Five-minute video from the Straits Times about the value of the new proposal

At the end of June 2021, the Ministry of Manpower (MOM) put out a tender for interested parties to operate nine proposed medical centres to serve migrant workers, particularly those housed in dormitories. Three of these centres will be co-located within large dorms while six others will serve migrant workers in the vicinity.

The six large dorms with co-located facilities are:

  • Sungei Tengah Lodge in Choa Chu Kang, which had 25,000 bed spaces pre-Covid;
  • PPT Lodge 1B (also called S11 dorm) in Punggol, which had 14,000 bed spaces pre-Covid; and
  • Tuas View Dormitory, which had 16,800 bed spaces pre-Covid.

With the new rules limiting the number of occupants to ten per room, it is likely that these dorms’ approved capacity has been reduced.

The six regional centres will probably be located within recreation centres in Penjuru, Gul Circle, Kranji, Woodlands, Kaki Bukit, and Loyang. Each of these locations is intended to serve dorms in its sector (see the map at 1 min 20 secs in the video above).

The intention is to make primary healthcare more accessible to low-wage migrant workers, particularly those living in out-of-the way places, which many dorms are. Another motive is for infection surveillance, part of ever-expanding State surveillance of migrant workers.

The successful bidder will be required to provide culturally-sensitive services, e.g. speaking workers’ languages. The latter may prove hard to achieve as few medical personnel currently come from similar backgrounds as our migrant workforce. Making providers hire interpreters may add to cost.

Will it help?

TWC2 welcomes the proposal. Making primary healthcare more accessible cannot not help, though many details may not fully emerge until the centres are up and running.

Yet, there are areas where more thought and action are needed. Barriers to seeking healthcare are not only restricted to physical distance. Planting medical centres closer where workers live may only go so far if demand for healthcare is held down by other factors. So long as these barriers are not removed, the potential of these investments may not be fully realised.

Provisioning is one thing. Unfortunately, many employer practices can stymie demand. Despite putting in so much cost and manpower, we may not get the better health outcomes hoped for unless we deal with these issues too.

The key issues that need attention are:

  • physical access
  • cost and payments
  • employer interference
  • fines for absence from work
  • threat of termination

Physical access

The six sectors (shown in the video) look nice on paper, but in fact there is very poor connectivity among the dorms and recreation centres in each sector. Take for example, sector F, whose proposed medical centre is supposed to be located within Penjuru Recreation Centre.

We reckon (from the map in the video) that Sector F has eleven purpose-built dorms. In the schematic map below, we show the bus routes that workers from each of these dorms can take to (possibly) get them to, or at least closer to, Penjuru Recreation Centre. As it obvious from the map below, it will be inconvenient for workers living in eight of the eleven dorms. Only three dorms are within easy walking distance from Penjuru Recreation Centre.

What is a Recreation Centre?

‘Recreation Centre’ is a bit of a misnomer. It’s better of think of it as a sort of village square around which are some shops and cafes. They usually have sports fields or sports courts as well. It is meant to provide some basic amenities for the workers staying in nearby dormitories.

Unlike dormitories, recreation centres are not as strictly gate-controlled though (as usually is the case for anything related to migrant workers) they are designed to be intimidating.

Kian Teck cluster of dorms

Workers living in the three dorms in the Kian Teck area will have a hard time getting to Penjuru. They are served by either bus 251 or 252, but both these routes terminate at Boon Lay Town Centre, many kilometres from Penjuru. There are some other buses in the area, but since those routes go even further away from Penjuru, they are not shown on our map.

Even reaching the bus stop can be a bit of a problem. Workers living in Kian Teck Hostel will need to walk perhaps 500m to reach the nearest bus stop to catch bus 251. Imagine if you’re sick or your leg hurts.

From Boon Lay, these workers could conceivably take the metro to Jurong East, and then change to bus 78 or 79 to get to Penjuru. But why bother? Why not just see a general practitioner in Boon Lay itself?

Toh Guan and Bukit Batok cluster

There is one dorm in Bukit Batok, called Acacia Lodge. Outside its gate is a bus stop served by bus 189. Alas, bus 189 goes to Bukit Batok Town Centre and ends there.

There are two dorms in Toh Guan. They are a stone’s throw from bus stops served by buses 41 and 183. Unfortunately, these two routes end in Jurong East Town Centre. Presumably, ill workers could then walk some 500 metres from the Town Centre terminus to another bus stop in Jurong East to catch either bus 78 or 79 which will take them to Penjuru.

But, as with the guys in Kian Teck, why bother? Why not see a general practitioner in Jurong East or Bukit Batok, and save all that travelling?

The Terusan cluster of dorms

Almost comically absurd would be the situation faced by workers living the the two dorms in the Terusan area. On the map, they are quite close to Penjuru, but a river separates them, and there is no bridge nearby.

To get to Penjuru, these workers would have to walk about one kilometre in the hot sun to Jurong Port Road since there are no buses serving the Terusan area itself.  From Jurong Port Road, they’d have to catch bus 79 which would take them to Penjuru.

The Aspri-Westlite dorm at Jalan Papan (Terusan cluster), with the low-rise Terusan Recreation Centre in the foreground. From the upper floors of the dorm, one can see the Penjuru Recreation Centre and its proposed medical centre across the river, but getting there is far from easy.

One way to overcome poor transport connectivity is for each sectorial medical centre to run a twice-daily ferry service to every one of the dorms in its sector. For example, each morning and each afternoon, there could be a bus waiting at each dorm for anyone wanting to see a doctor.

This will no doubt add to costs — who pays will be an issue. Besides, this assumes that workers have agency and that they are free to hop onto the ‘medical ferry’ if they feel ill. As will be explained below, employers can get in the way, defeating the best-laid plans.

Cost and payments

Currently, the medical insurance that employers are required to purchase needs only cover inpatient care and day surgery. See this page on the Ministry of Manpower’s website. The doctor consultations and prescriptions from these proposed medical centres will be outside the scope of insurance policies. Workers will either have to pay out of their own pocket or, if their employers agree, they may seek reimbursement.

It’s too early to say what the costs will be, but if it is not different from what general practitioners (GPs) charge in Boon Lay, Jurong East or Bukit Batok, then cost will become an obstacle. As it is, workers are put off by prevailing costs — precisely why they delay accessing primary healthcare.

Even if an employer is prepared to shoulder costs, the employer may prefer to negotiate a better rate with GPs in the area and direct his workers to the designated GPs. So, workers may find themselves forbidden to access these proposed medical centres (even if they can get there by bus).

Singapore needs to consider implementing a subsidy scheme for work permit holders in the same way we have one for senior citizens. Like many seniors, work permit holders have limited income, and yet, as Covid-19 has shown, excluding them from our universal healthcare system only creates public health hazards for everyone else.

Ideally, like the scheme we have for senior citizens, the subsidy should be available at any participating clinic; it should not be restricted to only the nine proposed medical centres. We have to bear in mind that some dorms are too far from the medical centres and anyway, a few hundred thousand other work permit holders do not even live in dorms.

Employer interference

Some employers will strongly prefer that their workers see only those doctors that the employer has designated. As mentioned above, they may thus forbid their workers from going to the proposed medical centres.

Besides cost reasons, another big motivating factor for employers is that when a clinic depends on the employer as paymaster, the employer may feel a right to influence doctors as to how much medical leave to give, or what treatments to carry out. Over the years, this has been one of the most common complaints that workers have brought to TWC2. Workers with broken bones are given just two days’ medical leave; workers ill enough to require hospitalisation (in the doctor’s opinion, as expressed to the worker in private) suddenly find that their boss has managed to ‘persuade’ the doctor to agree to sending the patient back to the dorm.

Nothing in the current proposal for medical centres addresses this problem of employer interference. Yet, if the aim is to improve better primary healthcare for workers, this is an issue that cannot be avoided.

Fines for absence from work

TWC2 has repeatedly seen cases where employers impose fines for absence from work. Not only is the daily wage docked for the day, an additional fine of perhaps twice the daily wage is deducted from the month’s salary.

We’ve even seen cases where these fines are imposed despite the worker having a valid medical leave certificate from a doctor. Employers often take the view that their foreign workers are malingerers, and see workers’ attempts to get medical leave with much suspicion.

MOM may say that workers have a right to complain, but workers also know that the price of complaining is too high.

Singapore has given employers the right to terminate workers at will. Once he has fired his worker, the employer is duty-bound, under the law, to send the worker home unless MOM intervenes and permits the worker to stay. For the worker, complaining about a fine means the loss of his job, likely repatriation and the depressing prospect of having to fork out thousands of dollars again to find a new job.

Even if MOM intervenes and permits him to stay, he is usually permitted only to stay until the case is concluded, not to stay to find another job.

A family doctor’s clinic beneath Boon Lay station.

For the worker, it is a simple calculation:

  1. Grudgingly bear the $50 or $100 fine for absence from work, or
  2. Complain to MOM about it, but also get sacked and then pay $5,000 to find another job.

It’s hardly any surprise that workers do not seek medical help until a condition has become serious.

So here again, drawing up beautiful plans for medical centres is not enough unless we tackle the many other factors that stop workers from seeking healthcare. These other factors are often in the very areas that MOM has tended to avoid doing anything about, such as the right to stay and look for another job and the endemic corruption we see in Singapore over recruitment costs.

Threat of termination

To be fair, many employers do not impose fines for seeking healthcare and taking medical leave. That, however, does not mean that workers still feel confident about seeing a doctor. Especially if he has a chronic disease that requires regular visits, the worker may fear that sooner or later, the employer is going to decide not to renew his work permit, preferring to hire another worker in better health.

The guy with diabetes or high blood pressure might be afraid to submit clinic bills for reimbursement, because his employer might soon notice his regularity of visits and get upset about costs. Yet, the worker himself may not be able to bear the costs.

He’d rather keep his medical condition under the radar, e.g. through self-medication.

The elephant in the room is the freedom of employers to terminate employment at will. Perhaps this is too fundamental an issue to overturn. But at the very least we should be able to improve policy by decoupling termination from repatriation and making it easier and cost-free for workers to get another job if they are sacked. Is that so hard to do?