published_or_final_version / abstract / toc / Social Work and Social Administration / Master / Master of Philosophy

Background China never stops taking effort to reform its health care system. Health care financing, which is one of the essential control knobs to health care system, has significant influences on the sustainability of the health system, the quality of services it delivers, the health status of the population as well as the success of the whole health care reform process. Objectives This article aims to summarize the evolution of China’s health care financing system, its current situation and challenges, discuss what lessons China can learn from the successful experiences or unsuccessful pitfalls of others countries on its health care financing reform. Methods Articles were searched through PubMed and CNKI. Further relevant articles were identified by searching the citations listed in retrieved articles manually. 96 articles were reviewed. Statistics about China’s health care system were mainly from government white paper, SHA technical paper, Chinese government websites and WHO website. The information about the performance of health care systems in other countries was mainly from OECD database and WHO website. Results In China, insufficient government expenditure and high out-of-pocket payments; social health insurance providing limited risk protection, with low-level risk pooling; escalation of costs; inefficient financing resources allocation in providers; disparities among regions and provinces all lead to the inequity and inefficiency of the health care financing system and create heavy financial burden on patients. Based on experiences from other countries, the total health expenditure in China could take an even larger proportion of GDP in the future; it is reasonable to increase general government expenditure to further reduce the household out-of-pocket payment and provide financial protection and ensure equity; expanding services coverage and proportion of the costs covered, gradually merging the risk-pool units and different schemes can make social health insurance a more powerful tool to make sure people’s access to basic health care; a new payment mechanism and stricter supervision on supply side can effectively contain the escalation of the costs; government should inject more funding to front-line institutions and the function of primary care in China can be stimulated by a good primary health care delivery system, in which the role of primary care provider is clearly defined as the gatekeeper of the health care system, with a proper referral mechanism; more responsibility should be taken by central government to allocate financing resources based on the fiscal capability of local governments; Chinese government should foresee the demand of aging population and take actions before it is too late. Conclusion It is consensus that China’s health care reform is heading at the right direction. However, there are a lot of problems in China health care financing system remaining to be solved. Health care financing system varies greatly in each country and there is no perfect health care financing system in the world. Thus no single country can be one hundred percent copied by China. But general principles and one or some most successful and advanced portions of other countries’ health care financing systems can still be used as references by China after further assessment. Unsuccessful oversea experiences are also precious lessons for preventing Chinese government from making same mistakes. A good health care financing system should be designed on the basis of a systematic review of all domestic financing policy and previous international experiences. / published_or_final_version / Public Health / Master / Master of Public Health

published_or_final_version / Community Medicine / Master / Master of Public Health

Introduction Accessibility to care is a key measure for quality health care. Waiting list resulted due to disequilibrium between demand and supply. Waiting time is a common issue in public health care services. Long waits and delays dissatisfy patients, affect clinical outcome and increase health care costs. Access management is therefore important to enhance patient safety, increase satisfaction and reduce service inefficiency. In Hong Kong, waiting lists for public specialist out-patient services have been increasing over the past years. Promotion of appropriate referrals and appropriate utilization between primary and secondary care was identified as one of the current strategies for service demand management. Referral guidelines were introduced to define the clinical conditions to be referred. Appropriate work up and trial of treatment was recommended before referral to specialist care. They were translated into standard referral letter templates and built into the existing electronic medical record system as an execution platform to facilitate workflow and enhance compliance. This electronic referral system was piloted since January 2010 in Department of Accident of Emergency and General Out-patient Clinic at one local public hospital in Hong Kong. Methods The objective of the study was to evaluate the effectiveness of current strategy in access management to public specialist out-patient services. All new case referrals to Medical and Surgical Specialist Out-patient Clinics (SOPC) of the pilot hospital from January 2010 to December 2010 were examined. While, the new case booking data from January 2009 to December 2009 in respective units of the same hospital was used as control group for comparison. Potential changes in number and distribution of new case bookings at medical and surgical SOPC as well as their corresponding waiting time were looked into. Comparison of referral pattern before and after the implementation of new referral system was performed. Results Changes in referral pattern in terms of distribution of triage categories have been observed. Number of semi-urgent cases was significantly increased in 2010 compared with 2009 in both Medical and Surgical SOPC (p=0.006 and p=0.048). Shortening of overall median waiting time was also seen in both Medical and Surgical SOPC of the pilot hospital in 2010. Consistent reduction with statistically significance was noted in all triage categories of both specialist clinics, except urgent cases in Surgical SOPC. Larger effect was seen in non-urgent cases, with 9 weeks and 4 weeks shortening of waiting time in Medical and Surgical SOPC respectively. For overall distribution of waiting time, persistent multimodal patterns were observed in both Medical and Surgical SOPC during the study period. Major peaks were identified within 2 and 8 weeks time of appointment, while scattered clustered bookings were seen along the timeline with waiting time up to years. Discussion The observed result was reinforcing the direction on current strategy, despite direct causal relationship could not be established at the moment. Changes in referral pattern could possibly be explained by the behavioral change of clinicians upon referral and triage of patients due to the introduction of the new referral system. Potential Hawthorne effect during the pilot period should therefore be considered. In view of the complexity and interconnectedness of various service components in the health care system, further studies should be of value to identify the change agent in the system and look into the efficiency gain as well as outcome improvement. Long term and regular monitoring mechanism of waiting time with specific set of performance indicators has to be in place for continuous quality improvement. Taking the public health approach by applying operational studies and simulation models should therefore be the way for further improvement of operational efficiency and service planning in the whole public health system. Conclusion Appropriateness of referrals and utilization between primary and specialist services was introduced for access management of public specialist out-patient services in Hong Kong. Changes in referral pattern with shortening of waiting time were observed. In order to manage the accessibility issue effectively, a balanced approach on demand, queue and capacity management was suggested to be adopted at the organizational level. Collaboration across sectors particularly with the direction to strengthen primary care would also be needed globally at the system level for a healthy, equitable and sustainable system. / published_or_final_version / Public Health / Master / Master of Public Health

In Hong Kong, access to elective surgeries in public hospitals is often associated with lengthy waiting times. Facing resource constraints and increasing demands from a rapidly ageing population, the Hospital Authority (HA) is constantly confronted by the healthcare rationing dilemma. To date, publicized data on elective surgery waiting times at the HA remain limited, and a standardized way of measuring waiting time is currently lacking. Recognizing that the definition of waiting time will form the basis for future policies in addressing the issue, a three-step approach will be taken in this paper. First, a comparison will be drawn for the varying definitions of waiting time worldwide. Next, a suitable definition will be proposed for Hong Kong, followed by analysis of where policy interventions are most needed for reducing waiting times. Finally, best practices for managing waiting times will be extrapolated from England, Canada, Australia, and Spain to serve as guidance for Hong Kong’s future policy direction. / published_or_final_version / Public Health / Master / Master of Public Health

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Chinese Historical Studies / Master / Master of Arts

abstract / Public Health / Doctoral / Doctor of Philosophy

This research evaluates government education and health spending in China and explores the underlying determinants of its spatial pattern. A framework defining local needs at three levels is proposed to analyze whether the expenditure has been reasonably allocated. Results show that both government education and health spending closely respond to local needs at the general level. The illiteracy rate is positively correlated with government education spending while the life expectancy is negatively correlated with government health spending. On the demand and supply sides, while government education spending is more responsive to local demand measured by student number, the needs from the supply side represented by the number of medical personnel appear to be more relevant when governments distribute resources into the health sector. One particular area that needs more effort is the responsiveness to the needs arising from the lack of teaching staff. The student-teaching ratio is now largely ignored when governments make decisions of education outlays. Given that the adequacy of teaching staff is a must to ensure the quality of teaching, governments are thus suggested to put more weights to this aspect in its decision-making process. As for the determinants of government education and health spending, this study takes a close look at three groups of key potential explaining factors identified in the existing literature – economic development, openness and decentralization. The findings pose challenges to the existing mainstream theories developed in the western context. Only per capita gross regional product is found to have significant explanatory power for budgetary expenditure on education and a significant negative relationship is revealed. On the other hand, both economic development and the degree of fiscal dependency are significant in explaining the spatial pattern of government health spending; and their relationships are both non-linear. The fixed-effects panel data regression model predicts that, ceteris paribus, a province with a per capita gross regional product of 20,265 yuan would have the most government health outlays while a province with a fiscal dependency ratio of 63.6% would have the lowest public health expenditure. Provinces with either higher or lower per capita GRP (fiscal dependency ratio) than the threshold value allocate fewer (more) resources into government health outlays. The most important recommendation derived from the findings of this dissertation is that the central government should keep an eye on those provinces that are neither fully financially dependent nor fully financially independent, because their government health spending tends to be particularly inadequate. / published_or_final_version / China Development Studies / Master / Master of Arts in China Development Studies

Despite attempts to contain health care cost, healthcare expenditure has been surging worldwide. Healthcare financing remains high on the political agenda and nations are struggling hard to balance cost containment with service quality, accessibility, efficiency, etc (Froetschel 2011). Hong Kong, of no exception, faces increasing pressure to raise public expenditure on health and is seeking new ways to finance healthcare. This paper attempts to provide an overview of Hong Kong’s existing health financing system and identify possible reform options. / published_or_final_version / Politics and Public Administration / Master / Master of Public Administration