13 April 1999

Golden Chance For Reforming Health Care System

(Keywords:- Harvard Report, financing, private sector, medical profession, quality)

          The long awaited "Harvard Report" on health care financing reform was finally delivered. Regrettably, this just off the oven document has lost its freshness, as much of its contents have been "leaked" to the media for quite some time. Amongst the contents are the proposal for "user pay" concept; mandatory insurance and medical savings; and "mudslinging" at the medical profession; for which no doubt the related professions and the politicians, the health economists and the public would have a "field day".

          One area that appears to have escaped critics and supporters alike is the basic principle of the document -- it calls for a change! The question to ask is: Do our health care system need a reform, and if so, what changes?

          The first question is a fruit cake. For when a policy on health care -- an essential social issue -- for this affluent and vibrant metropolis has not been debated, let alone reformed, for a quarter of a century, a change is imminent if not already too late! Needless to say, the demographic changes, the economic ups and downs and the ever increasing demand of a democratising society makes it imperative that a change is daunting.

          What changes? It is here that the Report must be commended, for it called for not just a new financing system, but a change in policy and a change in the governmental structure that is responsible for health care. In short, if change is needed for which there can be no dispute, then changes must begin all the way from the very top!

          Ever since the establishment of the Health and Welfare Bureau (formerly known as Branch), it is responsible for policies of two vital social elements, both consume a major portion of government budget for which there is no quantifiable return, and on which attract major complaints. Such heavy responsibilities of health care fall on an always understaffed bureau, with the top officials themselves invariably lack professional expertise and understanding. Furthermore, being appointed civil servants, they lack political clout and often shun away from making decisions that are controversial for which any health care reform will invariable attract.

          No, the accusing finger should not be pointed at the Secretary, but rather the system which encourages the principle of "the less you do, the less will be the mistake". It must be on this premiere that the health care system of Hong Kong is allowed to stay dormant for 25 years.

          The Report is thus right to coin this as "benign neglect", but wrong to accuse this as the result of "non-interventionism". For non-interventionism still requires the Government to come up with new policies, new directions from time to time for the market to consider to implement. The Report is thus dead right too to make the criticism: "At the maximum, the HWB has two full time professionals to perform the policy functions for 6.3 million people with public expenditure of more than $30 billion in 1998."

          Nor is the Bureau getting enough support from its executive arm -- the Department of Health. There is a complete lack of complete data on disease profiles and trend of diseases for the policy bureau to base on to plan the budget and policies ahead; Neither is there any drive to come forward with pledges for health indices. To wit, there are no data related to the number of cataracts in Hong Kong and its trend for which the policy bureau can plan its budget. Whilst many lethal and crippling diseases have a known etiology and generally preventable -- heart diseases and celebravascular problems are associated with dietary habits from the very young, from smoking etc -- there has been no push to start preventive programmes on these areas of information collection and transfer. On this aspect, the Department of Health has failed bitterly.

          The Report laid heavy criticism on the lack of control and vetting of private hospitals -- nothing is further from the truth. Yet, the law is there to empower the Director of Health to shoulder this job! Regrettably, it has so far been carried out only on a mode of a pre-arranged yearly visits to private hospitals, discussed issues over a cup of tea and scanning of their annual reports.

          In 1989, the then Medical Development Advisory Committee called for establishing and vetting standards of private hospitals. Yet, The issue became water under the bridge, after the Chairman was changed. Even today, with repeated request by concerned legislators, after a scandalising fatal tragedy involving a straight forward haemodialysis in a private hospital, the controller of private hospitals still procrastinates.

          The medical profession has done its share. For over a decade, it has called for a health policy to determine health indices, it has called for proper improvement of primary health care, it has called for a direction for better private and public cooperation, but alas these are crumbs on the bottom of a stone wall.

          Yes, Hong Kong needs desperately a health care policy change, a new health care funding formula. But does our civil service have the expertise to formulate such policies, and the political sensitivity, the dedication to carry them out often times against the ridicule of politicians and the public?

          The Report has been very critical of the medical profession. Whilst many of these are unfair and perhaps even erroneous, whilst many are isolated incidents, whilst in a profession that reached almost 10,000 strong, there are bound to be blacksheep, and that "one swallow does not make a summer", the profession should have the courage to accept these criticism, take it as an opportunity to instigate changes and improve an existing good service to a further height.

          The call for the setting up of a body to assure quality is a step in the right direction. Yet, this must be formulated within the medical profession, lest professional autonomy will be eroded. The Harvard Team laid some heavy accusation on the high doctor's charges. Whether this is overcharging or otherwise is in doubt. Yet, the profession should regularly come out with a list of average or range of fees for different procedures to give the public a general idea of their health care cost when needed. Medical practitioners themselves in private hospitals should set up individual specialty related peer review and assessment groups to vet hospital admission rights of new doctors and the standards of all services. There is nothing to be embarrassed being critical of one's colleagues nor is it ever denigrating to be so criticised. The Medical Council should consider instigating continuous medical education as a requirement on a three-year basis for continuation of registration to practice. After all, such will be required of a Traditional Chinese Medicine Practitioner upon enactment of the relevant law.

          Much has been said on the need for furthering public health education. This is downright wanting especially if and when the principle of "money following the patient" is accepted, so that the patients can "buy" with their eyes open. Yet such education should never be intended to equip the public to ridicule decisions of the health care providers, but more importantly to impart on him that he himself must take ownership of his own health.

          Finally, not every one will agree with all in the Report. Some may even discard the whole report. Yet if Hong Kong is to have a health care reform for the better, we should grab this Report as a vehicle for possible change.

          If this report can at least instigate ideas for change in the public and a determination to change in the government, whatever the change ultimately may be, then perhaps the purported $5 million spent on the consultancy has not vanished into thin air.

(South China Morning Post)