Hong Kong's Health System

Hong Kong's Health System: Reflections, Perspectives and Visions

Gabriel M. Leung
John Bacon-Shone
Copyright Date: 2006
Pages: 568
  • Cite this Item
  • Book Info
    Hong Kong's Health System
    Book Description:

    Having experienced benign neglect and inertia since the last major set of reforms when all public and subvented hospitals were corporatised in the early 1990s, Hong Kong's health system now faces another round of consultation about reform. This book provides a significant contribution to the discussions about the future of the system. The evidence-driven content draws from the deep expertise and experience of a wide spectrum of contributors, who represent virtually all relevant areas of the health system. Their multidisciplinary input, based on moral philosophy, political economy, macro-financing, health services research, business strategy and patients' experience, reveals areas that require urgent attention and focuses on the issues that matter most if Hong Kong is to achieve better population health through the health system. This book meets the critical need of students, academics, health care professionals, government officials, politicians, and the general public who have been struggling with how best to approach and understand the context and need for change. This book is a project of the Medical and Health Research Network, The University of Hong Kong. The Network, a University-wide multidisciplinary think tank, was established in 1999 in response to the release of the Harvard Report. Its research core members are academics in the fields of clinical medicine and nursing, public health, social work, statistics and actuarial science, economics and finance. It further draws from the wider policy and practice communities in its education, training and advocacy activities. Its mission is to collect, analyse, synthesise and disseminate evidence related to health, long-term and social care in Hong Kong and East Asia.

    eISBN: 978-988-8052-32-5
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-viii)
  3. Foreword
    (pp. ix-x)
    S.P. Chow

    With the release of the Harvard Report in 1999, Hong Kong witnessed unprecedented momentum in health care reform. A multidisciplinary group of academic researchers at the University of Hong Kong decided to pool their collective expertise and resources to contribute to this important policy change. In particular, the group believes that reform must be data driven, and supported by sound evidence. In 2000, the “Medical and Health Research Network” was formed. Based at the University of Hong Kong, it comprises medical practitioners, medical sociologists, health economists, health management specialists, statisticians and actuarial scientists. Its objective is to offer an independent...

  4. Preface
    (pp. xi-xiv)
    GML and JB-S
  5. List of Contributors
    (pp. xv-xx)
  6. PART I Forces of Change
    • Part I Commentary History, Ethics and Forces of Change
      (pp. 3-16)
      John Bacon-Shone and Gabriel M. Leung

      Whenever the Hong Kong public is asked what the most important public policy area is, the economy is usually the first priority and health care traditionally appears a long way down the list, although it did appear in fourth position after unemployment, governance and air pollution in the April 2005 survey that the Chief Executive Donald Tsang quoted to illustrate that constitutional development was not a priority (although governance clearly was!). Of course, health care incorporates some very different elements, and it is true that immediately after SARS hit Hong Kong with such a force, public health and hygiene has...

    • CHAPTER 1 A Historical Review: The Colonial Legacy
      (pp. 17-26)
      Derek Gould

      If the history of Hong Kong’s health system had to be summarised in one word, that word would be “expediency”. Government policy in the area of health care has been dominated by inactivity unless the government has been forced to act in the direction of economic (or to a lesser extent, political) considerations. Little has been done for purely social reasons. This can be attributed to public indifference, which has reinforced the official philosophy of laissez-faire and reliance on market forces.

      Health is not one of Hong Kong’s community values, and seldom impinges on the collective consciousness. As with education,...

    • CHAPTER 2 Philosophy, Ethics and Societal Values in Health System Reform
      (pp. 27-40)
      Marc Roberts

      As Hong Kong reforms its health system, it will face difficult decisions about burdens and benefits, priorities and responsibilities. These choices will and should reflect Hong Kong’s social values as processed by its political institutions. The important ethical aspects of these decisions are, however, not always easy to see amidst the noise and confusion of vigorous public debate.

      Some of the issues that the territory will face are factual, for example, how various kinds of health care markets would function in the Hong Kong context. Others turn on questions of values, such as whether the government should try to save...

    • CHAPTER 3 Confucian Care-Based Philosophical Foundation of Health Care
      (pp. 41-60)
      Julia Tao

      In most advanced industrial democracies in the world today, it is established that there is a legal “right” to health care or society has a moral duty to provide medically necessary services to ensure that everyone has access to needed services regardless of ability to pay.

      With the notable exception of the United States, where employment-based health insurance is purchased from private companies, the legal right to health care is embodied in a wide variety of types of health systems. These range from nationalised health care, where the government is the funder and provider of services, as in Great Britain,...

    • CHAPTER 4 Implications of the Demographic Transition
      (pp. 61-80)
      Paul Yip, Joseph Lee and C. K. Law

      Hong Kong has experienced rapid change in demographic structures over the last several decades. Although life expectancy at birth is now 78 and 85 years for men and women respectively (Census and Statistics Department, 2002), the total fertility rate (TFR) has reached a world record low of 0.8, which is well below the replacement level (that is, two children per woman).¹ In this chapter, we provide an overview of Hong Kong’s demographic trends and characteristics — population, fertility, marriage, mortality, migration and hospitalisation patterns. Longer life expectancy and prolonged declines in fertility result in an expanding aged population. Fast and intense...

    • CHAPTER 5 Changing Patient Expectations
      (pp. 81-94)
      Iris Chan and Mary Ann Benitez

      It was not until the turn of the new millennium that people became more vocal about what they expected of health care in Hong Kong, and they now demand better services. The major outbreak of SARS provided an awakening for the public. As the health system in Hong Kong moves into the next phase of its development, so too will patients’ rights be given the priority they seek. This chapter looks at the development of patients’ rights and how community mobilisation is necessary for patients to gain equal partner status in the management of their health.

      In March 1973, a...

    • CHAPTER 6 Comparative Health System Models in East Asia
      (pp. 95-108)
      Ruiping Fan and Ian Holliday

      Within their health care heartlands of modern scientific medicine, the developed states of East Asia, with which Hong Kong is most frequently compared, offer two distinct health system models. In Japan, South Korea and Taiwan, a social insurance model dominates. In Singapore, a provident fund model can be found. In China, with which Hong Kong is gradually reintegrating, a third model is being developed that combines social insurance and provident fund elements. In this chapter we analyse all three models. We also look at how each system relates to the still vibrant forms of traditional medicine that characterise the region....

    • CHAPTER 7 The Role of Public Health in Social Justice: The Next Steps in Hong Kong
      (pp. 109-134)
      Anthony Hedley

      Public health as an activity of the medical professional in Hong Kong has recently passed a very testing time. In the eyes of some civic bodies and the lay public, it has been found wanting in the most pejorative terms (SARS Expert Committee, 2003), while in other fora it has received unbridled accolades (Stockholm Challenge Award, 2004). My aim is to externalise and highlight a range of issues that I believe illustrate the challenges to public health, define the tasks and role of this professional specialty in Hong Kong and ultimately determine, from a humanistic point of view, whether or...

  7. PART II The Organisation and Management of Health Care
    • Parts II & III Commentary Organisational, Management and Quality of Care Issues
      (pp. 137-186)
      Gabriel M. Leung and John Bacon-Shone

      We begin the middle sections (Parts II and III) of the book by considering whether and why a public health system approach is important to achieving the best health outcomes for whole populations, echoing many of the arguments advanced in Chapter 7 by Anthony Hedley. Next, we introduce the macro-organisation of Hong Kong’s health system, and end by focusing on several key management and organisational issues at the meso- and micro-levels.

      Why do health systems matter? Since the late 1970s and early 1980s there has been accumulating evidence that the financing, organisation and delivery of care and services have a...

    • CHAPTER 8 Operations Management in the Public Sector
      (pp. 187-198)
      Janice Johnston

      The escalating complexity of health care organisations compels a change in the way we view problems. The resolution or amelioration of health care management challenges necessitates the coordination of many inter-related activities (Plesk, 2001). More specifically, a thorough evidence-based understanding of the fundamentals of systems operations and management decision-making is an essential aspect of managing problems associated with the efficient delivery of frontline clinical care activities. In a public health care system, many of these decisions are tactical in nature, i.e. they focus on structural, routine, repetitive decisions that are fixed within a bureaucratic framework (Krajewski, 1999). Evaluating the performance...

    • CHAPTER 9 The Private-Public Interface
      (pp. 199-208)
      David Fang

      In Hong Kong there is a saying that public health service provision is separated from the private sector by an impenetrable wall and never the twain shall meet. We could be witnessing the historic dissolution of that “Berlin Wall”, which is happening partly by design but mostly out of sheer necessity.

      The historical background dates back to pre-Hospital Authority days (before 1990). Public hospitals were under-funded, severely overcrowded and mired in bureaucratic civil service regulations. The WD Scott Report of 1986 proposed an independent Hospital Authority that could flexibly utilise and generate resources with all government and subvented hospitals under...

    • CHAPTER 10 The Emergence of Managed Care
      (pp. 209-222)
      Nelson Wong

      Managed care is a complex and evolving system of financing health care that originated in the United States. Managed care plans are prospectively priced on headcount, and are delivered across different organisational settings and effected through the modification of clinical practice using financial incentives, clinical guidelines and systems management with the aim of achieving cost-effective and consistent quality care. From the need to track, measure and promote quality was born quality assurance for health care. Managed care can be a confusing and difficult concept to grasp, and is often misunderstood even by health care workers because of its ever changing...

    • CHAPTER 11 Long-Term Care and Hospital Care for the Elderly
      (pp. 223-252)
      Chu Leung-Wing and Iris Chi

      In 2004, 0.82 million people in Hong Kong were aged 65 years and over, which represents 11.7% of the population. The proportion of elderly people in Hong Kong is likely to increase to 24% in 2031, which will create enormous demand for long-term care and health care services for the elderly. This demographic change is related to a decrease in birth in Hong Kong (Census and Statistic Department, 2002; Hospital Authority, 2003). The elderly dependency ratio will increase from 382 in 2001 to 562 in 2031. The average life expectancy at birth in Hong Kong in 2001 was 78.2 years...

  8. PART III Quality of Care
    • CHAPTER 12 Quality of Care and Patient Redress: A Professional Perspective
      (pp. 255-270)
      Felice Lieh-Mak

      Strictly speaking, systems of patient redress address two issues: the putting right of a wrong and compensation for the suffering that results from wrongdoing. Such systems are private and decentralised in the sense that it is left to the individual to enforce their rights. Hence, the effect of such a system on the quality of care is dependant on organisational or individual responses.

      Most systems of redress follow one of two models. The persecutory/disciplinary model is mainly intended to establish individual responsibility, fault and culpability. The finding of fault carries with it the possibility of sanctions, which can range from...

    • CHAPTER 13 Quality of Care and Patient Redress: A Patient Perspective
      (pp. 271-290)
      Chu Yiu-Ming

      In the last 30 years, the Hong Kong government has published two reports on hospital services. “The Future Development of Medical and Health Services in Hong Kong” was a government-commissioned report authored by the Medical Development Advisory Committee (MDAC) in 1974. The focus of the report was the development of solutions to the serious problem of the shortage of hospital beds at that time, and to explore ways in which new hospitals should be built in relation to the population distribution in different districts. Improvement in the quality of medical services was not an issue of concern for the committee...

    • CHAPTER 14 Nurses as Agents of Quality Improvement
      (pp. 291-302)
      Sophia Chan, David R. Thompson and Thomas Wong

      There has been an information explosion in science and technology, an ageing of the population, changes in health financing, escalating public expectations of the quality of the services and a growing recognition of the need to deliver high quality, safe and effective health care to patients to attain better health outcomes. The shift to a growing population that is mobile, ageing and has (often multiple) chronic diseases, along with the menace of emerging and re-emerging infections are likely to be the major threats to the health of the global community. Nurses, like other health professionals, are rapidly rising to meet...

    • CHAPTER 15 Quality Indicators and Health Targets
      (pp. 303-326)
      Geoffrey Lieu

      Quality of care has always been an integral concern in health service planning, management and provision. How to improve and maintain quality are key aspects of the health care reform agenda in many countries. Yet, quality must relate to explicitly stated goals or targets to have a meaningful influence. A number of health systems internationally have adopted the concept of health targets as an overarching inter-sector approach to both guide their reform initiatives and enhance quality and health. This chapter reviews the concept of health targets, including how the UK, Germany and the US have integrated the concept in advancing...

    • CHAPTER 16 Clinical Governance and Quality Management
      (pp. 327-336)
      Vivian Wong, Liu Hing-Wing and Helen Poon

      The promotion of clinical governance in health care management signifies a fundamental shift in the focus of clinical quality assurance away from the traditional profession-led paradigm, which emphasises self-governance, autonomy and a professional standard of care, to accommodate a client perspective that emphasises patient rights, transparency and accountability. Clinical governance sets out to ensure that effective systems are in place to monitor the quality of clinical practice, and in particular that practitioners are meeting standards and that health systems are enabling care delivery as intended. The objective is to enhance clinical practice — and thus patient outcome — through a systematic approach....

  9. PART IV The Financing of Health Care
    • Part IV Commentary Health Financing Reform
      (pp. 339-396)
      Gabriel M. Leung and John Bacon-Shone

      The last section of the book deals with perhaps the most important policy tool that is available in the health reform arsenal — that of health financing reform. Financing strategies certainly yield the most immediate results in health care — as in all other fields — because market agents, such as health care professionals and institutions, respond quickly when financial incentives are changed to realign their activities to maximise gains in the form of revenue, market share and other intangibles.

      There are three key inter-related dimensions in health finance — revenue collection, fund or risk pooling and purchasing or provider payment. Revenue collection refers...

    • CHAPTER 17 Health Financing Trends in Greater China
      (pp. 397-418)
      Paul Gross

      Despite several inquiries into its financing system since the late 1990s, there has been little concerted action to redress critical gaps on the supply and demand sides of health care in Hong Kong. I first review some current trends in health reforms in Taiwan and mainland China and draw lessons for Hong Kong in the second half of the chapter.

      Generally, new strategies for containing the growth of health expenditure are evident at two levels. First, payers (mainly governments and health insurers) are changing their organisational structures for health care, informing patients about the price and quality of care, using...

    • CHAPTER 18 The Origins of Hong Kong’s Domestic Health Accounts
      (pp. 419-434)
      Ravindra P. Rannan-Eliya

      Health accounts are a statistical representation of health expenditure flow in a country or territory that are comprehensive in the expenditure that they count, which includes both public and private sector expenditure. They represent the health sector counterpart to the national income and product accounts, which are the standard statistical framework for measuring and reporting overall economic activity in a country, and from which such macroeconomic aggregates as gross domestic product, national savings and private consumption are derived. In a similar manner, health accounts report aggregates such as total national health expenditure, their breakdown by source and use, and trends...

    • CHAPTER 19 Health Financing in Hong Kong: The Current Status
      (pp. 435-446)
      Raymond Yeung and Chan Wai-Sum

      Health financing has been on the political agenda around the world for more than a century (Starr 1982). As health systems worldwide grow both in their capacity to improve human well-being and in their cost, governments must increasingly pay attention to the financial aspects of these systems. Recently, health financing has moved to the forefront of Hong Kong’s policy agenda (Hong Kong Special Administrative Region (HKSAR) Government, 2000; Hsiao, Yip et al., 1999), as it did in the 1980s and 1990s (Scott, 1985; Hay, 1992). As with many post-colonial economies, Hong Kong has established a dual medical economy in which...

    • CHAPTER 20 A Systematic Approach to Reforming Hong Kong’s Health Financing: The Harvard Proposal
      (pp. 447-460)
      Winnie Yip and William Hsiao

      On the eve of the return of Hong Kong’s sovereignty to the Chinese government, the then Hong Kong government commissioned a team from Harvard University to evaluate the performance of Hong Kong’s health system and propose reforms. As the title of the final report, Improving Hong Kong’s Health Care System: Why and for Whom? indicates, the reform proposals only make sense if we know the objectives that the reform is to achieve and the problems that the reform is intended to alleviate. The answers to these questions will differ depending on the perspective from which the assessment is made. The...

    • CHAPTER 21 Health Financing and Resources: New Government Proposals
      (pp. 461-468)
      Looi-Looi Low and Su-Vui Lo

      As with many developed economies, Hong Kong is reviewing options for ensuring the sustainability of its health services in the face of population ageing and rising community expectations. Since the 1980s, the government has commissioned studies covering the many aspects of sustainability: resource aspects such as cost or financing arrangements and other health care resources, range of service and delivery models, and citizens’ health needs. A major reform was undertaken in 1990 after a comprehensive review of the health care system. The Hospital Authority was established to take over the management of all public hospitals while the Department of Health...

    • CHAPTER 22 The Challenges of Reforming Hong Kong’s Health System
      (pp. 469-484)
      Alan Maynard

      There has been continuous debate about the “failure” of health systems for decades. This debate tends to polarise the liberals, who favour a more laissez-faire and individualistic approach and the adoption of what is now called “consumer directed health reform”, and collectivists, who favour reform that is directed at the better regulation of providers. The former advocate individually orientated policies such as medical saving accounts and the extensive use of co-payments and deductibles (user charges). The latter focus on the failures of health care providers worldwide and the need to offer robust systems of consumer protection and observable, rather than...

  10. Epilogue
    (pp. 485-486)

    In the preceding pages, our contributors have attempted to highlight key questions, rather than provide complete answers. These chapters are not meant to be prescriptive in offering exact blueprints for reform. Rather, they are presented as material to be reflected upon, perspectives to be debated and visions that challenge orthodox thinking while foreshadowing prospects for the future.

    Gould (Chapter 1) laments the slow progress on key decisions about financing and macro-organisation since the 1980s, when the government first began to think about such issues. Twenty years on, it looks as though Hong Kong may finally be on the verge of...

  11. Notes
    (pp. 487-496)
  12. References
    (pp. 497-534)
  13. Index
    (pp. 535-548)