Methods
Study design and subjects
A cross-sectional survey was conducted one year after the launch of the voucher scheme (January-June 2010) among older people aged 70 or above who are eligible for the elderly healthcare voucher scheme in Hong Kong. Since there is no population register from which we could randomly sample older people in Hong Kong, we used a convenience sampling to recruit two groups of older people: (i) older people who were sick and were attending outpatient clinics in either public or private sectors, and (ii) older people who were generally well at the time of enumeration surveyed either in the parks while doing morning exercise or in the elderly health centres during their physical check up. Exercising in the parks is part of normal culture for older Chinese people living in urban environments. The elderly health centres are run by the Government with an aim to enhancing primary healthcare by providing health assessment, physical check up, counselling, curative treatment and health education to older people aged 65 or above with an enrolment fee of US$14 per year. The 3 selected public parks were chosen in the districts with higher, medium and lower average household income. The less healthy older people were recruited from 2 public general outpatient clinics and 12 private clinics in various districts in Hong Kong. Data were collected face-to-face by trained interviewers using a structured questionnaire. For some of the private clinics cases were interviewed over the phone using contact information provided by the doctors with consents obtained from the patients in advance.
Questionnaire
The questionnaire consisted of four sections: (1) Demographic characteristics, and healthcare services utilization pattern, (2) Awareness of the scheme e.g. whether the older people were aware of the scheme and channels to know about the scheme, (3) attitudes: (a) value assessment - whether the older people agreed that "the voucher is useful", "convenient to use", "the subsidy amount is enough", and "the coverage of services under the scheme is sufficient" and (b) perceived change of behaviours - whether the voucher scheme would encourage the use of private primary care services more than before and whether voucher scheme would change health seeking behaviours on where to see healthcare professionals, (4) Voucher usage, e.g. whether they have ever used the vouchers for private primary care services, reasons for not using it, types of professionals and medical services ever used for the voucher. English version of questionnaire used is available as additional file
1.
Outcome measures
The primary outcome of the study was the changes in perceived health seeking behaviour - measured by asking the older people if they thought there had been a change in their health seeking behaviour when they sought advice from healthcare professionals after the introduction of the voucher scheme. We also assessed who were the users of voucher scheme - measured by asking whether the older people had ever used vouchers to see private primary care professionals (which signals actual behaviour change especially for those who are used to seeing public doctors).
Statistical analysis
Descriptive statistics were collected on the awareness, attitudes and usage of voucher scheme. Univariate analysis of (i) perceived changes in health seeking behaviour and (ii) use of vouchers was undertaken. The variables that were significant in the univariate analysis were tested by logistic regressions to identify predictors of perceived behaviour change and factors associated with the use of vouchers and to estimate adjusted odds ratio (OR) with 95% confidence intervals (CI).
Ethics
Ethical approval was obtained for the study from the ethics committees in the Hong Kong Hospital Authority and Department of Health.
Discussion
Our study explored the impact of introducing a voucher scheme as part of healthcare reform to encourage greater use of private primary care services. Despite a reasonably high awareness of the voucher scheme, its usage was low. The impact of the voucher scheme on its primary target group, the frequent users of public outpatient services, was relatively small (only 21.0% of those usually see public doctors felt there was a change in their health seeking behaviours). The voucher alone was not enough to stimulate the Governments objective of greater use of the private primary care services. Those who were healthiest tended to be the most likely to consider changing their behaviour and those who were already using the private sector were the most likely to use the vouchers.
International studies have shown that voucher schemes are generally effective when used for specific targeted health services especially in the uptake of preventive measures. For example, studies in Nicaragua and France demonstrated that vouchers boosted the uptake of sexual & reproductive healthcare services and vaccination respectively [
20‐
22]. Evidence for the effectiveness of financial incentives was the strongest in drug misuse programmes [
32]. A World Bank study pointed out that voucher schemes are often aimed at under-utilized services and are most effective if targeted at specific groups [
16]. Another study by the King's Fund found that vouchers are effective in encouraging participation in simple behavioural tasks as well as lifestyle programmes [
27]. In our study, the elderly healthcare voucher scheme covers all the primary healthcare services including curative and preventive services in the private sector. Its focus is on the use of subsidized private primary care services in general, but not targeted at the under-utilized preventive services, which might partly explain why the voucher scheme in Hong Kong failed to induce any noticeable behavioural change amongst the users of primary health care services during the first year of the pilot period. There is little evidence worldwide on whether a voucher scheme could incentivize the use of primary care services and development of family doctor model of care in the private sector. Our study therefore provides the insight that a general voucher scheme as currently designed was not effective in incentivizing the use of private primary care services among the older people in Hong Kong, who are used to receiving much more affordable services from the public sector.
Our findings also showed that not only did the older people in our study not perceive a change of their health seeking behaviours upon the introduction of voucher scheme, but there was a low level of actual voucher usage in the private sector for primary care services (only 35.0% of older people had made use of vouchers). Older people who are used to seeking care from private doctors are more ready and prepared than those relying on the public healthcare system to make use of healthcare vouchers. Those older people who were used to seeing public doctors were less likely to use the vouchers (23.6%) compared to those used to seeing private doctors only (49.0%) or a mix of public and private doctors (41.6%). The main reasons given were that they did not wish to change their usual practice of seeing public doctors and that the subsidy amount is relatively low. This not only indicated that the older people are content with services currently received in the public sector, despite long waits and crowded conditions, but in a large part this might reflect their low willingness to pay, perceived inability to pay and uncertainty about the price and quality of services provided in the private sector. A separate study was being conducted among the older groups on their willingness to pay for private sectors. In addition to the demand-side subsidies, making the services and prices in the private sector more transparent and comparable with public sector might help patients in making better informed decisions. This study has provided important early insight into the impact of the voucher scheme among the target group. Presentation to policymakers has suggested that they might wish to consider introducing more cost-effective incentives by targeting other subpopulations or specific services.
Furthermore, since the current usage of vouchers is low and the older people mainly use them for acute conditions, attempts to encourage use of private services for maintenance or control of their chronic diseases needs review, as does potential use of vouchers for promoting other evidence-based programmes such as care supported by guidelines. The small proportion (7.0%) of health care vouchers used on preventive services indicated that most older people give preventive services a low priority when it comes to healthcare spending decisions. In Hong Kong, only 2.5% of the entire health expenditure is spent on disease prevention and health promotion [
33]. Further consideration should be put into designing vouchers for designated use for preventive services with evidence-based practice (such as cancer screening, hypertension or diabetes management) as this would address the unmet need that is known to exist, particularly since evidence from countries around the world has shown that primary care oriented health systems produce better health outcomes [
34]. Also, it requires the concerted efforts of the government, healthcare service professionals and the media to gradually induce a cultural change that puts more value and emphasis on preventive care. In addition, our study showed that older people usually see both public and private doctors as well as attend both Western trained and Traditional Chinese medicine practitioners when they are sick, implying a doctor shopping behaviour without a continuous doctor-patient relationship. One of the aims of the voucher is to promote the model of continuity of care from a family doctor. Our study does not provide information on whether the patients will build up this continuous doctor-patient relationship with the use of vouchers. However, government statistics showed that there are early results implying that older people tend to stay with the same private doctors if they use vouchers. Further study is needed to examine the effects of voucher on this aspect of the reforms.
As part of healthcare reform to promote greater use of subsidized private primary healthcare services, the voucher scheme still has room for improvement to make it more effective. There appears to be a lack of interest in the voucher scheme from both supply and demand side. Greater publicity and more variety of media promotion and approaches would increase awareness and usage. Also, given only half of the registered private Western medicine doctors have enrolled in the voucher scheme [
30], more healthcare professionals should be encouraged to enrol in the scheme to provide more choices for the older people. In addition, the level of subsidy should be reviewed since nearly 68.0% said the subsidy was not enough. Proper management and monitoring of voucher schemes is also necessary to ensure the actual consultation charges would not be increased by the voucher scheme. In our study, nearly half (44.8%) of the older people did not feel that there had been an increase in consultation fees subsequent to the launch of the voucher scheme, while 13.7% perceived an increase, and the rest (41.7%) said that they did not know. Further study is needed among the supply side to ascertain the range of co-payment charged by healthcare service professionals and whether the fees are beyond the willingness-to-pay of the older people. Reasons for the low participation rate of healthcare professionals should also be examined. Another aspect of the voucher scheme is its high transaction and administrative cost. Over-servicing might also occur because of the direct link between outputs and subsidies. The above factors might affect the effectiveness of the voucher scheme. Thus, any improvements should consider a feasibility assessment covering client expectation, support or enrolment from services providers, administrative and transaction costs, and accurate determination of price to ensure the efficiency of the voucher scheme [
14].
Apart from the demand-side subsidy, other incentives such as supply-side subsidy might also be considered in encouraging primary care and improve the quality of care e.g. pay-for-performance using the Quality and Outcomes Framework in United Kingdom. The private sector plays a critical role in healthcare services provision. A proper public-private partnership model should be examined to make better use of resources in both the public and private sectors and to provide greater choice of services for individuals in the community.
One technical limitation we faced was getting a representative sample of the target population. We chose a convenience sample by recruiting both healthy and sick older people from parks and clinics because there is no good way of getting a population-based study sample in Hong Kong. Primary care doctors do not have unique records for their patients and it is common for patients to adopt doctor shopping behaviours. However we recruited older people from different districts in Hong Kong to reflect different socio-economic characteristics and we did confirm that the age and sex distribution of respondents are similar to those of the population. However, a household survey with participants randomly selected from the list of household addresses would ideally provide a more representative sample. Also, it was difficult to recruit from private clinics and 80% of the participating private clinicians in our study had joined the voucher scheme, which might lead to an over-estimate of voucher usage among this subgroup of respondents.
Conclusions
Our study provides information about the impact of a policy change, the voucher scheme, and fills a knowledge gap about whether the policy change promoted its desired objective of greater use of the private sector in primary care. It also provided evidence for suggestions for improvement of the voucher scheme. Since many countries, including United Kingdom and United States, start to consider the use of financial incentives to promote changes in patients' behaviour, evidence about the effectiveness of vouchers is important. Hong Kong's recent experience provides an opportunity for others to draw lessons for healthcare reform in their own countries.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
All authors carried out and designed the study. CHKY wrote the first draft of the manuscript and all authors made important contributions to the subsequent draft. All authors have seen and approved the final version.