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Building community support for public health care in Hong Kong

A presentation to the Symposium 6, Hospital Authority Convention 2006

8-9 May 2006Hong Kong Convention and Exhibition CentreWong Chack-Kie, PhD, Professor, Social Work

DepartmentThe Chinese University of Hong Kong

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Outline of the presentation Introduction- risks in post-modern

societies A society of institutionalized individuals Implications for health care

arrangements in Hong Kong The institutional arrangements of health

care Solutions and challenge – engaging the

community Conclusion

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Risks in post-modern societies

Nowadays, our societies are characterized by risks which are global in nature (Giddens, 1991, 1998; Beck, 1992, 1998)

They are indeterminate Knowledge about them are contingent

about the probability of such risks, uncertainties over future outcomes and impacts (genetic

ally modified food, SARS, bird flu virus are examples) Great uncertainties over their side effects

People don’t blame nature, they blame economic and social organizations of risks management

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People blame the organization of risk responses !

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Why? The social side of post-modern risks

The dissolution of traditional norms and social bonds Decline of family, e.g. divorce, nuclear families Decline of traditional bonds of social class and co

mmunities (de-traditionalization) People become individualized, more insecure

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Ironically, they cling to new dependencies On fashion, social policy, economic cycles, and

markets Unfortunately, these are also sources of risks to

individuals, e.g., financial debt, welfare cuts, unemployment

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A society of institutionalized individuals People, are individualized, become reflexive

over the modernization process The decline of traditional norms and bonds Therefore, there is a shift of authority from

external to internal Individuals have to make choices for their

life They have to become active and

responsible for their choices Every choice may have a sequence of

outcomes which have long term effect, e.g., investment plan, study plan

They have to construct their own ‘”biographies” – no tradition to follow as it was before

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Institutionalized individuals These personal choices, strictly speaking, ar

e not really “personal choices” (Beck & Beck-Gernsheim, 2002) They are also ‘non-social’ in character They are institutionalized

People refer to institutional reference points for decision making

For example, rules and regulations of the welfare state or welfare system, such as student grants, unemployment benefits, mortgage relief, retirement benefits, with far-reaching personal consequences

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Implications for health care arrangements in Hong Kong

Public health care is an institutional arrangement

It has sets of institutional reference points which define benefits and obligations

In Hong Kong, public health care can be suggested as a heaven in a sea of uncertain markets It is universal, accessible by all It has good quality

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It is affordable - Extremely low cost to patients on the receiving end

In some words, patients as individuals, have more benefits than obligations on their parts

Public health care offer certainties in health care protection in a society with uncertain and indeterminate risks

They don’t want to be active and responsible for their health care

They don’t need to be active and responsible for their health care

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The economic and societal context of such arrangements Markets – growing uncertainties

Hong Kong has the most free economy in the world

The latest market cycle had the worst unemployment rates

In the aftermath of the Asian Financial Crisis and the SARS – once >8%

For those with job, employment not equal to income security

In 2004, 352,900 working people, i.e., 11% of the total work force, received a wage less than HK$5,000 a month

A figure worse than that in 1998, 6% or 179,800 working people

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Outcome of markets on income insecurity and social inequality

According to the 2001 Census, the lowest 40% households got 11% of total household income

Income inequality in its most extreme extent among rich societies, pre-tax gini-ratio at 0.525 in 2001

Generally 0.4 is regarded as the threshold, above which will generate social instability and unrest

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Society – uncertain and unreliable Can people seek help from family? In 2001, average family size in Hong Kong

was 3.1 In 2005 divorce cases as compared with

marriages 43,000:14,873 (3:1) Hong Kong people are westernized and

individualized Do these reflect family failures?

In 2004, we had 199,085 old age CSSA recipients Many had family relations but claimed that their

children are unable or unwilling to care for them In 2004, we had 102,623 CSSA recipients who

belonged to the single parent family category

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The outcome of such arrangements in terms of health care expenditures

Who shoulders the burden? Total health expenditure by source

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Health expenditure by source in Hong Kong, 1997/98-2001/02

1997/98

1998/99

1999/00 2000/01 2001/02

Government

52% 55% 55% 56% 57%

Employer 10% 10% 9% 9% 8%Insurance

3% 3% 4% 4% 4%

Household

33% 31% 31% 31% 30%

We have a comparatively large government sector! We have made our choice

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A comparative analysis – The Chinese case

We look at a comparator – China in its economic reform era (1978- ) With growing national wealth at a rate

of 8-9% annually Economic reform means growing

market uncertainties to people Many people suffer from laid-off,

unemployment, poverty Also family in decline - less support due to

more divorces and a smaller family size

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Health expenditure by source in China, 1997/98-2001/02

1980 1990 1995 2000 2002

Government 36.2%

25% 17% 14.9%

15.2%

Social health expenses e.g.,Government and labour insurance

42.6% 38% 32.7% 24.5% 26.5%

Individuals, e.g., out-of-pocket payment

21.2%

37% 50.3%

60.6%

58.3%China ‘chooses’ a smaller government sector and much more personal contributions!

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Nothing is natural or social Health care (financial)

arrangements are ‘non-social’ in character – either in China or in Hong Kong What are the institutional reference

points in China?

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In the early 1980s New rule - the Chinese government

capped the funding to public hospitals

New response - hospitals have to raise revenue by over medication

More medical examinations Sale of drug for profit

Medical treatment has become unaffordable by most, even those with insurance coverage

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Shift from Government Insurance (civil service) and Labour Insurance (State Owned Enterprises) to Basic Medical Insurance (more restrictions for spending, e.g., co-payment )

Shedding the financial responsibility on the part of government (Wong, Lo & Tang, 2006)

Public demand for affordable health care not transformed into any institutional reference point

The lack of any state guarantee for health care protection

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Perhaps China’s case is extreme, and on the worse side

In a WHO 2000 report, China is rated 188, out of 191 nations, in terms of fairness of financial contribution to the health system

We now look at the choices other rich countries made in terms of the financial role of government sector

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Public expenditure as % of total expenditure on health

Selected OECD countries (2003) Japan 81.5% Australia 67.5% France 76.3% Sweden 85.3% United Kingdom 83.4% United States 44.4% Hong Kong 57% (2001-02)

Not the lowest, more space to occupy if we “choose”

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What are institutional reference points of public health care in Hong Kong?

The basic rule – no-one should be denied of medical treatment due to lack of means

Institutional arrangements in health care The use of general revenue for funding

universal health care The irony is

People and government don’t want to increase their shares in the financing of public health care

Hong Kong spends much less than many advanced industrialized societies

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In Hong Kong, general revenue, or paying taxes, is the burden of the other In 1997-98 the top 100,000 taxpayers paid

54.8% of the total salaries tax Only 1.33 million taxpayers, out of 3.1 million

labour force, 6.7 million population In 2005-06 the top 100,000 taxpayers paid

58.2% of the total salaries tax Only 1.22 million taxpayers, out of 3.3 million

labour force, 6.8 million population Most people are not institutionalized

Not included in the taxpaying system Not having experience of contributing social

insurance, not only health care, but also for retirement and unemployment protection (MPF a regulatory personal savings system)

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Solutions Market health care

Unaffordable by most e.g., 40% of households with 11% of total household income in 2001

Public health care Overloaded, but with a stated intention

to keep the quality Civil society

Not truly engaged, unwilling to increase taxes or insurance system to fund the public health care system

Some progress in cost recovery, e.g. emergency ward fee increase

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Focus on the civil society – building community support

Why is this important? Societies are different in their support for

public health care system Value counts

Do we support the stranger’s need for health care? Politics counts

Whether public opinion turns into political decisions? The ‘rainbow’ report The Harvard report All apparently supported by the medical professionals,

but were not endorsed by the community

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The challenge ahead - governance of public health care It is primarily dominated by medical

professionals The relationship between the government

sector and its private counterpart also good Both are dominated by professionals Boundary blurred – e.g., public health care

professionals change to private practice The challenge is not in these two sectors

The community is not fully engaged!

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The real challenge is on building community support

The community needs to be managed about its expectations of public health care It is largely left out of the institutional

arrangements in the public health care governance

Passive patients, not collectively and actively engaged

No need to be active and responsible For the poor and the lower class, not able to

be active and responsible to make choice

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How to engage the community? -Some thoughts for thinking

The legislators Especially those from geographical

constituencies How can they be engaged is challenging

Experts – opinion leaders How to cultivate the consensus of those who

lead the public opinion? Editors of the press – they are those who

write the headlines? Patient groups – the direct stakeholders,

who are most vocal and will confront the HA Cooption of existing groups? Formation of new groups?

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Is there a need for a propaganda (publicity) war?

A case in question ‘Only a person with monthly income of

HK$3,000.00 has the coverage of the safety-net” – recently a spokesperson of a patient group said

The other side of the fact not conveyed to the public immediately and forcefully:

75% of the median income gets safety net coverage

Nearly all applications for waivers are accepted All the poor and long-term care patients who

have financial difficulties are taken care The issue of concern – people blame the

organization of the response to risks, not risks or themselves

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The vision matters - Institutional reference points needed to be changed?

Except the community is ready to use its wealth to fund a quality public health care system, the vision of the Hospital Authority to “maximize health benefits and meet community expectations” is impossible

The community should be involved in the debate of the role of HA and how it is funded

1) Basic health care protection or quality public health care

2) How to finance it?

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Conclusion We have a paradox in health care risk

management On the one hand – people are

individualized; they choose the institutional reference points with minimal costs or obligation on their parts

Some with good reasons to excuse their contributions

On the other hand – public health has a vision which is impossible to meet

Universal and quality care in a low- and narrow-tax regime

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Challenge on building community support The need to reshape the institutional

reference points on health care risks management

Apparently, the community is not included in the governance of public health care

It is not actively informed and engaged There is a need for a public debate about the

vision of public health care and how to fund it People need to realize that they are part of the social

and economic organizations of health care risk management

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