Understanding the perceptions on the availability and accessibility of public health services for the poor and socially disadvantaged. A qualitative study in Hong Kong.

doi:10.21203/rs.3.rs-2726736/v1

Download PDF

Research Article

Understanding the perceptions on the availability and accessibility of public health services for the poor and socially disadvantaged. A qualitative study in Hong Kong.

https://doi.org/10.21203/rs.3.rs-2726736/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background

8% of the population reports inability to financially afford primary care despite the universal healthcare policy in Hong Kong. This study aims to understand the multifactorial causes that contribute to the healthcare accessibility barriers.

Methods

Individual telephone interviews were conducted in 2020 on a group of participants from a previous study that identified themselves as unable to financially afford primary care. A total of 13 participants were interviewed.

Results

A thematic analysis, through the socioecological model, revealed four levels of factors that contributed to the participant’s healthcare inaccessibility: intrapersonal and interpersonal, institutional, community, and policy. The first level relates to the (1a) limited choice of outpatient care due to wealth status, (1b) inadequate knowledge of types and number of services provided, (1c) high non-monetary opportunity costs in seeking public healthcare services, (1d) reluctance to seek medical care unless the situation becomes serious and acute, and (1e) consumerist attitude and perception of quality of care received. The second level relates to (2a) price increase of public A&E departments, (2b) high price of private healthcare providers, (2c) inadequate General Out-Patient Clinics, (2d) complex steps to access General Out-Patient Clinics, (2e) unmet medical needs received from public healthcare services, (2f) inadequate employer support for ill employees, and (2g) inadequate public support for patients struggling with dental issues. The third level relates to (3a) insufficient support for patients struggling with physically accessing General Out-Patient Clinics. The fourth level relates to (4a) inadequate Elderly Health Care Voucher and (4b) inadequate Comprehensive Social Security Assistance (CSSA) and its exclusive requirements.

Conclusion

These findings increase our understanding of the patients’ barriers when accessing primary care. The data highlights the need for a multifactorial approach when attempting to achieve primary health care and to eliminate financial barriers completely for patients living in and around the poverty line.

Healthcare system

longitudinal qualitative

poverty

primary health care

health care access

health inequity

Research has consistently found evidence of inequities in primary care access. Limited access tends to affect the most vulnerable and socially disadvantaged^{1, 2, 3, 4}. This largely represents a phenomenon known as the inverse care law, where those who need medical care tend not to receive it. The law operates more profoundly when medical care is more exposed to market forces⁵.

While it is easy to assume that the presence of an accessible and affordable public healthcare system may solve all the problems, this may not be true. This is well illustrated by the case of Hong Kong. Despite a public healthcare system that aims to deny no one adequate healthcare due to a lack of financial means⁶, a previous study found that over 8% of the Hong Kong population were denied care due to a lack of financial means⁷. These people are generally sicker than the Hong Kong population, implying that those with greater healthcare needs may have greater financial difficulties in receiving medical care. Even though Hong Kong has a dual-track public-private healthcare system, a regular source of primary care is found to be pro-rich⁸ because outpatient care is predominantly private. To balance the demand for public and private healthcare, the Hong Kong government launched the Elderly Health Care Voucher (EHCV) scheme in 2009 to subsidize elderlies aged 65 or above with $257USD ($2,000HKD) each year to utilize private primary healthcare services. Nonetheless, the EHCV was not associated with the reduced utilization of public healthcare services⁹.

Poverty is closely linked to disadvantage and inequality. Effective policies to alleviate poverty remains a global and local concern. Amidst a period of economic growth in Hong Kong, poverty not only remains but is on the rise. Between 2016 and 2020, Hong Kong’s per capita gross domestic product grew from $43,731.107USD to $46,323.863USD, peaking at $48,5432.582USD¹⁰. However, the number of people living in poor households before any government intervention soared from 1,352,000 to 1,653,000 in just five years. In 2020, the poverty rate before intervention stood at 23.6 percent¹¹.

Although income and assets are functional proxy indicators of financial vulnerability as a barrier, other factors related to health-seeking behavior should be explored. Though current policies centers around the financial needs of patients, many are still left unable to access healthcare due to other, unaccounted, reasons. Understanding the perceived barriers from socioeconomically disadvantaged people may help policymakers to develop a more comprehensive and equitable healthcare system.

The study aims to explore the perceptions of the availability and accessibility of public healthcare services for poor and socially disadvantaged people in Hong Kong. We aim to identify the barriers to healthcare and the ways that individuals cope with these barriers. Through conducting semi-structured interviews, we will gain a more complete narrative of the factors that affect the health-seeking behaviors of this population.

A qualitative approach was used. The methodology was designed to elicit patients' perceptions about healthcare services via semi-structured interview over the telephone.

Participants and sampling

Participants were selected from a previous population-based study entitled ‘Trends and Implications of Poverty and Social Disadvantages in Hong Kong: A Multi-disciplinary and Longitudinal Study,’ which consisted of 2,282 adult participants from a random sample of all households in Hong Kong. Detailed procedures of stratified sample design had been described previously⁷. Of this random sample, 752 participated in a telephone follow-up survey from April to May 2020¹² and 60 of them (8.0%) did not seek medical care due to a lack of financial means from 2019 to their individual interview date. All 60 participants were approached by phone in November 2020 and were invited to join a semi-structured individual interview.

Data collection

In the absence of face-to-face interviews during COVID-19 pandemic period, semi-structured telephone interviews were conducted, which was shown to be a valid means of conducting in-depth qualitative interviews¹³. Moreover, it was shown that telephone participants were more likely to give personal comments since their faces were not identified¹³. The interviews lead to a relaxed two-way verbal communication with decreased social pressure and increased rapport, allowing researchers to elicit rich, detailed, and high-quality information and go into intimate and sensitive issues¹⁴.

A description of the study was given to the participants before the interviews. All participants were given time to consider if they agreed with participating in the interview and had the right to withdraw anytime. The investigators’ contacts were given for future queries. Verbal consent of participants was obtained before the interview. Participants were interviewed individually about topics related to their experiences in accessing healthcare services. Each participant was given a $200HKD ($7.8HKD ~ $1USD) supermarket cash coupon as an incentive for completing the interview.

The topics covered in the interview included: 1. physical and mental conditions, 2. financial burden, 3. prioritization of needs 4. time constraints, 5. healthcare availability, quality, and cost, and 6. coping strategies. The series of semi-structured questions were developed based on a literature review, and our previous quantitative survey. They were supplemented by follow-up probing questions for elaborations, dominant themes identification, and themes expansion.

A lead investigator with previous experience in conducting qualitative interviewing studies and a senior researcher conducted the interviews. Post-interview debriefings were done after the first five interviews to discuss the dynamics of the interview and determine when data saturation was reached to minimize interview bias.

All interview conversations were audio-taped, transcribed verbatim, and were cross-checked to ensure accurate documentation. A thematic analysis approach was used to synthesize results. The investigators became familiarized with the transcripts, looked for recurrent themes, and categorized the conversation according to the thematic structure. Initial codes were first conceptualized, which then underwent an iterative process to further define and identify relationships between specific thematic categories. A code manual was developed for organizing similar related text to assist in the interpretation and to provide a clear trail of evidence. Two researchers independently reviewed the codes and categories for reliability while discrepancies were resolved by discussion. The subsequent coding was identified by refining the coding schema through repetitive review until data saturation was sought. Main themes and subthemes were organized through discussion among investigators, summary tables, and a mind map. Illustrative comments were presented in quotes for the related themes.

Ethical approval for this study was granted by the Survey and Behavioural Research Ethics Committee of the Chinese University of Hong Kong (Reference No. SBRE-19-450).

Descriptive statistics of participants

60 participants were invited to join the semi-structured telephone interview. Among them, 20 did not answer our phone calls, 27 refused to join, and 13 agreed to join the interview. The final sample included 10 women and 3 men, with ages ranging from 45 to 81 years. The sample size was regarded as sufficient to reach thematic saturation since no new thematic information could be gathered. Table 1 shows the sociodemographic characteristics of individual participants, which was based on the results of the previously commenced telephone survey. Marital status of the participants was classified as never married, married, cohabitation, separated, divorced, or widowed. Information on education level, income poverty, social security and occupation were collected as the measurement for socioeconomic status. Education level was grouped as primary or below, secondary, and tertiary or above. Income-poverty was measured by equivalised household income, which was estimated by dividing total pretax monthly household income (including social security benefits) by the square root of household size. People whose equivalised household incomes fell below $5,250HKD (half of the sample’s median in the telephone survey) were classified as ‘income poor’, whereas those above were ‘non-income poor.’ Participants receiving the means-tested financial assistance from Comprehensive Social Security Assistance (CSSA) were regarded as recipients of social security. Occupation was grouped into five categories as employee, self-employed, umemployed, retired or looking after family. Medical condition was collected based on self-report of diagnosis by their doctors on chronic diseases. Participants were also asked to rate their health in general as poor, fair, good, very good, or excellent. The descriptive statistics below give insights into the variety of barriers that patients face from different sociodemographic backgrounds, allowing for an intersectional approach to data analysis and policy recommendations.

Table 1

Sociodemographic characteristics of individual participants
No.	Age	Sex	Marital status	Education level	Income- poverty	Social Security	Occupation	Chronic disease	Self-rated health
01	56	M	Never married	Secondary	Non-poor	No	Self employed	Coronary heart disease Diabetes High Cholesterol Hypertension	Fair
02	68	F	Married	Primary or below	Non-poor	No	Looking after family	Diabetes High Cholesterol Hypertension Rheumatism Sciatica	Fair
03	45	F	Married	Secondary	Non-poor	No	Looking after family	Hypertension Muscle Pain	Good
04	70	F	Married	Primary or below	Non-poor	No	Retired	No	Very Good
05	81	F	Widowed	Primary or below	Non-poor	No	Retired	Diabetes High Cholesterol Hypertension Muscle Pain	Fair
06	74	F	Married	Primary or below	Non-poor	No	Retired	Adhesive Capsulitis Cataract Diabetes High Cholesterol Hypertension	Fair
07	73	F	Widowed	Primary or below	Non-poor	No	Retired	Cataract Coronary heart disease High Cholesterol	Fair
08	70	M	Married	Primary or below	Poor	No	Retired	Coronary heart disease	Poor
09	49	F	Married	Secondary	Non-poor	No	Employee	No	Very Good
10	58	F	Married	Primary or below	Non-poor	No	Looking after family	No	Good
11	55	F	Married	Secondary	Poor	No	Employee	Gastroesophageal reflux disease Gum infection	Fair
12	64	F	Widowed	Primary or below	Poor	Yes	Looking after family	Back pain	Good
13	55	M	Married	Tertiary or above	Non-poor	No	Employee	Coronary heart disease Pituitary tumor	Good

Comparing the sociodemographic characteristics of the 13 participants and 47 non-participants from the results of the telephone survey (Supplementary Table 1), participants were more likely to be female (77% vs 57%) and non-income poor (77% vs 62%) but had similar mean age (63 years vs 64 years).

Interview length ranged from 16 minutes to 80 minutes, with a mean duration of 37 minutes. There was a focus placed on the experiential and anecdotal recounts of different factors that negatively affected people’s ability and willingness to seek primary care. Using the socioecological model¹⁵, various multidimensional gaps were identified. Individual and environmental factors were categorized by intrapersonal and interpersonal, institutional, community, and policy and legal levels. Intrapersonal factors include an individual’s knowledge, attitude, and behaviors, while interpersonal factors touch on social networks. Institutional factors cover the way relevant institutions are operated, community factors allude to institutions and informal networks within defined boundaries, and policy and legal factors refer to policies and regulations affecting the institutions and their function. Gaps on perceived barriers in various hierarchical levels and the relationships between these levels are summarized below. Short quotes within the narrative are reported and accompanied by a unique identifier of participants.

Intrapersonal and interpersonal factors

1a) Limited choice of outpatient care due to wealth status

Many of the participants are aware of their wealth status, income, and expenses, which influences their comparison with the “middle class” (a term generally used in Hong Kong to refer to those who are not poor or very wealthy). These participants believe that they are only able to and should only seek medical care from the most affordable option, which tends to be the government subsidized General Out-Patient Clinics (GOPC), priced at $6.5USD ($50HKD). The perceived limited options further contribute to other factors below. A working man helplessly said:

“If you are talking about the middle class, those who earn high wages, of course, they’re going to think [government subsidized public healthcare] is cheap. If anything, apart from the slightly longer time in waiting, they are going to thank you [for the subsidy]. But for us [author: poorer people], we do not earn much, we do not always have work to do, we lose a future visit to the doctor if we spend on a visit this time.” (01-working man)

1b) Inadequate knowledge of types and number of services provided

There is a general lack of knowledge on the locations of public healthcare services, limiting the utilization of the services. This is compounded by the fact that patients tend to not be inquisitive during their clinic or hospital visits and do not ask about alternative options even if the current service may not be the most convenient. An elderly man, when talking about traveling difficulties to his regular checkups, said:

“I don’t know where to go for public healthcare! I don’t know where the public clinics are located... The current hospital for my checkups is inconvenient, but I don’t know where to look for closer options… I’ve never asked the doctors or nurses at my current hospital for alternatives.” (08-elderly man)

1c) High non-monetary opportunity costs in seeking public healthcare services

There are other factors to be considered when deciding to access public healthcare. For patients who live further away from the closest GOPC or Accident and Emergency (A&E) Department, travel time is an important consideration. The time patients spend waiting during the visit is also significant.

“It takes me around 20 minutes from boarding the minibus to arriving at the hospital. Normally, I must wait at least one hour for the checkup, and at least 30 minutes for medicine collection. I have tried waiting for over two hours for medications before. I’ll have to waste three to four hours per regular checkup. This is unreasonable.” (08-elderly man)

Apart from that, patients who have limited mobility due to conditions such as osteoarthritis and osteophytes, experience difficulties when traveling, especially if the terrain is not easy to traverse. These patients must consider the extra effort needed.

“I experience chronic pain in my legs and spine. Every time I visit the public clinic, I must take the cab as I can’t walk.” (05-Elderly Woman)

Another significant factor may be items patients prioritize above their health. For example, those who are financially supporting children or parents tend to lower the priority for their health in exchange for their child’s or parent’s health because paying for themselves will mean that they will be unable to afford to pay for their child or parent. As a father said:

“It’s not a big deal for adults like myself. I can just head to the pharmacy to purchase some OTC medication. However, if my child became sick, I’m going to always prioritize them and bring them to private healthcare.” (13-father)

In other words, although they can afford public healthcare, they choose not to do so due to other considerations. Many of these considerations can be eliminated if they have the financial ability to afford private healthcare, which many of them are in extremely close vicinity and are incredibly accessible.

1d) Reluctance to seek medical care unless the situation becomes serious and acute

Due to the difficulties in accessing both private and public healthcare, patients often sit on their illnesses. Once the symptoms become debilitating, it then forces the patients to seek care. This allows the patients to delay the high costs of healthcare. The reluctance can be mitigated with government subsidies, such as EHCV. However, these subsidies are only available to a subpopulation and when these subsidies are no longer available or completely utilized, the reluctance reemerges. Defaulting to this mode of doctor-seeking behavior tends to cause the illness to develop further than it should, contrary to what the patients hope to achieve, i.e., a fast and cost-effective treatment for their illnesses. When the situation is dire, it causes the following situation to occur:

“I’ll be reluctant to spend money on visiting the doctor after knowing I’ve run out of Elderly Health Care Voucher. I rather purchase OTC pain killers. I’ll only go to the doctor’s when my headaches, my whole body aches, or when I have a fever or cold shivers. (08-elderly man)

1e) Consumerist attitude and perception of quality of care received

Hong Kong’s private healthcare focuses on providing outpatient primary care, while the public sector focuses on providing secondary care. People tend to associate “better and more effective” with private healthcare due to its higher price. Yet the price difference only exists because the public sector is heavily subsidized by the government. This perception of the healthcare system creates disdain against the public system and may cause patients to be less willing to seek public care. As an elderly woman expressed:

“In my experience, sometimes the treatment from the public sector is awfully slow or just doesn’t work. However, the medication from private doctors works much better and faster.” (02-elderly woman)

Institutional-level Gaps And Issues

2a) Price Increase Of Public A&e Departments

Hong Kong’s public A&E services underwent a price increase in 2017, from approximately $13USD ($100HKD) to $23USD ($180HKD)¹⁶. The government hopes to encourage appropriate usage of the A&E and to create a diversion of less urgent patients to other providers. The price increase in turn hurts the patients who would have otherwise been able to financially access A&E services but are now limited. There are two considerations when thinking of accessing A&E services. First, increased opportunity cost, as patients now must wait the same time or longer whilst paying more. As the price difference between A&E services and private healthcare shrunk, patients may opt for private healthcare albeit less frequently. As a stay-at-home mom lamented:

“I don’t think it’s reasonable. For example, with A&E charging $23USD ($180HKD) [per visit], if I save a little more and pay $10USD ($80HKD) more, then I can use private healthcare. If you’re talking about reasonable prices, the goal is to prevent people from abusing the system, so anything below $12.75USD ($100HKD) is acceptable and can achieve the goal.” (03-stay at home mom)

2b) High Price Of Private Healthcare Providers

The fees that private healthcare providers can charge are unregulated in Hong Kong, causing a wide range of fees and services depending on the provider’s location, experience, qualifications, etc. Despite the resulting high prices, the participants expressed that they would want to be able to access private providers. Unfortunately, the patients either can’t pay the fees upfront or it becomes a huge burden to their financial stability to do so. As an elderly woman said:

“Sigh, just a short visit to the cheapest [private] provider will cost you some hundred dollars. Just like that, some hundred dollars is gone. Even if the government subsidizes some of the cost, I’ll still weigh out my symptoms before choosing to go to a private provider.” (07-elderly woman)

2c) Inadequate General Out-patient Clinics

A public alternative to the A&E services are the GOPCs. However, these GOPCs are very limited in the number of patients they can service, with limited quotas per day. Due to the low quotas, the landlines for telephone appointment booking are often flooded by other patients. Patients may need to call 10 + times to get through to the staff. Even if the patient can get through to the staff, same-day consultations with doctors are difficult to arrange. Although there is an alternative booking method through the “Book GOPC” function in the Hospital Authority (HA) app fully launched in July 2020, there does not seem to have any adoption amongst the participants. This directly compromises the patients’ care, causing long delays between the presentation of symptoms and illness and the time medical care is accessed. As the stay-at-home mom says:

“I really do want to go to public healthcare. For example, when my hand hurts, I want to be able to access healthcare immediately. The question is, are there quotas available for you? It’s impossible to have an available timeslot for you. Every time I get through to them [via the phone], they say that the next 24 hours are already full. The same happens even if you stay up all night and constantly call their landline. I had tried calling for 3 days before being able to reserve a consultation time.” (03-stay at home mom)

2d) Complex Steps To Access General Out-patient Clinics

Accessing GOPCs in Hong Kong requires a telephone and certain competencies in utilizing technology. This may prove to be challenging to elderlies, the primary GOPC demographic. Over 1/3 of the total GOPC patients are aged 65 or above¹⁷. One participant has expressed that she does not, in fact, own a phone, causing her ability to access GOPCs to be near impossible. On the other hand, the elderlies who do own telephones have expressed another set of concerns. There are multiple steps to the telephone appointment booking system. The patient must repeatedly listen to introductions and input the correct information, including the patient’s preferred language, their Hong Kong identity card numbers or their birth certificate’s registration number’s first six digits, year of birth, confirmation of identity, confirmation of appointment, and any other services they require¹⁸. These steps can easily cause confusion and panic for the patient when instructions aren’t heard correctly or when the wrong numbers have been inputted. As another elderly woman frustratingly said:

“Where do you even go to queue up for GOPCs? I must call them to make an appointment. Sigh, I don’t even know how to call using smartphones! I have no clue how to input the numbers when they ask me to. In the past when I use my old cellphone, I can sometimes get through to the staff members if I’m lucky. However, they never have an available same-day consultation time slot.” (06-elderly woman)

2e) Unmet Medical Needs Received From Public Healthcare Services

Hong Kong is still in shortage of doctors. There are currently approximately 2 doctors for every 1,000 people in Hong Kong¹⁹. Of the doctor population, approximately 49% are serving in private practice²⁰. Unsurprisingly, doctors in the public sector face a large daily influx of patients, compromising their ability to give quality care in appropriate lengths of time. At times, the doctors, as reported by the participants, may feel robotic and apathetic. As explained by an elderly woman:

“They [the doctors (sic)] can’t be bothered to care about you even if you want to ask another question. You’re in your world and they’re in their world. I mean, you’d want to ask more about why you’re ill and about the illness itself, but all they do is get you out of the room and get you your medication at the pharmacy.” (04-elderly woman)

2f) Inadequate Employer Support For Ill Employees

Lower-income patients mainly work in low-paying sectors such as retail trade and food and beverage services²¹. These industries are largely dependent on the employee, whereby the absence of an employee can cause a direct negative impact on the company, especially in smaller stores. While employees are entitled to two paid sick leave days per month within the first 12 months of employment and are then offered four days per month thereafter, at a minimum²², employment situations may not always allow for such flexibility. For example, the shop may close for the duration of the sick leave, or the patient does not feel adequately protected by the legislation and fear negatively affecting the dynamic with their employer. This may seriously impede the patients’ willingness to seek medical care. As a working woman expressed:

“Usually, I take my personal leave to visit the doctors. It gets me worked up when I talk about sick leave. Apparently, my employer limits my sick leave to just five days within a 3-month period. After I take these five days of sick leave, they’ll reprimand and put pressure on me and ask me why I’m always so sick.” (11-working woman)

2g) Inadequate Public Support For Patients Struggling With Dental Issues

The public healthcare sector provides very limited dental services to the public. Full public dental care covers just primary school children, adults with intellectual disability, civil servants, in-patients, and referred patients. The public must either be content with the pain relief and tooth extraction-only public dental clinics or is left to search for their own solutions²³. This is unideal for patients with chronic dental issues or serious acute issues that need immediate treatment. With most dental services being private, many patients are at the mercy of their financial capabilities when seeking care. While EHCVs do cover registered dentists, a large portion of the public is left without any easily accessible but affordable dentists. As an elderly woman vented:

“I only visit the private healthcare when my gums were inflamed. They caused me terrible pain. The government doesn’t provide dental services… they don’t provide it!” (12-elderly woman)

Community-level Gaps And Issues

3a) Insufficient Support For Patients Struggling With Physically Accessing General Out-patient Clinics

Though only having an area of 1,106 km², there is, on average, just one GOPC available every 15 km² in Hong Kong. The limited and far-reaching GOPCs disproportionately affects the financially disadvantaged and those who struggle to physically access these clinics. There are no official transport routes that can carry patients from convenient public transport stations to-and-fro these clinics. Patients who are disabled or physically weak may resort to taking cabs, forming a financial barrier. With the basic cab starting fare of $3.4USD ($27HKD), patients may have to pay at least another 50% on top of their GOPC fees. As an elderly woman who lives by herself expressed:

“Ever since my leg started to hurt, I can’t walk to the clinic anymore. Though I find the price for GOPCs acceptable, the transportation fees… [are expensive (sic)]” (12-elderly woman)

Policy- And Legal-level Gaps And Issues

4a) Inadequate Elderly Health Care Voucher

Currently, elderlies aged 65 or above are eligible to use EHCVs at registered private healthcare providers. Originally only subsidizing $250HKD (around $32USD) per annum, the voucher amount has grown to $2000HKD (around $257USD) per annum. The scheme covers the use of private healthcare providers, Chinese medicine providers, dentists, chiropractors, registered nurses and enrolled nurses, physiotherapists, occupational therapists, radiographers, medical laboratory technologists, and optometrists. Charges in the private healthcare general providers can range from the 2013 average of $26USD ($200HKD)²⁴ to above $129USD ($1000HKD). On average, the annual EHCV subsidy will last the patient 10 visits to a private healthcare provider if other services are not required. The elderly patient is put through a cost-benefit analysis every time they grow ill, comparing a qualitative value, their illness, with a quantitative value, the amount of EHCV left. Coupled with the fact that elderlies lack a steady source of income, if any income, elderlies tend to stagger to the last possible moment. Yet, it must be recognized that patients only feel that EHCVs are inadequate due to the inaccessible public healthcare services, causing them to resort to private healthcare. As an elderly woman said:

“Every time I visit a private doctor, they always say that it’s okay because I have Elderly Health Care Voucher. Honestly, how many consults can the EHCV last, right? Never will I be able to afford any private healthcare if my EHCV runs out!” (05-elderly woman)

4b) Inadequate Comprehensive Social Security Assistance (Cssa) And Its Exclusive Requirements

Universal Health Coverage (UHC) is currently achieved under Hong Kong’s public healthcare system, while primary health care is still yet to be achieved. Those who are registered under the CSSA Scheme will receive free public healthcare at all levels. CSSA Enrollees must pass a set of income and asset tests, upon which they will receive a predetermined monthly subsidy plus any other eligible supplements. The subsidies range from $345USD ($2,685HKD) to $833USD ($6,485HKD) for any single person adults. The caveat to this scheme lies in the asset limit test, limiting an able-bodied adult to $4,237USD ($33,000HKD). The exclusive requirements of entry into the scheme may cause the implementation of primary health care in Hong Kong to be uncomprehensive. Those who are just above the entry requirements will not be given free public healthcare while also not being able to afford the high costs of private healthcare. For these patients, most, if not all, of their incomes go towards rent fees and necessities. As an elderly woman noted:

“This [those unable to access free public healthcare and can’t afford private healthcare] is the issue with Hong Kong’s healthcare. There are those who can’t afford to pay for healthcare but also don’t qualify for CSSA’s free healthcare.” (01-working man)

Coping Strategies

Following the identified gaps, patients develop coping strategies for the limited accessibility of primary healthcare. These strategies allow the patients to gain access to some form of healthcare with reduced monetary and non-monetary costs. However, the patients’ healthcare-seeking behavior consistency and outcome is greatly reduced.

The first coping strategy is utilizing Traditional Chinese Medicine (TCM). A typical consultation fee for TCM is $25USD ($200HKD)²⁵. Comparatively speaking, private TCM tend to cost less than private western medicine providers but cost more than public healthcare services. This third option eliminates the private sector’s financial barrier and the public sector’s time and effort barrier. Furthermore, both TCM services and costs are customizable. Patients can choose whether medications, certain procedures, or only consultations are needed, and anything in between. Finally, patients can self-replicate medication if given the medicinal recipe, increasing longevity in care and cost-effectiveness of the consultation. The positioning of TCM in the healthcare market complements many patients’ trusts in TCM and the necessity to incorporate TCM in their healthcare regimen. As an elderly woman noted:

“The [private TCM provider] consultation fee is $3.8USD ($30HKD) while the extra cost for medication can range from $3.8USD ($30HKD) to $12.75USD ($100HKD) or more, depending on the illness. It’s good that I go see TCM since I can make the medication myself at home.” (07-elderly woman)

The second coping strategy is purchasing over-the-counter (OTC) medication from pharmacies. Pharmacies are accessible and common in Hong Kong, selling both Chinese and Western healthcare products and medication. Without the need for consultations, the pharmacies only charge patients for their medication, often at a fee comparable to public healthcare. Additionally, medication can be purchased as a pack or as individual pills, further decreasing the cost. However, patients opting for this option have no access to any medical provider, requiring self-diagnosis before purchasing medication, which may inadvertently worsen their health. Yet the significantly reduced cost of OTC medication is these patients’ first consideration. As a father pointed out:

“It’s cheap! Think about it, every time I visit the doctor, that’s $25.5-38.2USD ($200-300HKD) gone. If I go the pharmacy to purchase OTC medications, that’s only $6.4-7.7USD ($50-60HKD).” (13-father)

Price gouging: Elderly health care voucher

It is not clear if price gouging is something experienced widely amongst the participants. Due to the lack of an interview question asking about EHCV price gouging, only one of the 6 participants who were eligible for the EHCV scheme had expressed her concern and experience. Therefore, the data is unsaturated.

An issue may unfortunately arise from the largely unregulated private healthcare when accepting said vouchers as a payment method: price gouging. An elderly man recounted his experience:

“For example, the private doctor will charge me $32USD ($250HKD) for consultation and medication for my cold if I pay out of pocket. However, if I opt to use my health care vouchers, they’ll charge me at least $38.5USD ($300HKD).” (08-elderly man)

Indeed, it is not unlikely, as a similar situation occurred with private optometrists in 2019. Upon review by the Department of Health, there were an abnormal amount of EHCV usage for optometric services. The 700 registered optometrists accounted for 27% of the total voucher amount issued with the median of the voucher claim to be $251USD ($1,951HKD) out of the available amount of $257USD ($2000HKD) per eligible senior per annum²⁶. A cap was proposed and enacted on 26 June 2019, whereby the usage on optometric services is limited at $257USD ($2000HKD) every two years.

If it is the case that price gouging occurs elsewhere in the EHCV scheme, it may further disenfranchise elderly patients who may already be struggling to afford health care. Further research needs to be done to determine whether this, in fact, is occurring in private healthcare. Regulations will need to be enacted to protect the elderlies.

Experienced Patient Decision-making

In the study, multi-leveled barriers that limit patients’ ability to access primary healthcare have been identified. The findings undermine the effectiveness of Hong Kong’s UHC in providing accessible primary healthcare to all patients. The described barriers coupled with the anecdotes of interviewed patients create a narrative that forms the Overarching Patient Decision-Making (Fig. 1) for patients who have stated that healthcare is inaccessible in part due to financial reasons. The patient may face different barriers at each step that may cause them to be reluctant in seeking public healthcare. This general schematic representation of decision-making is in no way exhaustive but seeks to provide a structural guide that encompasses the varied directions patients may choose.

The first step presents two options, to either seek care at the GOPCs or the A&E. The barriers of this step can be largely categorized into 3 groups: barriers that deter the patient from attempting to seek public healthcare, barriers that deter the patient from successfully seeking public healthcare, and barriers that deter the patient from seeking public healthcare again.

The first barrier can be characterized by uninformed patients, who are lacking patient education, feeling helpless from the “limited” healthcare options. Results show that patients may not know where or who to turn to and expressed confusion when asked about healthcare options, which may deter patients from looking for viable alternatives. On the other hand, our findings show that the inadequate support from employers may place employment pressures on the employees applying for sick leave. With the limited number of GOPCs that offer night and weekend services may cause patients to find it difficult to access public healthcare during the off-work hours. There are currently 73 GOPCs around Hong Kong, of which only 23 provide evening services, and 13 provide Sunday and public holiday services each with limited availabilities²⁷. While all A&E is also available in the evenings, the issues become that of long waiting times due to fewer nighttime staff. If the patient does not reach out for care and do not establish communication with healthcare workers, it then becomes difficult for the patient to have access to adequate healthcare.

The second barrier can be characterized by the negative experiences from navigating the physical barriers and complex steps when accessing GOPCs. It is labor intensive to overcome these barriers. Therefore, further disincentivizing patients from successfully seeking public healthcare.

The third barrier can be characterized by the limited number of public healthcare service providers, creating a bottleneck funneling patients into the few available outpatient public clinics, a patient traffic jam. Patients have also reported negative experiences with medical personnel, including being rushed out of the clinic and spoken to with poor mannerisms. This may cause patients to feel as if the healthcare professionals do not care about their health, but rather care about getting them out of the clinic as soon as possible. This greatly takes away satisfaction from the patients’ experience and may even contribute to the consumeristic attitude that was apparent from the findings of our study as the private healthcare sector runs in an open market, encouraging people to doctor shop for quality of care and satisfaction. In addition, the A&E price increase to divert patient load amplified the limitations from the few available GOPCs. For example, approximately 433,500 people live in the Sham Shui Po district in 2020²⁸. Despite having a large population, Sham Shui Po is only serviced by 5 GOPCs with an average of 1081.68 quotas per day on any given weekday and an average of 454.1 quotes on Saturdays from 20/6/2021 to 17/07/2021²⁹. Furthermore, the average waiting time for A&E services from the year before the price increase compared to the 3 ensuing years have not decreased³⁰. Looking at Triage 3 (Urgent), Triage 4 (Semi-Urgent), and Triage 5 (Non-Urgent) from the year 2016-17 and 2019-20, the average waiting time actually increased³¹. The GOPCs likely become flooded with more patients, causing further strain on the system. Finally, for patients who present with dental issues, they inevitably find out that the public services do not cover dental services for the public, only providing full dental care for primary school children, adults with intellectual disability, civil servants, in-patients, and referred patients. Most patients can only access pain relief and tooth extraction services from public dental clinics²³. In addition to patients being unaware of available services, the lack of dental services may cause patients to feel neglected and in turn forgo seeking dental healthcare. The issues above may, together, form a negative impression of public healthcare to the patients.

These barriers create a sense of reluctance in patients to seek public healthcare services again (Fig. 1, Step 2). This is crucial as it marks the step where patients may now deem public healthcare as inaccessible. The change in patients’ perception of Hong Kong’s public healthcare sector undermine the overarching policy and protocols put in place to offer accessible UHC, creating a dissociation between UHC and accessible primary healthcare.

Patients may then change their healthcare behavior depending on their circumstances. Coping strategies uncovers a crucial implication for patients’ reluctance to seek public healthcare. It is not necessarily that the patients are not able to afford public healthcare, but the non-financial opportunity costs, such as travel and wait time as well as physical inaccessibility, that are attached to seeking public healthcare is far too great for the patients to bear. As illustrated by the working participants, especially those who are paid by the hour, they may deem the time to be better spent at their jobs rather than to wait for public healthcare. For patients who may feel that the GOPCs are a nuisance to access and that the outpatient A&E waiting times are unreasonable, they either visit private healthcare or call emergency services. In both situations, patients must pay at least USD19 (HKD150) more for private healthcare and at least USD16.5 (HKD130) more for emergency services out of pocket than if they were to visit GOPCs. Though ambulance services are free, due to the disenchantment of patients with the public health system, our findings show that patients seem to be less inclined to call emergency services as opposed to seeking private healthcare providers. Furthermore, if the patient still has unused Elderly Health Care Vouchers provided by the government to subsize patients when visiting private healthcare, their likelihood of choosing of private healthcare providers also increase over choosing, emergency services.

It is at this point where the apparent financial barrier to accessing healthcare manifests and where the consumerist attitudes develop. Patients’ perceptions up to this point is likely that public healthcare is inaccessible in non-monetary terms and ineffective, while the impression of private providers is the complete opposite. The out of pocket and physically accessible nature of the private healthcare may create the impression that the care of the private healthcare is indeed better than the public sector. From that, patients may develop a preference for private healthcare, though they are unable to access it regularly due to financial constraints. Patients are then placed in a predicament, where they must choose between convenience but steep prices or inconvenience but affordable prices for their healthcare. This surfaces some important policy gaps that deters Hong Kong from achieving accessible primary health care. The accessibility of public health care may be further affected for those who are just outside the requirements to be eligible for the CSSA scheme, a government subsidy program for the poor. The CSSA scheme is means tested with income and asset limitations. With one of the highest housing and rental prices in the world, those not eligible for CSSA and must pay for open market housing prices endures a double burden. This creates a vicious cycle where housing unaffordability worsens health burden, which may worsen housing affordability³².

There is no social health insurance in Hong Kong despite recommendations from Harvard to develop such a program in 1999³³. However, the government has recently recognized the need for infrastructure to financially support patients to access private healthcare by introducing Voluntary Health Insurance Scheme (VHIS) in 2019, while the Hospital Authority has introduced Public Private Partnership (PPP) 2008. VHIS functions through outsourcing insurance plans to private firms while the government guarantee benefits that traditional private health insurance plans do not provide. It serves as a version of social health insurance that does not require mandatory contribution. PPP functions by the HA subsidizing private healthcare providers per service, significantly decreasing the co-payment for the patients. The issue is that both plans require the patient to pay out of pocket regardless. This poses as a financial challenge to support the monthly rates of VHIS plans or the PPP Program rates. Compared to Social Health Insurance, where the whole population is covered, the current plans in Hong Kong may not be adequate for those who have low incomes and retirees. Simply put, these plans are only available to those able to afford it.

The decision-making sheds light on patients’ pragmatic perception of a simple financial barrier to access healthcare. Our findings show that this perceived financial barrier is, in fact, a whole bucket of multifaceted social determinants of health that generate barriers to healthcare accessibility that may cause patients to feel increasingly disenfranchised. Visualizing the decision-making allows for better clarity when designing the way forward.

Policy implications

Part of Food and Health Bureau (FHB) of the Hong Kong government’s responsibility is to “ensure that no one is denied adequate medical treatment due to lack of means”. Though this vision of the healthcare system is well intended, this is not achieved empirically speaking. The problem lies in the execution of the policies. There are three main directions in which policies can be developed to aid those who are currently unable to access primary healthcare regularly: a) to increase supply of public healthcare services, b) to enhance patient knowledge on the availability of care, and c) to decrease financial restraints in accessing private healthcare providers.

Increasing the supply of public healthcare services will decrease the average number of patients at each service provider, while increasing the efficiency of these providers will decrease the time cost for each patient Furthermore, the decrease in workload for healthcare workers may positively affect patient safety. Ultimately, this may improve the timeliness for patients to be able to access healthcare services, improving the general health status of the population, further decreasing the overall burden on the system. Secondly, Patients play a crucial part in caring for their health. Educating patients on available options for care may cause healthcare to feel more accessible, further lowering the barriers. Finally, steps must be taken to tackle the apparent and immediate health inequity as time is needed to create an equitable primary health care system. This can be achieved through temporarily minimizing financial restraints in accessing private healthcare services. Incentivizing patients to utilize the private healthcare may decrease the overall workload on the public system in this transition period.

Limitations

The nature of the study is qualitative, meaning the results do not hold the statistical power to represent the public. However, the participants who took part of the study were selected from a previous study where they expressed their inability to access healthcare services due to financial constraints. These patients are in the exact position to identify gaps and issues within the current healthcare system through their experiences. Another limitation is that most participants are elderly or retirees, causing an underrepresentation of the workforce who may also struggle to access primary healthcare. Further studies will be needed to discover their unique set of challenges and how it may differ from the current results. In 2019, Hong Kong established Primary Healthcare Office, consequently, our results do not represent the latest changes after our data collection. Though that is the case, the gaps and issues identified in the study have yet to be resolved.

Policy makers should not only look to addressing the financial barriers, but to address the multidimensional barriers these patients face when accessing healthcare. Primary health care can only be achieved through a more equitable and accessible healthcare system that comprehensively includes the financially poor.

Ethics Approval and Consent to Participate

The study has been approved by the Survey and Behavioural Research Ethics Committee of the Chinese University of Hong Kong in June 2012. Informed consent was obtained from all individual participants included in the study.

Availability of Data and Materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Conflict of Interest

The authors declare that they have no conflict of interests.

Funding

There is no source of funding.

Author Contributions

JT: Substantial contributions to the conception, acquisition, analysis, and interpretation of data, and drafted the work.

DC: Substantial contributions to the conception, acquisition, analysis, and interpretation of data, and drafted the work.

SW: Substantial contributions to the conception and revised the work.

RY: Substantial contributions to the conception, acquisition of data, and revised the work.

Acknowledgements

There are no acknowledgements.

Clancy CM, Stryer DB. Racial and ethnic disparities and primary care experience. Health Serv Res. 2001;36(6 Pt 1):979–86.
Harris M, Harris E, Roland M. Access to primary health care: Three challenges to equity. Aust J Prim Health. 2004. 10.1071/PY04043.
Meyer SB, Luong TC, Mamerow L, Ward PR. Inequities in access to healthcare: Analysis of national survey data across six Asia-Pacific countries. BMC Health Serv Res. 2013. 10.1186/1472-696313-238.
Piccardi C, Detollenaere J, van den Bussche P, Willems S. Social disparities in patient safety in primary care: A systematic review. Int J Equity Health. 2018. 10.1186/S12939-018-0828-7.
Hart JT. The inverse care law. Lancet. 1971. 10.1016/s0140-6736(71)92410-x.
Food and Health Bureau (FHB). My Health My Choice.. 2010. https://www.myhealthmychoice.gov.hk/pdf/consultation_full_eng.pdf. Accessed 27 Dec 2022.
Wong SY-s, Chung RY-n, Chan D, Chung GK-k, Li J, Mak D, et al. What are the financial barriers to medical care among the poor, the sick and the disabled in the Special Administrative Region of China? PLoS ONE. 201810.1371/journal. pone.0205794.
Chung RY-N, Chan D, Chau NN-S, Huang S, Wong H, Wong SY-S. Poverty affects access to regular source of primary care among the general population in Hong Kong. Soc Policy Admin. 2019. 10.1111/spol.12538.
Cheung JTK, Wong SY, Chan DCC, et al. Can voucher scheme enhance primary care provision for older adults: cross-sectional study in Hong Kong. BMC Geriatr. 2020. 10.1186/s12877-020-01851-x.
“GDP per capita (current US$) – Hong Kong SAR, World Bank, China. ” 2022. https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=HK . Accessed 27 Dec 2022.
Census and Statistics Department (C&SD). Hong Kong Poverty Situation Report 2020. 2021. https://www.censtatd.gov.hk/en/data/stat_report/product/B9XX0005/att/B9XX0005E2020AN20E0100.pdf. Accessed 27 Dec 2022.
Chung RY, Chung GK, Marmot M, et al. COVID-19 related health inequality exists even in a city where disease incidence is relatively low: a telephone survey in Hong Kong. J Epidemiol Community Health. 2021. 10.1136/jech-2020-215392.
Vogl S. Telephone Versus Face-to-Face Interviews: Mode Effect on Semi-Structured Interviews with Children. Sociol Methodol. 2013. 10.1177/0081175012465967.
Novick G. Is there a bias against telephone interviews in qualitative research? Res Nurs Health. 2008. 10.1002/nur.20259.
Mcleroy KR, Bibeau D, Steckler A, Glanz K. An Ecological Perspective on Health Promotion Programs. Heal Educ Behav. 1988. 10.1177/109019818801500401.
The Government of the Hong Kong Special Administrative Region (GovHK). “Fees and charges at public hospitals to be revised next month.” 2017. https://www.info.gov.hk/gia/general/201705/22/P2017052200538.htm. Accessed 27 Dec 2022.
The Government of the Hong Kong Special Administrative Region (GovHK). “LCQ8: General outpatient service used by elderly persons.” 2018. https://www.info.gov.hk/gia/general/201804/11/P2018041100681.htm. Accessed 27 Dec 2022.
Hospital Authority (HA). Introduction of Telephone Appointment Service of General Out-patient Clinics.. 2019. https://www.ha.org.hk/haho/ho/hacp/IVAS_intro_txt_en.pdf. Accessed 27 Dec 2022.
Food and Health Bureau (FHB). Legislative Council Brief – Medical Registration (Amendment) Bill 2021. 2021. https://www.healthbureau.gov.hk/download/press_and_publications/otherinfo/210500_amendments_mro/e_legco_brief.pdf. Accessed 27 Dec 2022.
Food and Health Bureau (FHB). Strategic Review on Healthcare Manpower Planning and Professional Development.. 2017. https://www.fhb.gov.hk/download/press_and_publications/otherinfo/180500_sr/e_ch1.pdf. Accessed 27 Dec 2022.
Minimum Wage Commission (MWC). 2020 Report of the Minimum Wage Commission.. 2020. https://www.mwc.org.hk/en/downloadable_materials/2020_Report_of_the_Minimum_Wage_Commission_en.pdf. Accessed 27 Dec 2022.
Labour Department (LD). ”Cap. 57 Employment Ordinance Sickness Allowance”. 2012. https://www.elegislation.gov.hk/hk/cap57?xpid=ID_1438403463366_001&SEARCH_WITHIN_CAP_TXT=sick%20leave. Accessed 27 Dec 2022.
Department of Health (DH). “Dental Services.” 2022. https://www.dh.gov.hk/english/main/main_ds/main_ds.html. Accessed 27 Dec 2022.
Liu S, Yam CH, Huang OH, Griffiths SM. Willingness to pay for private primary care services in Hong Kong: are elderly ready to move from the public sector? Health Policy Plan. 2013. 10.1093/heapol/czs112.
Chan K, Tsang L. Public attitudes toward traditional Chinese medicine and how they affect medical treatment choices in Hong Kong. Int J Pharm Healthc Mark. 2018. 10.1108/IJPHM-02-2017-0009.
The Government of the Hong Kong Special Administrative Region (GovHK). “Cap on optometry claims proposed.” 2019. https://www.news.gov.hk/eng/2019/03/20190311/20190311_164640_925.html. Accessed 27 Dec 2022.
The Government of the Hong Kong Special Administrative Region (GovHK). “LCQ4: General out-patient services under Hospital Authority.” 2018. https://www.info.gov.hk/gia/general/201804/25/P2018042500638.htm. Accessed 27 Dec 2022.
Social Welfare Department (SWD). “Population Profile of Shamshuipo District.” 2021. https://www.swd.gov.hk/en/index/site_district/page_ssp/sub_ssp-profile/. Accessed 27 Dec 2022.
Hospital Authority (HA). Average Number of General Outpatient Clinic Quota for the Preceding 4 weeks (20/06/2021–17/07/2021) Sham Shui Po District.. 2021. https://www.ha.org.hk/pas_gopc/pas_gopc_avg_quota_pdf/202130/sham_shui_po.pdf. Accessed 27 Dec 2022.
The Government of the Hong Kong Special Administrative Region (GovHK). “LCQ14: Services of the accident and emergency departments of public hospitals.” 2020. https://www.info.gov.hk/gia/general/202001/15/P2020011400653.htm. Accessed 27 Dec 2022.
The Government of the Hong Kong Special Administrative Region (GovHK). “LCQ7: Consultation time of out-patient services of Hospital Authority.” 2017. https://www.info.gov.hk/gia/general/201711/01/P2017110100484.htm. Accessed 27 Dec 2022.
Chung RY, Chung GK, Gordon D, et al. Housing affordability effects on physical and mental health: household survey in a population with the world's greatest housing affordability stress. J Epidemiol Community Health. 2020. 10.1136/jech-2019-212286.
The Harvard Team. Improving Hong Kong’s Healthcare System: Why and for Whom? 1999. http://www.fhb.gov.hk/en/press_and_publications/consultation/HCS.HTM. Accessed 27 Dec 2022.

No competing interests reported.

SupplementaryTable1.docx

Download PDF

Version 1

posted

You are reading this latest preprint version

Understanding the perceptions on the availability and accessibility of public health services for the poor and socially disadvantaged. A qualitative study in Hong Kong.

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Participants and sampling

Data collection

Results

Descriptive statistics of participants

Intrapersonal and interpersonal factors

1a) Limited choice of outpatient care due to wealth status

1b) Inadequate knowledge of types and number of services provided

1c) High non-monetary opportunity costs in seeking public healthcare services

1d) Reluctance to seek medical care unless the situation becomes serious and acute

1e) Consumerist attitude and perception of quality of care received

Institutional-level Gaps And Issues

2a) Price Increase Of Public A&e Departments

2b) High Price Of Private Healthcare Providers

2c) Inadequate General Out-patient Clinics

2d) Complex Steps To Access General Out-patient Clinics

2e) Unmet Medical Needs Received From Public Healthcare Services

2f) Inadequate Employer Support For Ill Employees

2g) Inadequate Public Support For Patients Struggling With Dental Issues

Community-level Gaps And Issues

3a) Insufficient Support For Patients Struggling With Physically Accessing General Out-patient Clinics

Policy- And Legal-level Gaps And Issues

4a) Inadequate Elderly Health Care Voucher

4b) Inadequate Comprehensive Social Security Assistance (Cssa) And Its Exclusive Requirements

Coping Strategies

Price gouging: Elderly health care voucher

Discussion

Experienced Patient Decision-making

Policy implications

Limitations

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1