Interrogating the conditions for political collaboration between the state and the medical profession: a case of Hong Kong

ABSTRACT

The existing literature on the relationship between the state and the medical profession highlights their mutual dependency as one condition of their political collaboration. However, this mutual dependency is insufficient to explain such political collaboration. The application of the two-level game concept has enabled me to analyse the possibility that the failure of political collaboration is caused by the division of the medical profession. Hong Kong provides a case to support this hypothesis. In turn, the division of the medical profession can be further traced to public–private imbalance in the healthcare system, cap on government funding to public healthcare and increase in medical complaints from patients. These issues increase the heterogeneity of the medical profession, particularly the differences between junior/frontline and senior doctors. The Hong Kong Medical Association (HKMA), which represents junior doctors, lacks an incentive to collaborate because it believed that senior doctors would not fight to protect professional self-regulation. However, if professional self-regulation was weakened, then junior doctors would lose considerably. Consequently, the uncompromising position of HKMA has resulted in the eventual failure of the political collaboration between the medical profession and the state.

KEYWORDS:

• Medical profession
• political collaboration with the state
• two-level game
• division of the profession
• heterogeneity
• institutional explanation

Acknowledgement

The author is grateful for the comments from anonymous reviewers. The author takes full responsibility for all remaining mistakes and omissions. He also thanks Sabrina Luk, Cressida Lui, Betty Yung, Amy Ho and Shae Wan Chaw for comments on an earlier version. The research for this paper was made possible by a research funding from the College of Professional and Continuing Education (CPCE) of the Hong Kong Polytechnic University.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1. Collaboration is conceptually similar to cooperation. The difference is that while cooperation targets more defined tasks and a more structured division of labour, collaboration focuses on more open tasks and less structured division of labour (Nissen, Evald, & Clarke, 2014). I choose to describe the interdependent relationship between the medical profession and the state as collaboration rather than cooperation because I believe the relationship is less structured and more intricate. But going beyond the context of healthcare, I shall use the two concepts interchangeably.

2. By now, a large literature has been accumulated about the analysis of two-level game through formal modelling. For a selective samples, see Iida (1993, 1996), Mo (1994, 1995), Pahre (1997), Pahre and Papayoanou (1997), Smith and Hayes (1997), Tarar (2001) and Van Laerhoven (2010).

3. Giaimo (1995, p. 355) and Davies (2014, p. 237) described the relationship between the state and the medical profession as a ‘bargain’. This description also implies that the relationship is mutually dependent.

4. The other stakeholders in Hong Kong’s healthcare system include the Health and Medical Development Advisory Committee (HMDAC) and Hong Kong Private Hospitals’ Association (HKPHA). HMDAC is a major advisory committee of the government tasked to review and develop service models for healthcare in the public and private sectors, as well as propose long-term healthcare financing options. HKPHA represents Hong Kong’s 12 private hospitals, which comprise the private healthcare sector. However, HMDAC and HKPHA play relatively minor roles in the system, particularly when the concern is on the political collaboration between the state and the medical profession. Patient groups are also a non-major stakeholder in Hong Kong’s healthcare system (Cheng, 2007, pp. 811–14). Through the years, there has only been a low level of community involvement in the discussion of healthcare policy and patients’ rights.

5. Examples include Dr Ko Wing-man (高永文), former Secretary for Food and Health; Dr Chan Hon-yee Constance (陳漢儀), Director of Health; Dr John C. Y. Leong (梁智仁), Chairman of HA; Professor Joseph Lau Wan-yee (劉允怡), Chairman of the Medical Council of Hong Kong; and Dr Gabriel Choi (蔡堅), President of HKMA. Particularly, the highest government official in charge of healthcare policy has been a medical doctor until 2017, when the position was given to a nursing professor.

6. For example, after Klein studies the politics of healthcare reform in the UK after the Second World War, he concluded that the history of the National Health Service ‘can be seen largely as a series of attempts to manage this mutual dependency’ (Klein, 1990, p. 700).

7. The HA market share is expected to be even higher if it is measured by bed days because patients are expected to stay longer in public hospitals than in private hospitals owing to the difference of charges for specialist service between the public and private sectors. In 2006, the government disclosed that the HA market share in terms of the number of bed days was over 90% (Food and Health Bureau (FHB), 2008, p. 124). However, the figure was 80.5% in the same year in terms of the number of inpatient discharges and deaths.

8. The percentage of doctors providing hospital care should be even lower because a certain number of HA doctors are assigned to provide primary healthcare service through outpatient clinics.

9. From 2004–2005 to 2013–2014, the HA workload increased by 3.8% annually, although the number of public doctors increased by an annual rate of only 2.3%.

10. Complaints received by the HA can be about staff attitude, administrative procedure or others. Complaints may not be handled by the Public Complaints Committee (PCC) of the HA.

11. Only appeal cases will be handled by the PCC of the HA.

12. In the public healthcare sector, senior doctors refer to doctors in HA with the rank of associate consultants and above. In the private sector, senior doctors refer to specialists with relatively extensive clinical experience and professional reputation in the field. Senior doctors in both sectors enjoy higher income and status than junior doctors.

13. The literature on cooperation also discusses the impact of other types of heterogeneity, such as benefit heterogeneity and belief heterogeneity. I will use the literature on endowment heterogeneity because the difference between junior and senior doctors in terms of what they have is about endowment heterogeneity. Endowment heterogeneity is also called resource heterogeneity.

14. Eventually, the government compromised and proposed another amendment bill to reform MCHK. Accordingly, one-half of the seats in MCHK were given to elected members, whilst the other half was given to appointed members. That is, the balance between the elected and appointed members was restored. HKMA supported the government’s new proposal and the amendment bill was passed in 2018 (Medical Council Reform bill passed [醫委會改革草案通過], 2018). The success of the MCHK reform in 2018 provides an additional piece of evidence for my argument that the failure of the 2016 reform was not caused by any conflict between the medical profession and the state. It was caused the division within the medical profession, particularly the division between the junior and senior doctors.

15. There has been general observation about ‘professional homogeneity’ being undermined by the increasing competition in the market for services (Frenk & Duran-Arenas, 1993). There has also been local observation in Hong Kong about the tension and division of the medical profession (Cheung, 2002; Leong, 2002). But there is no further effort to explain this phenomenon.

16. Elston distinguishes between three types of professional autonomy: clinical autonomy, economic autonomy and political autonomy. In Hong Kong, medical dominance remains in terms of clinical autonomy, but not with respect to economic autonomy and political autonomy. Proletarianization happens with respect to working condition, not to income or status. To the extent that the medical profession is divided, its political power is limited to the power to oppose.

17. Hall and Taylor (1996) distinguish between three kinds of institutionalism, namely historical institutionalism, rational choice institutionalism and sociological institutionalism. I am leaning more towards historical institutionalism. For a few samples of the literature of historical institutionalist explanation of healthcare system, see Immergut (1990, 1992), Jacobs (1995), Hacker (1998, 2004) and Chan (2016).

18. For a recent example to apply a rational choice institutionalist explanation of healthcare system, see Liu (2016).

19. This emphasis on the contingency of social life is particularly distinctive in the literature of historical institutionalism, sequencing and path dependence. Apart from Orren and Skowronek (1994), substantial contribution to this literature include Ikenberry (1994), Thelen (1999, 2000), Pierson (2000, 2004) and Mahoney (2000). See Falleti and Mahoney (2015) for a more recent contribution.