per cent – again, a much higher figure than what citizens in many similar economies pay.

This can severely limit one’s access to the healthcare system, particularly for big-ticket items like recurring treatments for long-term chronic conditions. The Budget’s emphasis on infrastructure – increasing the number of hospital beds, for instance – does not satisfactorily address the problem of access.

Mr Yeoh urged the need to think beyond the current 3M (MediSave, MediShield, and MediFund) system.

“In the 1980s and ’90s, Singapore’s healthcare model shifted to a more market-based system, rather than one based on social needs. The burden shifted to individual savings and family responsibility,” he said.

This system is problematic. For example, MediSave contributions are based on income, which puts people like the self-employed and entrepreneurs at a disadvantage. To qualify for MediFund aid, applicants have to first exhaust their own assets and the assets of their immediate family, and the success rate of MediFund applications is not currently publicly available data.

Fundamentally, Mr Yeoh asserted, “access has to be universal. If you need care, you need care, whether you can afford it or not. Healthcare is a universal human right. Few democratic societies will tolerate a non-universal system when they can afford it.”

He pointed out that this universal financial access needed both higher state spending on healthcare as well as a more complete and compulsory risk pooling system to bring the private out-of-pocket share of health expenditure down to the 20 to 30 per cent range that is common in most advanced Asian countries today.

Mr Yeoh also commended the budget for making inclusive growth an important theme and for widening the social safety net with a raft of individually modest but collectively significant measures. However, here again the prime need of the underprivileged was not suffciently addresed in his view.

In particular,  the needs of the working poor remain unresolved. The bottom 10 per cent of working-age  households earned around $800 to $900 a month, compared to a bare subsistence need of around $1,200 to $1,500 estimated by the Department of Statistics or the Ministry of Community Development, Youth and Sports for a 4-person household.

The main social support programme, the Workfare Income Supplement (WIS), only gives them $50 to $100 cash a month each employed person. This needs to be at least trebled to make a serious reduction in poverty in Singapore. While they received some help from programmes like ComCare, these were more designed for helping the unemployed rather than working families whose wages are just too low to support a decent living, and thus reaches only about 20 per cent of the roughly 100,000 households who need help.

EMPLOYMENT & CARE-GIVING

Dr Teo You Yenn noted that Budget 2012 contained several family-related initiatives. These include:

• The formal introduction of a per-capita income ceiling for childcare subsidies, which makes more households eligible for these subsidies.

• General orientation toward expanding the possibilities for women from low-income families to enter employment.

ComCare subsides for childcare, kindergarten and student care, Dr Teo stated, show a strong emphasis on work as a pre-condition. In general, the 2012 Budget is focused on enhancing the capacity and incentives for work. The desired objective is to increase the number of two-wage families.

Why might this a problem? If the current conditions of lack of flexible work and highly gendered and unequal division of labour are not addressed, then “housework and caregiving, already heavily entrenched as women’s work, are likely to be further devalued as peripheral parts of being parents” when care is further commodified.

It is also likely that women will take on a ‘second shift’ of caregiving and housework after coming home from work,” she said. “Women may be given greater access to work, but the valiant efforts directed at incentivizing work are not accompanied by similarly valiant efforts to alter the conditions of work, such as more flexible working hours. Public resources are devoted primarily to supporting women only insofar as they work.”

Instead of a “dual-income-and-second-shift” model, she urged the consideration of a dual-worker dual-caregiver model. “Parents have the right to give care and the right to meaningful family lives. We need public policy that allows for a meaningful range of behaviours and norms.”

Further, “access to childcare support should not be predicated on work. All children have the right to care”, she asserted. This is particularly important for addressing class inequalities and social mobility of children.

“The state has the capacity to alter behavior. It is important to change the conditions of work and home, and not be focused solely and narrowly on getting women into the workforce.

SUPPORT FOR PERSONS WITH DISABILITIES

Ms Judy Wee lauded Budget 2012’s aim to enhance Special Education (SPED) schools, but pointed out that it was even more important to help integrate students with disabilities into mainstream schools.

“Society does not behave like SPED schools, and it is currently very difficult for SPED students to go into mainstream employment,” she said. “In most SPED schools, students often do not complete their education like everyone else. This makes it harder to compete in employment and in society thereafter.” Whereever possible, students with special needs should be encouraged and supported to attend mainstream education.

In addition, ensuring the close proximity of SPED schools to mainstream schools will help facilitate the interaction of students from both types of schools. This will help SPED students to better integrate into society and abled students will have the opportunity to be familiar with others in society, she believed.

Ensuring that all primary and secondary schools are fully accessible  was also important – not only to students with disabilities but also for parents and grand-parents who may have limited mobility to be able to  participate in the schools’ events as well as teachers and students who may become sick or injured and who may have to rely on a wheelchair to move around .

Another urgently-needed measure: A database that clearly tracks the number of disabled persons in Singapore.  The current official estimate states that about 3 per cent of population are disabled persons. “How about the elderly who become disabled?,” asked Ms Wee. “Who are the disabled people in Singapore? If you can’t find them, you can’t help them.”

The most important thing that should underpin all the initiatives aimed at helping the disabled: Ask people with disabilities  what they need. “We need to participate in the decision-making, whether it relates to education, employment or quality of life. Empower  people with disabilities and get them involved .”

COMPARING AWARE’s RECOMMENDATIONS WITH ALLOCATIONS IN BUDGET 2012

Dr Vivienne Wee compared AWARE’s recommendations with allocations in Budget 2012. A matrix aligning AWARE’s recommendations with budgetary allocations, with citations of comments of Ministers and MPs, was distributed to all participants. (See the matrix and AWARE’s Budget recommendations here and here.)

Dr Wee raised questions about the people excluded in a budget that was supposed to be inclusive, such as the following:

• Why is no attention paid to the fact that many women do not have enough Medisave?
• How will women who stop paid employment or who take part-time jobs to care for the elderly be supported, if they cannot even afford to hire domestic workers in the first place? The monthly subsidy of $120 to help with the maid levy for families caring for an elderly member at home assumes that all carers are able to afford to hire domestic workers in the first place.
• Why is financial assistance for those with low income targeted only at families with children of school-going ages? This excludes low-income singles, single mothers, couples without children and families without children of school-going ages.

The most noticeable gap relates to AWARE’s nine recommendations for widened access to subsidies for infant care and childcare, on which Budget 2012 was totally silent. “Why? What is implied by the silence?,” Dr Wee asked. What this silence means on a practical level is the continuing discrimination against certain groups in Singapore:

1. Unwed mothers and stay-at-home mothers will still be discriminated against.
2. Working mothers are favoured because they contribute to economic growth.
3. Married mothers are favoured because they reinforce family ideology.
4. Families have to provide infant care as their private solution to a private problem – too bad if they can’t afford alternatives other than staying at home.
5. Whether employers establish childcare places or flexible working arrangements is up to them.
6. Fathers do not need any leave to care for babies – neither two weeks nor one month. They do not / should be active parents.
7. Childcare is women’s responsibility. Maternity leave must remain maternal.
8. Single fathers with dependent children should not get same tax relief on the levy given to female employers of foreign domestic workers because these single fathers should be encouraged to remarry.

Dr Wee also questioned why we continue to lack reliable statistics on vulnerable groups in Singapore that are sufficiently detailed, consistent, regularly updated and disaggregated by sex, age and citizenship. For example, why was the Central Registry of Disabled Persons closed in 1987? This was, in any case, only a register of users of disability services. Why is there no full register of persons with disabilities? How can we be inclusive if we don’t even know who has to be included?

DISCUSSION

The animated discussion that followed raised many important points, including the following:

• The dominant paradigm underlying healthcare financing in Singapore is, first, that health is a personal responsibility and, second, the family is the first line of support. But this is a flawed paradigm because it does not take into consideration the health implications of ageing, which cannot be consigned simply to the personal responsibility of elderly people, especially elderly women, who many not have the financial resources to pay for their healthcare.
• Moreover, the paradigm assumes that the family is always able to pay for the healthcare needs of the elderly. Caregivers are in fact depleting their savings and earnings to care for elderly family members. A fundamental paradigm shift is needed if healthcare needs of the vulnerable are to be addressed.
• There is a need to think about the 3M system because MediSave is derived from one’s own CPF (which is tied to employment, thereby leaving stay-at-home wives and other unemployed persons vulnerable) and MediShield premiums have to be paid by oneself, while MediFund is accessible only to the destitute.
• It was noted that MediFund is designed to be difficult to access, as it is assumed that people would otherwise cheat the system. As a result, MediFund has become very inaccessible, especially to the vulnerable who tend to have lower education and no financial resources to speak of.
• The question was raised about why Singapore cannot have compulsory health insurance. In response, it was noted that the dominant paradigm of making healthcare the responsibility of self and family implies that it is not the responsibility of the government. There is thus no compulsory health insurance as the government does not want to pay the premiums of those who cannot afford such insurance.
• It was noted that in the healthcare system was more universal in the past. From the mid-1980s onwards, this was replaced by a more market-oriented system. However the healthcare market is highly asymmetric and cannot provide universal healthcare as a public good. This has to change so that there is universal access to healthcare.
• But there is a lack of awareness of healthcare rights in society. As a result, instead of asking for a better public healthcare system, some people are asking for euthanasia – the right to die, because they cannot afford to stay alive.
• There was a suggestion that there should be risk-pooling of the amounts that individuals have in Medisave. The total is sizeable yet individuals may not have enough in their separate accounts. Risk-pooling would enable probability distribution.
• There is currently much anxiety among Singaporeans about not having enough financial resources for their old age and for their healthcare.
• Hospitals are involved in debt collections of insolvent patients, instead of focusing on the provision of caring for their health.
• The point was raised that a paradigm shift is also needed for social welfare, because the Many Helping Hands policy has led to the duplication of services and competition between them. But a blind spot prevents the MCYS from seeing these flaws of the system. Instead of seeing the ineffective redundancy, the eco-mapping approach that is used rates positively the high ratio of helpers to the needy person, without questioning whether this is the most appropriate and cost-effective response.
• It was noted that in the 1960s and ’70s, the PAP legitimised itself as a provider of social security. But its more recent adoption of the economics of privatisation has caused it to abdicate its role of caring for the less fortunate. In the context of a world polarised by globalising forces, there is a need for governments to play a corrective role by helping to level an uneven playing field. Leaving the less fortunate to sink or swim by themselves carries the risk of letting society splinter apart of its own accord.
• There was discussion about the various sources of income available to the Government that enable it to play a more supportive role for the vulnerable members of society.
• With regards to persons with disabilities, it was suggested that research should be done on what wages they are getting.
• A medical practitioner who has many patients who are elderly and disabled noted that lift upgrading is still not a priority in many HDB blocks.
• It was noted that instead of trying to provide a supportive environment for persons with disabilities – for example, by enabling all schools to accept disabled pupils – the Government was taking a particularistic approach by over-investing in Special Education (SPED) schools.
• On the other hand, the Singapore School For The Deaf in Mountbatten, which has been an established institution for almost five decades and which has long served as a centre for deaf culture, is going to be closed in 2016 by the Government with no reasons given to the deaf community.

The discussion made it clear that there is a need for sustained advocacy by civil society groups and greater responsiveness on the part of the state for building a truly inclusive Singapore.

Ultimately, participating in the decision-making process requires all under-represented and marginalized communities to take a more pro-active approach. As Dr Teo put it: “People who have the relevant expertise need to exert more consistent pressure on the government, and not just once every four years.”