As the fifth wave of the COVID-19 pandemic has peaked, both daily infections and death rates have plunged. However, epidemiology experts warn the sixth wave is sure to come. The healthcare system in Hong Kong has shown to be ill-suited to defend the health of residents.
So far, we have rightly seen the virus as an adversary to defeat. That is why Chinese mainland have come to the aid of Hong Kong with countless supplies. To build a better healthcare system, we must begin to see the pandemic as a moment of epiphany.
Coming to terms with an outmoded civil servant system, Mrs Carrie Lam Cheng Yuet-ngor proposed reforms, among which included restructuring healthcare authorities. Mr John Lee Ka-chiu, the chief executive-elect, has signaled he will follow through the planned reforms. For Mr Lee to demonstrate leadership, he needs to draw talents from far and wide to marshal a team that governs with clear goals and executes with ruthless efficiency. Long-standing problems in our healthcare system should inspire the traits a leading health policymaker should (and should not) possess.
Takeaway 1: Taking the initiative to coordinate health policies across constituencies is what defines a leading health authority.
To start with, no one disagrees that health authorities have botched pandemic policies. The raison d’etre of the Food and Health Bureau is to lead health policies. Instead, the organization took a back seat, gleefully performing piecemeal tasks doled out by the chief executive and other government departments. Being closest to the pool of talents from which it can draw, the bureau has performed below the expectations of our citizens. Coordination that should happen between the Department of Health (DH) and the Hospital Authority (HA) is vastly lacking. The record of patients who have received COVID-19 jabs in general outpatient clinics (GOPCs) under the HA fails to register in the electronic health system. That led to dose confusion when they attended community vaccination centers. At the outset of the outbreak, staff in the DH recommended test-positive patients to attend emergency hospitals (under the HA), yet medical workers there suggested these patients leave by taking public transport. Home isolation was a public health policy meant to stem further community outbreaks. Medical workers were right that the majority of test-positive patients recover by themselves. But because the policy is effectively asking the public to sacrifice individual freedom for social good, it has been received poorly. Two years into the pandemic, it helps little that the major health departments appear discombobulated — there is no consensus hitherto on which patients can isolate themselves at home, which patients need to be quarantined in makeshift hospitals, and which patients should receive inpatient care in HA hospitals.
Takeaway 2: Forward thinking in healthcare means accounting for demographic shifts in the population and devising future-proof policies.
Little is the use of forward thinking if coordination is wanting. That may be the reason for health authorities to bathe in complacency when Hong Kong enjoyed almost six months of zero local cases and only a few imported cases a day. The rest is history. Applying the lesson we learned in this pandemic to the greater scheme of health, policymakers need to face the inevitable tide of an increasingly aging population that Hong Kong is woefully unprepared to deal with. Rising healthcare expenditures coupled with a dwindling taxable population spells financial disaster in the region. A fragmented primary health system looms over the future of our health. With health authorities spearheading few primary-care initiatives, general practitioners (GPs) enjoy limited latitude to provide care beyond the common cold, gastroenteritis and chronic knee pain. Anecdotes of patients queuing for a year to be seen at specialist clinics are in large part because specialists struggle to “step-down” chronically stable patients. Patients bemoan a lack of alternative care they trust besides specialists. Expect another year of queues to be seen by specialists after opting into GP follow-up, lament some patients. GPs are restricted from ordering sophisticated investigations and so struggle to keep up with diagnostic criteria that grow more complex each day. The 11th version of the International Classification of Diseases (ICD11) quintupled that of ICD10 developed just a decade ago. That translates to five times as many disease entities as previously understood in medicine — and it is ceaselessly expanding alongside scientific discoveries. Lack of a functioning primary-care system feeds more patients who seek rapid reprieve from minor ailments into emergency clinics, grinding the urgent-care system to a halt when it is most needed. Splurging on specialist and urgent-care expansion is tantamount to building more highways to relieve congestion — when the cost-efficient solution is to encourage use of public transport.
Takeaway 3: Data-driven policies should be a norm, not an aspiration.
Inconsistent policymaking during this pandemic stemmed from poor data collection and analysis. “Living with the virus” left a figurative gap ajar through which the omicron variant breached in many Western countries. Their scientists were equally quick to amass, clean and analyze such data. Health policies were fine-tuned according to infection rate, death rate, hospital utilization rate and other economic indexes. Though far from perfect, their macabre scenes (of children and older adults dying while gasping for air) offer valuable insights into ways we ought to use data to inform policymaking. Two years into the pandemic, Hong Kong can barely argue it is coursing through uncharted waters. For instance, European guidelines have long proposed home isolation of infected people who are relatively healthy to avoid overloading hospitals. Costly hospital infrastructure is built specifically for patients who require advanced life support such as blood gas monitoring and oxygen tanks to fill their lungs. Sapping healthcare workers’ time and hospital resources to nurse those who do not need such level of care is self-defeating. At a moment when hospital-bed and patient-utilization statistics were not collected from private hospitals in Hong Kong, government health officials had to draft policies blindfolded. Consequently, private hospitals turned their backs on COVID-19 patients, citing a shortage of negative-pressure wards, a rarity only few could enjoy in public hospitals. Moreover, feeding big data into AI algorithms for data analysis and prediction has proved to raise efficiency in certain areas. It also spurs research and development of electronic tools that will come to benefit the health of people. To dovetail with the national 14th Five-Year Plan (2021-25), it is high time Hong Kong picks up the pace in health data collection, harmonization, analysis and application.
Takeaway 4: To get citizens’ political buy-in, public messaging needs to be on point.
The biggest stakeholders of any health policy are the citizens it aims to benefit. Lack of trust in the government renders good policies to become poor ones. Rapid antigen testing and self-reporting are cost-effective policies when cases exceed well beyond the capability to perform universal polymerase chain reaction testing. Despite the good intentions, uncertainty about what could befall a person who self-registers as COVID-positive became a major reason for underreporting. In this case, fortunately, the trend matters more than the actual numbers. In other cases, underwhelming public messaging could prove detrimental. Consider the case of the government’s double about-face on tightening pandemic measures in March. Rumors about an impending citywide lockdown prompted residents to scurry for necessities in supermarkets, emptying grocery shelves. The government issued an official message a few hours later stating no such policy had been planned. The next day, the government revealed plans for a citywide lockdown and universal testing, which confirmed residents’ fears. Such plans were later canceled and replaced with social-tightening measures. Inconsistency fuels fear that potentially destabilizes the special administrative region at a time when Western powers conspire to tussle for influence in the region. Learning from lessons the past offers, a health policymaker possessing certain qualities is more likely to succeed.
Trait 1: Recognizes healthcare as a complex system and understands the interests of stakeholders.
The specialist-physician community in the US wields immense political clout over health policies. This has long stymied reforms that democratize healthcare and lower health expenditures. In Hong Kong, officialdoms in the Hospital Authority and the Medical Council are mostly held by specialist doctors who pride themselves on narrow areas of expertise. Seasoned clinical experience is a double-edged sword — while their domain expertise is irrefutably valuable in clinical consultations, the parochial lens through which they see healthcare, biased heavily by their specialist practice, may lead Hong Kong down a rabbit hole. To most specialists, improving healthcare means training more specialist doctors, prescribing exorbitant novel drugs, and procuring state-of-the-art technologies. As exciting as these may seem, the big elephant — older adults not getting the healthcare they deserve — remains in the room. Evidence in the US shows unconstrained healthcare expenditures balloon and fill the coffers of physicians all the while achieving minimal improvement in quality of health and life expectancy of the citizens. Specialists also view health-seeking behaviors linearly — it starts from a patient experiencing symptoms and ends at the point of hospital discharge or clinic consultation. Such a perspective is counterproductive. The mission of the World Health Organization implies that health embodies much more than the absence of disease. In essence, betterment is undergirded by wholesale policy that prevents illnesses, empowers patients to self-manage disease under the guidance of physicians, transforms health behaviors, and provides aftercare for the chronically debilitated. Physicians with public health experience are trained to predict domino events set off by shifts, however minor, in a complex system. They also adapt swiftly to meta changes pertaining to political winds and cultural traditions. Make no mistake: Specialists are integral to the big machine of healthcare. They benefit patients most by flexing expertise in niche areas in which they have been vigorously trained. Drafting public-health policies is just not one of them.
Trait 2: Embrace public health to be bigger than science and medicine — politics and economics can break vested interests.
Drafting and executing public health policies require deftness in politics. Take Singapore for instance; its health authorities successfully mobilized the mass public to vaccinate and stay away from urgent-care facilities unless necessary by enacting a raft of policies that bill uncompromising residents. The former was driven by a policy that allows the government to withdraw subsidized healthcare from patients who refuse COVID-19 vaccines. The latter was made possible by legislation that states whoever misuses urgent-care facilities for nonurgent illnesses, as judged by medical workers, will receive a bill of six times the subsidized amount. And the bills of those who fail to pay will be footed by their family members by automatically deducting money from their Central Provident Fund accounts, a mandatory escrow for employees. In-depth understanding of cultural pain points conditioned their people to use healthcare resources efficiently. That is crucial in a relatively small economy with limited resources. Science alone falls short of reaching such ends. Over the years of practice, physicians have grown accustomed to solving everything with science. It makes sense they do so because curing diseases should be grounded on data and evidence. Taking calculated risks and adapting to the flux of uncertainties have become their weakest link. And physicians who employ such mentalities would be severely penalized were their practice to deviate from the norm — Bolam’s test remains the gold standard in most medicolegal cases. On the other hand, policymakers who refuse to embrace politics and economics in policy implementation will find themselves mired in quicksand. To move big policies forward, the new health leader must leverage political power to break vested interests with mettle.
Trait 3: Be a team leader, not only a team player.
Listening to stakeholders across the landscape offers valuable information. Yet a policy appears facile to citizens when health departments claim they have listened to opinions while barely coordinating efforts among themselves. A vision greater than the individual tasks is needed to create cohesion in a fragmented system (it seems far-fetched to shut two ossified health machines in Hong Kong for an overhaul). And the health policymaker, as the captain of the ship, should inspire such goals. He or she is obliged to make a point about coordination. Junior staff in the DH are content to be able to recite guidelines set by seniors. Instead, they can do a better job scouting for loopholes and contradictions in the guidelines and feedback. Physicians in the HA seem never able to contact their GOPC counterparts in the DH, despite miscommunication is proved to be one of the top reasons for medical errors. Nor does any GOPC look interested in expanding its services to receive stable patients from specialist clinics. Start with the low-hanging fruit. Build bridges to facilitate collaboration. It is far easier to incentivize people by reforming systems than by working the other way around. A confident leader will avail our people of doing just that.
Epilogue
Hong Kong has been blessed with a vibrant economy, thanks to hardworking residents. No longer should we take for granted the growth our city has enjoyed. Rather than relying on the support of our motherland, ask what we can do for our country. Seeing off the risks an aging population brings is no doubt a top priority. Appointing a bold health official to rebuild our healthcare system is the first step, a move we must not get wrong.
The author is a licensed medical doctor in Hong Kong and holds a Master of Public Health degree from Johns Hopkins University in the US state of Maryland.
The views do not necessarily reflect those of China Daily.