Health Care Blueprint: Services, Mode of Delivery and Financing
Dr York Chow, Secretary for Health, Welfare and Food, was the Foundation's guest speaker on 21 April 2005. This is a summary of his remarks.
Dr York Chow said that he had been an orthopedic surgeon. When people asked him if he was still cutting, he said to them that politicians never cut. In fact, even while a practicing surgeon, he had preferred to talk in terms of a reconstructive process, restoring function and life to the human frame. It was the same in regard to the health care system. It needed enhancement rather than cuts.
Health system, and problems
First, Dr Chow said, he would outline Hong Kong's existing health care system. This was unique, one of a kind in the world. The basic structure and approach were established shortly after the Second World War. The system followed a colonial philosophy. Health was seen in terms of welfare and charity. The system had not changed much since then. Today, charges were still extremely low. The philosophy was that the patient was supposed to pay for his meals - for the horrible meals in the hospitals - and would get the health care free. Thus only 4% of the cost of the hospital system was recovered from charges; 96% was paid by the taxpayer.
This system worked well in the 1950s, 60s, 70s and perhaps even the early 1980s. But in recent years the increase in longevity had greatly increased costs. The funding requirement had increased three-fold in the past 15 years. This was due to two factors.
Firstly, men now lived over 78 years and women over 84 - one of the highest lifespans in the world. Such high longevity was due to the high quality of the health care system. Professional standards were very high; medical ethics were good too. These qualities had to be maintained through any forthcoming reforms. But longevity increased costs.
Secondly, the cost of health technology was rising, and in unpredictable ways. The techniques for treatment, investigation, testing, operations were being developed all the time, and the cost increased tremendously. External events also impacted health expenditure unpredictably. For example, Avian flu meant that stocks of antivirals and protective clothing had to be built up. New techniques were needed to assess the cost-effectiveness of medicine.
Hong Kong was very unusual in that 95% of inpatients were treated in the public sector, compared with 85% of primary care delivered by private doctors. Only 50% of doctors were in the public sector. The private hospital sector was very small. There was a great imbalance between the public and private sectors. In most countries, citizens had access to both private and public health care, with competition between the two. The Hong Kong citizen had a choice too, of the best doctor, best carer, best hospital. Some Hong Kong people liked to go doctor-shopping, trying doctors one after another until they found one whose advice they liked. This was costly and resource-wasteful.
Solutions
You could not separate service from financing, Dr Chow said. The Government had commissioned three consultancy reports on financing, but the public and legislators had been lukewarm. Perhaps this was not surprising: no one would be keen to invest in something without knowing what was going to be done with the money.
The Health, Welfare and Food Bureau had formed a health and medical development advisory committee. It would look at three areas - primary care, including family health; inpatient and district care such as emergency facilities, which had to be in all districts; and tertiary care, by which was meant high-tech facilities and those requiring special expertise, which would be concentrated in a few locations. Once the service model was worked out, they would look at the costing of it and the options for meeting those costs. He hoped to bring out a conceptual paper by the end of the year.
Health care reform overseas typically took a long time, five years, ten or even twenty years, Dr Chow said. It was an economic and a political process. You could not do much if the economy was bad. But now the Hong Kong economy was getting better, and it was the right time to drive forward. It was very difficult, but the idea had to be sold to the community. The energy had to be generated. If we did not act now, it would be harder later on, Dr Chow said. He liked to say that Hong Kong's health care system was a pre-malignant condition. It had to be treated before it became malignant when there would be real problems to deal with. The example of 30,000 people marching in Taiwan the previous day was a case in point. The health insurance system there had broken down.
When it came to thinking about reform, Hong Kong had the advantage of starting from a clean sheet, as nothing much had changed since the war. We can learn from other governments.
Questions and answers
Could there be choice for everyone? Dr Chow would like to see healthy growth for both public and private sectors. The private sector should take on more; then the public sector could disburden itself. The problem currently was pricing. An operation in a private hospital would cost a five-figure or even a six-figure sum, whereas in a public hospital it would be just five or six hundred dollars.
Everyone had to have health coverage. But fewer than one million people in Hong Kong had medical insurance. And the policies were not governed by the government, just negotiated privately between the insurer and the insured. You never heard of insurance companies going bust, so it was likely that they had a big margin in the premium. The government had to look after the disadvantaged. There had to be a safety net.
Was the primary sector growing fast enough? It had grown rapidly in the past few years. In the old days, to make money doctors had gone into the private sector. Patients had been driven out of the public sector by the poor service, and the private sector doctors had been able to see a hundred patients a day. But that had changed. The public sector service was much better. So private doctors had to compete. They were more transparent on price, and they communicated more with their patients, telling them how many days a course of antibiotics should be taken, for example. On the professional side, things were also better. Doctors took continuing professional education, although it was not yet linked to the licence.
The Hospital Authority had been training family doctors. The College of Family Physicians had been started in 1992. Now it was training 50 or 60 family physicians a year. Within five years or so there would be nearly 1,000 of them. There was also a College of Pediatricians and College of Physicians which produced community care specialists. Within five or ten years there would be more specialists for primary care in all areas of Hong Kong. The trick was to persuade citizens to use them, rather than go to the Accident and Emergency departments of the public hospitals. Nowadays, family doctors in the New Territories would charge around HK$100 to HK$150 per consultation, which did not compare too badly with the A&E charge of HK$100, especially when one took into account the taxi fare there and back. And the family doctor had the better relationship with the patient and understood his problems; the patient did not need to register each time, and be attended to by a stranger.
Were there enough specialists in the private sector? Dr Chow said that at present, there was insufficient competition. It was related to the socialist way of managing public hospitals. Only the university doctors could take private patients; most of the Hospital Authority doctors could not. Overseas, it was normal for public sector doctors to take private patients. In Hong Kong this had been discussed for years; there was concern over possible abuse, but that could be managed. The reform really needed to be introduced.
The above does not necessarily represent the views of the Foundation.