South China Morning Post
Emily Tsang and Elizabeth Cheung
Experts speak out on our ageing population, with one saying that a voluntary health insurance scheme will not be enough to cope
The elderly in Hong Kong live longer than their peers in other top cities such as New York and London. They are also the healthiest and the least likely to suffer from chronic diseases.
That’s the good news. The bad news is the aged in Hong Kong are likely to receive worse health care than those in the other two cities. There are also fewer doctors per patient for them and they are more likely to end up in institutionalised care.
The prospects for improving their living standards also remain gloomy given the shortage of doctors, overburdened public hospitals, a frail primary care system and a shortage of old-age homes.
Citing these findings from his years of studying the Hong Kong system, American professor Victor Rodwin believes there is an urgent need to do much more than having a voluntary health insurance scheme, as recently proposed by the government, to solve the litany of woes.
“It is best to have a compulsory health insurance scheme,” suggests Rodwin, author of Health in Hong Kong: An International Urban Perspective, which was published in 2011.
The New York University expert in community health and medical care systems was in town last week for a big conference organised by Chinese University’s new centre for bioethics, on challenges facing governments over ageing populations.
Late last month, the government proposed a reform aimed at freeing up capacity in the strained public health sector, which cares for 90 per cent of the city’s patients. At the heart of the proposal is a voluntary medical insurance scheme to offer better coverage to policyholders to encourage them to turn to private health care when they need to, rather than postpone medical attention until it becomes too little, too late and too costly.
“The voluntary health insurance scheme is a way to begin to solve the problem, but it would not help those people who cannot afford to buy it,” said Rodwin in an interview with the South China Morning Post.
“Just taking away the pressure on the public sector is not solving the problem. It has to solve the problem of the poor people – to help them get insured and get cheaper health care.”
The situation is serious as Hong Kong is on the brink of the “silver tsunami”, with a rapidly ageing population. A third of the city’s population will be 65 years or older in 2041, up from the current proportion of 14 per cent.
A fast-greying population is going to push up demand for health care services in the city, as official figures show that those aged over 65 need on average six times more inpatient care than younger people.
Citing his research, Rodwin points out that while Hong Kong’s elderly enjoy a healthier and longer life than their counterparts in other cities like New York and London, the health care system in Hong Kong “is not as good as most people suppose”.
The life expectancy for Hongkongers is 79.3 years for men and 85.5 years for women, exceeding 78.6 years and 83.1 years, respectively, for males and females in London. New Yorkers have the shortest life expectancy among the three, at 76.3 years for males and 82 years for females.
Among those in the three cities, Hongkongers are also least likely to be overweight and to be suffering from hypertension or other illnesses.
But Rodwin, also the coauthor of the book Ageing in Hong Kong, A Comparative Perspective, believes such data would be “misleading” without examining the accessibility of medical services for the elderly.
Professor Victor Rodwin says just taking away the pressure on the public sector is not solving the problem. 
According to Rodwin’s study, Hong Kong’s avoidable hospital conditions rate – which is the proportion of patients who can avoid expensive hospital care if they had received appropriate medical service in time – is the second lowest among the three cities surveyed, at 49.5 per 1,000 older people.
But the figure is relatively high given the fact that the population is in relatively good health, says Rodwin.
“It suggests that health system improvements can save lives,” he adds.
“This can be the result of a weak primary care system in Hong Kong. Many residents delay visits for primary care and are admitted to overcrowded hospitals after an exacerbation of their condition that should have been managed by primary care physicians,” he says.
The allocation of resources between primary and secondary health care in Hong Kong ought to be reviewed, Rodwin and several other experts at the Chinese University conference maintain.
In a similar vein, Dr Alexander Kalache, president of the International Longevity Centre in Brazil, also argues that Hong Kong’s primary health care system should be improved.
“Primary health care can be a cheaper solution … Ninety per cent of problems of all people can be treated at the community level through primary health care at a much lower cost,” says the former WHO director from South America who is an expert on ageing.
In Hong Kong, primary care is mostly in the realm of the private sector, which charges fees per service, while public hospitals offer almost-free services. Only about 30 per cent of Hongkongers have employment-based insurance, which allows them subsidised access to primary health care. The rest have to pay.
As such, many delay primary care visits to prevent paying until they get sick enough to be admitted to a public hospital, further burdening the strained system.
Last year, the government quadrupled the annual subsidy for the Elderly Health Care Voucher Scheme, which allows eligible people to visit private clinics, from HK$250 to HK$1,000. But the scheme is only for those aged 70 and older, leaving out many who could avoid being sent to hospital through early primary intervention.
The quality of the primary care system has also come into question.
An article titled “The Primary Healthcare System and Health Insurance in Hong Kong”, by the College of Family Physicians, said that many family doctors had come under the control of large medical organisations and insurance firms in recent years, which affected doctorpatient relations as patients shopped for medical advice and doctors failed to develop long-term ties and trust with patients.
Professor Joseph Lau Wan-yee, chairman of the city’s medical watchdog, the Medical Council, agrees reforms are needed and that family physicians should be better trained before they can set up a private clinic or work under a medical group.
Currently, newly qualified doctors can set up private clinics immediately upon graduation, without experience or post-graduate training.
Both Lau and Medical Association president Dr Louis Shih Tai-cho believe the training system is in need of a major revamp. They are now in talks to effect changes, including ensuring that all medical graduates get at least two years of family medicine training before they can open a clinic.
Rodwin says another pressing issue for Hong Kong’s health care system is the shortage of doctors, especially in public hospitals. The public sector is short of about 250 practitioners at any one time. The ratio of registered doctors was 13.7 per 1,000 people aged 65 years or above in 2009 – the lowest among the three cities. Comparable figures are 32.2 for New York and 28.5 for London.
Compared to New York and London, Hong Kong has also not done enough to ensure a range of living arrangements that allow the elderly to remain in the community rather than be in institutional care.
Rodwin says the government needs to do more to introduce innovative forms of housing with on-site services. In the end, such services will prevent older people having to move into homes for the aged, which take up scarce land.
The rate of elderly people living in institutions is high in Hong Kong at 6.8 per cent, compared to 3.9 per cent in New York and 2.3 per cent in London.
Rodwin believes the government should consider other ideas, such as targeting specific districts with a higher proportion of elderly and sick residents.
Delivering special services to them, such as early health screening, preventive measures like an exercise regimen, healthy meals and volunteer opportunities, can help them. With such resources spent early on, he says fewer elderly people will likely end up needing hospital care.
Rodwin also warns that the influx of migrants and pollution from the Pearl River Delta region will impose further strains on elderly care in Hong Kong.
Hong Kong must embrace longevity revolution, says Alexandre Kalache
Hong Kong needs to do away with compulsory retirement and allow people to decide when they want to stop work as life expectancy soars, says an ageing expert.
Alexandre Kalache, president of the International Longevity Centre in Brazil, says societies should embrace the “longevity revolution”.
He says that instead of seeing the elderly as a burden, the should be empowered to make their own life choices and be looked upon as a boon rather than a bane to society.
In Hong Kong last week for an ethics of ageing policy conference to mark the launch of the Bioethics Centre at Chinese University, Kalache said that with modern medicine, people were healthier and living longer than ever before. Hence, the longevity revolution – or “more older people living longer but in better health with better education and more knowledge”.
Kalache, a 69-year-old Brazilian, explained how he was part of the revolution. When he was born in 1945, the life expectancy in his country was 43. Now, it has exceeded 73 years.
“Hong Kong cannot continue to retire people at 60,” he said. “It’s not viable nor desirable.”
He said people ought to have the right to choose when to retire.
In April, the government announced that the retirement age for newly hired civil servants would be extended to 65, with the private sector expected to follow.
Kalache did not have a specific retirement age in mind, but he said: “It has to reflect the life expectancy of a country. Look at life expectancy at 60 … you have to calculate how much social security will cost, based on 30 years.”
Paying attention to individual care would also help the elderly maintain their own independence and pose less of a burden on institutional care, Kalache said.
Four kinds of “capital” were essential for enhancing self-care, he said. First was to maintain one’s own health, with attention to diet and exercise and mental well-being. Second, was to embrace lifelong learning and acquire new knowledge to keep mental faculties sharp. Third was the need to be in social networks such as family, friends and community and the fourth was to ensure adequate finances.
The conversation on ageing and the elderly should focus not just on how to help those with chronic illnesses but on prevention and well-being, such as them remaining a strong part of the community, he said.
Kalache himself is a “poster boy” of the longevity revolution. He is energetic and feisty, and throughout the interview he mentioned his family frequently and with affection.
His life, he said, was in stark contrast to that of his grandfather, who died at 65 half a century ago. “All the images I had of my grandfather was a very old man that was slowly walking to the grave. That has changed,” he said.