Response of the Hong Kong College of Paediatricians to the Report on 'Improving Hong Kong' Health Care System: Why and For Whom?' by the Harvard Team

The Hong Kong College of Paediatricians would like to express our appreciation to the Government of Hong Kong SAR for commissioning a team of economists, physicians, epidemiologists, and public health specialists from Harvard University to conduct a study on Hong Kong's health care system in November 1997. This reflects the Government's determination to review the strengths and weaknesses of the current system of financing and health care delivery and to propose strategic options for improving the system in Hong Kong.

The Hong Kong College of Paediatricians is one of the 15 constituent specialty colleges of the Hong Kong Academy of Medicine. The main objects for which the College is established are:

• to promote for the public benefit the advancement of knowledge of the science and art of Paediatrics;
• to act as a body for the purpose of consultation in matters of educational or public interest concerning Paediatrics; and
• to develop and maintain the good practice of paediatrics by ensuring the highest professional standards of competence and ethical integrity

Hence, the College, acting as child advocate, is obliged to express our views on the Harvard Report, to ensure that quality health service must be provided to all children in need without any barrier, be it financial, administrative or otherwise.

The Harvard Report has put much emphasis on options to improve financial sustainability of the health care system; however, the College would like to focus on the more important issues of improving equity, quality and efficiency of health care delivery for children in Hong Kong.

What the 'Harvard Report' did not address

• The report did not address issues relating to children. Children cannot speak for themselves. Children have no income and cannot insure for themselves. They are most vulnerable to adverse influences. They need their family and the society to nurture and protect them during this vulnerable period of growth and development.
• The report did not address the important issues of promotive and preventive health care for children. Health of children has a great effect on productivity and output of a society, as it will influence a child's ability and motivation to learn. These effects, in turn, influence adult productivity and advancement of a society. The protection of health and improvement of health status of children must be of paramount importance and priority. Actions must be taken principally by health services to promote child health and development and prevent childhood illness and handicap.
• The report did not address rehabilitation service to children with chronic illnesses and disabilities. There is no well defined policy for rehabilitation service and the Government has relied heavily on voluntary agencies for the provision of such services. These children are at greatest risk to suffer from adverse influences if they are not provided with a comprehensive, accessible, equitable quality health service.

Our proposals
Preventive Paediatrics
The College is of the opinion that the Government should take up the responsibility to provide primary, secondary and tertiary prevention in child care.

• Primary prevention aims to reduce the incidence of disease in children and its subsequent sequelae. The childhood immunization programme has been successful in preventing diseases, such as poliomyelitis, hepatitis B, etc. Services provided by the Maternal and Child Health Centres should be free and have been very successful in providing vaccination coverage of over 95%. The Government should also take up the responsibility to promote positive parenting to prevent child abuse and child behavioural problems and to promote healthy diet and life style to prevent future chronic diseases.
• Secondary prevention aims to treat patients either in order to cure them or to reduce the more serious consequences of disease through early diagnosis and treatment. This will reduce the prevalence of the diseases. Hence, the neonatal screening programme provided by the Clinical Genetics Service and the developmental screening programme provided by the Child Assessment Centres should be free.
• Tertiary prevention aims to reduce the progress or complications of established disease. It consists of measures to reduce impairments and disabilities from the disease or injury and so minimize any handicap which may result. Thus after developmental screening has revealed motor, visual or hearing impairments before disabilities have become apparent, consequent early application of remedial measures may limit the adverse effects of such impairments. For example, tertiary prevention through the rehabilitation of children with physical handicap can enable them to take part in daily social life and bring about a great improvement in the well-being of these children. The Government should coordinate and subsidize these multidisciplinary rehabilitation programmes.

Organization of Child Health Services

The bulk of primary health care is currently provided by the private sector (curative) and the Department of Health (preventive). The more sophisticated medical problems are referred to specialists in the Hospital Authority and the private sector. At present, child health services are fragmented and compartmentalized.

Proper interface and collaboration among the Department of Health, Hospital Authority and the private sector should be promoted. This could be achieved by:

• establishment of effective communication channels;
• streamlining of referral and follow-up services;
• development of shared care programmes;
• formulation of clinical practice guidelines and protocols; and
• setting up a common database for continuity of care.

A dual system of public and private practice could co-exist and provide the freedom of choice for patients and avoid monopoly of services.

There should also be better coordination between health care services and other service providers, such as education and social services.

Professional Accountability and Quality Improvement Programmes

The College opines that improving safety and quality of care should be a central concern for all those in the health care system: policy makers, government, governing bodies, managers, health practitioners and consumers alike. The professional regulatory bodies, i.e. the Hong Kong Medical Council, would ensure that professional self-regulation keeps pace with public expectations and is more open and accountable. The health care professionals should take up the key responsibility of ensuring health care safety and quality. The general principles would be:

• Those organizing and managing the health care system should be responsible for creating and maintaining a system which provides safe and high quality care: accreditation.
• Those practising within the system should be responsible for the standard of their own practice and should share responsibility for creating and maintaining a system which provides safe, high quality health care: peer review practice, medical record review, etc.
• All those managing and working in the system should work together and with consumers to improve the safety and quality of health care: incident monitoring and development of valid safety and quality of care indicators.

Professional Development

The College is committed to training and professional development of its members. Since its inauguration in 1991, the College has published its own journal, organized postgraduate training courses and update series and conduct examinations in Paediatrics to ensure the highest professional standard of competence and ethical integrity among paediatricians in Hong Kong. The maintenance of a high professional standard among our paediatricians is the best way to ensure that quality health care is delivered to children in our society.

Conclusion

The Hong Kong College of Paediatricians believes that the Government of Hong Kong SAR is committed to improving the health care system in Hong Kong. We believe that the central goal of quality improvement in health care is to sustain what is good about the existing system while focusing on the areas that require improvement. We believe that quality improvement could be achieved by partnership between the Government and the clinical profession. We believe that the ultimate aim of this partnership is 'HEALTH FOR ALL'.

We would like to conclude by quoting from the United Nations Convention on the Rights of the Child (1989) which embodies the right of every child to:

• Equity regardless of race, religion, nationality or sex
• Special protection for full physical, intellectual, moral, spiritual and social development in a healthy and normal manner
• Adequate nutrition, housing and medical services
• Special care if handicapped
• Love, understanding and protection