Building community support for public health care in Hong Kong

1. 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 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 (genetically modified food, SARS, bird flu virus are examples) • Great uncertainties over their side effects • People don’t blame nature, they blame economic and social organizationsof 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 communities (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, are 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 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 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? CKWong HA 2006 Convention

19. 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 personalsavings 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

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