Elsevier

Health Policy

Volume 91, Issue 3, August 2009, Pages 229-238
Health Policy

Public and private healthcare services utilization by non-institutional elderly in Hong Kong: Is the inverse care law operating?

https://doi.org/10.1016/j.healthpol.2008.12.012Get rights and content

Abstract

Objectives

To assess the factors associated with healthcare services utilization by the non-institutional elderly across five types of service utilization (Western medicine doctors in Government clinics, private Western medicine doctors, Chinese medicine practitioners, Emergency Units, and hospitalization).

Methods

A secondary data analysis of a territory-wide cross-sectional survey collected by the Government among a representative sample of 4812 elderly (aged 60 and above) in Hong Kong.

Results

Our analysis, based on Anderson's behavioral framework, shows that need factors (relating to actual or perceived illness and diseases) are significantly related to the healthcare services utilization examined. However, enabling factors, such as monthly household income per capita, play a significant role in determining the utilization. Although the lower-income elderly consult more Government clinics and less private clinics than the more affluent, they have a lower total utilization of healthcare services despite having significantly greater healthcare needs.

Conclusions

This suggests a mismatch of need and supply within the mixed economy of private and public healthcare services and suggests the existence of an ‘inverse care law’ in Hong Kong amongst elderly citizens. The findings raise concerns of inequities in Hong Kong's healthcare system, raising implications for future healthcare reforms.

Introduction

According to World Health Organization [1], it has been predicted that there will be an increase of some 694 million elderly globally (a growth of 223%) between 1970 and 2025. Hong Kong is no exception. The proportion of the population aged over 65 in Hong Kong is expected to increase from 0.8 million (12%) in 2006 to 2.2 million (26%) by 2036 [2]. The elderly population has relatively greater health needs. There were around 19,560 in-patients staying in the public hospitals in Hong Kong as of 31st March 2006 of which 51% were aged 65 and above [3]. Furthermore, these elderly consumed six-time more in-patient care (in terms of bed-days) than persons aged below 65 [4]. As a result of chronic illness, multiple morbidity and disability, the need and demand for healthcare services by the elderly population is likely to expand, and thus the cost of healthcare is expected to increase as well. This in turn poses an issue of affordability for both the individual and society. In terms of the public and private share of health expenditure in 2004/05, in-patient care was predominantly financed by public funding (75%) whereas ambulatory services were largely financed by private funding (63%) in Hong Kong [5]. Since Hong Kong relies solely on tax revenue to finance its public health system, the financial sustainability at the current low level of taxation has been questioned in many local studies [6], [7], [8]. Thus, the Hong Kong Government has recently published a healthcare reform consultation document with a main objective of rethinking the current financing arrangements [4]. It also intended to address the significant public-private imbalance and the insufficient emphasis on an effective and holistic primary care system in Hong Kong.

Improving cost-effectiveness without decreasing quality of healthcare services are important issues worldwide for which there are no simple solutions. In reforming health systems it is important to identify the key factors relating to healthcare services utilization in all parts of the healthcare system (public, private, primary care, secondary care, etc.) and to take such factors into account in planning policy and practice changes.

International and local studies [9], [10], [11], [12], [13], [14], [15], [16] have documented different types of healthcare services utilization patterns and the associated factors among the elderly using the Anderson's Behavioural Model. According to the Model, the use of healthcare services is defined as a function of predisposing, enabling and need factors [17]. It suggests an equal access to healthcare services when demographics and need factors play a dominant role in predicting utilization. Most of the studies conducted in different healthcare systems such as those of tax-based system in Spain [12], private health insurance system in US [11], [16], [18], or social health insurance system in Germany [13] and Israel [14] showed that predisposing and enabling factors had little impact on the healthcare services utilization whereas the need factors played an important role in affecting utilization. Another US study [9], on the other hand, indicated that need factors were not the most important predictors of utilization. On the contrary, private insurance was found to be associated with physician visits and hospitalizations. A study in Canada further pointed out that the high-income group had a higher chance of being hospitalization [19]. This inequality in hospitalization with respect to income was also found in a UK study conducted in 1998–2000 [20]. Such ‘mismatches’ between need and supply has been termed the inverse care law which states that “The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.” [21]. In general terms, this relates to a poorer volume and quality of care for less well off individuals or communities relative to need [22].

Hong Kong has a “dual” health care system with both public and private sectors providing primary and secondary care services. The Hong Kong Government's health care policy is that “no one should be denied adequate medical treatment through lack of means” [4]. The public outpatient and inpatient services are largely funded by the Government through general taxation with the rest paid by fees and charges at the point-of-care where the private health services are mainly from out-of-pocket household expenditure and the remaining from private insurance or employer-provided medical benefits [23]. A local study on factors associated with the use of publicly funded healthcare services among Hong Kong Chinese elderly conducted in 1996 showed that the public healthcare services utilization were significantly related to the need factors [10]. They concluded that publicly funded health services in Hong Kong were equitable. However, their study was conducted nearly 10 years ago before the introduction of various healthcare reform consultations regarding healthcare financing and services delivery [24], [25], [26]. There has been a restructuring of fees in the public healthcare system since then. There have also been changes in socio-economic conditions, including an economic downturn in 2003 and demographic changes especially in the ageing population. Moreover, the previous study only looked at publicly funded health services [10]. Thus, the present study describes the current healthcare services utilization by the Hong Kong elderly including different types of utilization in the public and private sectors, Western and Chinese medicine, and primary and secondary care levels. Studying the healthcare services utilization patterns of the elderly population is important in order to plan for an equitable, high quality and cost-effective health services delivery system.

Section snippets

Materials and methods

This was a secondary analysis of data collected at Thematic Household Survey on the topic of “socio-demographic profile, health status and long-term care needs of older persons” conducted by the Census and Statistics Department of the Government of the Hong Kong Special Administrative Region in June to August 2004 [27]. The Thematic Household Survey is a series of territory-wide, cross-sectional rounds of survey carrying out every quarter aiming to collect statistical information on different

Respondents’ profile

Table 1 showed the respondents’ profile of all the 4812 elderly interviewed. The mean age was 71.2 years (standard deviation of 7.7), approximately half were male, and most were currently married. More than a third had received no education. Regarding the monthly household income per capita (adjusted for household size), 16.5% had less than HK$2,000 per month while 45.3% had HK$2,000-4,999. The median household income per capita was around HK$3,750. Less than half (44.0%) had prepared for

Discussion

In the present study, we have explored the relationship of different types of healthcare services utilization with the predisposing, enabling, need and personal health practices factors as specified in the Anderson's model. We found significant associations between need factors (relating to actual or perceived illness and diseases) and different healthcare services utilization, and between socioeconomic status and healthcare services utilization. In terms of need factors, our study showed that

Conclusions

Our results provide updated and comprehensive information on the use of healthcare services among the elderly in Hong Kong. Lower-income elderly consult more Government clinics and less private clinics than the higher-income group, but overall have a lower total utilization of healthcare services than the more affluent. However, those of lower socio-economic status have significantly more health problems including more multiple morbidities. This suggests a mismatch of need and supply within the

Acknowledgement

We would like to thank the Labour and Welfare Bureau, and the Census and Statistics Department of the Government of the Hong Kong Special Administrative Region, which provided us with the data for this study.

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