Health Management and Social Care Booklets

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Health Management and Social Care Booklets

The design of the HMSC curriculum rests on the notion of the interconnectedness of the various levels at which phenomena related to health and sickness, well-being and ill-being, and personal and community care are to be understood. The curriculum aims to enable students to explore all of these levels as well as the relationships between them. The different levels can be interpreted as the individual, the family, the peer group, the community, the institutional setting, society, the nation and the world (Figure 1).

Figure 1 The Various Levels and Essential Questions of HMSC

Individual

Institution

Family Peer

Community Society

Nation World

What are the global and local health and social issues?

How can we build a health and caring society?

What does health mean to a community?

What does health mean to you?

How can we stay healthy?

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This part includes 19 booklets of learning and teaching reference materials for teachers.

The topics and information in these booklets are selected and organized based on the five essential questions from various levels mentioned in the curriculum design in Chapter 2 of the Health Management and Social Care Curriculum and Assessment Guide (Secondary 4-6)(2007). The booklets facilitate teachers to develop an overall framework of HMSC and identify the key concepts of the curriculum so that their students will be more able to critically assess the relevant issues. Details of these booklets are as follows:

Levels Essential Questions Booklets

Individual, Family and Peer

What does health mean to you?

Personal Needs and Development across Lifespan

Health and Well-being

Physical Well-being - Healthy Body Mental Well-being - Healthy Mind Social Well-being - Inter-personal Relationship

Healthy Community Caring Community Ecology and Health Building a Healthy City Health Care System Social Welfare System

Medical and Social Care Professions Health and Social Care policies Social Care in Action

Health and Social Care Issue - Ageing Population

Health and Social Care Issue - Discrimination

Health and Social Care Issue - Domestic Violence

Health and Social Care Issue - Addiction

Health and Social Care Issue - Poverty

How can we stay healthy?

What does health mean to a community?

How can we build a healthy and caring society?

What are the local and global health and social issues?

Community

Local and Global Societies Society

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Each booklet will start with the essential questions. The expected learning outcomes in terms of knowledge, skills, value and attitude as well as the content outline will be listed as an overview. Teachers are advised to adapt and flexibly use the materials based on school or community situation, background of students, interest, learning skills and the prior knowledge of students. Social issues as well as the graphic organizers that illustrated in Booklet 3.1.5 can be used to help student organize and analyze complex and abstract concepts, construct their knowledge effectively and achieve deep understanding.

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How can we build a healthy and caring society?

The holistic concept of health has been elaborated from different perspectives and dimensions in Booklet 1 -9. In Ottawa Charter, definition of health is further elaborated as ‘a resource for everyday life, not the objective of living. It is a positive concept, emphasising social and personal resources as well as physical capabilities.’ If health is the social and personal resources, it needs to be properly managed.

Simply speaking, management is to guarantee the use of resources in the most appropriate way in the most appropriate time and place through planning, organising, directing, coordinating and controlling the use. Management is not just the concern of government and commercial organisations. Non-governmental organisations and other social care organisations also need to be properly managed. Therefore, health management is planning, organising, directing, coordinating and controlling the resources to meet the health needs. In Booklet (10) to (14), it is explored how to achieve holistic health through organising, allocating and utilizing resources from the levels of the system, policy, professionals and professional services.

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Booklets Topics in HMSC Curriculum and Assessment Guide

Health Care System

Social Welfare System

Medical and Social Care Professions

Health and Social Care Policies

Social Care in Action 10

11

12

13

14

Compulsory part

2D Developments in the health and care industries

3B Developing health and social care / welfare policies

3C Implementing health and social care policies 3D Cultural and political disagreements and tensions

4A Disease prevention (primary, secondary and tertiary) and using precautions in our daily living patterns and lifestyles

Compulsory part

5A Professions in health and social services 5B Health and social care services and agencies

Compulsory part

3B Developing health and social care / welfare policies

3C Implementing health and social care policies 3D Cultural and political disagreements and tensions

Compulsory part

4D Social care, healthy relationships, social responsibility and commitment in the family, community and groups

5A Professions in health and social services 5D Leadership in health and social care

The topics of Health Management and Social Care Curriculum and Assessment Guide included in the Booklet 10-14 are listed in the following table:

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10.1 Development of Healthcare System in Hong Kong 10.2 Healthcare System in Hong Kong

(A) Three Levels of Medical Care (B) Overview of the System

(C) Overview of Medical and Health Services (D) Alternative Healthcare Practice

10.3 Healthcare Reforms

(A) Ageing Population (B) Dependency Ratio

(C) Implications for the Needs of Care Services (D) Proposals on Reform

(E) Health Financing Models in Different Countries

(F) Public and Private Sectors and their Roles in Healthcare Services

10.4 Conflicting Agendas in the Healthcare Reform

(A) Private-public Debates and Tensions (B) Private vs. Public Responsibility

(C) Financing Principles – Percentages to be paid by Users and Tax Payers (D) Priorities of Resource Allocated to Related Parties and Organisations (E) Cost – Effectiveness vs. Clients’ Satisfaction

(F) Example of Collaboration between Public and Private Sectors - Cataract Surgery Programme

Contents

10 Healthcare System

8

14 14 15 18 22 25 25 25 26 27 32 38 41 41 43 43 44 44 45

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Through the study of the topic on healthcare system, students are ex- pected to:

Values and attitudes

Understand that value judgments may vary among different individuals or parties

Analyse and appreciate viewpoints or issues from different perspectives

Respect cultural and ideological differences

Appreciate alternative healthcare practices

Knowledge

Understand the concepts of health care

Understand how the development of healthcare system is affected by social factors

Identify the issues and concerns related to the healthcare system

Identify instruments of policies

Compare healthcare policies in Hong Kong with other regions / countries

Understand the conflicts and tensions in the healthcare context

Develop personal opinions on healthcare policies

To achieve the above learning targets, teachers may use the following questions to enhance understanding:

What is health care?

Why does the existing healthcare system need to be reformed?

In what ways can a healthcare system build a healthy community for all?

Learning Targets

Key Questions

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10.1 Development of Healthcare System in Hong Kong

Primary Health Care (PHC), in World Health Organization’s definition, is the essential healthcare made accessible to people at a cost a country and community can afford, with methods that are practical, scientifically sound and socially acceptable. It is based on the belief of ‘health for all’ which was proposed and was formally put forth in the 1978 Alma-Ata Declaration. The Declaration of Alma-Ata was clear about the values pursued: social justice and the right to better health for all, regarding participation and solidarity.

To what extent can the healthcare system in Hong Kong build on these values and achieve the goals of the PHC proposed by World Health Organization? This booklet aims to outline the framework, development and concerns about the healthcare system in Hong Kong. As the ageing population is a global and local trend which has an impact on the healthcare system, especially the healthcare financing, the series of healthcare reforms aiming at solving this problem will be introduced. Students are expected to be able to evaluate and develop their view points on the healthcare system and healthcare reform.

The healthcare system in Hong Kong has undergone many changes to meet the challenges of the healthcare needs. The major milestones of the development of the healthcare system are outlined in the table on the next pages:

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Period Critical Events

1840s

1850s - 1960s

In 1841, the government of the Qing Dynasty was defeated by the British government in the Opium War. Due to the cession of Hong Kong Island, Hong Kong became the British colony for over a hundred years.

There was no healthcare system or health policy in the initial stage in the colonial period.

At that time, most of the hospitals and medical equipment were procured for the British officials in Hong Kong. It had been changed gradually.

During this period, the government focused only on sanitation and disease control by a Committee of Public Health.

The colony adopted a “laissez-faire” administrative approach in medical services.

Government medical services were first introduced in Hong Kong in 1843 with the appointment of a “colonial surgeon” whose patients were mainly garrison and European residents in Hong Kong.

In 1854, 70 soldiers died of dysentery when they got ashore.

An epidemic killed more than 800 people during February to April in 1855.

A number of government hospitals were set up with services mostly to cope with mental disorders, contagious diseases; and largely for government employees.

Most local residents went to private traditional Chinese medicine practitioners.

The Chinese lived at Tai Ping Shan Street at that time.

Most of them were living alone. They had no relatives when they died. Kwong Fuk Tsz (also named as People Temple) was used to enshrine and worship the ancestors of these homeless people. After the plague, the Chinese leaders strove to build hospitals for the Chinese. The first private charity hospitals – the Tung Wah Hospitals was then set up.

On 26 March 1870, the first hospitals for the Chinese - the Tung Wah Hospitals were established. ‘Tung Wah’ means the Chinese in Guangdong. It was staffed by both traditional and western medical practitioners at that time.

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Period Critical Events

1850s - 1960s Sai Ying Pun Hospital (also known as Government Civic Hospital) was founded in 1874 at Queen's Road West. It was the first public non-military hospital in Hong Kong.

The establishment of Nethersole clinic in the Victoria Peak was another important development in medical services for the local residents. Nethersole was named after the mother of Davis, a member of the former London Missionery Society (now it is called the Council for World Mission).

In 1887, Sir Kai Ho built Alice Memorial Hospital in memory of her beloved wife who died in 1884. It was the first hospital in Hong Kong that served the local poor Chinese with western medicine.

In the same year (1887), the Hong Kong Chinese College of Medicine was established, pioneering the local medical training through setting up the teaching hospital in Alice Memorial Hospital.

In 1904, the Alice Memorial Hospital, the first maternity hospital in Hong Kong and China, was set up.

In 1906, due to the shortage of hospital beds, the sister of Sir Kai Ho, Ho Miu Ling, donated money to build the Ho Miu Ling Hospital.

Due to the overcrowding problem, the Alice Memorial Hospital merged with the Nethersole Hospital and Ho Miu Ling Hospital to become Alice Ho Miu Ling Nethersole Hospital in 1954.

Although Hong Kong's medical facilities were improving, in the spring of 1894, an epidemic broke out in Guangzhou, leading to the death of more than 100,000 people. In the same year in May, in the vicinity of Tai Ping Shan Street, Sheung Wan, where the Chinese people concentrated and inhabited, the plague broke out. Over a hundred people died everyday. Consequently, over 2,552 people died of plague.

About 100,000 Chinese left Hong Kong and trade declined.

After that, the plague occurred occasionally during the thirty years. 1,290 people died of plague from 1898 to 1900.

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Period Critical Events

1850s - 1960s

1964 A White Paper on the Development of Medical Services in Hong Kong was issued by the government. It was followed by the expansion of government clinics and hospitals, in accordance with the government policy to provide subsidized or free medical and personal health services for all those unable to purchase or obtain care from other sources.

After that, there was no major development in the healthcare system in Hong Kong until the governor Sir MacLehose who led Hong Kong into a golden age of reform.

Medical Development Advisory Committee (MDAC) was appointed by the government in 1973, re-constituted in 1992 as the Health and Medical Development Advisory Development Committee (HMDAC) to provide a continuous review and advisory service for the development and implementation of medical and health services.

In 1974, a re-statement of government health policy in the White Paper “The Further Development of Medical and Health Services in Hong Kong” tabled in incremental development rather than radical changes of direction. It proposed medical and health services to be organised on a regional basis.

During this period, there was rapid expansion of hospital facilities, but slower increase in general outpatient services and clinics in providing primary medical care. More than 70% primary medical consultations took place in the private sector. Further outpatient services were provided under an arrangement between the Housing Authority and the Voluntary Estate Doctors Association through which about 300 public housing estates set up low-cost clinics for residents.

1970s - 1980s

At that time, the government adopted an extreme policy to demolish a number of Chinese accommodations to force the people to move out. Simultaneously, the Tung Wah Hospital Board tried to control the plague by asking the immigrants, mostly the coolies, to register their addresses in order to manage the public health condition. However, it was strongly opposed and led to a strike in the port.

During this period, the control of plague did not rely on effective medicine, but on working hard to achieve public health. ‘Washing Tai Ping Tei’ was one of the important measures at that time.

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Period Critical Events

1980s - 1990s

1990s - 2000s

Responding to the calls for a review of hospital medical services and their administration, the Executive Council approved a review in 1984. The consultant report - the

“Scott Report” was issued in December 1985 with recommendations to establish a statutory authority to provide hospital medical services and their administration.

In 1987, the government decided to establish the Hospital Authority as a statutory authority to oversee and manage the provision and delivery of services in an integrated hospital service which would encompass all government and subvented hospitals.

On 1 October 1988, the Provisional Hospital Authority was established.

On 1 April 1989 the Medical and Health Department was split into the Department of Health and the Hospital Services Department.

On 1 December 1991, the Hospital Authority formally took over the management of the 15 government and 23 subvented hospitals and institutions in order to provide an integrated public hospital services.

The provision of public health and preventive programmes became the responsibility of a government department - the Department of Health.

In 1993, the consultation document “Towards Better Health”

was published which advocated subsidising medical services according to the affordability of clients.

With the return of sovereignty in 1997, the first policy address of the Chief Executive promised to conduct a comprehensive health reform.

The Harvard’s Report was published in 1999, proposing health financing models.

Development of primary health care was limited to the community-based maternal and child health services.

1970s - 1980s

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Period Critical Events

2000s onwards The health financing models encountered resistance in 2001. It was known as offering a long term scheme which included health management and contributory saving. In the mean time, the structure of medical costs and charges of public health services were under review.

In 2002, the new charge, $100, was adopted for the A&E service in hospitals. The new charges were also effective in other health care services in public hospitals since 2003.

The consultations on the reform of health care financing started but no substantive action was taken due to the resistance created by socio-economic and political factors.

The management of 59 General Outpatient clinics transferred out from Department of Health in 2003.

The Hospital Authority became responsible for delivering a comprehensive range of secondary and tertiary specialist care and medical rehabilitation through its network of healthcare facilities.

The Hospital Authority also provided some primary medical services in 74 primary care clinics.

Responding to the SARS Expert Committee Report, the Centre of Health Protection (CHP), was set up in 2004.

It aims to provide systems on disease control to tackle health threats and to respond to outbreaks of infectious diseases in collaboration with local and international health organisations.

Public private interface (PPI) in health service delivery is being developed to provide more choices for patients as well as maximize the use of combined resources between the public and private health sectors.

A healthcare reform consultation ‘Your Health Your life’

was launched in 2008 to seek public views on the future development of the Hong Kong healthcare system and financing arrangement. In the consultation paper, the reform is proposed to be undertaken in five areas including:

enhancing primary care to put greater emphasis on preventive care, promoting public-private partnership in health care, developing electronic health-record sharing, strengthening the public healthcare safety net, and reforming healthcare financing arrangements.

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10.2 Healthcare System in Hong Kong

Healthcare services in Hong Kong are customarily categorized into three levels, namely, primary, secondary and tertiary medical care, depending on the nature of services required.

(A) Three Levels of Medical Care

1. Primary medical care

In the following part, primary medical care mainly refers to the medical part of primary healthcare. It is the first point of contact that patients make with their doctors, such as general practitioners. It covers curative and preventive care, continuing care, health promotion and education, as well as referral to specialists.

2. Secondary medical care

Secondary medical care refers to specialist medical care and hospital care.

Secondary medical care services include acute and convalescent in-patient care, day surgery, specialist out-patient, and Accident and Emergency services.

3. Tertiary medical care

Tertiary medical care refers to highly complex and costly hospital care, usually with the application of advanced technology and multi-disciplinary specialized expertise. Tertiary medical care services are usually required by patients with complicated but relatively less common diseases or are suffering from catastrophic injuries or illnesses. Some examples of tertiary medical care services are organ transplants and radio-surgery of the brain including the use of Gamma Knife.

The public sector is the predominant provider of secondary and tertiary medical care in Hong Kong. Apart from general out-patient clinics (GOPCs), the Hospital Authority (HA) also manages all the public hospitals in Hong Kong. As at the end of 2006, there were 39 public hospitals with a total of 27,755 hospital beds, compared to 3,124 beds provided by 12 private hospitals.

Reference:

Your Health, Your Life — http://www.fhb.gov.hk/beStrong/

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(B) Overview of the System

1. The Policy

“The Government aims to ensure no one in Hong Kong is deprived of medical care because of lack of means. It provides a wide range of public services and facilities to meet the healthcare needs of the community. It also works endlessly to safeguard public health – combating infectious diseases and promoting health education.” This declaration from the introduction in the Yearbook 2006 of Hong Kong Government outlines the mission of the healthcare system in Hong Kong.

In the ‘2007-08 Policy Address’, healthcare policy highlighted the following areas:

Enhancing primary health care and promoting family doctor-based services

Purchasing healthcare services from the private sector

Exploring alternative models of public-private-partnership to facilitate integration of the public and private healthcare sectors, promote healthy competition for service quality and professional standards, and provide more choices for the public

Developing medical centres in paediatrics and neuroscience to upgrade the healthcare services

Developing a comprehensive strategy to prevent and control non- communicable diseases and enhance health education to improve the population’s health

Strengthen the regulation of Chinese medicine, and enhance the integration of the Chinese medicine profession into the public healthcare system

Developing a territory-wide, patient-oriented electronic health record.

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2. The Structure

3. Hospital Authority

Policy

Making Food and Health Bureau

Delivery Hospital Authority

Department of Health

Responsible for the delivery of medical treatment and rehabilitation services in Hong Kong.

Responsible for managing publicly funded hospitals, specialist care and related services.

Responsible for safeguarding the health of the community through promotive, preventive, curative and rehabilitative services with four core roles, namely regulatory, advisory, health advocacy and promotion, and disease prevention and control.

Responsible for providing a range of primary care, public health, rehabilitative and health promotion services.

Responsibilities Under the Hospital Authority Ordinance, the Hospital Authority has the following responsibilities:

Advising the government of the needs of the public for hospital services and of the resources required to meet these needs

Managing and developing the public hospital system Recommending to the Secretary for Health, Welfare and Food Bureau appropriate policies on fees for the use of hospital services by the public

Establishing public hospitals

Promoting, assisting and taking part in education and training of HA staff and researching on hospital services

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Financing Structure

It is totally financed by government funding through taxation.

The Hospital Authority is an independent organisation which is accountable to the Government through the Secretary for Health and Welfare, who is responsible for the formulation of health policies and monitoring the performance of the Authority.

In 2008, it manages a Head Office, 41 public hospitals / institutions, 47 specialist outpatient clinics and 74 general outpatient clinics to deliver a comprehensive range of secondary and tertiary specialist care and medical rehabilitation; as well as some primary medical services.

The organisation structure can be found from the following organisation chart of regional clustering and managed by Cluster Chief Executives:

Chief Executive

HongKong EastCluster

HongKong WestCluster

Kowloon Central Cluster

Kowloon East Cluster

Kowloon West Cluster

NewTerritories EastCluster

New Territories West Cluster

Head Office

For more information about the Hospital Authority, refer to:

http://www.ha.org.hk

For more information about the Department of Health, refer to:

http://www.dh.gov.hk

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(C) Overview of Medical and Health Services

1. Primary Healthcare Services

Primary healthcare is the first point of contact where individuals and their families are subject to a continuing healthcare process, which aims at avoiding hospitalisation and improving their health condition in general.

✐ Clinic Services

Public general outpatient services of Hospital Authority are primarily targeted at low-income families, patients with chronic diseases and other vulnerable groups. The majority of Hong Kong people seek outpatient services from the private sector. Services are also provided by registered Chinese medicine practitioners and listed Chinese medicine practitioners.

✐ Family Health

The Department of Health provides a comprehensive range of health promotion and disease prevention services through its maternal and child health centres and woman health centres for children up to five years of age, and women aged 64 or below. The government-subvented Family Planning Association (FPA) of Hong Kong offers comprehensive services and health information on sexual and reproductive health treatment and counselling through its various clinics, youth healthcare centres, women’s clubs, and libraries.

✐ Student Health

For primary and secondary school students, the Department of Health offers health assessment, health education and individual health counselling with emphasis on health promotion and disease prevention through its student health service centres and special assessment centres. To further safeguard students’ health, school health inspectors pay regular visits to schools to check on their environmental hygiene and sanitation standards, while health officers and nurses provide advice on the control of communicable diseases.

Teams from the Department of Health pay annual visits to primary schools to vaccinate students against communicable diseases.

Reference: Hong Kong Year Book http://www.yearbook.gov.hk

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✐ Elderly Health

The Department of Health has set up elderly health centres and visiting health teams to enhance primary health care for the elderly, improve their ability to care for themselves, encourage healthy living and strengthen family support to minimise illness and disability of their elders. The elderly health centres provide people aged 65 or above with comprehensive primary healthcare services which include health assessments, physical check-ups, counselling, curative treatment, and health education. The visiting health teams conduct health promotion activities for the elderly and provide training for carers to enhance their health knowledge and skill in caring for the elderly.

✐ Community Health

Community health service aims to minimise the needs for inpatient services by the public and facilitate patients’ rehabilitation in the community. The service is provided by family physicians, community paediatricians, community physicians, general practitioners and community-allied health practitioners. The community health service also includes the community nursing services, community geriatric assessment, community psychiatric nursing services, and other community allied health services. Care-givers trained on the job in homes are permitted also to render community health services on a collaborative basis. The service provides medical support for the elderly who are discharged from public hospitals.

Volunteer groups have also been set up to help old people who have been discharged from hospitals. A telephone nursing consultation service has also been set up to provide home instructions and advice on disease management. There is also stationing of community nurses at care centres and non-governmental organisations to provide on-site care for people in the district. With regard to rehabilitation and palliative services, the hospital clusters under the ambulatory care centres are set up to take on discharged patients for short-term rehabilitation and an integrated palliative day care centre is started to provide a full spectrum of physical, rehabilitative, psychological and spiritual services to the patients and families in need.

✐ Dental Health

The School Dental Clinics, run by the School Dental Service Division of the Department of Health, provide preventive dental services which include annual dental check-ups and basic dental care to primary students each year. The government dental clinics provide emergency dental services to the general public and there are also the specialist oral healthcare services in seven public hospitals to inpatients and others with special oral health needs. The Department of Health also monitors the level of fluoridation in water supplied to the public to reduce dental decay among people living in Hong Kong.

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2. Secondary, Tertiary and Specialised Healthcare Services

Secondary, tertiary and specialised healthcare services are provided mainly in hospitals run by the Hospital Authority.

✐ Specialist Outpatient Service

Secondary and tertiary ambulatory services in the public sector are provided mainly through the Hospital Authority’s specialist clinics. At these clinics, patients’ symptoms are assessed, and arrangements made for specific tests to be carried out to facilitate diagnosis, treatment, as well as follow-up treatment for patients who require long-term specialist care.

Most public hospitals have specialist clinics for internal medicine, surgery, as well as obstetrics, gynaecology, paediatrics, orthopaedics and traumatology, ear nose and throat, neurosurgery, oncology and cardiothoracic surgery.

Many hospitals also have subspecialist clinics for cardiology, respiratory medicine, kidney disorders and other illnesses.

✐ Acute Inpatient Service

Inpatient services are offered to patients who require intensive therapy for their acute illness. Supported by full ancillary services, clinicians in public hospitals are able to effectively treat patients with different medical needs through a comprehensive range of clinical specialities, including internal medicine, surgery, neurosurgery, clinical oncology, cardiology, obstetrics and other such operations and treatments.

✐ Accident and Emergency Services

The hospitals provide service for people critically ill or injured who need urgent medical attention, or for victims of disasters. Since April 1999, patients attending the accident and emergency departments of public hospitals have been classified under five categories according to their state of health or injuries: Critical (Category 1), Emergency (Category 2), Urgent (Category 3), Semi-urgent (Category 4), and Non-urgent (Category 5).

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✐ Other Special Services

Physiotherapy

Occupational therapy

Dietetic advice

It is concerned with human function and movement, to maximize potential as well as to promote, maintain and restore physical, psychological and social well-being.

Example: exercise for the back after occupational injury needs the advice from the physiotherapist.

To provide daily living skills evaluation and training, home modification to increase function and safety, education in use of adaptive equipment, and activities to promote upper- limb capacity.

Example: rehabilitation exercise of fingers after industrial injury on upper limb to restore fine movement of fingers with advice from the occupational therapist.

To identify nutrition problems, assess the nutritional status of patients, develop care plans, monitor the effectiveness of dietary changes and provide dietetic advice regarding patients’ health status.

Example: the advice on the diet for patients of Diabetes.

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(D) Alternative Healthcare Practices

1. Traditional Chinese Medicine (TCM)

In Traditional Chinese Medicine, the body is seen as a delicate balance of two opposing and inseparable forces: yin and yang, the concept of two opposing yet complementary forces described in traditional Chinese medicine. Yin represents the cold, slow, or passive aspects of the person, while yang represents the hot, excited, or active aspects. A major theory is that health is achieved through balancing yin and yang and a disease is caused by an imbalance leading to a blockage in the flow of qi (vital energy). In TCM, the vital energy or life force which is supposed to regulate a person's spiritual, emotional, mental, and physical health and to be influenced by the opposing forces of yin and yang along pathways known as meridians.

2. Acupuncture

Acupuncture is an alternative method of treatment which originated in China. It is a relatively painless treatment which involves the insertion of fine needles at specific points of the skin. Acupuncture has been found to enhance health and the immune system as well as addressing specific symptoms.

Practiced in China and other Asian countries for thousands of years, acupuncture is one of the key components of traditional Chinese medicine (TCM). The term

"acupuncture" describes a series of procedures involving the stimulation of anatomical points on the body using a variety of techniques. The acupuncture technique that has been most often studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation.

Chinese Medicine Council of Hong Kong http://www.cmchk.org.hk

CUHK- Institute of Chinese Medicine http://www.icm.cuhk.edu.hk

Hong Kong Jockey Club Institute of Chinese Medicine (HKJCICM) http://www.hkjcicm.org

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3. Naturopathy

Naturopathy, also called naturopathic medicine, is a whole medical system that originated in Europe. Naturopathy aims to support the body's ability to heal itself through the use of dietary and lifestyle changes, together with complementary alternative medicine therapies such as herbs, massage, and joint manipulation.

This involves a whole medical system — one of the systems of healing and beliefs that have evolved over time in different cultures and parts of the world.

Naturopathy is rooted in healthcare approaches that were popular in Europe in the 19th century, especially in Germany, but it also includes therapies (both ancient and modern) from other traditions. In naturopathy, the emphasis is on supporting health rather than combating disease.

The practice of naturopathy is based on some key principles:

Promote the healing power of nature.

First do no harm. Naturopathic practitioners choose therapies with the intent to keep harmful side effects to a minimum and not suppress symptoms.

Treat the whole person. Practitioners believe a person's health is affected by many factors, such as physical, mental, emotional, genetic, environmental, and social ones. Practitioners consider all these factors when choosing therapies and tailor treatment to each patient.

Treat the cause. Practitioners seek to identify and treat the causes of a disease or condition, rather than its symptoms. They believe that symptoms are signs that the body is trying to fight disease, adapt to it, or recover from it.

Prevention is the best cure. Practitioners teach ways of living that they consider most healthy and most likely to prevent illness.

The physician is a teacher. Practitioners consider it important to educate their patients in taking responsibility for their own health.

Acupuncture aims to restore and maintain health through the stimulation of specific points on the body called meridians. Qi can be unblocked by using acupuncture at certain points on the body that connect with these meridians. Sources vary on the number of meridians, with numbers ranging from 14 to 20. One commonly cited source describes meridians as 14 main channels "connecting the body in a web like interconnecting matrix" of at least 2,000 acupuncture points.

For further information, please refer to:

http://nccam.nih.gov/health/acupuncture

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For further information, please refer to:

http://nccam.nih.gov/health/naturopathy/

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10.3 Healthcare Reforms

The ageing trend in Hong Kong's population has continued during the past 10 years, with the median age rising from 34 in 1996 to 39 in 2006, according to the 2006 Population By-census results. Anticipating that the aging pace will accelerate in 2015 or 2016, about 27% of Hong Kong's population will reach the age of 65 or above in the 2030s.

At present, the size of the working-age population (aged 15-64) is larger than the population of children (those under age 15) and the elderly (over age 65). This demographic feature enables societies to spend relatively less, for example, on schools and old-age medical expenses and to invest savings for economic growth. However, it is expected that the dependency ratios will rise as the aged population inceases and the working-age population decreases.

The impact of population ageing is increasingly evident in the old-age dependency ratio, the number of working age persons (age 15 - 64 years) per older person (65 years or older) that is used as an indicator of the 'dependency burden' on potential workers. Between 2005 and 2050, the old-age dependency ratio will almost double in more developed regions and almost triple in less developed regions. The potential socioeconomic impact on society resulting from an increasing old-age dependency ratio is an area of growing research and public debate. In Hong Kong, the impact of population ageing is increasingly evident in the old-age dependency ratio, the number of working age persons (age 15 - 64 years) per older person (65 years or older), that is used as an indicator of the 'dependency burden' on potential workers. In Hong Kong, the ratio of our working age population to the elderly population is 6:1 in 2009, and will become 4:1 in 2020 and 3:1 in 2030. In the foreseeable future, there will be less and less young people who can help share the livelihood expenses (including medical expenses) of the elderly population.

(A) Ageing Population

(B) Dependency Ratio

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The ageing population will accompany an increase in chronic diseases, and the strain on treatment, rehabilitative and relevant social services will also increase.

For example, since the demand for hospital beds will increase with age, healthcare expenditure is expected to increase largely due to the increasing health needs of the ageing population:

2004 public health expenditure: about $38 billion

2015 projected public health expenditure: about $78 billion 2025 projected public health expenditure: about $127 billion (Health and Food Bureau, March 2008)

According to the 2008-09 Budget from the Financial Secretary of Hong Kong, an ageing population definitely brings about an increase in demand for healthcare services. In 2008, nearly half of the total expenditure of the Hospital Authority is used to provide healthcare services for the elderly. The cost of providing such services to the elderly is on average six times that for other groups.

As people live longer, there is an increased demand for health and care related to chronic conditions such as cardiovascular and cerebrovascular diseases, malignant neoplasms, chronic obstructive pulmonary disease, osteoporosis and dementia. It is a fact that older individuals have a greater cumulative risk of chronic illness and disability requiring more intensive medical and rehabilitative services. As the ageing process of the population accelerates, an unstoppable rise in the proportion of the elderly is expected. Therefore, it is expected that the expansion of the health sector, especially geriatric specialty is unavoidable. For example, it requires more hospital beds, more advanced medical technology, more healthcare workforce particularly in gerontology and new insurance products.

As most of the elderly have retired and have lesser income, it is likely that in the future they will have to continue to rely heavily on the public sector for health. Since it is impossible for the government to increase public healthcare expenditure indefinitely, introduction of supplementary financing in parallel by various forms of financing package has been proposed to ensure the sustainable development of the healthcare system in the long run.

(C) Expansion of Healthcare Expenditure and Services

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Hong Kong has a relatively simple healthcare financing system. Services provided by the public sector are financed almost entirely through general revenue. There are no national health insurance contributions or any other health related tax.

Services provided by the public sector include almost 90% of inpatient care, 15% of outpatient care, preventive and rehabilitative care. All Hong Kong residents are eligible to receive care, either free or at a heavily subsidized rate, from institutions under Department of Health or the Hospital Authority.

In the private sector, direct payment is the dominant mode of financing. As there is no public health insurance in Hong Kong, almost all the care provided by private practitioners is paid by individuals, employers or private insurance. Cross financing between the public and private sectors – i.e. public funds paying for services provided by private practitioners or private payment of services provided by public institutions - is minimal.

Because of the ageing population, increased medical costs and community expectation, the financial burden of the government healthcare system is increasing.

The sustainability of the current healthcare system under the present policy of low-tax, high-subsidy and high-quality is being questioned.

There are different attempts to review and amend the mechanisms for financing healthcare services. Therefore, the government is making a new arrangement in reforming the healthcare system. Political Parties and Members of the Legislative Council have continuing debates on the healthcare financing models.

(D) Proposals on Reform

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1. Healthcare Financing in Hong Kong

The following are features of the healthcare financing in Hong Kong:

Tax-based financing system

General taxation, Health insurance plans, Out-of-pocket payments Share of

financial responsibility

Hospital services

Primary healthcare services

Medicines

Individuals cover around 3% of the cost for public hospital services by out - of - pocket payments and / or health insurance.

Medical safety net to assist patients with financial difficulty in paying public hospital bills.

Fees and charges for private hospital services are covered by out - of - pocket payments and / or health insurance.

Patients pay full cost for services in the private sector.

Patients who cannot afford private sector services can use subsidised public services.

Patients are required to pay a small sum (HK$10) for each government - subsidized prescription except medicines provided during hospitalisation.

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2. “Towards Better Health” (1993)

Five health financing models have been proposed in the consultation document

“Towards Better Health” in 1993. They are:

Model of percentage subsidy approach

Model of target group approach

Model of coordinated voluntary insurance approach Model of compulsory comprehensive insurance approach

Model of prioritisation of treatment approach

It is a restatement of the Scott Report recommendation that hospital inpatients should be charged a low percentage of the average bed-day cost, instead of a notional food cost.

By these, three main types of hospital – acute general, convalescent/ infirmary, and psychiatric are subsidized at the same percentage.

It comprises two major elements – semi-private rooms and itemised charging – plus an option for waiver of charges.

It aims to provide patients with a greater choice, while achieving greater equity in financing. Semi-private rooms promise a superior standard of accommodation for better- off patients who opt to pay a higher daily fee while itemised charging is an income based proposal.

It involves the creation of a body to accredit medical insurance policies designed to cover treatment at public facilities. The idea is to increase consumer protection and transparency while involving relatively little government intervention in the industry.

It requires all households to participate in a centrally administered medical insurance scheme. Such scheme would cover primary and hospital care, up to a certain standard, in both the public and private sectors. Participants could also upgrade the level of coverage by purchasing supplementary insurance from medical insurance companies.

This model seeks to overcome the problem of overloaded public facilities by listing medical conditions and treatments in order of priority and funding them in accordance with available resources. Patients with low priority medical conditions would simply not be treated, freeing resources and reducing waiting time for more important cases.

3. “Lifelong Investment in Health” (Harvard’s Report) (1998)

After more than 5 years of debates on the above stated medical financing models, there was no consensus on implementing any of them. Therefore in 1998, another

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4. “Your Health Your Life: Healthcare Reform Consultation Document” (2008 and 2010)

Cap the Government Budget for Health Care

User Fees

Health Security Plan and

Long-Term Care Savings Accounts

Capping the government budget for health has many of the features of existing financing system. The only measure involved is setting an explicit upper limit on government healthcare expenditures (or a limit on the rate of growth of those expenditures).

The aims of raising user fees for public facilities are twofold:

to manage the government budget, and to reduce the overuse of nearly free public health services. The fee has to increase steadily to assure that government expenditure remains at a constant percentage of Gross Domestic Product (GDP). This option shifts the burden of increasing healthcare costs from the government onto households.

This model consists of two separate components: mandatory contributions to individual savings accounts to be used to purchase long-term care insurance upon retirement or disability (MEDISAGE), and a Health Security Plan (HSP) for inpatient hospital and outpatient services for certain serious chronic diseases (The Harvard Team. 1998).

For further information on the proposal, refer to “Lifelong Investment in Health” from the following web site:

http://www.fhb.gov.hk/en/press_and_publications/consultation/

HCR1.HTM

consultation team - The Harvard Team - was appointed by the Government to examine the existing financing system and recommend changes. Besides maintaining the current financing system as one of the options, three other options were provided in the Harvard’s Report. They are:

In 2004, a paper on “Studies on HealthCare Financing and Feasibility of a Medical Savings Scheme in Hong Kong” was presented to the Legislative Council Panel on Health Services. Even though no consensus was made since then, discussion is going on. Until 2008, another healthcare reform consultation paper - “Your Health Your Life: Healthcare Reform Consultation Document” - is launched calling the discussion on the whole range of financing options. There are three models with six schemes in raising existing government funding to improve and sustain quality healthcare suggested in this consultation document. They are:

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Tax-like Model

User-pays Model

Individual Health Insurance Model

Social Health Insurance

Out-of-Pocket Payments

Voluntary Health Insurance Medical Savings

Mandatory Health Insurance

Personal Healthcare Reserve

All members of the working population are required to contribute a certain percentage of their income to finance healthcare protection for the whole population. All the contributions are paid into a social health insurance fund to provide subsides to the whole population for the use of public and private healthcare services covered by the social health insurance.

It needs to increase the user fees for using public healthcare services.

With the exception of low-income and under-privileged groups, service users are required to share a larger portion of the costs for healthcare.

This option encourages members of the public to purchase private health insurance in the market voluntarily.

It requires a specified group of the population to deposit part of their income into a personal medical savings account to meet their own future healthcare expenses.

It requires a specified group in the population to purchase individual health insurance regulated by the Government.

It requires a specified group in the population to deposit part of their income into a personal healthcare reserve account. Part of the deposit will be used for subscribing to a government-regulated personal healthcare insurance, and the remainder will be accrued in the account to continue subscribing the insurance and meet other medical expenses after retirement.

For details about the healthcare reform, please refer to the following website: http:// www.beStrong.gov.hk

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The models for health care in different countries can be classified as follows:

(E) Health Financing Models in Different Countries

1. Market Orientated Approach

Allocation of resources will be done according to consumers’ willingness to pay and privatisation of organisations that provides health services.

✐ United States (USA)

➢ Private Insurance

Until September 2009, a majority of the population relies on private insurance as their sole means of health care cover. Under such a system, the level of access to healthcare services is determined by the level of insurance cover which an individual can afford to purchase, and contributions are based not only on the ability to pay but also on an individual’s health risk assessed by the insurer.

2010 healthcare reform second stage public consultation

For further information, please refer to pelow website:

www.MyHealthMyChoice.gov.hk

Second Stage Public Consultation

First Stage Public Consultation

Introduce supplementary

financing

Develop electronic health record Enhance

primary care Promote

public-private partnership

Strengthen healthcare safety net Health

Protection Scheme

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Part A

Hospital insurance (HI)

Medicare Part B

Supplementary medical insurance (SMI)

Coverage

Financing

Almost all persons over the age of 65 are automatically entitled to Medicare part A. It provides coverage of inpatient hospital services, up to 100 days of post-hospital skilled nursing facility (SNF) care, home health services, and hospice care. Patients must pay a deductible each time their hospital admission begins. Medicare pays the remaining costs for the first 60 days of hospital care. A limited number of beneficiaries requiring care beyond 60 days are subject to additional charges. Patients requiring SNF care are subject to a daily coinsurance charge for 21-100 days .

Part A is financed primarily through the HI payroll tax levied on current workers and their employers. Employers and employees each pay a tax of 1.45 % on all earnings, as in 2000. The self-employed pay a single tax of 2.9% on earnings, as in 2000.

Part B is voluntary. All persons over the age of 65 and all persons enrolled in part A may enroll in part B by paying a monthly premium.

Part B provides coverage for physicians’ services, laboratory services, durable medical equipment, hospital outpatient department services, and other medical services.

Part B is financed through a combination of monthly premiums levied on

programme beneficiaries and Federal general revenues.

Beneficiaries’ premiums have generally represented about 25% of part B costs; Federal general revenues account for the remaining 75%. (House Ways and Means Committee, 2000)

➢ Medicare

Medicare is a nationwide health insurance programme for the aged and certain disabled persons. The programme consists of two parts: Part A - hospital insurance (HI); Part B - supplementary medical insurance (SMI).

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➢ Medicaid

Medicaid is the health program for eligible individuals and families with low incomes and limited resources. The Medicaid programme began in 1965. It is administered by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services and jointly funded by the states and federal government.

Medicaid aims to help low-income groups to pay for their medical expenses, which is different from hospital insurance in Medicare. Although both of them are health insurance, Medicaid provides health insurance to the low-income people of all ages whereas Hospital Insurance in Medicare is for individuals aged 65 and above or with disability.

The eligibility of individuals and families are determined by the states.

Each state has its own requirements and procedures of application.

If the applicants are receiving social security from the Social Security Administration, he/she is eligible for Medicaid. Generally speaking, it is provided for the low-income families, the disabled person in need of long-term care and the elderly in need of medical assistance and long-term care.

Medicaid does not pay money to the applicants. It directly pays the service providers. In some services, the applicants also need to pay a small proportion of the fee on their own.

2. Social medicine approach

Since health services are necessities for maintaining life and relieving suffering, everyone is entitled to reasonable access to health care, regardless of the ability to pay, e.g England, Canada.

✐ England

Policy Making

and Delivery Policy Making Delivery

Department of Health.

Several types of statutory organisations (in particular strategic health authorities and primary care trusts) are responsible for providing or ensuring the provision of healthcare services in their respective geographical areas.

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Healthcare Financing

Guiding Principles

Share of Financial Responsibility

Policy Evaluation

Hospital services

Achievements Primary health services

Medicines

Challenges

Tax-based financing system.

General taxation, national Insurance premiums, health insurance plans and out-of-pocket payments.

To provide universal services for all people based on clinical need, not the ability to pay, because health care is a basic human right.

To provide access to a comprehensive range of service through primary and community health care and hospital- based care.

Public hospital services for eligible persons are free of charge unless they choose to be treated as private patients.

Faster accessibility to the National Health Services (NHS).

Enhancement of the health status of the overall population.

Increasing number of people adopting healthier lifestyles.

Fully subsidized by public money, patients receive primary healthcare services provided by private medical practitioners free of charge.

Patients are required to pay a flat rate for each prescription.

Owing to the exemptions granted to specific groups such as children and low-income families, around 85% of the prescription items dispensed are free to patients.

Deficit/overspending of the NHS organisations

The National Audit Office and the Audit Commission recommend that the NHS financial regime should provide right incentives for best practice to enhance the quality of service and clinical productivity; and develop a more transparent financial reporting system to have an early identification of the financial problems of the NHS organisations and prompt reaction to

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3. Mixed Mode Approach

Essential health services are available with reasonable access regardless of the ability to pay; but private health services are available to whoever could afford to pay or with insurance coverage, e.g Hong Kong, Australia.

✐ Australia

Policy and Delivery of Health Care

Guiding principle

Healthcare Financing

Commonwealth government

State and territory governments

Australian Health Minister’s Conference

Funding sources Type of financing system

Holds the overarching responsibility for making and administering nation-wide health financing policies.

Administers healthcare financing schemes.

Facilitates universal access to health care while allowing choice for individuals through substantial private sector involvement in delivery and financing.

Formulates policies governing the delivery of healthcare services and regulation of health-related personnel and premises.

Delivers healthcare services.

Offers a platform for health ministers of various levels of governments to discuss health policies and programmes.

General taxation.

Medicare levy.

Health insurance plans.

Out-of-pocket payments.

Tax-based financing system.

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Share of financial responsibility

Policy Evaluation

Hospital services

Achievements Primary healthcare services

Medicines

Challenges

Public patients in public hospitals are free of charge.

Private patients in either public or private hospitals receive 75% government subsidy on medical services and cover all other costs by out-of-pocket payments and/or health insurance.

Increasing private sector involvement in the delivery and financing of healthcare services.

Increase in the take-out rate of health insurance.

Patients receive government subsidy to cover 85% of the cost on private out-of-hospital services and the remaining 15% is covered by out-of- pocket payments but not by health insurance.

Medical safety net will provide assistance to those patients with difficulty in handling payments.

Patients are required to make a co-payment for acquiring government- subsidized prescription medicines.

Pharmaceutical safety net will assist patients in making the co-payment.

Corresponding increase in government expenditure on rebate.

Higher-income households receiving a larger rebate.

Lack of incentive for insurersto manage high-cost cases cost-efficiently.

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Some professionals in the healthcare sector expect that the healthcare reform will encourage more patients to use the private services in order to reduce both the financial and workload burden on the public sector. In the healthcare reform, the competitive but complementary roles between the public sector and the private sector are under discussion.

(F) Public and Private Sectors and their Roles in Healthcare Services

1. The role of the public sector

✐ Disseminations of health information

Many health and social services such as information and control of contagious diseases are for public good. One person’s use of health information does not make it less available for others to consume.

For example, one person can not benefit from the control of infectious disease, does not exclude another person from benefitting. Therefore, the public sector is responsible for delivering information to the public by encouraging behaviours that carry positive impacts on public health and to discourage those with negative impacts.

✐ Ensuring function of safety net for the disadvantaged groups

Provision of health services to the poor is a socially acceptable approach to poverty reduction. Private markets will not give the poor adequate access to essential care. Therefore, public finance of essential health care is justified to alleviate poverty. It can be in the form of free delivery services, or below-cost public services, or provision of subsidies to private providers and non-governmental organisations that are voluntary non-profit making but are willing to serve the poor.

✐ Protecting consumers through regulation, education and information

A healthcare system based purely on market mechanism is likely to fail to efficiently provide the population with sufficient quantity of services and quality of care. Markets work best when information about goods and services are readily available and producers and consumers are equally well informed. In certain circumstances, many users of care services are

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2. The Role of the Private Sector

✐ Complementary roles from private sector

As a developing city seeking to pursue human resource development vigorously through expansion of services, including education, health, welfare, family, housing programmes, it will be increasingly difficult for government to organise, finance and deliver these services in sufficient quantities and high qualities to meet population needs within a short period of time. Resource constraints in the healthcare sector is particularly acute as expanding economics continue to put upward pressure on the prices of pharmaceuticals, medical technologies, and the wages of trained health and social personnel making it increasingly costly to procure these services, train and retain manpower. It is the time to seek complementary roles from the private sector so that public sector resources can be more efficiently used to achieve other social goals.

poorly educated: these users have difficulties in gauging the substantive quality and the appropriateness of the care they receive. Under these informational conditions, service providers of the private sector may have the incentives to provide lower quality of service, inappropriate types of care, non-efficacious care, and charge a higher price to the services provided. As a result, institutional responses can be explored and the government should take the lead in such situations. These responses include regulation, education and information for consumers to make efficient choices of the public provisions of health and social services.

✐ Advocating equity in accessing health and social care services

The public sector plays a key role in attempting to achieve equity as it is a very important societal objective. This is the reason why both finance and delivery of services have been taken up by the public sector particularly in areas where demand is insufficient to stimulate private provision.

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✐ Acting as a valuable distribution channel for priority services

In many countries private sectors are the primary care provider for large segments of the population, and thus they are a valuable distribution channel for priority services. For example, most countries undertaking health sector reform generally seek to improve equity, access, quality, efficiency, and sustainability of care services. From the following perspectives, private sectors may have advantages over the public sector in assisting the government to achieve these objectives:

➢ Equity: It is considered the private sector encourages higher income segments of the population to use their services. It can contribute to equity by freeing up government funds that can be used to provide priority services to segments of the population that cannot afford to pay.

➢ Access: Private providers may be located in areas convenient and may be available during more convenient time for the service recipients. It increases the accessibility of services.

➢ Sustainability: The private sector can contribute to sustainability by creating an open market for health and social services, independent of changes in government policies and budgetary constraints.

For further information on the role of different sectors in healthcare system, refer to the following web link:

http://www.hkdf.org/papers/9310health.htm

Figure

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References

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