HEALTH policy ELSEVIER Health Policy 53(2000)147-15 www.elsevier.com/locate/healt Health care in Hong Kong and mainland China: one country, two systems? Karen A. Fitzner a.b., c, d, e, Sheryl Coughlin a, b,,,d, e, Cecilia Tomori a, b, c, d, e. Charles L Bennett a, b c. d, e, *k Department of Community Medicine, Faculty of Medicine, Unicersity of Hong Kong, Hong Kong, SAR, China b School of Health Services Management, University of New South Wales, Sydney, NSW, Australia VA Chicago Healthcare System/Lakeside Division, Northwestern University School of Medicine, Chicago, IL, USA The Robert H. Lurie Comprehensive Cancer Center, Northwestern University School of medici Chicago, IL, USA e Institute for Health Services Research and Policy Studies orthwestern Unicersity School of Medicine, Chicago, IL, USA Received 15 December 1999; accepted 10 April 2155 Abstract Hong Kong and Mainland China are undertaking health reform following recent eco- omic fluctuations and Hong Kongs transformation to a Special Administrative region of China in 1997. Despite spending only 4.7% of its Gross Domestic Product on health care. one third as much as in the United States, Hong Kong has developed health statistics comparable to those in leading western nations. In contrast, Mainland China's 3.6% of GDP expenditure on health is associated with health statistics and expenditures similar to those found in most developing countries. Hong Kong has adopted health care financing and organizational health systems that are commonly seen in centrally planned economies, while its economy functions as a highly capitalistic enterprise. In contrast, mainland China has integrated many features of health care systems associated with market economies, while its overall economy is largely centrally planned. In this paper we examine the policy factors associated with these disparate health systems and investigate whether they can be main- tained according to the one country, two systems' approach that has been adopted by Chinese policy makers. C 2000 Elsevier Science Ireland Ltd. All rights reserved author. Present address: Lakeside vA Medical Science Building. 400 E Ontario Av l,USA.Tel.:+1-312-9436600;fax:+1-312-6402496 cbenne(anwu.edu(C L. Bennett) 0168-8510/00/S- see front matter o 2000 Elsevier Science Ireland Ltd. All rights reserved PII:S0168-8510(00)00090-7
Health Policy 53 (2000) 147–155 Health care in Hong Kong and mainland China: one country, two systems? Karen A. Fitzner a,b,c,d,e, Sheryl Coughlin a,b,c,d,e, Cecilia Tomori a,b,c,d,e, Charles L. Bennett a,b,c,d,e,* a Department of Community Medicine, Faculty of Medicine, Uni6ersity of Hong Kong, Hong Kong, SAR, China b School of Health Ser6ices Management, Uni6ersity of New South Wales, Sydney, NSW, Australia c VA Chicago Healthcare System/Lakeside Di6ision, Northwestern Uni6ersity School of Medicine, Chicago, IL, USA d The Robert H. Lurie Comprehensi6e Cancer Center, Northwestern Uni6ersity School of Medicine, Chicago, IL, USA e Institute for Health Ser6ices Research and Policy Studies, Northwestern Uni6ersity School of Medicine, Chicago, IL, USA Received 15 December 1999; accepted 10 April 2155 Abstract Hong Kong and Mainland China are undertaking health reform following recent economic fluctuations and Hong Kong’s transformation to a Special Administrative Region of China in 1997. Despite spending only 4.7% of its Gross Domestic Product on health care, one third as much as in the United States, Hong Kong has developed health statistics comparable to those in leading western nations. In contrast, Mainland China’s 3.6% of GDP expenditure on health is associated with health statistics and expenditures similar to those found in most developing countries. Hong Kong has adopted health care financing and organizational health systems that are commonly seen in centrally planned economies, while its economy functions as a highly capitalistic enterprise. In contrast, mainland China has integrated many features of health care systems associated with market economies, while its overall economy is largely centrally planned. In this paper we examine the policy factors associated with these disparate health systems and investigate whether they can be maintained according to the ‘one country, two systems’ approach that has been adopted by Chinese policy makers. © 2000 Elsevier Science Ireland Ltd. All rights reserved. www.elsevier.com/locate/healthpol * Corresponding author. Present address: Lakeside VA Medical Science Building, 400 E Ontario Ave, Chicago, IL 60611, USA. Tel.: +1-312-9436600; fax: +1-312-6402496. E-mail address: cbenne@nwu.edu (C.L. Bennett). 0168-8510/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0168-8510(00)00090-7
K.A. Fitzner et al./Health Policy 53(2000)147-1 Keywords: Hong Kong: China; Healthcare policy; Healthcare reform; Health economics 1. Introduction When Britain returned Hong Kong to China in 1997, Deng Xiao Ping stated that China will maintain a one country, two systems'policy. The unification of Hong Kong and China presents an opportunity to address the impact of political changes on health care policy in the Pacific Rim, analogous to the situations described in eastern European countries a decade ago [1]. The two regions differ in overall goals of health policy. Mainland Chinas health policy objectives include prevention of communicable diseases, achievement of 90% coverage of childrens immunization [2 and development of programs targeting AIDS [3] and smoking [4), goal common to most developing countries. To meet these objectives China plans to adopt health care structures commonly associated with market economies. [5] In contrast, Hong Kongs health care system has a well-developed immunization program and comprehensive infectious disease control, but, like most developed countries, faces escalating expenditures and limited public financial resources [6] Hong Kongs current approach incorporates many aspects found in centrally planned economies [7]. The 'one country, two systems'concept provides a frame- work for comparing the development of mainland health care practices and policies with those of Hong Kong. In this paper, we examine the current state of health care in the two regions, describe their health policy objectives, and consider whether the divergent health care funding, policies, and objectives will continue in the 21st 2. Health care in mainland China and hong kong 2. Health status In China life expectancy rose from 34 to 69 years between 1931 and 1989 and infant mortality (under 5 years) decreased from 173 deaths per 1000 live births in 1960 to 44.5 per 1000 in 1990 [8]. Currently, inadequate housing and sanitation, lack of a clean water supply, a large number of absolute poor in rural areas living in extreme conditions, and a recent emergence of an urban underclass plague the population's health Because Chinas present health policy emphasizes combating communicable diseases, it does not provide for the increasing demands of the aged in either current or future policy. In addition, the dependency ratio of children aged 0-14 years is 38.5%[8], further straining health care resources due to costs associated with increasing immunization and childbirth and infancy In comparison, life expectancy and infant mortality in Hong Kong are compara ble to those of other market economies, with a life expectancy of 79 years, a decade
148 K.A. Fitzner et al. / Health Policy 53 (2000) 147–155 Keywords: Hong Kong; China; Healthcare policy; Healthcare reform; Health economics 1. Introduction When Britain returned Hong Kong to China in 1997, Deng Xiao Ping stated that China will maintain a ‘one country, two systems’ policy. The unification of Hong Kong and China presents an opportunity to address the impact of political changes on health care policy in the Pacific Rim, analogous to the situations described in eastern European countries a decade ago [1]. The two regions differ in overall goals of health policy. Mainland China’s health policy objectives include prevention of communicable diseases, achievement of 90% coverage of children’s immunization [2] and development of programs targeting AIDS [3] and smoking [4], goals common to most developing countries. To meet these objectives China plans to adopt health care structures commonly associated with market economies. [5] In contrast, Hong Kong’s health care system has a well-developed immunization program and comprehensive infectious disease control, but, like most developed countries, faces escalating expenditures and limited public financial resources [6]. Hong Kong’s current approach incorporates many aspects found in centrally planned economies [7]. The ‘one country, two systems’ concept provides a framework for comparing the development of mainland health care practices and policies with those of Hong Kong. In this paper, we examine the current state of health care in the two regions, describe their health policy objectives, and consider whether the divergent health care funding, policies, and objectives will continue in the 21st century. 2. Health care in mainland China and Hong Kong 2.1. Health status In China life expectancy rose from 34 to 69 years between 1931 and 1989 and infant mortality (under 5 years) decreased from 173 deaths per 1000 live births in 1960 to 44.5 per 1000 in 1990 [8]. Currently, inadequate housing and sanitation, lack of a clean water supply, a large number of absolute poor in rural areas living in extreme conditions, and a recent emergence of an urban underclass plague the population’s health. Because China’s present health policy emphasizes combating communicable diseases, it does not provide for the increasing demands of the aged in either current or future policy. In addition, the dependency ratio of children aged 0–14 years is 38.5% [8], further straining health care resources due to costs associated with increasing immunization and childbirth and infancy. In comparison, life expectancy and infant mortality in Hong Kong are comparable to those of other market economies, with a life expectancy of 79 years, a decade
K.A. Fitzner et al./Health Policy 53(2000)147-155 longer than in Mainland China, and a ten-fold lower infant mortality rate of 4. 1 per 1000 in 1990. Table 2) Similar to mainland China, the percentage of elderly persons in Hong Kong is expected to increase to 13.3% by 2016[9]. Hong Kong olicy makers are currently developing Long Term Aged Care Policy to respond to this demographic shift. 2. 2. Morbidity and mortality Mainland China's morbidity is largely attributable to infectious diseases such neumonia in the rural areas and cerebrovascular diseases and cancer in the urban areas, while Hong Kongs major causes of morbidity are cancer and heart disease (Table 2). Hong Kongs population is affected by chronic illnesses, such as diabetes, more rapidly than that of mainland China [11] 23. The economic situation and healthcare Chinas government budgetary expenditure dropped from 33. 8% of GDP in 1978 to 14. 1% of GDP in 1994, reflecting government decentralization. China's bud getary expenditures on health (3.6% of GDP or US Sll per capita) and public expenditures on health care(2.0% of GDP)are significantly lower than in industri lized nations, other Asian countries and Hong Kong (Table 1)Nonetheless, such emphasis on economic development may ultimately improve the populations health and welfare by increasing financial resources for public health measures and medical care Table I Health indicators selected countries. 1990 Health Public sector Life expectancy Child mortality xpenditure ( health expenditure at birth (years) (under fives, pe 1000) China(1993 3.6 69(M=679,44.5 F=71) Hong Kong 79(M=76 2) Other Asian 62 Economies Established market 9.2 European former 3.6 Latin American 4.0 economies Source: World Bank, The Chinese Economy. 1996. p.54. Source: Hong Kong Census and Statistics Provisional 1997 figures by the Department of Healt
K.A. Fitzner et al. / Health Policy 53 (2000) 147–155 149 longer than in Mainland China, and a ten-fold lower infant mortality rate of 4.1 per 1000 in 1990. (Table 2) Similar to mainland China, the percentage of elderly persons in Hong Kong is expected to increase to 13.3% by 2016 [9]. Hong Kong policy makers are currently developing Long Term Aged Care Policy to respond to this demographic shift. 2.2. Morbidity and mortality Mainland China’s morbidity is largely attributable to infectious diseases such as pneumonia in the rural areas and cerebrovascular diseases and cancer in the urban areas, while Hong Kong’s major causes of morbidity are cancer and heart disease [10] (Table 2). Hong Kong’s population is affected by chronic illnesses, such as diabetes, more rapidly than that of mainland China [11]. 2.3. The economic situation and healthcare China’s government budgetary expenditure dropped from 33.8% of GDP in 1978 to 14.1% of GDP in 1994, reflecting government decentralization. China’s budgetary expenditures on health (3.6% of GDP or US $11 per capita) and public expenditures on health care (2.0% of GDP) are significantly lower than in industrialized nations, other Asian countries and Hong Kong. (Table 1) Nonetheless, such emphasis on economic development may ultimately improve the population’s health and welfare by increasing financial resources for public health measures and medical care. Table 1 Health indicators, selected countries. 1990 Health Public sector Child mortality Life expectancy expenditure (% at birth (years) (under fives’, per health expenditure GNP) 1000) (% of total) China (1993) 69 (M 3.6 58 =67.9, 44.5 F=71) 4.1 Hong Kong 79 (M= a 4.6 76, a 54a F=82)b Other Asian 4.5 97 39 62 Economies Established market 60 9.2 76 11 economies European former 3.6 71 72 22 socialist economies Latin American 4.0 60 70 60 economies a Source: World Bank, The Chinese Economy. 1996. p.54. Source: Hong Kong Census and Statistics Department. b Provisional 1997 figures by the Department of Health
K.A. Fitzner et al./Health Policy 53(2000)147-155 考 :二
150 K. A . Fitzner et al . / Health Policy 53 (2000) 147–155 Table 2 Leading causes of death in China 1996 and Hong Kong 1991/1992 Chinaa Rank Hong Kongb Urban Rural Total deaths (%) Disease Total deaths (%) Disease Total deaths (%) Disease Malignant neoplasms Cerebrovascular disease 31.6 22.3 Respiratory disease 25.2 1 15.1 17.3 Heart disease 2 Cerebrovascular disease Malignant neoplasms 21.7 Pneumonia Heart disease 13.1 16.4 Malignant neoplasms 16.4 3 9.6 4 Respiratory disease 15.3 Trauma and toxicosis 11.1 Cerebrovascular disease 5.2 10.8 Heart disease Trauma and toxicosis Trauma and toxicosis 6.5 5 a Source: state statistical bureau. China Statistical Yearbook 1997. pp.732–733. b Source: Hong Kong digest of statistics 1997
K.A. Fitzner et al./Health Policy 53(2000)147-155 For over 20 years, until the Asian economic crisis of 1997, Hong Kong had a prosperous and steadily growing economy [12]. Today, growth is slower but Hong Kong continues to be relatively prosperous compared to other parts of Asia. Hong Kong currently spends 4.6% GDP on health [13](Table 2) 2. 4. Health care systems and policies China and hong Kong have contrasting health care structures. The majority of Chinas population obtains health care on a fee-for-service basis [14, while Hong Kong has a mixed medical economy, in which 85% of primary care is provided by the private sector and 92% of hospital care is provided by the public sector [6] Chinas current health care policy, carried out by its Ministry of Health, focuses on prevention and public involvement and a balance between western and traditional medicine. Future Chinese policy goals include continued reforms to improve health care and increase health investment [2] Hong Kongs health care policy, implemented by its Health and Welfare Bureau and Hospital Authority, has until recently focused on ensuring public provision and eliminating access barriers [7]. The 1999 Consultancy Report prepared by a Harvard University team assessed the capability of financing arrangements to meet future needs and recommended reform options for consideration [6]. The Harvard Team suggested five possible options for the future of health care policy in Hong Kong [15]. The first three options maintaining the status quo, capping the government budget on health and raising user fees- were not recommended by the Consultants. The first recommended reform option includes compulsory enroll- ment in a Health Security Plan(HSP)and establishment of an individual savings account, called MEDISAGE. The HSP, paid jointly by employers and employees, would offer protection against catastrophic events and certain chronic diseases and MEDISAGE would be available for purchasing long term care insurance upon retirement or disability. The final recommended option suggests a move toward competitive integrated health care. 2.5. Health care utilization Chinese medical practices differ substantially from those in developed countries In China, the average length of hospital stay in 1994 was 15 days [16, 17], which esulted in an average occupancy rate of 96% with wide variations between urban and rural hospitals [16] Kongs citizens frequently use health care services, indicated 960 800 hospital discharges in 1996[18 and a per capita yearly average visits to doctors practicing western style medicine. Many seek care fror western and traditional practitioners for the same illness episode [6, 19]. The average length of stay was eight days in Hong Kongs public sector hospitals and 3 days in the private sector, significantly shorter than stays in mainland China. Public patients in Hong Kong are more likely to have complicated or costly illnesses than those in private hospitals. Despite over-utilization of premier facilities in 1996-1997
K.A. Fitzner et al. / Health Policy 53 (2000) 147–155 151 For over 20 years, until the Asian economic crisis of 1997, Hong Kong had a prosperous and steadily growing economy [12]. Today, growth is slower but Hong Kong continues to be relatively prosperous compared to other parts of Asia. Hong Kong currently spends 4.6% GDP on health [13] (Table 2). 2.4. Health care systems and policies China and Hong Kong have contrasting health care structures. The majority of China’s population obtains health care on a fee-for-service basis [14], while Hong Kong has a mixed medical economy, in which 85% of primary care is provided by the private sector and 92% of hospital care is provided by the public sector [6]. China’s current health care policy, carried out by its Ministry of Health, focuses on prevention and public involvement and a balance between western and traditional medicine. Future Chinese policy goals include continued reforms to improve health care and increase health investment [2]. Hong Kong’s health care policy, implemented by its Health and Welfare Bureau and Hospital Authority, has until recently focused on ensuring public provision and eliminating access barriers [7]. The 1999 Consultancy Report prepared by a Harvard University team assessed the capability of financing arrangements to meet future needs and recommended reform options for consideration [6]. The Harvard Team suggested five possible options for the future of health care policy in Hong Kong [15]. The first three options — maintaining the status quo, capping the government budget on health and raising user fees — were not recommended by the Consultants. The first recommended reform option includes compulsory enrollment in a Health Security Plan (HSP) and establishment of an individual savings account, called MEDISAGE. The HSP, paid jointly by employers and employees, would offer protection against catastrophic events and certain chronic diseases and MEDISAGE would be available for purchasing long term care insurance upon retirement or disability. The final recommended option suggests a move toward competitive integrated health care. 2.5. Health care utilization Chinese medical practices differ substantially from those in developed countries. In China, the average length of hospital stay in 1994 was 15 days [16,17], which resulted in an average occupancy rate of 96% with wide variations between urban and rural hospitals [16]. Hong Kong’s citizens frequently use health care services, indicated by the 960 800 hospital discharges in 1996 [18] and a per capita yearly average of nine visits to doctors practicing western style medicine. Many seek care from both western and traditional practitioners for the same illness episode [6,19]. The average length of stay was eight days in Hong Kong’s public sector hospitals and 3 days in the private sector, significantly shorter than stays in mainland China. Public patients in Hong Kong are more likely to have complicated or costly illnesses than those in private hospitals. Despite over-utilization of premier facilities in 1996–1997