Hong Kong SAR, China 42 nd NAPCRG Annual Meeting Pre- conference Workshop- International Collaboration in Innovating Health Systems Cindy L.K. Lam Danny D. B. Ho Professor in Family Medicine Department of Family Medicine and Primary Care The University of Hong Kong

Demographics of HK’s population Area: 1,104 sq. KM, <25% developed Population: 7.2 million World longest life Expectancy :all 83, M 80.9, F 86.6, y Ethnicity: 92.6% Chinese Unemployment rate: 3.4% Annual GDP/capita:HKD295,303 (US$37,859) (11 th ) Total expenditure on health: 5.1% of GDP Public 48.7 %; Private 51.3 % doctors ~ 1: 600 people CMP

Overall health system design HK Government Food & Health Bureau Hospital Authority (public) Hospital (90%) Private Hospitals (10%) Private Primary C (82%) Western medicine (73%) Chinese medicine (9%) Populatio n Primary C (18%) Department of Health Personal Special gr Pub health Laws & regulationsPrevention

How primary care is delivered in HK 12 ( 3.6%) hospitalized 39 (11.6%) consulted specialists 1000 persons in the general population 353 Reported illnesses consulted Lam C.L.K. et al HKMJ 2011; 17 (suppl): S28-S (73.5%) consulted PC, Referral rate 2.8% 96 (28.6%) consulted CMP Over a period of 4 weeks

Fee x service & free choice of doctors Overall (N=3148) RFD (n=1150) ORD (n=756) NRD (n=1157) During Last Episode of Illness - Used any medical service (%) *‡ Consulted reg. PC doctor (%) *‡ Consulted A&ED (%) *‡ Admitted to the hospital (%) *‡ Median priv. Consult, fee (HK$) Consulted > 1 doctor (%) * Mean Annual Consultation Rate Access to primary health care in HK *Significant difference between RFD/ORD and NRD; ‡ Significant difference between RFD and ORD Source: Lam C.L.K. et al HKMJ 2011; 17 (suppl): S28-S32.

What are the benefits? No citizen is deprived of health care Strong public health esp. children: free childhood immunization rates >98%, annual health & dental check Free PCV & flu vaccine x children & elderly Public medical services including Ix & Rx almost free (PC $6, SOPC $8, Hospital $12/day) Free choice of care, easy access to private care The world’s longest life expectancy (83) at one of lowest health care expenditure (5%GDP)

What are the drawbacks? Any doctor can provide private PC Variation in standard of PC Doctor shopping, lack of continuity Poor public–private integration Cost/ workload of PC limits comprehensive whole person or preventive care Frequent but short consultations Private PC mostly solo and lacking of multidisciplinary support Long waiting time x public specialist care

Impact on patient care Last consultation ALL (N=3148) RFD (n=1150) ORD (n=746) NRD (n=1157) Preventive care4.4%3.9%3.2%5.4% Prescription91.7%93.2%94.4%87.8% Felt enabled (%) * # 65.2 # 65.4* Health got better49.3%53.5%* 50%^44.8%*^ Satisfied93.8%96.1%*93.9%^92%*^ # ^ Significant difference between groups marked, by multivariate logistic regressions Source: Lam CLK et al, Front. Med. 2014; doi: /fmed

Growing health care burden in HK million (14%) in 2013 to 2.6 million (30%) in 2041 in HK. 65+ use 6X more in- patient bed-days than <65 Shift of care from private PC to public 2ry care Public hospital services will not be sustainable

Ability of health system to respond to challenge ↑Govt. health budget from 15% to 17% Promotion of supplementary private health financing options Ear-marked resources (1 billion) to enhance primary care from –Public-private partnership, e HR, purchase private service –PC Directory to enable a FD x everyone –Mx. frameworks for chronic D & prevention –Multidisciplinary CHC

Lessons for other countries Strict gate-keeping of hospital service by PC is most cost-effective Free choice of PC doctors makes PC accessible Doctor shopping limits continuous & comprehensive care People with a FD reported better outcomes in a pluralistic PC system Dual financing model results in private- public segregation & reverse shift of care 11