By Eric Lai

Hong Kong’s plan to reduce public healthcare subsidies from 97% to 90% by 2030 represents a significant shift in one of the world’s most heavily subsidised systems. While the territory’s health bureau portrays this as necessary realignment, the proposed reform warrants careful consideration of its far-reaching implications for healthcare equity and access.

The most immediate concern is that increased costs will deter patients from seeking timely treatment. Healthcare decisions are rarely made with perfect information—patients struggle to distinguish between symptoms requiring immediate attention and those that can wait. By raising financial barriers, there is a risk of turning today’s “unnecessary” emergency visits into tomorrow’s complex and costly hospital admissions. This is particularly true for elderly patients, for whom conditions like urinary tract infections often present atypically as confusion or agitation—symptoms easily misclassified as non-urgent but requiring prompt intervention to prevent serious complications.

Officials argue that some patients exploit Accident & Emergency departments for minor ailments that could be better handled elsewhere. This accurately identifies a symptom while missing the underlying pathology: Hong Kong’s striking lack of accessible primary care alternatives.

Despite publishing a Primary Care Blueprint in 2022 promising District Health Centres and better coordination, implementation has proceeded at a glacial pace. Only a fraction of healthcare spending is directed to primary care compared with specialist and hospital services, creating an imbalanced system that naturally funnels patients toward hospitals. The 2024 Policy Address acknowledged the need to strengthen public healthcare, but the current reforms appear to address symptoms rather than causes.

Proponents of subsidy reduction point to other developed healthcare systems, noting that even at 90%, Hong Kong’s subsidy remains generous compared with Singapore or the United Kingdom. This comparison risks overlooking crutial differences across healthcare infrastructure. Both these systems are built around robust public insurance frameworks that spread risk and costs across the population. Singapore’s Medisave, MediShield Life and Medifund create a safety net alongside personal responsibility, while the UK’s National Health Service provides near-universal coverage through taxation.

Hong Kong lacks such a social health insurance system, despite a 1999 Harvard recommendation to establish one. The government launched the Voluntary Health Insurance Scheme (VHIS) in 2019, but participation has been tepid among the middle-aged and the elderly. Without comprehensive infrastructure to distribute cost through risk pooling, reducing subsidies simply shifts expenses to individuals without accompanying protections.

Hong Kong’s public healthcare system was designed to “deny no one” regardless of financial constraints. Yet research shows that approximately 8% of residents have been unable to afford necessary medical care, with this group experiencing worse health outcomes than the general population. This suggests patients with higher healthcare needs face greater financial barriers to treatment.

While Hong Kong operates a dual public-private healthcare framework, access to regular primary care remains inequitable, favouring wealthier individuals. This disparity arises because outpatient services rely heavily on private providers, creating cost-related obstacles for lower-income groups.

The assertion that patients “exploit” emergency departments for minor illnesses might have overlooked Hong Kong’s chronic underinvestment in primary care. According to the 2022 Blueprint, only around 30% of healthcare spending is allocated to primary care, compared with over 50% in other developed settings. A patient who falls ill outside office hours has few options: General Outpatient Clinics typically close by 5pm (with some exceptions), District Health Centres lack capacity to serve as after-hours alternatives, and community pharmacies run by local NGOs are few. This system architecture turns patients to emergency departments for common conditions like influenza-like symptoms or gastroenteritis.

Nonetheless, it is encouraging to see that the new waiver, combined with the existing subsidy scheme, could benefit up to 1.4 million people in Hong Kong. As the scheme is implemented, however, it is crucial to ensure that patients in need are not overwhelmed by a complex digital process. There should also be an adequate number of medical social workers to support those who are less digitally capable, ensuring they are not left behind.

While officials justify reforms as preparation for an ageing population, it is crucial not to ignore the unmet needs of frail older adults. Recent research suggests that prevention and treatment of chronic diseases have been so effective that they likely have contributed to increased life expectancy among Hong Kong’s elderly. The incidence of conditions like lung cancer and diabetes has shown a declining trend in older people.

Instead, older patients increasingly present with “geriatric syndromes” such as frailty or cognitive impairment that defy disease-specific protocols. Our unpublished research data show an increasing trend of diagnoses tagged as “symptoms, signs and abnormalities not elsewhere classified” (for example, acute confusion, decreased general conditions) in recent years. These patients are often classified as semi-urgent or non-urgent due to their non-specific presentation.

For Hong Kong, the path forward lies not in austerity but in bold, evidence-based restructuring that aligns with its ageing population’s needs. Reducing subsidies without risk-pooling mechanisms or substantial expansion of primary care investment risks deepening healthcare disparities. To achieve this, Hong Kong should focus on developing a robust primary care system that provides accessible and affordable services to all segments of the population.

In the long run, the government should refine strategies to redirect patients from public to private networks of primary care doctors. Geographically, most people can easily find a general practitioner within a 15-minute radius from their residence. It is increasingly important to develop a system that makes doctor visits affordable and ensures doctors are equipped to handle the complex, non-specific health issues of older adults. A 21st-century healthcare system should strive for greater equity while adapting to demographic realities.

Prof. Eric Lai, Research Assistant Professor, Institute of Health Equity, The Chinese University of Hong Kong

This article with revised version was published on South China Morning Post.

By Eric Lai

Emergency rooms of public hospitals in Hong Kong are typically swamped with patients during traditional flu peaks in winter. The recent jump in Covid-19 cases is only aggravating the already egregious situation. It is not uncommon to see waiting times exceeding 8 hours – an outright ordeal for patients who rely on the public healthcare system.

Such scenario partly reflects the under-development of the primary care system in Hong Kong. Around 60 percent of Accident and Emergency (A&E) cases belong to semi-urgent and non-urgent cases, most of which could be handled with community doctors. It is perhaps opportune that the Government announced the Primary Healthcare Blueprint to formulate strategies strengthening the primary healthcare of Hong Kong, given the challenges brought by the increasingly ageing population.

Hong Kong’s healthcare system was being ranked as one of the most efficient in the world, but it clearly shows signs of overload and lack of sustainability. The Blueprint rightly emphasised a paradigm shift from a treatment-oriented system to a prevention-focused one, with the district health centres taking up the roles of screening, education and chronic disease management in the community. Patients are also incentivised to have a regular family doctor as their first contact point for healthcare and management of their chronic conditions. Indeed, it was shown that patients with multiple morbidity but having a regular source of primary care had a 23% lower risk of hospitalization than those who do not.

However, despite all the efforts in improving primary care in Hong Kong, structural barriers have not been paid adequate heed of. Affordability for chronic disease management has long been an issue. Among the frequent users of the public system are the older people – three-quarters of the older population in Hong Kong have at least one chronic conditions, which usually require multiple follow-ups, long-term medications and investigations. Whether the financial incentives under the “Chronic Disease Co-care Scheme” in the Blueprint would be adequate for the older people to pursue disease management in the private sector remains to be assessed when it eventually rolls out. Nonetheless, the experience of the Elderly Healthcare Voucher Scheme suggested that it does not help reduce public care utilisation, unless the price difference between the two sectors could be substantially narrowed. In Hong Kong, poverty among the older people has always been more serious than other age groups. Their choice for public care over private care will only sustain the conundrum.

On two things, moreover, this Blueprint, or more broadly, the ageing policy in Hong Kong, is narrowly focused. First, it misconstrued health as healthcare. According to the World Health Organisation, around 30 to 55 percent of the differences in health within and across countries are down to a collective of wider social factors. In short, the conditions in which people are born, grow, work, live and age all shape the conditions of daily lives, which in turn affecting our health. Health differentials arise from societal distribution of these factors – those who are more socially disadvantaged often, say, lack access to (or knowledge of) necessary resources that are conducive to health.

Take health literacy for instance. Provision of healthcare services is a two-way street – even in the presence of a world-class and affordable system on the supply side, it has to be made known and comprehensible for the needed. Health literacy is poorer among those who are older, have poorer education attainment and live in inadequate housing. The notorious complexity of the booking and referral system of the public sector in Hong Kong often intimidates those who indeed warrant necessary medical attention, resulting in delayed treatment (or on the contrary pursuing unnecessary consultations with minor ailments).

The traditional connotation of health as healthcare has hindered how resources were allocated and how policy impact was measured. Health might not be the aim of social and economic policies, but it will inadvertently be the result. One of our previous research showed that social isolation, some form of which was observed in almost 40 percent of older people in Hong Kong, is related to poorer physical functioning. Another large local study reported that larger living space and lower residential density were linked to lower blood pressure. Older people are at higher risk of death in the midst of extreme hot weather. None of these determinants of health fall into the realm of healthcare. Policymakers should thus take into account the health dimension when formulating, say, housing, welfare, environmental and transport policies.

Second, the Blueprint has largely associated ageing with chronic diseases. Even in the absence of chronic diseases, the ageing process itself also results in changes that predispose to declining physical and cognitive function, which may ultimately lead to dependency and increased usage of health services. Age-related changes, such as walking slowly, decreased grip strength or memory loss, could be grouped under the umbrella of geriatric syndromes, which can be prevented or alleviated by appropriate exercise and trainings. The Blueprint should therefore be expanded to incorporate management and prevention of geriatric syndromes at the district health centres or collaborations with district partner organisations.

Population ageing is a global phenomenon; Hong Kong is no exception. What is urgently needed for Hong Kong is a roadmap from the fear of ageing to the future that thrives on ageing. It is thus imperative to realise that to age successfully means more than mere absence of diseases. When longer lives in good health are combined with physical and social infrastructures that enable older people to be productively engaged, the whole of society will benefit as a result.

Prof. Eric Lai, Research Assistant Professor, Institute of Health Equity, The Chinese University of Hong Kong

This article with revised version was published on South China Morning Post.

By Gary Chung and Richard Lee

Poor housing worsens both physical and mental health, especially for the socially disadvantaged households living in tiny and crowded places or subdivided flats under the greatest housing unaffordability in Hong Kong. The pressing call is echoed in President Xi’s speech in July calling for bigger and more affordable homes for Hong Kong people and a greater state role in addressing the issue.

International review shows that individuals living in a crowded household have higher risk of infectious diseases and mental health problems, while local studies reveal associations of household crowding with various adverse health outcomes such as hypertension, anxiety, and stress.

Our recent commentary published in The Lancet Regional Health – Western Pacific has also emphasized that household crowding, broadly defined as the number of occupants exceeding the capacity of the available dwelling space in terms of rooms or floor area, is linked to health inequality in Hong Kong. Household crowding is highly sensitive to one’s socioeconomic position, living conditions, and the neighbourhood environment, which could be an indicator to monitor health inequalities in Hong Kong.

It is commendable that the Chief Executive John Lee in his first Policy Address announced the minimum size requirement of no less than 26 square metres for newly built subsidized flats (except 1 and 2-person units) and the planned introduction of Light Public Housing (LPH) to increase housing supply and shorten waiting time for public housing.

Substantial impact is anticipated as close to 50% of the Hong Kong population live in public rental or subsidized housing. If designed and implemented properly, these initiatives can potentially alleviate household crowding by offering relatively larger flats or rehousing residents in subdivided flats to LPH, thereby partially mitigating the existing health inequalities.

To achieve maximum impact of these measures, we suggest the government conducts a health impact assessment, similar to environmental impact assessment, at the stage of design and implementation to investigate how the health of residents, especially the disadvantaged, would be affected, and how their needs could be better addressed.

The impact of social determinants of health – conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping these conditions of daily life – on population health and associated inequalities in Hong Kong is evidenced in reports by the CUHK Institute of Health Equity. We hope to see more positive moves to improve the health of people, with housing as a first step.

Prof. Gary Chung, Research Assistant Professor, Jockey Club School of Public Health and Primary Care, Richard Lee, Functional Manager, Institute of Health Equity, The Chinese University of Hong Kong

This article with revised version was published on South China Morning Post.

By Anson Chau and Richard Lee

‘Resilience and Contributions of Older Women’ – the theme of this year’s International Day of Older Persons named by the United Nations – has spotlighted the achieved and potential contributions by older women, recognising their resilience in the face of environmental, social, economic and lifelong inequalities.

The case in Hong Kong can’t be more relevant: women enjoyed the longest life expectancy in the world, and it has outperformed men for some 20 years since 1986 while a narrowing gap is observed in other countries. The contributions and resilience of women in bringing the prosperity of Hong Kong should come with their ageing well, which goes more than long life to having a happy, meaningful, and satisfying life.

Indexes to track changes of well-being compiled by the Institute of Ageing at The Chinese University of Hong Kong from 2017 to 2020, however, seemed to tell a different story. Compared with male counterparts, older women had higher poverty rate, rated themselves poorer in health, had lower mental health and were frailer.

The inequality could be related to the development of Hong Kong over decades intertwined with various social factors. Over the life course, women has lower chance of education opportunities before the introduction of compulsory education; lower rate of labour participation rate, especially for those who are married; higher share of caregiving responsibilities and the dual role to take care of family and work which affect their career prospects. While the credits of informal and caregiving work by older women are not easily spotted and recognized, they bear the most of the burden as exemplified during COVID-19 in which women suffered from lower well-being and caregivers had higher level of stress, lower general self-efficacy, physical and psychological health, in addition to ageism portrayed on older people.

The International Day of Older Persons gives us a timely reason to applaud the efforts by older females over the past generations and to strive for a more gender-equitable society in fixing societal causes perpetuating the inequalities of women. Building on improvements made over the years, a lot more needs to be done such as a more women-friendly workplace, timely and adequate support to caretakers and frail elders. Resolution for a better society by all of us will give us reasons to be optimistic on this cause.

Dr. Anson Chau, Postdoctoral Fellow, Richard Lee, Functional Manager, Institute of Health Equity, The Chinese University of Hong Kong

This article with revised version was published on South China Morning Post.

By Jean Woo

The answer posed by the title of this article may seem obvious: that pandemic policies are formulated as a crucial part of public health. However, a more in-depth exploration show that the situation is complex and one may not simply assume that all pandemic policies equate with good public health. To do so would imply that these policies override all other aspects of public health. Current debates among Western societies on this topic are highlighted, and discussed with respect to current pandemic policies in Hong Kong, where differences in culture and health and social systems exist.
 

Horton [1] put forward the concept of using the term syndemic instead of pandemic to describe COVID 19. There is a need to consider biological and social interactions between conditions and states, interactions that increase a person’s susceptibility to harm or worsen their health outcomes, rather than follow purely biomedical solutions to COVID 19. An integrated approach is advocated and would likely be more successful than simply controlling epidemic diseases or treating individual patients. This theme is further developed by the Lancet Chatham House Commission on improving population health post COVID-19, which highlights that in order to maintain resilience: breaking barriers between clinical, academic, and policy boundaries, involvement of commercial and other non-state actors, public, policy makers, in modifying key behaviours contributing to NCDs are important strategies [2]. Another aspect in the formulation of pandemic policies is the disagreement between scientists on what should be done, which contributes to a breakdown of trust of pandemic policies [3]. Lastly a book has been written attacking pandemic policies as an example of ‘biomedical imperialism’, ending with a plea to put both health and care back into healthcare [4].

These comments resonate with the situation in Hong Kong. The government has a panel of scientific and medical advisers, who all have different perspectives based on their area of expertise. The media frequently reports on the opinion of various experts, presumably based on which government policies are made. It can be seen that pandemic policies appear to be dominated by infectious disease and public health experts, who would not have the responsibility of considering the impact of such policies for the whole of society. This is not to negate the important scientific contributions that have been made, such as the monitoring of social movements using the Octopus cards, that enables prediction modelling, as well as the screening of drainage system of housing blocks for COVID-19 pandemic response policy that incorporates risk benefit considerations, that does not accentuate health inequalities, and that are guided by ethical principles. With successive mutations in the virus, policies need to respond in a timely fashion to fulfill such criteria. These principles also apply to policy implementation. Formulation of policies should take into account not only scientific evidence, but with input from the public as well as experts in ethics, and communicated to the public on this basis.

While older people are recognized as the most vulnerable group in terms of hospitalization and death, such that pandemic policies place vaccinations of older adults of the highest importance, the adverse health and social consequences of pandemic policies have received little attention. Among Western societies it has been pointed out that COVID-19 has given rise to some of the worst examples of ageism, where the pandemic has been characterized as ‘the boomer remover’, where age becomes a rationing criteria for use of ventilators in Italy, and unwillingness to adopt social distancing measures by younger people to protect their older relatives [5]. Hong Kong cannot be said to be deficient in its intensive care provisions in normal circumstances, such that age alone will not be used as a criteria for rationing. There are other clinical indicators of likely response to intensive care treatment, such as frailty, that may guide management. However, when the system is overwhelmed, some form of rationing is unavoidable. This is not apparent to the public, and yet public dialogue would be welcomed, as there is increasing interest about choice of treatment in hospitals, and even choice of admission to hospitals, for those in the last years or so of their life [http://www.ioa.cuhk.edu.hk/end-of-life-care ].

COVID-19 shines a spotlight on how health and social welfare system have been grappling with unmet needs of the aging population for some time already in all sectors: primary care, hospital care, long term care in both community and residential care settings [6]. Fragmentation and lack of communication exist between health and social service providers; policies exist but there are problems with effective implementation and evaluation. Performance targets are constructed for the service providers rather than for care recipients, suggesting that ‘care’ may not be appropriately included in the phrase health care or social care system.

It is well established that older people who fall ill and admitted to hospital often require a period of rehabilitation before they can recover premorbid functioning, even though the acute problem has been resolved. Before the pandemic, non-acute hospitals as well as Geriatric Day hospitals fulfill this function. During the pandemic Day Hospitals were shut down. Non-acute hospital beds are often used to make up the short fall in hospitals beds due to increase demand for covid cases. At the height of the pandemic three nonacute hospitals were told to convert to care for covid patients. A large number of sick patients with COVID admitted to hospitals were older adults. At a time when such rehabilitation services are in high demand, paradoxically such services were cut. The consequent pent up demand has not become apparent, but would likely contribute to an epidemic of frailty and disability in the not too distant future [7]. Furthermore, older adults who survive COVID 19 infection have persistent symptoms and functional impairment, particularly those with multi morbidity and frailty, requiring a period of post acute care [8, 9]. Such services must be regarded as essential and not take a second place to acute care. From a broader perspective, older people are more vulnerable to pandemic measures in addition to the infection. Successful pandemic control must be balanced against adverse consequences of pandemic measures [10]. Community support services must also be regarded as essential, and not left to individual non-governmental organizations to decide. Withdrawal of services results in functional and cognitive decline, resulting in carer stress [11].

There is a need to go beyond a biomedical vision for solving this syndemic, and to distinguish the difference between biosecurity and public health [12]. There is an urgent need to develop a resilient health and social care system that work in synergy; with fit for purpose policies to support this.

Prof. Jean Woo, Co-Director of Institute of Health Equity; Director of Jockey Club Institute of Ageing, The Chinese University of Hong Kong

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References

1. Horton R. “Offline: COVID-19 is not a pandemic”. Lancet 396 (2020): 874.
2. Rutter HR, Horton R and Marteau MM. “The Lancet-Chatham House Commission on improving population health post COVID-19”. Lancet 396 (2020): 152-153.
3. Horton R. “Offline: Science and the breakdown of trust”. Lancet 96 (2020): 3945.
4. Horton R. “Offline: How others see us Comment”. Lancet 398 (2021): 1290.
5. Morley JE. “Editorial: 2020: The Year of The COVID-19 Pandemic”. J Nutr Health Aging 25 (2021): 1-4.
6. Woo J. “Designing Fit for Purpose Health and Social Services for Ageing Populations”. Int J Environ Res Public Health 14.5 (2017): 457.
7. Grund S., et al. “The COVID rehabilitation paradox: why we need to protect and develop geriatric rehabilitation services in the face of the pandemic”. Age Ageing 50 (2021): 605-607.
8. van Haastregt JCM., et al. “Management of post-acute COVID-19 patients in geriatric rehabilitation: EuGMS guidance”. Eur Geriatr Med 13 (2022): 291-304.
9. Chen LK, Woo J and Arai H. “What we need for COVID-19 post-acute care”. Eur Geriatr Med 13 (2022): 1-2.
10. Lim WS., et al. “COVID-19 and older people in Asia: Asian Working Group for Sarcopenia calls to actions”. Geriatr Gerontol Int 20 (2020): 547-558.
11. Wong BP., et al. “The impact of dementia daycare service cessation due to COVID-19 pandemic”. Int J Geriatr Psychiatry 37.1 (2021).
12. Horton R. “Offline: Reasons for hope”. Lancet 396 (2020): 1057.

By Eric Lai and Richard Lee

We deplored to have learnt from Professor Paul Yip’s commentary that household income of the lowest decile has hardly increased since the handover. We also acknowledged that the entrenched issue of poverty must become a policy priority of the newly formed government in order to fulfil the UN’s 2030 Sustainable Development Goals and President Xi’s to-do list for the Chief Executive.

Nonetheless, a deeper issue is that poverty and deprivation are closely related to people’s health. Despite Hong Kong is proud to have the world’s longest life expectancy, not all of its people are necessarily leading healthy lives. A previous local study showed that those who earned less than $15,000 were around 50% more likely to suffer from more than one chronic disease than those earning $40,000 or more. Another study showed those living in more deprived neighbourhoods are at higher risk of death, especially for males. It is pathetic that a city with extensive wealth inequality takes no proportionate heed of the increasing health divide. Extensive evidence demonstrated that such neglect would accrue immense medical and social costs in the long run.

Factors such as work environment, neighbourhood and physical environment and education all play substantial roles in people’s health. The World Health Organisation considered that these factors, collectively known as the social determinants of health, account for 30 to 55% of our health. Yip’s suggestions of minimum wage review, provision of a family-friendly work environment and employee protection are therefore to be applauded because these are conducive to workers’ well-being, particularly those on the lower rung of the social ladder. It is also a welcome trend to see some local organisations pilot four-day working week, giving employees more flexibility to strike a work-life balance.

The health dimension cuts across myriads of ways in our institutions, and goes beyond the amount of money in bank accounts.

To name a few, ingenious town planning with high walkability and green coverage encourages people to exercise, helps cool the city and reduces heat-related illnesses amidst global warming. Ample and affordable choices of healthy food should be easily within reach for most people. Provision of adequate housing is essential for people’s mental health.

Well-being of people is increasingly recognised as an indicator of liveable societies. Eradication of poverty is undoubtedly an important part of the equation, but a large part also rests on across-the-board efforts by government and the civil society to put health and well-being for all as priority.

Dr Eric T.C. Lai, research assistant professor, Richard Lee, manager, Institute of Health Equity, Chinese University of Hong Kong

This article with revised version was published on South China Morning Post.

上回提到，嚴格防疫措施除了影響學童的運動水平和精神健康，更加劇了社會經濟地位所導致的不平等。透過運動提升學童的抗逆力可能是其中一個具成本效益的普及性預防策略，以改善其精神健康和減低健康差異。惟要充分發揮運動對學童精神健康的益處，提高整體運動量和促進平等參與十分重要。

多元促進平等體育運動參與

一般人認為，學童做運動與否純粹是基於個人選擇。然而，健康公平的研究中發現，不同的社會、經濟和政治因素均影響市民健康的生活方式和決定。這些重要的「社會決定因素」包括學童的家庭背景，學童就讀學校的環境，學童居住的社區設計和社會環境，以及公共衞生和社會政策等等。

由「香港健康活力兒童計劃」製作，並自2016年起發表的「健康活力兒童-香港兒童及青少年體力活動報告卡」，能為學童運動所面對的 「社會決定因素」提供有用的參考數據。最近一份於2018年發表的「報告卡」涵蓋12個評價指標，並為各項指標訂立由A+至F的「等級」，有助了解香港的現況，促進國際間的比較，並提供制訂體育活動及健康政策的依據 。以下就以家庭、學校、社區和政策層面進行討論。

家庭層面：學童的運動習慣深受家庭背景和家長的運動取態所影響。根據2018年的「報告卡」，每周與家人運動最少一次的兒童和青少年僅佔37% 和23%，且不足兩成的中學生家長每周運動至少三次，故此家庭方面的指標只獲評為「 D-」級。若家長重視子女的運動發展和精神健康，便須以身作則多做運動。本地研究更指出，於運動水平較高家庭成長的基層學童，享有較好的生活質素和精神健康，可見運動推廣以家庭為本的可塑性。

學校層面：學校在推廣校園體育風氣和鼓勵課餘運動參與的角色同樣毋庸置疑。更重要的是，學校是基層學童的保護網，提供免費或以可負擔的價錢參與課內、外體育活動，甚或專項運動訓練的機會，從而灌輸逆境自強的運動家精神。「報告卡」就學校層面的評級為「 C」，代表在避免過份影響學校日常運作的前提下，校園體育推廣仍有待加強。

社區層面：「報告卡」就社區及環境設施層面的評級達「B 」級，顯示大部份人對居住環境安全及鄰近運動設施感到滿意。不過，相較於家庭背景較好的學童，基層學童的體育運動參與較容易受到其鄰近體育設施的多樣性、適宜步行的程度、以及公園的安全性等環境因素所影響。由此可見，運動友善的社區環境和充足的社區體育設施，能為資源相對較少的基層學童提供支持，從而促進平等運動參與。

政策層面：就政策而言，協助學生建立活躍和健康的生活方式早已是香港中、小學七個學習宗旨之一。雖然「報告卡」中政府策略及資源投放一欄的指標評級只是「 C」級，但教育局近年加強推動運動政策，並於2021/22學年啟動「躍動校園 活力人生」計劃，致力支援學校並凝聚不同持份者進一步推廣多元化的體育活動，鼓勵學童盡早培養恆常運動的習慣和正面積極的態度。無奈的是，嚴格的防疫措施令這些運動推廣政策的效果大打折扣，削弱了學校和社區環境對基層學童的保障。故此，政策制訂者應平衡防疫措施的即時效益及對學童長遠的身心健康代價，深思應如何在「新常態」下實踐運動推廣政策，重喚學童以至社會各界對體育運動的重視。

「復常」之餘應建立更健康和平等的社會環境

平等的體育運動參與和普及性精神健康支援是促進學童發展及改善健康差異的重要一環，亦是讓學童能夠全心學習追求學問的先決條件。透過運動增強抗逆力和精神健康，不但有助紓緩疫情對學童的影響，更重要的是未雨綢繆，減輕下一個疫症或災難事故來襲時對學童的衝擊。最後，隨著疫情漸趨緩和，社會的焦點不應只是「復常」，更重要的是如何在百廢待興之際轉危為機，多管齊下建立一個更加運動友善、有利學童精神健康和平等的社會環境。

作者

香港中文大學健康公平研究所博士後研究員鍾嘉麒博士

香港中文大學健康公平研究所經理李衛棠先生

這篇文章在2022年6月23日刊登在星島日報-家長版星島教育。

疫情加劇學童體育運動參與和精神健康的不平等

政府在疫情下推行的防疫措施（包括停課、關閉運動和休閒場所等），限制了學童進行戶外運動的機會，令他們難以建立良好的運動習慣，反而花費更多時間在電子器材和社交媒體上；不同種類的運動訓練和身體活動水平卻顯著下降。這種情況與政府一貫的運動推廣政策背道而馳，而對於缺乏社會資源的基層學童而言，疫情對其高強度運動參與的影響尤其嚴重。換言之，嚴格的防疫措施除了降低整體學童運動水平，更很可能加劇了體育運動參與的不平等。

另一方面，學童在疫情下長期承受的擔憂、學習壓力，以至限聚措施引致的孤獨和適應困難，均嚴重地影響他們的精神健康。一個非政府機構在去年底公布的調查結果顯示，在3,669名受訪學生中，超過一半出現抑鬱情緒表徵，情況令人憂慮。此外，香港中文大學健康公平研究所就新冠疫情下青少年精神健康不平等的課題，進行了一個跨國性的研究，其中在香港12所學校訪問共1,095名學生。研究的初步結果顯示，社會經濟地位較低的學童，在疫情期間較容易感到焦慮、絕望、悶悶不樂和對未來失去信心。不過，研究同時發現，學童如果有較強的抗逆力，則會減輕社會經濟地位對其精神健康的不良影響。研究結果意味著增強學童的抗逆力能夠提升學童的精神健康，從而減低社會經濟地位所導致的不平等情況。

藉運動推行普及性精神健康支援

健康公平論述中的「比例普遍主義 (proportionate universalism)」認為，政策的擬定必須關顧到所有社會階層，進而逐步解決社會底層以及最弱勢社群的問題。故此，政策必先要全面而普及，但執行的程度和強度也要與風險和需求成正比。套用於精神健康議題上，教育局在最近開設的「校園‧好精神」學生精神健康資訊網站中，提出的「三層支援模式」（即鼓勵學校透過「普及性」、「選擇性」及「針對性」三個層面促進學童的精神健康），與上述的「比例普遍主義」有不少共通之處：要促進學童的精神健康及其平等，學校或其他持份者的支援應先涵蓋所有學童以防患於未然，再就其情緒需要和精神健康風險，按比例投放較多資源作選擇性和針對性的支援。

然而，學校在推行普及性精神健康支援方面並不容易，尤其是在密密麻麻的課堂中，再加入教授學生情緒認知、正向心理學等知識，對教學安排和學生吸收的能力都是莫大的挑戰。因此，揉合精神健康支援於學童的體育運動發展目標上，可以是其中一個具成本效益的普及性預防策略。運動不但促進身體健康，本地研究更清楚表明，體育運動鍛煉能有效增強學童的抗逆力，從而改善精神健康和減低健康差異。要充分發揮運動對學童精神健康的益處，提高整體運動量和促進平等參與十分重要。

香港在推動學童體育運動發展的表現如何？哪些範疇尤其值得關注？下回我們將從家庭、學校、社區和政策四大層面進行深入討論。

作者

香港中文大學健康公平研究所博士後研究員鍾嘉麒博士

香港中文大學健康公平研究所經理李衛棠先生

這篇文章在2022年6月22日刊登在星島日報-家長版星島教育。

By Eric Lai

The Covid-19 pandemic has exposed the plight of the underprivileged in society. Imagine the life of a typical grass-root person in Hong Kong – for example, a contract cleaner working nine to 12 hours a day, six days a week, and earning just above the statutory minimum wage of HK$37.50 (US$8) per hour.

They can hardly afford any time for exercise or the money for a gym membership. The weather can be unforgiving – summer days are scorching, but those working outdoors may not have adequate access to basic amenities such as running water and shelter to rest and cool down. This is not to mention occupational hazards like falls and injuries.

It is therefore not surprising that the socially disadvantaged among us have worse health than others. Although Hong Kong is proud to have the world’s longest life expectancy, it does not necessarily mean all of its people are living healthy lives.

As shown in the recent Health Equity Report by Chinese University’s Institute of Health Equity, marked health inequalities exist in Hong Kong. Two of the findings are that chronic diseases are more prevalent among those with lower income; and those living in poorer neighbourhoods have a higher chance of death.

There is always a tendency to assume that society can rely on medical solutions to cure social problems.

Many tend to think that health is about individual behaviour. But, very often, health choices are not free choices. It is the resources we have available, not our free will, that dictates whether we can afford healthcare for our children, the environment in which we work, the air we breathe in our neighbourhood, and the people from whom we seek health advice.

Some of the most advanced medical interventions would be of little use if a person is living in poverty or in cramped subdivided flats. These factors are collectively known as the social determinants of health, and they account for 30-55 per cent of our health outcomes, according to the World Health Organization.

So, our health is not only defined by things like seeing doctors, taking medicine or walking 8,000 steps a day. Unfortunately, there is always a tendency to assume that society can rely on medical solutions to cure social problems. At the end of the day, it does not matter how great our healthcare system is if we keep sending people back into the conditions that made them sick in the first place.

It is therefore welcome to see that, after government intervention, Hong Kong’s poverty rate in 2020 dropped to 7.9 per cent. Still, we can expect the poverty situation to deteriorate following the fifth wave of Covid-19 in early 2022, the economic impact of which will be hardest on grass-roots workers.

The good news is that companies and civil society can do much to reduce or eliminate health inequalities. Particularly, businesses have a key role to play in improving people’s health. For starters, the bottom line is that the working environment should be conducive to the health of employees and free from occupational hazards.

Scholars and social welfare advocates also urge employers to pay a living wage, so that employees can afford basic provisions for their families, such as food, healthcare and housing.

Besides, some big employers have started to improve employees’ health by providing exercise facilities, healthy meals, or counselling services to improve mental health.

The WHO has found that working 55 hours or more every week is an occupational risk factor linked with a higher risk of cardiovascular diseases. The UK has just embarked on the world’s biggest trial of a four-day working week, with 70 companies taking part.

Overall, there is plenty of scope to be creative, but the essence is to ensure that health and personal empowerment becomes the ethos of business.

Companies could also pay more attention to the health effects of their goods and services on end users and the wider community. For example, the unaffordability of some healthy food and the limited choices available can be a major obstacle to a healthy diet.

According to a survey by Polytechnic University in 2016, 65 per cent of those aged between 15 and 59 ate out four or more days a week, and a third ate out every day. The recent increase in food costs as a result of the pandemic and supply chain disruptions will hit the underprivileged hardest.

It is in businesses’ best interests to take health equity into account in their operations. Investors have begun to pay attention to companies’ performance in environmental, social and governance (ESG) indicators. But as Professor Michael Marmot, a pioneer of health equity research in the UK, pointed out in his latest report, ESG must become “ESHG” to include “health” more explicitly.

Businesses will be more productive with a physically and mentally healthy workforce. They will also be recognised as responsible actors in improving people’s quality of life and the environment, and become forces for good in society, thereby attracting and retaining talented people who care about more than just a pay cheque.

Action on the social determinants of health require across-the-board efforts by the government, civil society and businesses, not just the healthcare sector. Evidence shows we can reverse the systemic differences in health across society with appropriate policies and actions. But, we have to want to make a difference.

Eric T.C. Lai is research assistant professor at the Institute of Health Equity, Chinese University of Hong Kong

This article was published on South China Morning Post.