From Medical Health Reform to a Comprehensive Social Protection System

Patrick C.P. Ho

目前，香港社會人士熱烈討論醫療改革及融資方案。其實，這比較上是單向性和狹窄的改革方向，本文探討全面性的社會保障制度的重新定位及建議成立一個高層的、跨部門的社會保障計劃委員會。

Since the signing of the Joint Declaration between the Chinese and British governments, Hong Kong had been preparing itself for a transition into a new start in 1997. During this period of change and uncertainty, the late colonial government, in the last two decades, expended minimal initiatives in reshaping Hong Kong's social institutions and structures to meet the challenges of an ever-advancing society. The social polices were, at their best, reactive in nature in response to sporadic demands and immediate necessities, and at their worst, piecemeal, incoherent, and wanting in a proactive dimension and a long-term commitment.

Since 1997, with the establishment of the Hong Kong Special Administrative Region, the Government has taken upon itself the task to examine the present social policies in anticipation of the present and future needs of Hong Kong in the first part of the twenty-first century. Considerations of policy reforms were initiated on all fronts : public housing, education, civil service, urban administration, district organisation, culture and recreation, environment and health, social security assistance, and medical services, to name a few. The intentions for these reform considerations were well-meant. But before the government embarks on any major review of social policies, its role and its commitment in the areas encompassed by these policies have to be delineated.

The policies pertaining to social security in Hong Kong have been fragmented, lacking a macroscopic perspective, and the responsibilities of the government, its philosophy and position have not been clearly defined. Without a unified standard and a demarcation of the social security baseline, each government department involved has only its own concern to consider designing a set of systems that best suits its purpose, resulting in a variation of baselines and positions in assessment parameters and disjointed directions of implementation.

For example, under the Housing Bureau, the public housing programmes, housing for senior citizens scheme, home ownership scheme, tenants purchase scheme, and the buy-or-rent option all have different application policies and standards. Under the Health and Welfare Bureau and its Department of Social Welfare, unemployment scheme, the comprehensive social security assistance (CSSA) scheme, disability scheme, and other social welfare schemes all have different assessment criteria. With regard to medical health and welfare, the baseline for government's responsibility is even more nebulous: essentially every Hong Kong citizen has the right to low-cost public medical services, and if financial hardship can be shown, even the low cost to these services can be waived. But the standards for assessing financial difficulty for public medical service are again different from those of the aforementioned schemes. Furthermore, in year 2000, the mandatory provident fund for retirement security will be implemented and this scheme falls in the domain of the Economic Services Bureau. Therefore, different bureaux have different areas of the social service security scheme to tackle and each has its own brief and purpose, and thus its own rules and account. Thus it is not difficult to imagine the complexity of the situation and the confusion caused by the varied policies.

Today, are we undertaking health reform for the sake of health care related problems alone, housing reform for the sake of housing condition, and welfare reforms for the sake of social protection alone? If so, what ensues will be a revision of the different policies in different directions and in a quite incoherent and un-coordinated manner. Perhaps, we should seize this golden opportunity to examine our social needs at this juncture in anticipation of the changes which may arise in the next one or two decades, and review and revise our overall policies on social welfare and security. But before embarking on such a mammoth task, it is of paramount importance for the government to formulate a central position or philosophy of social justice which is deeply rooted in the social value system of our society and supported by public expectations. With this baseline or philosophy come the government's commitments and those of the citizens and of the other public and private institutions. When each other's roles and responsibilities are clearly defined, a cohesive and all-embracing social and welfare security policy can then be organised with a unified standard of protection and which should prevail in every social welfare scheme including housing, social assistance, old-age assistance, disability, unemployment, medical and health, and retirement. In other words, medical and health reform should not be the concern of only the Health and Welfare Bureau; it calls for the participation and the involvement of the reform plans considered by the other bureaux. Medical and health reform cannot be examined in isolation. It has to be done as part and parcel of the overall social security policy review.

Furthermore, for the twenty-first century, the developments of health and medical services have advanced in leaps and bounds, and have exceeded the anarchron passive model of disease diagnosis and therapy. Primary health care, prevention, and rehabilitation have been gradually assuming a mainstream position in the public's health demand. Personal health maintenance, enhancement of the quality of life, and protection against diseases have become a primary concern over treatment of illnesses. Medical and health delivery systems have been gradually transformed from being hospital-based to community-based, and home-based. In addition, medicine in society has also shifted from being led by western-medicine to a novel combination of team approach consisting of Chinese medicine, nursing care, paramedical services, pharmaceutical industries and alternative medicine, in a holistic approach. With a division of labour, each party defining its specific function and role, a coordinated health delivery system can then be expected to meet the needs of society.

With an adjustment of service delivery emphasis, medical and health development cannot be confined to reorganisation of the internal structures and mechanisms of the medical system alone. Indeed, it has become an overall social and political consideration. Elements of the medical and health policy should permeate into, and become dimensions of considerations within, the policies pertaining to other aspects of social protection, such as economic policies, immigration, social welfare, housing, education, environmental protection, and home and district affairs policies.

At this point, I would urge the government to consider establishing a high-level, cross-departmental social protection/security commission consisting of Secretaries from the Health and Welfare Bureau, the Housing Bureau, Economic Services Bureau, Home Affair Bureau and Security Bureau. Taking into consideration the overall development of Hong Kong society and its needs, this commission should conduct in-depth studies, discussion and planning, and after wide consultation, formulate a set of effective and coherent unified comprehensive social protection policies, to meet the challenges of the future generations.

Prof. Patrick C.P. Ho is an ophthalmologist and a Vice Chairman of the Hong Kong Policy Research Institute.