PII: S0277-9536(98)00158-0

Soc. Sci. Med. Vol. 47, No. 7, pp. 927939, 1998 # 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0277-9536/98 $19.00 + 0.00

A SURVEY OF THE HONG KONG HEALTH SECTOR: PAST, PRESENT AND FUTURE
ROBIN D. C. GAULD
Department of Preventive and Social Medicine, University of Otago Medical School, P.O. Box 913, Dunedin, New Zealand AbstractThis paper considers the involvement and performance in the health sector of the Hong Kong government prior to and beyond the transfer of sovereignty from Britain to China in July 1997. The paper commences with a historical survey of health services development, which provides insights into why the health system functions in its present haphazard manner. This section culminates by discussing the 1991 establishment of the statutory Hospital Authority which was an attempt to alleviate escalating problems in the administration of hospitals and public health services. Next, the paper surveys the present, discussing, respectively, the roles of government and private service providers, health care outcomes and the contribution of traditional Chinese medicine. Finally, the paper outlines a range of pressing issues which Hong Kong's future policy-makers will need to confront: the organization of the health sector, health nancing and the health policy decit. In the conclusion, it is posited that there is a need for government to formulate a health policy and to clarify its role in the provision of services. # 1998 Elsevier Science Ltd. All rights reserved Key wordsHong Kong, health policy, health services development, health sector restructuring

INTRODUCTION

On 1 July 1997, the government of China resumed sovereignty over Hong Kong, ending some 150 years of British rule. With the transfer of sovereignty complete, it is a time of much analysis of the performance of the Hong Kong government. It is time to assess the past, look at the present and consider future policy requirements. It is also time to comment on the various successes and failures of government and to identify areas which demand attention by the new post-handover government of the Hong Kong Special Administrative Region. Against such a background, this article reviews the Hong Kong government's involvement and performance in health services provision. It is posited that this performance has generally been unsatisfactory, with a fundamental failure of the government over the years to provide adequate levels and standards of public health services. This has been a function of the fact that, as history demonstrates, the government has been slow, if reluctant, to commit to or take a lead in health policy development. Despite this ambivalence, the Hong Kong population has always had access to a basic range of public health services and a reasonably clear system has developed over the years in which primary care is privately provided, with some primary services available in the public sphere for the less nancially mobile, while secondary care is largely publicly provided, with higher quality secondary care available at a cost in the private sector. The government has never been free from criticism for neglecting health
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services. The result has been poor standards, underprovision and ineciency. In recent years, government performance in its role as a direct health service provider has improved as it has worked to upgrade public facilities. However, in indirect provision roles, such as policy-making and regulation, its performance remains less than adequate. Prior to discussing the current situation the article runs briey through the history of health services development in Hong Kong, as this provides insights into why the health system functions as it does today. Accordingly, Section 2 considers health services developments from the establishment of the colony in the 1840s. The section focuses generally upon the question of government involvement, the main problems confronting government and its respective responses. The section culminates in a discussion of the 1991 founding of a statutory Hospital Authority set up to alleviate escalating, age-old problems with public hospital administration. Section 3 reviews various successes and failures of the health system. It considers the nature of government provision, the role of the private sector, health outcomes and the place of traditional Chinese medicine. Section 4 explores a range of issues that were sidelined in the lead-up to the transfer of sovereignty, but which remain crucial to health policy-makers. In Section 5, arguments presented in the article are reiterated, in particular that the Hong Kong government has lacked clarity over its role in health. It is proposed that what is required of the new administration is active involve-

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ment in health policy and health services development.

HEALTH SERVICES DEVELOPMENT IN HONG KONG

The early years (18411940s) In the early years, from the founding of modern Hong Kong up to the period of Japanese occupation, three key factors gave shape to the health system: (1) a focus of government on sanitation and disease control; (2) a colonial ``laissez-faire'' approach to administration and (3) a consequent triad of providers that emerged in the health ``marketplace''. These factors are discussed in Sections 2.1.1 and 2.1.2. Conditions of society and government interventions. When it was colonized in 1841, Hong Kong was viewed by its new European settlers as a virtually uninhabitable environment. Its large swamps and tropical climate were a breeding ground for highly contagious diseases and fevers (Sayer, 1980, p. 138). Despite this, with growing trade and employment opportunities, the population grew rapidly, mainly indigents from China in search of work. Initially, the only authority on the Island was military, while the rst civil servants were appointed in mid-1841 (Collins, 1952, pp. 2526). It was not until 1843, however, with the appointment of the rst SurgeonGeneral, that health was given any government attention and this was only as illness had inltrated the colonial hierarchy. A Committee of Public Health was simultaneously established to develop and enforce a rigid set of sanitary rules (Endacott, 1973, p. 68). Such appointments set the standard for subsequent development of public health services in Hong Kong: they were made in reaction to mounting problems, in this instance, an absence of sanitation systems. Eorts by the Surgeon-General and the Committee of Public Health to control sewage and hygiene standards were destined largely to fail. The government's position was dicult, as dictated by an explicit colonial mandate to induce free-trade with minimum intervention (Scott, 1989, pp. 41 42). Attempts to regulate health standards were resisted by both inuential government administrators and members of the business community as an expensive unnecessary intrusion and anathema to the spirit of ``laissez-faire''. Thus, while regulations existed, they were not enforced until Hong Kong suered recurring cholera and plague epidemics. In short, government intervention was minimal, as was the place of preventive medicine. These early ``failures'' marked the commencement of a recurring pattern over the following decades in which consecutive government-sponsored boards of sanitation and public health were thwarted in their eorts to raise the quality of general sanitation standards (Endacott and Hinton, 1962, pp. 162

163). The ``pattern'' was briey interrupted in the mid-1890s with the onset of plague which, over the next 10 years, claimed thousands of lives. As a consequence, at the policy-making level, greater emphasis was placed upon preventive medicine, but, echoing the past, this produced few genuine changes to the status quo (Sayer, 1975, p. 96): it was far easier to ``cure'' after-the-fact. Such problems were nally addressed in the 1930s with the appointment of the rst ever Director of Medical and Sanitary Services who produced a lengthy report condemning the lack of emphasis government placed upon public health and preventive medicine and the resultingly haphazard development of health services and regulations (see Wellington, 1930). But, in keeping with history, the government was unwilling to impose unpopular health regulations. Health services and hospitals. Ill-health induced by the environment prompted a demand for hospital-based treatments. However, the policy of the London Colonial Oce was to discourage the building of public hospitals as private provision of health care was considered to be a more desirable alternative. The Colonial Oce asserted that government could provide only partial nance for hospital construction, that any building project could only go ahead if local capital was sucient and that, once completed, a government hospital would have to be self-nancing (Endacott, 1973, p. 69). Naturally, the rst hospitals providing Western medical treatments were privately owned and operated and most services were catered for by private practitioners. Public hospitals surfaced later and provided services mainly for government employees, but also accepted fee-paying patients (Collins, 1952, p. 81). The predominant Chinese population of early Hong Kong were suspicious of Western medical practices. For its part, the government was generally dissatised with the state of Chinese medicine. This hiatus led to the founding, in 1870, of a Chinese hospital under the combined sponsorship of government and the Chinese community. Known as the Tung Wah, the hospital oered traditional Chinese treatments free-of-charge. The Tung Wah was operated initially with relative freedom from government intervention. This freedom, however, was curbed after the 1890s when the hospital's traditional approaches were seen to have contravened government eorts to quell the plague epidemic. Thus, the Tung Wah was subjected to increasing government control, including a requirement that it oer Western treatments. Given the limited availability of places in government hospitals, the Tung Wah's emphasis on traditional medicine and an inability of most patients to pay for private health care, missions and benefactors were left to ll the void. The rst of such hospitals were established in the early-1880s. Like Tung Wah, these institutions received a small gov-

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ernment subvention (Paterson, 1987, p. 72). Their medical orientation was Western and services were oered free to the general public. By the early 20th century, this institutional ``triad'', government, subvented hospitals (including Tung Wah) and private providers, was entrenched. By this time, government's commitment to hospital care had increased in response to drastic bedshortages and gradual abatement of the laissez-faire principle. Adding to pressures on hospital facilities was a 1902 decision that all civil servants be given free and preferential hospital treatment. In later years, this would prove to be a burden on the increasingly overloaded health system (Endacott and Hinton, 1962, p. 167). By the 1930s, for instance, hospital overcrowding was pandemic as bed-shortages and outpatient numbers continued to grow (Wellington, 1937, p. 110). It was not until the early-1940s that a recommendation to expand hospital bed numbers was nally endorsed by the Colonial Oce in London. The post war years (1940s-present) An ever-expanding population. The infrastructure of Hong Kong was devastated during the 1941 1945 Japanese occupation (Welsh, 1993, pp. 412 .). Following the war, hospitals and health systems needed to be re-established, while bed-shortage problems were surpassed by an immediate need for qualied doctors and nurses. In administrative terms, it was Colonial Oce policy to restore the same civil service structure that had existed before the occupation (Collins, 1952, p. 174). Thus, when operations resumed, as well as the sta and bed shortages, the local administration faced the task of operationalizing public health and hospital systems within what was arguably an outdated and inappropriate administrative structure. However, an even greater problem was the enormous population inuxes Hong Kong experienced, with one million people returning from China in 1945 alone (Endacott, 1978, p. 270). The greatest challenge for the health sector over the following decades was coping with an everexpanding population. Refugees owed into Hong Kong as a result of the civil war in China and eventual capture of the south by the Communists. Most were extremely poor and the cost of private medicine was beyond their means (see Hong Kong Government, 1956, Chap. 1). The government had no alternative but to acknowledge the problem and continue to expand its own operations alongside those of ``subvented'' hospitals.
*In 1960, the bed-to-patient ratio in Hong Kong was 2.67 per 1,000 population; in Scotland, a comparatively well-developed jurisdiction, the ratio was 12.75 beds per 1,000 people (Hong Kong Government, 1963, p. 7).

This is not to suggest that the government proactively engaged in health services development. Two characteristics of government interventions over this period of ``growth'' indicate the contrary. First, while the population continued to escalate, there was no perceptible eort by government to develop a health strategy, it was neither ``laissezfaire'', as in the earlier colonial period, nor committed in a ``hands on'' manner to the development of adequate service levels. This said, concern at the policy vacuum was voiced at frequent intervals in the Legislative Council. On the one hand was the debate that a clear strategy for development and provision of services was required if demand were to be satised; while on the other, the argument that, lacking a clear policy on the extent of government involvement in health, government-provided services were rapidly evolving into a variant of Britain's ``national health service'', with the roles of government (in terms of policy) and consumer (in terms of where, publicly or privately, various services could be sought) in the system anything but clear. Second, there were few real attempts to deal with the historical decit of hospital bed shortages or growing queues at government outpatient clinics. A health policy?. In the early-1960s, the government declared its intention to provide ``...low cost or free medical and personal health services to that large section of the community which is unable to seek medical attention from other [private] sources'' (Hong Kong Government, 1962). In 1963, a 10-year strategy for the expansion of medical services was issued (Hong Kong Government, 1963). The plan outlined government intentions to provide an even distribution of services across Hong Kong, while acknowledging that it would be impossible to match the bed-to-patient ratio of a developed Western economy (Hong Kong Government, 1963, p. 7)*. At the culmination of this period a second similar 10-year expansion plan was launched by government (Hong Kong Government, 1974). There were few dierences between this and the earlier plan, although the second plan recommended that services be organized on a ``regional'' basis to reect development of the fast growing New Territories. Each region would revolve around a major government hospital supported by smaller subvented hospitals and outpatient clinics. However, the plan to ``regionalize'' dwindled against the greater need to maintain basic services through a rapidly expanding and increasingly cumbersome central bureaucratic structure. By the conclusion of the second 10-year period serious questions were being raised over the suciency of publicly provided health services and, in particular, the administrative framework. Chronic overcrowding, with temporary ``camp-beds'' lining hospital corridors, was a persistent problem for

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which the performance of the Medical and Health Department was blamed. Similarly, while some hospitals were particularly well resourced, others endured severe sta, equipment and facilities constraints*. In the post-war years, the only real changes to health sector administration were in sta levels, reecting expansion and the introduction of new services as they became available: there was not one attempt to restructure to cope with the demands of growth and change. To illustrate the extent of expansion, in 1950, the Department employed 2,617 people (including hospital employees); by 1989, in its nal year of existence, this total had climbed to 27,821. In 1983, the government appointed its rst ever Secretary for Health and Welfare (policy), largely in reaction to constant calls from Legislative Councillors for review and restructuring of the health sector and criticism of the government's lack of attention or commitment to adequate health services provision{. The appointment spelled the beginning of a cycle of gradual but certain change. Henry Ching, the new Secretary, viewed the health system in much the same way as that of its critics,
*This problem persists today. The former-subvented hospitals remain ``second-best'' in terms of their ability to attract funding for new equipment and upgrading of facilities. Similarly, an historical over-resourcing in favour of Hong Kong Island hospitals has yet to be rectied: statistics show that there are 4.17 beds per thousand population on Hong Kong Island, in Kowloon the ratio is 4.06 per thousand, while in the New Territories it is 3.92 per thousand (Hospital Authority, 1995b, pp. 120121). Calculations performed on these statistics suggest that on Hong Kong Island there are some 127 head of population per hospital sta member, while in Kowloon there are 136 per sta member and in the New Territories 179 per sta member. {Perusal of the Proceedings of the Hong Kong Legislative Council is telling in this respect. From around the mid-1970s, the issue of health services delivery was increasingly aired, particularly in reaction to the fact that, despite a major government review of the Medical and Health Department conducted in 1979 containing a number of recommendations in nine volumes with some 136 appendices attached, no administrative changes had been enacted, nor did change appear likely. In particular, the review had supported the need to ``regionalize'' health administration, stating that ``...the department is in a transitional stage between centralization and decentralization, the least satisfactory structure of all... in a department as large and complex as the Medical and Health Department'' (Hong Kong Hansard, 27 October, 1983, p. 139). Throughout the period of this review, the government, via the Medical and Health Department had continued to fail in one of its major health services goals: the provision of hospital beds. For example, in 1978, there were 19,434 beds against a target of 23,615 needed to satisfy a predetermined ratio of 5.5 beds per 1,000 population. Predictions at that time were that the gap between supply of hospital beds and demand would continue to widen (see Medical Development Advisory Committee, 1979).

in particular, that there were ``...weaknesses in administrative processes'' which were creating widespread discontent within the health sector and the broader community and thwarting the ability of the government to cope with change and deliver acceptable levels of service (Hong Kong Hansard, 9 November, 1983, p. 185). Ching believed that an internal inquiry would prove ineective and, as had previously been the case, would be easily subjugated by the Medical and Health Department which favoured maintenance of the status quo. Thus, shortly after his appointment, he declared an intention to conduct an independent review (Hong Kong Hansard, 9 November, 1983, p. 185). The Governor of Hong Kong later announced that consultants would be commissioned to undertake a review of the administration and organization of (only) Hong Kong's hospitals (Hong Kong Hansard, 4 October, 1984, p. 21), leaving the domain of primary care, which was dominated by the private sector, largely unfettered. W.D. Scott and Co., an Australian aliate of accountants Coopers and Lybrand, were selected to conduct the review and directed to: (1) Consider ways of integrating government and subvented hospitals under a new organizational structure. (2) Examine the internal administration of hospitals. (3) Search for more eective ways of using existing resources and of controlling costs. (4) Advise upon alternative methods of stang hospitals. (5) Consider charging mechanisms and the possibility of providing dierent classes of hospital bed (see Chung et al., 1989, Appendix 1.2 ``Terms of Reference''). The report that resulted, entitled the ``Scott Report'' after its principal author (Scott, 1985), was made available to the public on 25 March, 1986. It contained few surprises. The recommendations reected changes taking place elsewhere, most notably Britain, in the organization and management of public services (see Klein, 1995). Notable of the report is the frequent use of management rhetoric. Principal recommendations were that: (1) A statutory Hospital Authority (HA), independent from government but accountable to it through a board, be established to enable eective integration and management of government and subvented hospitals. (2) A Chief Executive and appropriate management sta be appointed in each hospital to strengthen management functions and be accountable for overall hospital functions. (3) All HA employees be employed on new exible terms. (4) A separate body assume responsibilities for public health functions, i.e. disease prevention and health promotion.

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The Scott Report was, of course, only a ``report''. It was some 3 years before any further action was entered into. In the interlude, the report was considered at various levels of government; it was widely debated in the media and raised the ire of public sector unions. Late in 1988, a Provisional Hospital Authority (PHA) was established to construct a detailed plan for implementation of the Report. Health services, by this time, had further deteriorated, which worked to the government's advantage in that arguments that change was required were corroborated. Health workers and the public voiced continuing concern at overcrowding in wards and outpatient clinics and the general decline in health care standards*. Public doctors made frequent charges that their work was hindered by bu*By this stage, hospital sta shortages were so severe that it was commonplace for inpatients to be nursed by family members. In some wards, overcrowding was such that there was no room between beds: the only way to gain access was by climbing over bed ends. Doctors would routinely treat patients in hospital corridors in full public view. At outpatient clinics patients would have to line up from very early in the morning in order to obtain a numbered ``appointment disk'' in the hope that they would be seen that day. Frequently, after waiting all day, patients would have to return the next day to see a doctor; those who wished to curtail their queueing time would often patronize hospital accident and emergency departments, where waiting times were shorter, contributing to pressures on the hospital system (see Ng, 1989, 1990; Hay, 1992). Subvented hospitals were particularly hard hit as their levels of funding, compared with the government operated hospitals, were poor. Moreover, the subvented sector was viewed as ``second rate'' by health workers, exacerbating recruitment diculties in times of sta shortages and increasing patient patronage in the more desirable government hospital sector. {As the Medical and Health Department maintained responsibility for all decisions over resource allocation, most hospitals lacked any form of on-site administration. With a lack of resident decision-makers in hospitals, it was left up to senior clinical sta to organize themselves, resulting in a situation where wards and clinics were often run like separate organizations with no connection to one another and no formally dened relationship with the Medical and Health Department. Patient records were virtually non-existent as there was no record keeping to speak of. Thus, other than by asking the patient, there was no way of telling what a patient's history was, what medication they were taking, or what treatments had previously been administered (see Hay, 1992; Ng, 1989, 1990). Such conditions caused high levels of workplace stress and low morale among public doctors. Wastage rates escalated through the 1980s, particularly among senior medical sta who were able to move easily into private practice. The medical shortage and departure rate came to a head in the late-1980s, resulting in the Medical and Health Department oering a benet package designed to keep medical professionals in the public sector (Hong Kong Standard, 19 September, 1988). This failed to alleviate the problem, as did a later attempt to relieve work loads by introducing ward clerks to perform clerical duties (South China Morning Post, 26 August, 1989).

reaucratic processes and that they were, in turn, unable to provide an eective response to patient needs{. Probably the greatest problem facing government,however, was the dogmatic health sector unions, of which over 40 were in existence, the vast majority of whom were keen to see hospital facilities upgraded, but were against any alterations in employment conditions. In 1989, the PHA produced an advisory document (Chung et al., 1989) which was a strategy for implementation that the government closely adhered to, but not without hiccups. For example, while the subvented hospitals were generally comfortable with the prospect of being subsumed under a new authority, as this would mean full-funding, more resources and an upgrading in status to supposedly equal that of the government hospitals, there was continued resistance from government health unions. As the Scott Report had earlier advocated, in early-1989, the Medical and Health Department was split into a new Department of Health (5,226 employees), to take charge of the various preventive medicine and health promotion functions and a Hospital Services Department (HSD) (22,425 employees), to be responsible for hospital employees. It was intended that the HSD be a transitional arrangement, in that its employees would switch to HA terms and conditions of service once the new entity was operational. However, under threat of union insurgency, which may have aected service continuity during the transition period, the government permitted civil servants to opt for either the new HA terms or to continue employment within the core civil service. As a consequence, when the HA commenced hospital management it faced the predicament of employing directly only a fraction of its workforce. The HSD assumed the role of paymaster of the majority of HA employees. The number of sta directly employed by the HA has been steadily growing since its inception, but around one-quarter (approximately 12,000) remain as HSD employees. The PHA was converted into the governing Board of the HA to guide initial development (Hospital Authority Newsletter, May, 1991, p. 3). Further delays were caused by problems locating appropriate executive-level personnel, i.e. with an understanding of the requirements of ``management'', an appreciation of health issues and legitimacy in the eyes of the health community. Similar problems were experienced in recruiting Hospital Chief Executives. As a result virtually all HA hospitals are now headed by a medical professional, with the HA supplying continuous instruction in ``management'' techniques. The transition from the old government operated and subvented health services to the new statutory HA has been arduous, but this is to be expected given the enormity of the changes taking place and the challenges facing the reformers. For instance, the public and a very large workforce have

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demanded constant reassurances that the changes are intended to produce better services; the HA was required to take over the management of some 39 hospitals, integrating these within a uniform organizational framework, and a multitude of agreements between employees, hospital management committees, the HA and the government have had to be negotiated leading to a number of concessions mainly on the part of government. Understandably, there have been diculties. The HA's strategy for coping with transitional exigencies has been to promote uniformity across its hospitals. Here, centrally-derived management structures, known as the new management initiatives (NMI), have been prescribed, bolstered by mission statements and a relentless espousal of ideas of organizational ``culture-change'' toward a quality*For instance, in the 19941995 operating year there was a 10.6% growth in the numbers attending specialist outpatient clinics (Hospital Authority, 1996, p. 25). Similar levels of growth have been experienced in previous years and are well beyond the level of population growth which in the 19941995 year, for example, was 2.1% (Hong Kong Government, 1995, p. 443). {Nurses have alleged that, since the establishment of the HA, their workloads have increased due to the fact that recruitment of nursing sta has not kept pace with the expansion in patient numbers. Moreover, they have been under increasing pressure to perform administrative duties as devolution of responsibility to hospital level has been implemented. In 1996, responding to industrial unrest, the HA conceded that ``some'' hospitals could do with more nurses and that under-stang was a source of stress among nurses (Sunday Morning Post, 21 April, 1996). More recently, nurses have threatened industrial action over stang shortages. The HA has acknowledged a shortfall of some 580 nurses (around 3.5%). It has agreed to recruit 200 new nurses, but suggests that the remaining 380 positions can be covered by ``re-engineering'' of duties. The nurses have replied that this is not a practicable approach, as substantial re-engineering has already taken place and there is little room for further eciency gains (South China Morning Post, 7, 8, 11 and 30 October, 1997). Morale among nurses has been poor for some time resulting in high sta wastage rates. In 1993, the turnover rate was 10.2%; in 1994, this increased to 13.3% (Hospital Authority, 1995a, 1996); by 1996, the rate had dropped back to 8.7% (Liu and Lee, 1997, p. 40). {Hospitals in areas where there is a high population concentration experienced consistent overcrowding in 1996. For example, the United Christian Hospital, which has some 700 beds, was regularly admitting up to 60 patients per night into ``excess'' beds. Similarly, the Queen Mary Hospital, with around 1400 beds, was averaging 1620 excess beds per night for much of the year (South China Morning Post, 21 April, 1996; Sunday Morning Post, 18 August, 1996). The intensive care unit of the Prince of Wales Hospital has periodically been unable to admit critically ill patients, placing them instead in general wards. In a controversial case, in early-1997, a cancer patient died while awaiting surgery which was repeatedly delayed to make way for accident victims. In the aftermath, it emerged that only 75% of scheduled surgery is able to be performed in any one day due to bed and sta shortages (South China Morning Post, 9 January, 1997).

care, customer-focused, responsive health services delivery system (see Hayllar, 1995). Since 1992, the HA has generated an annual business plan containing corporate goals and strategies, leading to the unveiling in 1994 of the ``Corporate Vision 2000'' (see Hospital Authority, 1994).

THE CURRENT SITUATION

Government's role in health services provision Government commitment to the provision of secondary services was conrmed with the founding of the publicly funded HA. As noted above, the government has historically been the principal provider (or nancier via the scheme of subvention) of Hong Kong's hospital beds. Its role here has increased since the HA was formed, mainly because the quality of services has improved, while access to services, as loosely dened in 1962 (see above), has remained unrestricted, nominal charges apply to all in-patients, but no bonade resident of Hong Kong is denied treatment if unable to pay. Between 1992 and 1994, HA market share of in-patients grew from 90.5 to 92.1%, with the private sector share proportionately diminishing (Hospital Authority, 1994, pp. 2122). In 1995, patient throughput growth was calculated at 12%, making further inroads into the private sector market share (South China Morning Post, 28 March, 1996; Hospital Authority, 1996, p. 25). In response to the demands for more and better facilities and services and the high costs of the new private-sector style management system, the government has simply increased the HA funding levels each year since its inception. Growing patronage has also been experienced at specialist outpatient clinics serviced by the HA*. Again, this has been met by increased public funding. Such increases have been a cause for concern as establishment of the HA was motivated by the prospect not only of upgrading facilities and producing better service quality, but also ultimately capping levels of secondary care expenditure. With the present growth in HA clientele, it would appear that the government will face serious diculties in limiting its nancial obligation to public health care (more on this below). Despite the budgetary expansion, the HA has required hospitals to pursue preconceived savings targets. Working toward such goals has not been straightforward and, as a consequence, a variety of problems have surfaced. In particular, front-line workers (for instance, nurses) face mounting pressures to ``perform'' but they are having to work longer hours often without necessary resources to assist performance. In turn, sta turnover rates at many hospitals have been increasing{. Periodically, hospitals have been unable to cope with patient volumes. The result of this has been overcrowding and the return of camp-beds{. In sum, while fund-

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ing has grown it has failed to satisfy demand for services. By contrast and in keeping with history, the provision of primary health care in Hong Kong today is largely the prerogative of the marketplace, although patronage of private providers, who receive no government subsidy, has been declining as standards in the universally accessible public sector have improved. In 1990, it was calculated that private practitioners provided some 70% of primary medicine (Young et al., 1990, p. 131). This share of patients has since diminished to around 66%. The remainder of the population, for whom private consultation fees are well beyond an aordable level, patronize either the Department of Health (12%), which administers some 59 general outpatient clinics, HA outpatients and accident and emergency clinics (11%), or traditional Chinese medicine practitioners (around 10%) (Liu and Lee, 1997, p. 12). While no-one is denied treatment, the hallmarks of the government clinics are extended waiting times and substandard facilities and service which tend to deter all but the most needy and nancially immobile patients*. Private providers have tended to
*On waiting times at government outpatient clinics, see * on p. 931. The 1990 primary care review (see below) found that the average patientdoctor consultation at a government clinic was 3.3 min. There was no such thing as a patientdoctor ``relationship'', with understandings of patient problems correspondingly low. Prescribing levels were very high and there was no eort on the part of the clinics to promote good health among patients. Consequently, there was a high incidence of ``doctor shopping'', where patients consult two or more doctors during the same illness, among government clinic patients, with at least 46% of patients reporting this practice (Young et al., 1990). {It should be noted that accurate and up-to-date information on government activities is dicult to obtain as Hong Kong government maintains the power to withhold information as it sees t. Although the government insists that it has implemented most of the primary care recommendations, a recent independent review suggests otherwise arguing that implementation of the recommendations has been limited and very slow and that when inquiring about progress on implementation ``...no response was received from the government'' (Liu and Lee, 1997, p. 2425). {Since around the start of 1997, there have been increasing cases of medical negligence reported in government hospitals, prompting an internal inquiry into emergency procedures. For example: there have been two cases where patients have been given the wrong blood type, one resulting in death (South China Morning Post, 13 August, 1997); an elderly woman died after being administered a drug overdose by hospital sta (South China Morning Post, 19 August, 1997); another elderly woman died when air, which was intended to be pumped into an airpillow, was accidently pumped into an anaesthesia tube in her neck (South China Morning Post, 20 August, 1997) and, a nurse mistakenly fed milk into a patient's bloodstream via a tube in the neck, instead of into the stomach via a nasal tube (South China Morning Post, 28 August, 1997).

benet from patients opting to ``exit'' (Hirschman, 1970) from the public clinics as, in classical economic terms, they exercise their choice to pay for better, personalized and higher quality services. Since its establishment in 1989, the Department of Health has been gradually improving the standard of clinics, primarily in terms of record keeping and scheduling of appointment times. Also provided by the Department are a range of preventive medicine and health promotion services. Further outpatient facilities exist under an arrangement between the Housing Authority and the voluntary Estate Doctors Association in which around 300 public housing estates house low-cost clinics for eligible low-income residents. A recent survey indicates that currently around half of Hong Kong households possess some form of employer-subsidized medical insurance and that those insured visit doctors with much greater regularity than those who are not (Ng and Li, 1996). In 1989, acting on criticisms that the Scott Report ought to have been a study of the entire health system, not merely hospital-based services, the government engaged a review of primary health care (Young et al., 1990). This produced over a hundred recommendations, which were endorsed by government in 1991, including that a statutory primary health care authority be established to coordinate all (both public and private) primary health care services in Hong Kong. It was also proposed that, over the longer-term, a ``supra'' Health Authority be created over and above a hospital division (the HA) and a primary health care division. It was recently reported by government that most of the minor recommendations had been implemented, but that the aforementioned recommendations, which have signicant policy and nancial implications, would need to be further examined in the context of the overall development of medical and health services (Hong Kong Government Daily Information Bulletin, 29 October, 1997){. In the Hong Kong health sector, government assistance, at least in the secondary sector, is readily available. Certainly, no-one in Hong Kong is refused treatment. Up until relatively recently (ca. 1991), service standards were questionable and remain so at general outpatient and emergency clinics. This aside, eorts to provide for the less fortunate (those unable to pay for medical treatment) have been reasonably successful. Those without the nancial freedom to seek care elsewhere, the poor, the chronically ill and those requiring specialized treatments, have been the principal users of government facilities, but must endure second-rate service standards and lengthy waiting times{. Health care outcomes At a brief glance, Hong Kong's health record is very good. Key indicators suggest that the general health of Hong Kong residents today is practically

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unrivalled. In 1996, infant mortality rates reached an all-time low of 4.1 deaths per thousand live births, while life expectancies at birth continued to increase to 75.9 years for men and 81.5 for women (Hong Kong Government, 1997, p. 467). If government expenditure as a percentage of gross domestic product (around 5%) is inserted into the equation then, with its comparatively small outlay, in value for money terms, Hong Kong arguably boasts the world's best health outcomes*. While it is a record which the Hong Kong government should be proud of, it would be wrong to suggest that the good health of the populace is a direct outcome of government interventions. Indeed, observers have long noted a lack of clear direction in the planning and development of health services in Hong Kong. There is a dearth of ocial data from which unequivocal conclusions over the origins, occurrence and treatment of illness and disease can be drawn. However, in an analysis where the information that is available is compared with data from the United States, Hay (1992, pp. 19; pp. 31 3) has argued that it is more likely the health record of the Hong Kong population is a function of cultural and lifestyle traits, than of the availability of good preventive and curative public health services. The place of traditional Chinese medicine (TCM) Survey researchers have recently noted that the ``health care system in Hong Kong is clearly dominated by modern Western medicine'' (Lee and Cheung, 1995, p. 109). In any society, there will exist a variety of alternatives to mainstream health services. In Hong Kong, the principal alternative is traditional Chinese medicine (TCM). TCM is widely practiced; it has an important but unclear role in the health system, mainly due to the fact that there is virtually no data available on TCM patronage or the outcomes of therapy. In Hong Kong, TCM has never been regulated. As such, there is much variation among practitioners in the services provided, general standards, education and training. TCM training traditionally involved an on-the-job apprenticeship with knowledge conveyed from patriarch to ospring, although this system has been in decline and increasingly practitioners are receiving some form of formal institutional training. Estimates are that there could be anywhere between 4,000 and 10,000 TCM practitioners in Hong Kong, outnumbering by two to three times the number of registered Western-medicine practitioners (Lee, 1983). This alone suggests that patronage of TCM is high and that it would have some sort of impact on general health outcomes. Recent research indicates that around 60% of the
*Japan is the only country which produces better vital statistics, at a gross domestic product expenditure level of 6.9% (OECD, 1996).

population have consulted a practitioner at some time, while self-prescribing of herbal treatments is even more widespread (Working Party on Chinese Medicine, 1994, p. 5). Allegations of malpractice have been rising in recent years, with the media and government highlighting increasing cases where poisonous or hazardous substances have been dispensed. It is widely believed that such malpractice is the direct manifestation of a general decline in TCM standards. The phenomena of self-prescribing and self-treatment exacerbates this problem, as many people go straight to shopfront dispensaries where the operators often possess an insucient knowledge of the herbs or mixtures they are preparing and distributing (Working Party on Chinese Medicine, 1994, pp. 89). In 1989, recognizing a long overdue need for ocial acceptance, regulation and information about TCM and herbal distribution, the government established a Working Party on Chinese Medicine (1994), which in due course submitted a report. The Working Party suggested that TCM standards should not be measured against those of Western medicine and that regulation may be troublesome owing to the wide range of standards and practices in Hong Kong. Nevertheless, in its inquiries, the Working Party found little resistance among TCM practitioners to some form of regulation and registration. Accordingly, the Working Party recommended that: (1) A committee be established to steer implementation of the report and advise, in particular, on a statutory framework for the promotion, development and regulation of TCM. (2) A list of TCM practitioners be compiled and criteria developed for their eventual registration. (3) The processing and sale of potent herbs be controlled and a list of these published for public reference. (4) Educational initiatives be encouraged in view of long-term development of TCM. Progress on these recommendations has been slow. Following the Working Party's advice, a Preparatory Committee on Chinese Medicine was created and reported back to government in April 1997 (Preparatory Committee on Chinese Medicine, 1997). Essentially, the Preparatory Committee report reiterated the Working Party's recommendations, but provided specic advice for further policy development and implementation, in particular the formation of a statutory Council on Chinese Medicine to monitor and regulate the TCM profession. The Chief Executive of Hong Kong subsequently announced that enabling legislation would be introduced in the 19971998 session of the Provisional Legislative Council (Tung, 1997) but it has since been disclosed that this is to be delayed until the 19981999 session to allow further consultation with the TCM industry and consideration of how TCM can be incorporated into the mainstream medical system (South China

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Morning Post, 7 November, 1997; Health and Welfare Branch, 1997).

GOVERNMENT INTERVENTION: KEY CHALLENGES

cisions have been postponed until beyond the July 1997 handover date (Yuen, 1995). Sections 4.1, 4.2 and 4.3 discuss issues which require attention by the administration of the new Hong Kong Special Administrative Region of China. Health sector conguration The Hong Kong health system, in its present conguration, represents a considerable challenge for decision-makers. Whether government should actively engage in further shaping of the system, or simply allow development to evolve free from intervention is a pertinent question. The establishment of the HA has complicated this issue. First, its appearance seems to have reinforced government commitment to the time-honoured practice of curative, ad hoc policy-making*. The result has been an inherently uncontrollable reinvention of the former Medical and Health Department: the head oce, or executive, of the HA now controls the operational data necessary for informed central government decision-making; moreover, it is unwieldy and frequently accused of being bureaucratic for its secretive operating style and rigid hierarchy which makes for lengthy processing of decisions. The root of these problems lies in the structure and operational dynamics of the HA. The governing Board of the HA has retreated to a position where it now does little more than formalize recommendations put to it by the executive. For its part, the head oce is led by a chief executive supported by 16 deputies who have experienced diculties communicating with one another and in functioning as a united voice. Many hospital chief executives (as well as head oce deputies) have commented that there is frequently more than one decision and strategy emanating from the centre. This has produced confusion and frustration for those reliant upon and bound by head oce directions (Gauld, 1996). Second, the decentralization of health administration has unintentionally given rise to a range of new voices in the health debate (including service ``consumers''), highlighting various policy predicaments and echoing the fact that collaboration between actors is never easily achieved in a quasimarket climate (Le Grand and Bartlett, 1993; Walsh, 1995). In brief, a series of divisions has been constructed across the health sector, both within and between the various organizations and institutions. The HA is a management organization; its objectives are to produce more and better services and establish something of an internal market in health delivery{. While service standards are, without doubt, improving, and it is as yet early days in the establishment of the HA, there is a need for the government to monitor closely the interface between the various public providers and public and private providers. The government is aware of burgeoning problems{, but until recently has shown little interest in intervention}.

Since the Hong Kong government commenced a program of public sector reform, changes to the way in which public services are delivered have been occurring across the policy spectrum (see Hong Kong Government, 1989; Lee and Cheung, 1995a). When governments introduce policy changes, in general they do so in the hope that positive results will be produced. The downside of change is that it often accentuates remaining and consequent problems. The Hong Kong health system, as argued above, has its share of diculties. Many of these appear to be rather entrenched. The resumption of Chinese sovereignty over Hong Kong has further complicated matters in that putatively sensitive de*Although the decision to establish the HA was a radical departure from the previous non-committal approach of government to health issues and was widely debated in public and throughout the health sector, it is referred to here as ``ad hoc'' policy-making because the government failed to consider the broader health policy picture and the structure of the sector. From the point that the Scott review of the hospital sector was announced in 1984, Legislators and observers stressed to government that the terms of reference were too restrictive: that the entire health sector, including primary care should be reviewed and that failing this there would remain a variety of problems with the conguration of the health sector. {One of the motivating factors behind the HA structure was the idea that all HA hospitals would function as independent entities, responsible for their own operations and accountable for their performances to the head oce of the HA. In terms of an internal market, the idea was that hospitals' performances would be measured against one another. This would enhance competition and provide an incentive to individual hospitals to dene and curb their costs and boost eciencies. A longer term goal, which the HA is still working toward, is explicit contracting for service delivery between Hospital Chief Executives and the head oce of the HA so that volumes of hospital services to be provided can be predetermined and bulk purchased in advance with the hospital taking the risk for cost overruns. {Such problems include the underprovision of services, stang shortages, premature discharging of patients and competitive behaviour which is leading to service duplication and is undermining the ability for hospitals to collaborate with one another in service delivery initiatives. }In 1996, the Health and Welfare Branch conducted a ``macro-level examination of the Hong Kong health care nancing and delivery system, which addresses issues such as the role of the public and private sectors, the interface between primary, secondary and tertiary care, existing sources of funding and the scope of public services'' (Liu and Lee, 1997, p. 3). In the light of this study, the Secretary for Health and Welfare recently announced that an ``overseas consultant'' will be contracted to review the entire health care system (South China Morning Post, 11 October, 1997).

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Privately run hospitals and clinics are nding it increasingly dicult to compete in a market where the HA is driving forward in upgrading public sector standards and facilities, which continue to be heavily subsidized by government (the HA is 98% taxpayer funded). Private providers have recently voiced concern at their diminishing market share, arguing that the government ought to promote a ``two-tier'' health system in which the nancially able are given low priority in public hospitals (South China Morning Post, 7 May, 1996). Recognizing its ``encroachment'' upon the turf of private providers, the HA, of its own volition, has produced an indeterminate, but potentially highly complicated, plan for health sector integration. The HA argues that Hong Kong needs a ``seamless'' health care system, in which demand for services of all types is ``managed'' through the forging of an ``interface with other health care providers'' (Hospital Authority, 1995a, pp. 2532). If public resources are to be eectively allocated, so that there is not duplication of services, then close cooperation between public institutions, the HA, its hospitals and the Department of Health and the building of collaborative relationships between them and private providers, where deemed appropriate, is essential. However, in its present form, the system seems to be developing in a contrary manner, with few signs of cooperation within the public sector, or between public and private providers. Thus, over and above any initiatives in ``seamless'' health care taken by the HA, the government needs to convene a debate over what sort of system is desired and required by the people of Hong Kong and the various existing service providers. The issues that need to be addressed, and to which there are no easy answers, include: (1) The extent to which government should remain involved in the ``business'' of providing health services. (2) The extent to which private provision should be encouraged. (3) Whether government should be actively engaged in strategic service planning and overall system management and, if so, whether an entity such as the HA or one with a broader jurisdiction should be assuming this role on its behalf. Financing health services Around the world, the issue of health services funding is receiving increasing attention. In Hong Kong, as noted above, the populace is rapidly ageing, producing growing demands for services and technologies that are costing more and more to provide. The Hong Kong government faces a serious dilemma over health nancing: how is it to contain health spending and deliver better quality services, while upholding a policy of universally accessible care? Since the government's contribution to health care (as a percentage of GDP, see above) is rela-

tively small in relation to that of other countries, it may well be that incremental increases in funding are quite acceptable, as many have argued, if Hong Kong is to provide and maintain an internationally reputable health service. The question of funding is connected to the issue of health sector organization. If the government wants a level playing eld among the various service providers in Hong Kong, particularly those of hospital inpatient care, then it needs to bear in mind the incentives required to facilitate optimal utilization of the various facilities. Put simply, so long as all government facilities are heavily subsidized for all users the private sector is not likely to be able to oer eective competition. In a similar vein, while primary services remain predominantly privately nanced, a signicant proportion of the population will remain unable to access high quality primary care, creating continued pressure on fully subsidized, public primary and secondary services. In 1993, reecting mounting pressures for reform, the rising costs of the HA and the fact that none of the previous health sector reviews had examined the crucial question of funding, the government produced a short discussion document on health nancing (Hong Kong Government, 1993). The document outlined the need for modications in health funding to reect broader changes in demographics, socio-economics, user expectations and rising medical costs. Drawing upon the reform experience of a number of other health systems, it listed ve possible funding options for Hong Kong which range from forms of service rationing and targeting of priority groups, to various insurance schemes. That no substantive action has resulted may be of little surprise, given that funding is perhaps one of the more delicate of health care issues, and that of the various alternatives, none is as attractive to health care users as universally-accessible, heavilysubsidized services (Gould, 1995). Although prior to the handover the government of China did not comment on the discussion document, any of the possible change options or the issue of nance per se, it was generally acknowledged in Hong Kong that funding reforms were a topic best left for discussion by the post-July 1997 administration of the Special Administrative Region. While the HA is beginning to raise the issue of funding reform, the fact that it has remained o the central policy agenda since the distribution of the discussion document indicates the lack of commitment by government to taking supposedly ``hard'' decisions. Ironically, recent survey research suggests that the government would be largely supported by the public if it were to increase taxes to fund escalating demand, or to structure user-charges in accordance with income (Lee and Cheung, 1995, pp. 9899; Sunday Morning Post, 30 June, 1996).

Survey of the Hong Kong health sector

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In short, the Hong Kong public values their health system and the gains achieved in recent years and, rather than see an overall decline in quality or restrictions on access, are prepared to pay more for services. It seems that the government either refutes this or, as yet, has failed to take the lead in the funding debate. Given Hong Kong's reputation as a low-tax economy and international trends to decrease income taxation, it is quite likely that some sort of compulsory health insurance scheme, along the lines of the Singapore provident fund, will be instituted to alleviate the government's growing commitment to health care funding. Following history, however, it is likely to be some time before any such change occurs*. The elusive ``health policy'' The dilemmas discussed above relate directly to the issue of health ``policy'' (which remains virtually non-existent) and cannot be eectively tackled until the Hong Kong government explicitly acknowledges the broader picture. As noted elsewhere (e.g. Yuen, 1992; Liu and Lee, 1997), the last time the government issued a policy document was in 1974. Furthermore, there exists no public forum, other than the Legislative Council, in which the community can contribute to health policy debates. Again, it has been the HA that has taken steps to solicit public opinion, but the extent to which HA policy reects this is negligible, given that the function of HA forums is generally one of post-policy-making explanation. The HA continues to function as something of a shop-front for government health policy, with its regular issue of documents giving the outward appearance that policy action is occurring, but there will come a point in time when macro-issues of organization and funding will need to be debated. The policy problem may well be one of scale: the health system is expansive and fosters an array of ingrained institutional and organizational interests, most with an investment in aspects of the status
*The funding issue is likely to be considered as part of the forthcoming consultant study of the Hong Kong health sector. As yet, no date for the consultant study has been announced. If the study were to take place in 1998 and a report delivered by year-end, this would then need to be debated in public and throughout the various levels of government. Thus, it is unlikely that enabling legislation would be introduced until, at the very earliest, the 19992000 legislative year. {It was initially envisaged by government that the Scott report would be implemented swiftly, but, as mentioned above, resistance from the policy community thwarted this plan. Incremental changes are sometimes advisable if there is a longer-term strategy underpinning them. There is no evidence to suggest that the Hong Kong government has a clear strategy for the health sector which it is working towards (see Liu and Lee, 1997). Indeed, it is still working towards the idea of forming such a strategy.

quo. Developing and implementing policy that alters the way an entire system functions may only be possible with the support of the wider policy community (Sabatier and Jenkins-Smith, 1993; Howlett and Ramesh, 1995). The Hong Kong government was genuine in its eorts to involve this community in realizing the highly unpopular HA proposal. In so doing, the lesson the government seems to have gleaned from its experience is that incremental changes to existing systems are a more practicable alternative than the pursuit of strategically planned, rational policy solutions{. Ironically, the lesson it ought to have learned is that consultation is vital when formulating policy: a workforce and community mobilized by participation are more likely to appreciate the need for change, are likely to provide important perspectives that better inform policy decisions and, with a sense of belonging, will assist rather than impede policy-making and implementation. Through the various modications to the health sector over the last decade, most notably, the initiation of pluralistic competition among its own organizations, the government has induced a concomitant debate over health policy. The debate should not be perceived as a menace, but as a challenge, to be fervently pursued. The historical decit here needs to be addressed. The formulation of a Hong Kong health policy is not only necessary, but highly conceivable and is in line with the unfolding across the broader populace of a participatory, democratic ethos (Leung, 1996).
CONCLUSION

The Hong Kong government's involvement in health services provision has grown over the years, often involuntarily, to the extent that a comprehensive range of services are available practically freeof-charge to all residents. This seems to run in contrast with a common view that Hong Kong is a pillar of laissez-faire, free-market capitalism (see Rabushka, 1979; Friedman, 1980). If it were, then one might expect not constant expansion of government health services and continued commitment to universal access but the converse, limited service provision and incentives for consumers so that they patronize alternative (private and voluntary) providers. The Hong Kong government's role in health is reective of a customarily pragmatic approach to policy, in which radical or unpopular change is seldom embarked upon; for the sake of social stability, its commitment to health services provision may be a small price to pay. Standards of service delivery have, in the past, been variable, if inadequate, and have acted to deter all but the most needy from the public sector. Since the 1980s, the health sector has been undergoing a transformation, but the policy environment has remained static, health restructuring has

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R. D. C. Gauld Hay, J. W. (1992) Health Care in Hong Kong: An Economic Policy Assessment. The Chinese University Press, Hong Kong. Hayllar, M. R. (1995) Implementing management reforms in Hong Kong's public hospitals. Asian Journal of Public Administration 17, 178226. Health and Welfare Branch (1997) Consultation on the Development of Traditional Chinese Medicine (November 1997). Medical Division, Health and Welfare Bureau, Hong Kong. Hirschman, A. O. (1970) Exit, Voice and Loyalty: Responses to Decline in Firms, Organizations and States. Harvard University Press, Cambridge. Hong Kong Government (1956) Hong Kong 1956. Government Printer, Hong Kong. Hong Kong Government (1962) Hong Kong 1962. Government Printer, Hong Kong. Hong Kong Government (1963) The Development of Medical Services in Hong Kong. Government Printer, Hong Kong. Hong Kong Government (1974) The Further Development of Medical and Health Services in Hong Kong. Government Printer, Hong Kong. Hong Kong Government, Finance Branch (1989) Public Sector Reform. Government Printer, Hong Kong. Hong Kong Government (1993) Towards Better Health: A Consultation Document. Government Printer, Hong Kong. Hong Kong Government (1995) Hong Kong 1995. Government Printer, Hong Kong. Hong Kong Government (1997) Hong Kong 1997. Government Printer, Hong Kong. Hong Kong Hansard (various) Ocial Report of Proceedings of the Hong Kong Legislative Council. Government Printer, Hong Kong. Hospital Authority, Hong Kong (1994) Business Plan 19941995. Hospital Authority Public Aairs Division, Hong Kong. Hospital Authority, Hong Kong (1995) Annual Plan 1995 1996. Hospital Authority Public Aairs Division, Hong Kong. Hospital Authority, Hong Kong (1995a) Annual Report 19941995. Hospital Authority Public Aairs Division, Hong Kong. Hospital Authority, Hong Kong (1996) Annual Plan 1996 1997. Hospital Authority Public Aairs Division, Hong Kong. Howlett, M. and Ramesh, M. (1995) Studying Public Policy: Policy Cycles and Policy Subsystems. Oxford, Toronto. Klein, R. (1995) The New Politics of the NHS, 3rd edn. Longman, London. Lee, R. P. L. (1983) Problems of primary health care in a newly developed society: reections on the Hong Kong experience. Social Science and Medicine 17, 14331439. Lee, R. P. L. and Cheung Yuet-Wah (1995) Health and health care. In Indicators of Social Development: Hong Kong 1993, eds. Lau Siukai et al. The Chinese University Press, Hong Kong. Lee, J. C. Y. and Cheung, A. B. L. (eds.) (1995a) Public Sector Reform in Hong Kong: Key Concepts, Progressto-Date, Future Directions. The Chinese University Press, Hong Kong. Le Grand, J. and Bartlett, W. (eds.) (1993) Quasi-Markets and Social Policy. Macmillan, London. Leung, B. K. P. (1996) Perspectives on Hong Kong Society. Oxford, Hong Kong. Liu, E. and Lee, V. (1997) Long Term Health Care Policy. Research and Library Services Division, Provisional Legislative Council Secretariat, Hong Kong. Medical Development Advisory Committee (1979) The 1979 Review of the Medical Development Programme. Government Printer, Hong Kong.

occurred within a framework the hallmarks of which are incrementalism, arduous processing of issues and a lack of political will to ensure that reform promises are made and delivered upon. Moreover, it remains unclear what the Hong Kong government is attempting to accomplish in health: it seems to have few goals or objectives and has no grounded theory for policy action. Under the circumstances, any appraisal of government performance in health can only be speculative. The restructuring of health care institutions, culminating in the founding of the HA in the early1990s, has initially produced immense improvements in the standards of public hospitals and other health care facilities. It has also meant that some health planning is occurring (albeit at the periphery) and that, increasingly, questions are being raised over the future conguration of health services funding and delivery in Hong Kong. However, it seems that, at present, historical determinants prevail. The government continues to be apathetic: it has shown only limited interest in tackling imminent problems and does not appear to be overly concerned with developing strategies for the future. In the light of this, the health system has coped remarkably well in providing health services for the general public. Nevertheless, in a rapidly advancing and changing society such as Hong Kong, there is growing pressure on the administration to forge a new approach to the making of health policy and the provision of health services. In this respect, this paper has emphasized a series of health sector issues that demand coordinated action by the government and legislature of the new Hong Kong Special Administrative Region. What is required is a rm commitment, backed by political will, to accomplish proclaimed goals in the organization and delivery of health services.

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Chung, S. Y. et al. (1989) Report of the Provisional Hospital Authority. Government Printer, Hong Kong. Collins, C. (1952) Public Administration in Hong Kong. Royal Institute of International Aairs, London. Endacott, G. B. (1973) A History of Hong Kong, 2nd edn. Oxford University Press, Hong Kong. Endacott, G. B. (1978) Hong Kong Eclipse, ed. (and with additional material by) Alan Birch. Oxford University Press, Hong Kong. Endacott, G. B. and Hinton, A. (1962) Fragrant Harbour: A Short History of Hong Kong. Oxford University Press, Hong Kong. Friedman, M. (1980) Free to Choose. Penguin Books, Harmondsworth. Gauld, R. D. C. (1996) Policy processing in theory and practice: health reform in Hong Kong and New Zealand. Unpublished Ph.D. thesis, Department of Politics and Public Administration, The University of Hong Kong, Hong Kong. Gould, D. B. (1995) The implementation of health policy in Hong Kong. Asian Journal of Public Administration 17, 105115.

Survey of the Hong Kong health sector Ng, A. (1989) Medical and health. In The Other Hong Kong Report, eds. T. L. Tsim and Bernard Luk. The Chinese University Press, Hong Kong. Ng, A. (1990) Medical and health. In The Other Hong Kong Report 1990, eds. Richard Wong and Joseph Cheng. The Chinese University Press, Hong Kong. Ng, Ying-chu and Li, Sung-ko (1996) The Utilization of Private Family Doctor Services in Hong Kong. BRC Working Paper Series No. WP 96002. School of Business, Hong Kong Baptist University. OECD (1996) Health Care Reform: The Will to Change. Organization for Economic Cooperation and Development, Paris. Paterson, E. H. (1987) A Hospital for Hong Kong: The Centenary History of the Alice Ho Miu Ling Nethersole Hospital. The Hospital, Hong Kong. Preparatory Committee on Chinese Medicine (1997) Report of the Preparatory Committee on Chinese Medicine. Government Printer, Hong Kong, April (in Chinese). Rabushka, A. (1979) Hong Kong: A Study in Economic Freedom. University of Chicago Press, Chicago. Sabatier, P. and Jenkins-Smith, H. (eds.) (1993) Policy Change and Learning: An Advocacy Coalition Approach. Westview Press, Boulder. Sayer, G. R. (1975) Hong Kong, 18621919: Years of Discretion. Hong Kong University Press, Hong Kong. Sayer, G. R. (1980) Hong Kong, 18411862: Birth, Adolescence and Coming of Age. Hong Kong University Press, Hong Kong.

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Scott, I. (1989) Political Change and the Crisis of Legitimacy in Hong Kong. Oxford University Press, Hong Kong. Scott, W. D. et al. (1985) The Delivery of Medical Services in Hospitals: A Report for the Hong Kong Government. Government Printer, Hong Kong. Tung Chee-hwa (1997) Policy Address 1997. Government Printer, Hong Kong, October. Walsh, K. (1995) Public Services and Market Mechanisms: Competition, Contracting and the New Public Management. Macmillan, London. Wellington, A. R. (1930) Public Health in Hong Kong. Report to the Hong Kong Government, CO 129/531. Wellington, A. R. (1937) Changes in the Public Health Organisation of Hong Kong During the Period 1929 to 1937. Memorandum No. 4/1937, Sessional Papers Laid Before the Legislative Council of Hong Kong. Welsh, F. (1993) A History of Hong Kong. Harper Collins Publishers, London. Working Party on Chinese Medicine (1994) Report of the Working Party on Chinese Medicine. Government Printer, Hong Kong. Young, R. et al. (1990) Health for All: The Way Ahead, Report of the Working Partly on Primary Health Care. Government Printer, Hong Kong. Yuen, P. P. (1992) Medical and health. In The Other Hong Kong Report 1992, eds. Joseph Y. S. Cheng and Paul C. K. Kwong. The Chinese University Press, Hong Kong. Yuen, P. P. (1995) Health care services. In From Colony to SAR: Hong Kong's Challenges Ahead, eds. Joseph Y. S. Cheng and Sonny S. H. Lo. The Chinese University Press, Hong Kong.