New Pricing Model For Chronic Disease Economics Essay

Abstraction: High drug monetary values are a major barrier to patient ‘s entree and conformity to the medicine, nevertheless low drug monetary values are frequently argued that detering advanced research and development. A redesign pricing theoretical account has been proposed for Singapore health-care system to better patient ‘s conformity without compromising the outgo of public wellness attention and the net income of makers as good. In the theoretical account, people would buy the one-year licence of the drug from maker whereby warrant unchained entree to a clinically optimum figure of prescriptions over the class of twelvemonth and Statin is used as presentation of how the theoretical account works.

Pharmaceutical Market Singapore. Spending on Pharmaceutical is outpacing growing in entire disbursement in Singapore and other Asiatic states. Harmonizing to the Business Monitor International ( BMI )[ 1 ]for Singapore, disbursement of pharmaceuticals in 2010 reached Singapore $ 858 million ( USD $ 629 million ) , lifting to $ 903million in 2011 with a growing rate of 5.2 % in local currencies. Despite the low influence on the entire outgo of health care, the increased drug disbursement has raised concerns by and large on the handiness of patients to the much-needed pharmaceutical merchandises. In fact, private infirmaries and clinics account for around 70 % of pharmaceutical market gross revenues yet authorities infirmaries account for merely 5 % of the market in 2012.

Singapore Healthcare. In rich states, inventions in medical specialties contribute to lower morbidity and premature mortality from chronic disease. However in low-and middle-income states, the available and usage of medical specialties remains unsure and financially stultifying to the wellness system or to the patient and his or her household[ 2 ]. With an outstanding economic growing but decelerate in the average family income doing a big income disparity with a high Gini coefficient ( 0.454 )[ 3 ]parallel with several other planetary metropoliss such as Hong Kong and taking US metropoliss like New York.

The rise in medical cost has outstripped average income growing and the low income population is unable to maintain up with the gait of addition. Additionally, the current wellness attention system left many people uninsured or under-insured falling through the cleft. This concern is non merely within the low income group, harmonizing to 2009 AXA Life mentality Index[ 4 ]showed that Singaporeans aged from 25-50 have a worsening strong belief that their wellness will keep up over the following 12 months, the following five old ages and upon retirement, the lowest compared to other Asiatic states.

Rising Concern of Chronic Disease. With increasing life anticipation from 78 old ages in 2001 to about 82 old ages in 2010 2 and more sedentary life style doing a heavier load of chronic disease. In fact, bulk of the primary attention stakeholders like GPs are private sectors, hence with the construct of “ free market ” in Singapore health-care system, the hapless is the most vulnerable and raise a important concern. For illustration, a low-income Singapore citizen gaining $ 1,400 monthly in average3, each office visit of GP costs $ 80 with monthly chronic medicine – 6 % of their monthly income, given that they have no kids and unsophisticated instance.

This state of affairs consequences in a repeating tendency of single who can non afford chronic medicines or even the wellness attention services waiting until they become sufficiently sick to necessitate polyclinic or infirmary attention.

This self-contradictory state of affairs by and large leads to increase in hospital admittances, morbidity and mortality as the load become linear. In 2011, Singapore infirmaries were owed SGD $ 110 million in outstanding patient debts, there were 136,000 measures outstanding for two months or more translating to SGD $ 48 million in entire arrears and is increasing by twelvemonth. More than 80 per cent of these outstanding measures were incurred by Singaporean patients1. .

From the point of view of clinician, the effect of this tendency would probably lend to the uninterrupted addition in patients out of pocket payment in consequence of presenting a menace on patients ‘ behaviour and result. For clinician, out of concern of patients ‘ conformity, normally try to extenuate the high cost by offering drug vouchers or pill splitting[ 5 ]. Besides for pill dividing – dividing the higher dose tablet to avoid high cost, may non be suited for all medicines and pose certain dangers to patients like uneven split or sustain-release preparation. This state of affairs is non uncommonly seen in Singapore public scene and as a druggist, patients particularly for aged normally complain about the trouble in splitting.

The clinical jobs of high monetary values are a barrier to patient ‘s conformity with intervention. In RAND, monetary value of the medicine does impact the demand and this consequence exaggerates in the hapless population. The impact of high monetary value is of critical importance and should non be neglected as it does impact the clinical results of the patient for case uncontrolled diabetes, uncontrolled high blood pressure or high cholesterin to call a few. All these jobs of disobedience would impute to higher admitted rate and decline the quality of life of patient ensuing in higher outgo needed in the health care system.

Healthcare strategy for Singapore citizen. Pricing and reimbursement systems in Singapore are by and large straightforward whereby drug pricing is left to market forces in private sectors, whereas, in the populace sector, drugs are divided into two classs: ‘standard ‘ and ‘non-standard ‘ drugs. The ‘Standard List ‘ comprises indispensable medical specialties chiefly generic drugs to run into the demands of population while the ‘Non-standard List ‘ is predominately used in the private sector.

With the challenge of ageing population, the load of chronic non-communicable disease is acquiring heavier. Harmonizing to the Burden of Disease Database from Business Monitor International ( BMI ) , the figure of disability-adjusted life old ages ( DALYs ) lost to non-communicable disease histories for 91.5 % of DALYs presently lost to all diseases in Singapore in which shows that more attending should be put on the medical service of this country.

Medisave for Chronic Disease Management Programme ( CDMP ) strategy is introduced to put aside portion of the income of every Singaporean to pay for the disbursals of sanctioned lists of health care service and medicines. The CDMP programme covers in sum of 10 chronic diseases for diabetes, high blood pressure, lipemia, shot, asthma, COPD, schizophrenic disorder, major depression, bipolar upset and dementedness. The intent of this is to cut down the out-of-pocket hard currency payment from the patients up to 15 % copayment with up to $ 400 per year.A If the bound of the Medisave history has reached, the excess disbursals will be deducted from the histories of their partner, kids or even grandchildren.

Not plenty aid for the hapless In 2009, occupants of Singapore withdrew a sum of SGD 600mn ( US $ 428.56mn ) from their Medisave histories, up from SGD $ 590mn ( US $ 428.56mn ) in 2008. Residents complained that about 50 per cent of Medisave backdowns in 2009 went to pay for dependants ‘ medical disbursals ensuing they themselves may non hold sufficient fund for themselves

Critics argued that Medicare financing system has been neglecting to undertake the turning health care costs and jobs among the hapless and aging population. However, it reduces the out of the pocket payment for patients in each visit the other part of the payment is contributed from their ain CPF. For case patient taking Lipitor which DDD costs about SGD $ 3, their up-front payment can be every bit low as SGD $ 0.45 and SGD $ 2.55 paid by their ain CPF- certain % part from their monthly wage. If Lipitor is listed in SDL2, which means patient is eligible for 50 % subsidisation, and the other 50 % of copayment could be paid by 85 % from CPF and 15 % out of pocket ( SGD $ 0.225 ) . Besides if the patient has used up their Medisave history, their partner or kids histories have to pay for it. As a consequence, the lower income or unemployment would be well vulnerable to this programme, as they may wash up the histories of their ain partner and kids who may besides belong to the groups of hapless income, presenting a menace of “ hapless supports the hapless ” .

In short, these affect the sickest the most, since they surely reach the caps earlier than the other patients and so pool the hazards among the household by devouring their caps on drug benefits. Subsequently greater degree of non-compliance for those chronic patients ensuing in worse results and do non cut down disbursement consequently.

Pharmaceutical Manufacturer In Singapore, basic chronic medical specialty is normally available in the standard pharmacopeia, nevertheless for advanced medical specialty, when they are available they frequently are non subsidized or patients need to pay significant monetary values. For case, a month supply of Lipitor 40mg daily could be SGD $ 84 for patients whereas it merely cost AUD $ 35.4 to patients under PBS in Australia.

Drug maker should sell the same drug in “ differential pricing ” in which higher in richer states, frailty versa. In economic theory, makers should put monetary values at a markup over fringy cost that is reciprocally relative to the monetary value snap of demand so as to maximise their net income by expand entree every bit much as possible with varied fringy addition. However, differential pricing merely works if the state with higher pricing is non affected by that of lower pricing elsewhere by parallel trade or importing of drug. Therefore, manufactures instead non offering lower monetary values in the poorer states for fright of hazard of parallel export to protect their chief beginning of net income in higher monetary value states and leave the monetary value unaffordable to the emerging states.

A New type of Pricing Model The cardinal clinical job is that unaffordable drug monetary values pose a barrier to patients ‘ conformity. In a wall street journal synergistic canvass, 35 % of grownups considered fiscal consideration as a ground for disobedience and the consequences is corroborated by legion surveies. Non-compliance can take to farther worse wellness position thru uncontrolled medical conditions In which cut down the productiveness and increase medical cost.

Drug copayment is normally used for prosecuting patients in doing rational determination about health care. In economic footings, copayment brings the patient judgement if the interventions are truly effectual and necessary, thereby minimising moral jeopardy. There are two premises have been made that 1 ) medicines prescribed by physicians can run from really utile to non utile ; and 2 ) patients themselves are able to separate. Otherwise copayment will be merely like reallocation of the cost of insurance. While confronting with high copayment with deficient dependable information, patient tend to do tradeoffs over clip.[ 6 ]

In Singapore or other emerging states, it is common that patients by and large are less educated to separate in effectual and uneffective attention. As a consequence, if patient is confronting high copayment, they may non take to go on their intervention which benefit to their conditions so as to take down the wellness attention cost. Recent grounds is clearly showed that mortality and reinfarction rates of patients who have suffered myocardial infarction is reduced by 1.1 per centum and 13.1 per centum correspondingly with no copayment in which would salvage about USD $ 6000 per patient[ 7 ].

This theoretical account is applicable for any intervention every bit long as repeated medicine is require to keep effectual clinical results in which intervention costs depends on the degree of usage. Indeed, patients who suffer from chronic disease would be benefited the most for which medicine would be taken for a long period with lower co-payment is needed.A

The licence theoretical account by economic expert two portion pricing which normally applied in non-medical universe for illustration in all-you-can-eat counter, telecommunication service or OEM licence for package. Alternatively of bear downing you every clip you use the package, you have to pay the fixed licence fee up-front. What make pharmaceutical market similar to all these service are 1 ) there are tantamount replacements ( e.g Me-Too drugs ) and 2 ) the really low cost of production.

Another illustration, the concern theoretical account of fittingness nines in which members normally pay a fixed fee monthly or annually so as to derive limitless usage of the installations in the period of clip. With that, members will be more motivated for more frequent visit and accomplishing better wellness result which would profit both parties. In the same manner, the increased use would intend higher conformity for patients and later with better clinical result and besides profit to the manufacture.A

A new theoretical account of drug licence is proposed to take down the co-payment in which to better the conformity of the patients to intervention[ 8 ]and yet without compromising the net income of drug makers. In this theoretical account, patient has to pay for one-year “ license fee ” for the drug they take in order to buy prescribed medicines in the class of one twelvemonth.

An exemplifying illustration: The instance of Statins ( Branded Statin )

In general, Singapore citizen pay 50 % co-payment of any drug listed in the SDL2 list[ 9 ]in the public sectors. With the aforesaid facts demonstrate the high copayment raised the concerns of affordability of the patients and the attachment to the prescriber drug, a chronic medicine was chosen to be an illustration to exemplify how the theoretical account works. Statin was used every bit illustration as there are comparatively established surveies conducted in US and generalizing the consequences of the surveies to local scenes[ 10 ].[ 11 ]

The aim of this paper is to demo patient ‘s conformity can be improved while remain the outgo of wellness program and the net income of pharmaceutical industry unchanged compared to be local subsidisation scheme- Standard Drug List ( SDL ) .

The Selling Price of Statin The mean selling monetary value of day-to-day dosage of Branded lipid-lowering medicine ( Lipitor 40mg ) is SGD $ 3.00 from six different public establishments in Singapore. In the current position, Lipitor is non listed in the SDL therefore patients have to pay for full monetary value. In this theoretical account, we assume that Lipitor is listed in SDL2 – 50 % copayment system.

Local Data of Average statin conformity and copayment

Conformity is defined in medicine ownership ratio ( MPR ) — the proportion of prescribed yearss for which prescription are filled over the subsequent 12 months.

Based on literature publication, the satisfactory conformity degree of lipid-lowering medicine is considered as 0.8[ 12 ], albeit slightly arbitrary, it has been widely accepted in the international degree. Therefore, if copayment is eliminated, conformity degree would be expected to be improved to ( 12 months *0.8 = 9.6 months ) .

Due to miss of local empirical survey in the association of conformity and copayment, the local conformity was extrapolated from a recent survey in US. Based on the survey, each $ 10 addition in copayment, lipid-lowering medicine conformity fell on about 5-6 % in US10. Assuming Lipitor costs every bit much as in Singapore, we estimate there is 5-6 % bead in conformity with every SGD $ 12.2 addition in copayment. This estimation could be conservative compared with Singapore with lower income in mean which may do higher impact on the snap. In this theoretical account, the monetary value snap of patient in SG on lipid-lowering medicine is assumed to be the same in US.

Assuming the additive relationship between the copayment and attachment to the prescribed drug with that two monetary value points, mean patients ‘ conformity is estimated and adjusted harmonizing to the varied sum of copayment in three different scenarios.

Pricing Model Scenarios

In this illustration, three scenarios 1 ) position quo ( 50 % copayment ) 2 ) pure drug licence theoretical account with zero copayment and 3 ) drug licence with copayment in which the drug licence fee is paid for lower copayment will be simulated. In the 2nd and 3rd scenario, the drug licence would be eligible for 12 months prescriptions filled per licence.

To show the drug licensing theoretical account the out of pocket from patient and the net income of industry remains unchanged, out-of-pocket copayment of patients for the branded lipid-lowering medicine and the net income of the industry in three scenarios will be kept as changeless though all scenarios. With these two unchanged monetary value constituents preset in the theoretical account, varied monetary value of copayment or license fee is obtained among these scenarios.





Benefits Of Drug Licensing to Patients, Health Plan, And Manufacturers: The instance of Statin


SDL2 ( 50 % Copayment )

Drug License

License and Copayment

Patients ( per lipid-lowering medicine user )


Copay per prescription B, degree Celsius

$ 45

_ g

$ 13

Cost-share on the licence

_ g

$ 312

$ 198

Average compliancea

58 %

80 %

74 %

Number of 30-day Rx yearly




Out of pocket payment for Branded lipid-lowering medicine vitamin D

$ 312 H

$ 312 H

$ 312 H



Health Plan


Plan Prescription costs

$ 312

_ g

$ 115

Plan licence costs e

_ g

$ 312

$ 198

Entire cost for lipid-lowering medicines

$ 312

$ 312

$ 312





Manufacturer monetary value per Rx

$ 90

$ 0

$ 71

Industry cost per Rx degree Fahrenheit

$ 0

$ 0

$ 0

Drug licence fee

_ g

$ 312

$ 198

Industry net income

$ 625 H

$ 625 H

$ 625 H



a Based on the conformity rates reported in DP Goldman, ” Changing Pharmacy Benefits with Clinical Status: The instance of Cholesterol-Lowering Therapy, ” AJMC 12, no. 1 ( 2006 ) :21-28

B Approximate estimatied mean monetary value of day-to-day dosage ( 20mg atorvastatin ) from Singapore public establishments

hundred Assume Brand lipid-lowering medicine is listed on the SDL2 strategy ( 50 % copayment )

vitamin D Excludes medisave coverage: 85 % of the monetary value could be utilized for upfront payment from the patients

vitamin E License fee cyberspace for patient cost sharing on the licence

f Assume minimal for convenience

g Not applicable

H preset as changeless


Position of Patients

Assume the branded lipid-lowering medicine is listed in SDL with 50 % copayment, one-year out of pocket payment for each patient would bear down SGD $ 312.3 in entire ( 6.94 prescriptions yearly x $ 45 ) . In the Drug License illustration, with no excess out of pocket payment from each user, therefore the licence fee is the same as entire one-year copayment in the SDL scenario. Entire out-of-pocket payment for lipid-lowering medicine maintains the same in the licence theoretical account, nevertheless the mean conformity has shown to be improved about 22 % ( Estimated conformity from the theoretical account: Drug License 80 % ; SDL2 58 % ) compared to the current SDL2 theoretical account.

Health Plan

The mean selling monetary value of Lipitor 40mg in three public establishments is about SGD $ 3. In this theoretical account, we assume the branded lipid-lowering medicine ( Lipitor ) is listed in SDL with 50 % subsidisation – 50 % is paid by public wellness program and the other 50 % is paid by patient in the signifier of copayment. In this illustration, each lipid-lowering medicine user cost the wellness program SGD $ 312 ( $ 3 x 30 yearss x 7.8 prescription per twelvemonth x 50 % ) .

In the pure licence theoretical account, presuming the out-of-pocket payment of patient remains the same as the position quo, public insurance company would be charged the same licence fee SGD $ 312 per twelvemonth for each lipid-lowering medicine user which in return for 12 months ( 1 twelvemonth ) of prescription with zero copayment. Since the wellness program merely paid for the licence fee, hence the entire outgo for each lipid-lowering medicine user is the same as the SDL2 theoretical account.

Pharmaceutical Industries

Assuming the fringy cost of the drug is insignificantly low and can be negligible in the theoretical account. From the position of pharmaceutical industry, the entire net incomes from gross revenues to the wellness program is this is equal to the merchandising monetary value of the drug times the figure of prescriptions filled in a twelvemonth which is SGD $ 625 ( $ 90 per monthly supply x 6.94 months ) . In the licensing theoretical account, the entire net income is tied to the one-year licence issued from the wellness program to the user. Under the licensing theoretical account, every bit long as the wellness program could afford SGD $ 625 per users yearly in which


Puting a rational monetary value from the licence theoretical account could perchance profit together of the different stakeholders for case authorities, insurance companies, and patients. The theoretical account merely demonstrated that with an appropriate pricing of license fee, patient conformity could be improved without any compromising of the out of pocket payment, the disbursement in wellness attention program and the net income of industries. Bettering patients ‘ conformity associated with better disease management7 and it would convey cost economy as a consequence of decreased medical disbursement, in the long tally, all parties can portion the benefit with drug licensing.[ 13 ]


There are several other restrictions in this analysis as some of them have mentioned in the old subdivisions.

First, the administrative cost for the drug licensing theoretical account is non included in the cost. The more simplified of streamline procedure in the drug licence theoretical account for makers, authorities and patients could bring forth nest eggs to cover the costs of the plan which we believe is non big compared to other costs described in the theoretical account.

Second, the analysis required a figure of simplifying premises, for case treating patients irrespective of their attachment, and presuming Singapore patients would hold the same affordability and their monetary value snap to the copayment of branded intervention.

Finally, merely short term consequence on conformity is addressed in the theoretical account, if the conformity on the chronic medicine grows, the fringy net income of the makers would be underestimated in the long tally and the possibility of decrease in licencing fee could be accomplishable over clip to farther better the fiscal profile of the licensing theoretical account for authorities.

Practical concerns of the Drug licensing theoretical account

1.A A A A Firstly, drug licensing is non a replacing of existed wellness program in Singapore instead to conjoint together to profit different groups of patients. For illustration, patient whose clinical diagnosing is non warrant for specific intervention would non be suited for licencing theoretical account whereas for patients whose conformity is needed for the intervention, drug licence therefore can guarantee use with lower co-payment. Therefore, drug licences could move as an enlargement on top of the existed strategy SDL2 in Singapore for chronic medical specialty to better conformity.

2.A A A A A A Secondly, it is rather straightforward that though conformity would certainly improved with the licensing theoretical account, the up-front licence fee itself could be excessively high for patients whereby it is detering them to initial the therapy. In this theoretical account, we have illustrated that lower licence fee can be applied to patients with copayment ( lesser than the position quo of copayment ) in each visit. As a consequence, conformity of the intervention is still comparatively improved compared to the current system. An option is to offer those patients who are non clinically benefited from the intervention are eligible for partial or to the full refund after a certain period of test. For other options for case like “ societal loan ” to the patients or revenue enhancement tax write-off if executable from the authorities

3.A A A A A A Another concern is the inclination of inordinate and abuse of the drugs with lower or zero copayment which in economic footings, the licensing system would do “ moral jeopardy ” . Indeed, moral jeopardy arises where the being of coverage increases the chance of incurring outgo for the covered hazard or increase the sum of that outgo. In other words, patient will do more usage of the service than they would if they had to pay full monetary value[ 14 ]. However if we take a closer expression of the theoretical account reveals that moral jeopardy could be irrelevant. First, increased usage of the drugs wouldA non incur higher cost for the wellness program. Integrating copayment system into the theoretical account would anticipate to cut down unneeded use induced by moral jeopardy and the entire outgo of wellness program[ 15 ].

The substructure of this theoretical account is already existed in private insurance of wellness attention in Singapore and most of the states, whereby two portion pricing agreement between insurance companies and patients is applied to monetary value the premier fee in return for lower or zero copayment for the health care service. If the insurance company offered a program that cover chronic choice at lower copayment rate, it is rather straightforward that concern of inauspicious choice would be an issue in pulling sickest patients.14

From the position point of public wellness attention, plans that do non distinguish by patient group clearly face fewer barriers but will probably hold less favourable fiscal profiles. The appropriate grade of aiming should be depends on the cost of get the better ofing this barrier relation to the benefit for better targeting.

The function of Manufacture in pattern in Singapore.

We would anticipate that with this theoretical account, the makers switching the focal point from marketing to patients or clinicians to research in the value of the corresponding medicines in disease direction as the bulk of the gross tied to the licence fee where is developed by the populace or private insurance company.

The alteration of this concern theoretical account would decidedly impact on the inducement of existed selling scheme of aggressive selling to patient and clinicians and we would anticipate that brings positive alteration to the society15. For illustration, the “ Black Box ” warning was issued by FDA late about the possible overexploitation of erythropoietin to handle anaemia. Under the system of drug licence theoretical account, the bulk of gross is tied to the figure of licences instead than prescription being filled, as a consequence, the industries do non hold inducement to promote patient or clinicians to devour more of the drugs

Drug licencing theoretical account encourages industry to provide the medicines straight to the stakeholders instead through the distributers to take down their administrative cost. With the lower border of the drugs now, makers would mean to cut cost in selling and in distribution thru distributers. This would profit to the patient every bit good as we know the markup from different phase of distributer is well high as a consequence overpricing to the patient significantly. This would avoid unneeded markups before the medicines reach the patients and besides let the maker more involved with public and private health care puting.

Engagement in this strategy should be commercially and strategically attractive for the maker.The licence fee pricing would profit both the maker and the insurance company in budgeting and pull offing the hard currency flow. This benefit in return to cover the supply of medical specialty at lower border and honor the stakeholders or the insurance companies to obtain their drugs entirely and besides without compromising any important loss in net income harmonizing to the simulation theoretical account.

The function of Public health care supplier

From a wellness attention supplier ‘s prespective, the drug licensing theoretical account started to alter the bringing of wellness attention. As the wellness attention services are heterogenous in clinical benefit, with the same copayment rate for chronic and acute medicines seemed inefficient and can take to underutilization of indispensable chronic intervention. This drug theoretical account implement the compartment of “ clinical medium ” attack by seting patients ‘ out-of-pocket based on the expected conformity and the value of the medicines.

From the consequences of the survey by Hse et Al. should promote motion towards the drug licence theoretical account to extinguish the cost sharing for clinical recommended attention to guarantee higher rates in conformity. As the determination of Hsu et Al. high spot, the usage of cost sharing and bounds on prescription-drug benefits to command disbursement is counterproductive both medically and in the immediate effort to restrict disbursement. With the effectual schemes of the drug licensing theoretical account, it could better both patients conformity without any addition in outgo or even reduced the entire outgo in the long term.

For farther development, the theoretical account would anticipate to increase inducement for wellness attention contriver to near for more holistic health care by affecting local primary attention sectors where chiefly run by private sector to set up a comprehensive health care like Chronic Disease Partnership Model service in cost effectual mode locally.

Healthcare Reform

Health attention in Singapore is still taking a cost containment attack to command the growing in disbursement continues to concentrate on increasing copayment, detaining in subsidising of advanced medical specialty and enforcing caps on disbursement and office visits. In add-on, the failure to include primary attention and overloading polyclinic and infirmary attention has already come at a monetary value instead a consistent growth monetary value.

The end of the wellness attention system is to better wellness, non to salvage money. Delaying bringing of high value medicine or dropping coverage could salvage money in the short term, but is non societal desirable. The drive thought behind the redesign insurance theoretical account “ Drug License Model ” could 1 ) make betterment in conformity of chronic medicine and guarantee benefits from medical promotion, and ( 2 ) preserve makers ‘ inducement to develop high value medicines. With these two strong grounds, we believe that altering the current local pricing construction could profit the societal public assistance in the hereafter.

We believe that a pilot survey of drug licensing with maker and authorities would be a utile manner to research the possibilities and to analyze the benefit of this theoretical account in Singapore.