1. 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 clklam@hku.hk.

2. 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 % 12649 doctors ~ 1: 600 people + 9000 CMP

3. 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

4. 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 1 336 consulted Lam C.L.K. et al HKMJ 2011; 17 (suppl): S28-S32.. 247 (73.5%) consulted PC, Referral rate 2.8% 96 (28.6%) consulted CMP Over a period of 4 weeks

5. 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 (%) *‡ 71.780.274.760.8 - Consulted reg. PC doctor (%) *‡ 57.783.865.326.4 - Consulted A&ED (%) *‡ 7.34.37.89.6 - Admitted to the hospital (%) *‡ 3.11.73.64.0 - Median priv. Consult, fee (HK$) 180 175165 - Consulted > 1 doctor (%) * 14.115.615.211.8 Mean Annual Consultation Rate 8.510.410.25.9 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.

6. 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)

7. 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

8. 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 (%)67.470.7* # 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: 10.3389/fmed.2014.0002.

9. Growing health care burden in HK 65+ 1.0 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

10. 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 2009-13 –Public-private partnership, e HR, purchase private service –PC Directory to enable a FD x everyone –Mx. frameworks for chronic D & prevention –Multidisciplinary CHC

11. 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