Welfare attitudes and health care financing reform in a dual-track medical system: The case of the voluntary health insurance scheme in Hong Kong

Sin Man Mandy WONG

Research output: ThesisDoctoral Theses


Health policy and health care reforms all over the world have attracted substantial scholarly attention. Healthcare financing reform represents a major rebalancing effort to redistribute financial responsibilities between the state and its citizens. It is therefore a politically sensitive undertaking that must be built on strong popular support if it is to succeed. Unfortunately, the widely witnessed decline of public trust in the state and the rise of populism and anti-retrenchment sentiments have narrowed the political window for structural reforms, making health care financing reforms even more difficult to implement. Political trust is essential for welfare reforms; the failure of many health care reforms worldwide was at least partially attributable to the lack of political trust, which may obstruct necessary retrenchment efforts.
How does public opinion react to a proposal for health care financing reform in a society characterized by low political trust? What are the policy implications of popular attitudes for the legitimacy of welfare reforms? The Hong Kong Special Administrative Region (SAR) offers an ideal backdrop for investigating these issues. This research seized the great opportunity when the SAR Government was about to launch a major health care financing reform, i.e. the Voluntary Health Insurance Scheme (VHIS) in 2014 that was intended to rebalance private-private mix in Hong Kong’s health care financing. Adopting a mixed-method design in empirical investigation, this study collected quantitative data from a telephone survey of Hong Kong citizens in 2014 while in-depth interview was extensively employed to collect qualitative data. Broadly, this study has yielded four significant conclusions. First, reinforcing some recent studies in the international literature, the thesis reveals the multi-dimensionality of welfare attitudes through quantitative analysis. The latent attitudinal structure encompasses three dimensions: nominal support for the reform, willingness to purchase the regulated private health insurance, the expectation for government responsibility in health care. People’s attitudinal patterns varied considerably across the three dimensions. While their nominal support and intention to purchase were both moderately low, people’s expectation for government involvement in health care was polarized. Taken as a whole, there was no overwhelming evidence showing that a welfare reform emphasizing private financing responsibility is destined to be drawn in massive social opposition.
Second, the influence of the self-interest explanations dominated people’s intention to purchase the proposed insurance, a practical behavioural decision, whereas ideological leaning, egalitarianism in particular, played a significant role in shaping their normative views in the other two dimensions (i.e., public support for the health care financing reform and expectation regarding government responsibility in health care). Remarkably, trust turned out to be the fundamental motive behind people’s welfare opinions. More important, trust included not only the general political trust in policy-making institutions, but also how citizens perceived government responsiveness, its citizen participation, and policy competency. If citizens trust in policy-makers’ capability to undertake reforms and maintain good institutional competence, they tend to be more receptive of welfare reforms that do not materially benefit themselves.
Third, a tricky but salient phenomenon warrants close attention and is very illustrative of the dynamics of health care reform in Hong Kong: individuals typically associated with higher health risks did not favour the alternative financing instrument, nor did they seem to be desperately concerned with health care, because the highly equitable government-funded health system always provides a reliable safety net for all in Hong Kong. As a result, policy-makers are trapped in a situation in which only marginal reforms are politically possible. Fourth, this thesis, particularly its qualitative phase, has discovered a battery of nuanced attitudinal dynamics that are peculiar to Hong Kong and hardly documented in the existing literature. For example, the traditional principles of self-reliance and self-sufficient seem to be upheld by the current generation of older adults too, in part limiting their expectation for extensive government responsibility in health care, something that I was not expected prior to the interviews. Moreover, some people did not necessarily expect the government to extensively engage in direct provision of health services but instead, preferred the government to tackle more fundamental issues such as strengthening health regulation. In addition, Hong Kong’s public health care system appears to be built on the strong value of social solidarity and positive attitudinal feedback, but the ideological framework goes beyond the linear depiction of egalitarianism and should be further unpacked in future studies. This study also draws policy implications. First, the revealed intent to purchase VHIS plans was not low given the scheme’s voluntary nature. Second, most of the empirical evidence
suggests the population’s continued reliance on the public medical system. Hence, to what extent this moderate health care financing reform is able to achieve its stated goals is doubtful. Third, more high-powered policy instruments on the financing side and more concerted reforms on the provision side are necessary to address the long-standing health policy problems in Hong Kong. Fourth but importantly, the government must revisit its citizen engagement strategies and pay sincere efforts to rebuild political trust in the Hong Kong society, which is critically important for social welfare reforms. All rights reserved.
Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • The Education University of Hong Kong
  • HE, Jingwei Alex, Supervisor
  • CHOU, Kee Lee 周基利, Supervisor
  • MOK, Ka Ho Joshua, Supervisor
Publication statusPublished - 2019


  • Welfare attitudes
  • Health policy
  • Health care financing reform
  • Hong Kong
  • Political trust
  • Theses and Dissertations
  • Thesis (Ph.D.)--The Education University of Hong Kong, 2019.


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