Hong Kong Needs a Roadmap for Population Ageing
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.
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.
