Hong Kong, Taiwan, Singapore, and Malaysia are initiating health care reform to meet the changing demands of populations with improved socioeconomic status and access to modern technologies and who are living longer than in previous generations. Hong Kong, in particular, is facing a unique set of circumstances as its people prepare for the transition in 1997 from a British colony to a Special Administrative Region of China. While spending only 4% of its gross domestic product on health care, it has a large and regulated public hospital system for most inpatient medical care and a separate, loosely regulated private health care system for most outpatient medical care. In 1993 the Secretary for Health and Welfare of Hong Kong initiated a year-long process to debate the pros and cons of 5 fundamental programs for health care reform. After a year of open consultation, options were chosen. We describe the Hong Kong health care system, the fundamental changes that have been adopted, and lessons for reformers in the United States.
A case of drowning.
A young man who with friends visited the United States - Florida for a holiday had an accidental drowning in the swimming pool in one of the resorts.
He was brought out of the pool and underwent CPR and quickly transported to the nearest hospital. However, his clinical condition was critical.
He has Hypoxic Brain damage and was on a ventilator for a period of 6 months. His stay in the hospital was punctuated by a number of medical complications like lung infections, cardiac issues, and bed sores.
He needed to go back home to the United Kingdom.
His Insurance was running out. The Embassy got involved.
One of the personnel suggested HI Flying - Air Ambulance International for the patient transfer in a Commercial flight vis-a-vis an Air Ambulance Charter flight which was beyond the affordability of the family.
HI Flying - Air Ambulance Team approached the treating doctor and received all medical records. They process the medical clearance and the patient was on way to London the following week.
A ground ambulance took the patient from Heathrow airport to an NHS Hospital Bed as HI Flying arranged admission and consultant with the help of their GP.
Overall the transfer was efficient and quick.
The treatment was good in Hong Kong, however UK was their home and they were happy to back on familiar grounds.
An Insight to Hong Kong Health Care system
Hong Kong is a territory of 5.9 million inhabitants and
an area of 1,076 km2. Most of its inhabitants (98%) are
Chinese.8 About 3.3 million people live in urban Kowloon
and Hong Kong Island, with a population density of more
than 40,000 persons per km2, making it one of the most
densely populated areas in the world. In contrast, the remaining population lives in the New Territories, where densities in various districts are frequently in the range of1,000 to 2,000 persons per km2. Although a great deal of uncertainty surrounds the changes that will occur after
1997, the existing institutions and social, economic, medical, and educational systems are expected to remain
in place (Draft Basic Law of the Hong Kong Special Administrative Region of the People's Republic of China, April 1988).
The per capita health expenditure in Hong Kong in 1991 was HK$3,400 (US$440), substantially lower than
that of Japan, the United Kingdom, the United States, and Canada ("Health for All: The Way Ahead," a public consultation document of the Primary Health Care Committee of Hong Kong, 1991). Similarly, the per capita gross domestic product (GDP) of Hong Kong (HK$85,145
[US$10,900 in 1991]) is also substantially lower than that
of the other countries.
Despite the relatively low expenditure on health care, health status indicators are better in Hong Kong than inmany other countries. In 1991 infant mortality was 5 per1,000 live births-compared with 10 per 1,000 live births in the United States-and, relative to the United States,
life expectancy for Hong Kong adults was two more yearslong for females and four years longer for males.
The basic principle of the health care system is that "Hong Kong has a safety net under a 'no turn away' policy, which ensures that no one is denied adequate medical treatment through lack of means. This is the law" (minutes of the Hong Kong Legislative Council, October 13,
1993). Although most of the costs of health care are paid by the government, some costs are borne by the citizens
of Hong Kong ("Health for All: The Way Ahead"). For those who cannot afford to pay, the government provides
the funds. Health care is not linked to employment so that workers are free to change jobs without fear of losing
access to health care. Although per capita physician visits are about twice as high in Hong Kong, this difference is accounted for by
the following factors:
* "Doctor shopping," which is practiced by 46% of the population, whereby more than one physician is consulted for the same illness;
* A low level of diagnostic evaluation;
* A high level of prescribing medications for a few days at a time; and
* Shorter patient visit a times-an average of 3 minutes
per patient compared with the 10- to 20-minute visits in
the United States.
Long-term care and community service facilities will be promoted. Hospitals will be clustered into eight functional areas to provide
vertically integrated care. Specific arrangements will be
made for interhospital transfers, networking, and the horizontal integration of specialist services. Hospital budgets
will be based not on historical expenditure patterns and
bed numbers, but instead will reflect future needs. To increase accountability, each hospital will have a governing
committee made up of members from the public and
private sectors and a hospital chief executive. Resource
consumption profiles will be established, and a prototype
specialty costing system will be used for resource allocation purposes. Strategic planning, business planning, explicit statements of roles and responsibilities, performance reviews, communications improvements, and continuous quality improvement are being emphasized by each hospital chief executive.
The private health care system consists of 12 private hospitals and numerous private physicians.
The private system is large and provides 20% of the inpatient medical care, 11% of hospital beds, and 70% of the outpatient visits and is staffed
by 3,424 private practice physicians (compared with 2,819 in the public health system). Patients generally seek
private outpatient medical care by self-referral. Private hospitals charge a basic fee for inpatient room services. Physicians are paid fees for service and
have no financial incentive to shorten the duration of
hospital stays or to limit the number of diagnostic tests
or treatments. Medical resources and physician fees are
charged separately, with the charge for each item varies according to the class of patient. Patients are required to pay a deposit before admission, and patients with long stays are usually asked to settle their bills every five days.
Physicians in the private sector believe staunchly in a
free market for health care and 95% operate solo practices. There is extensive price discrimination in the private sector. The same physician may charge 2 to 20 times for a first-class patient as for a third-class patient.'5 (The class of a patient is determined by the type of room service received-private room [first class], semiprivate[second class], and ward [third class]). A report by the medical Insurance Association of Hong Kong identified
twofold differences in charges among private physicians for several diagnostic tests and operations.'" The fee
structure is rather loose, and negotiations are often carried out in a way that would be unsettling to western cultures. Many patients receive medical care in the private sector without knowledge of the physician's fee scale; an increasing number of patients, however, are attempting
to agree on the fees before seeing the physician.Physician fees are usually paid at the time of service, with less than 10% of fees being paid directly by insurance companies.
Hong Kong, like the United States, is facing changesin its society that requires increased health care expenditures, Its population is aging, medical costs are rising, new medical technologies are being developed, and community expectations are increasing.
The annual per capita out-of-pocket expenditure is HK$1,745 (US$223), with widespread variation due to
the frequent use of unregulated traditional Chinese medical care, large variations in the use of services according
to socioeconomic class, and differences in medical fees according to socioeconomic status.
The diffusion of new technologies in Hong Kong lags
behind that in the United States. Because of the regionalization of medical services, there are often queues for the
use of the latest technologies in public hospitals.
Patients may be asked to purchase expensive equipment
such as prosthetic hips, cardiac catheterization equipment, or cardiac pacemakers. In the past, magnetic resonance imaging (MRI) has been difficult to obtain at public hospitals because there was only one MRI scanner.
Government outpatient departments are crowded.
Queues begin to form one to two hours before a clinic
opens, and appointments are given for as many as 80 patients per physician per half-day. After the daily quota of
appointments is given out, no further appointments are
taken. Because physicians see a large volume of patients,
there is little time to communicate with patients and even
less for counseling, reassurance, and education.
Emergency care is a basic right of all Hong Kong and
British residents. Because of free care at emergency departments and substantial queuing at outpatient clinics,
emergency departments are often used inappropriately for
nonemergent and routine ambulatory care.
The major lesson from the Hong Kong experience is in the process of health care reform, rather than the actual
health care system. In the United States, policy makers are actively pursuing cutbacks in health care financing in
a debate marked by confrontation among political groups, lobbyists, and constituents, whereas health care reform in
Hong Kong was based on collaboration among the various parties who participated in extensive rounds of consultation and debate.