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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 2006 Hong Kong Convention and Exhibition Centre Wong Chack-Kie, PhD, Professor, Social Work Department The Chinese University of Hong Kong. - PowerPoint PPT Presentation
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CKWong HA 2006 Convention 1
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
CKWong HA 2006 Convention 2
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
CKWong HA 2006 Convention 3
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
CKWong HA 2006 Convention 4
People blame the organization of risk responses !
CKWong HA 2006 Convention 5
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
CKWong HA 2006 Convention 6
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
CKWong HA 2006 Convention 7
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
CKWong HA 2006 Convention 8
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
CKWong HA 2006 Convention 9
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
CKWong HA 2006 Convention 10
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
CKWong HA 2006 Convention 11
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
CKWong HA 2006 Convention 12
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
CKWong HA 2006 Convention 13
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
CKWong HA 2006 Convention 14
The outcome of such arrangements in terms of health care expenditures
Who shoulders the burden? Total health expenditure by source
CKWong HA 2006 Convention 15
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
CKWong HA 2006 Convention 16
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
CKWong HA 2006 Convention 17
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!
CKWong HA 2006 Convention 18
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
CKWong HA 2006 Convention 20
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
CKWong HA 2006 Convention 21
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
CKWong HA 2006 Convention 22
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”
CKWong HA 2006 Convention 23
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
CKWong HA 2006 Convention 24
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)
CKWong HA 2006 Convention 25
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
CKWong HA 2006 Convention 26
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
CKWong HA 2006 Convention 27
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!
CKWong HA 2006 Convention 28
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
CKWong HA 2006 Convention 29
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?
CKWong HA 2006 Convention 30
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
CKWong HA 2006 Convention 31
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?
CKWong HA 2006 Convention 32
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
CKWong HA 2006 Convention 33
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
CKWong HA 2006 Convention 34
- END -