A

SOCIAL POLICY & ADMINISTRATION ISSN 0144-5596
DOI: 10.1111/spol.12274
VOL. 52, NO. 3, May 2018, PP. 750–770
Public Satisfaction with the Health System and Popular

Support for State Involvement in an East Asian Welfare
Regime: Health Policy Legitimacy of Hong Kong
Alex Jingwei He
Department of Asian and Policy Studies, The Education University of Hong Kong,
New Territories, Hong Kong
Abstract
The legitimacy of social policies has gained increasing attention in the past decade, against the
backdrop of fiscal austerity and retrenchment in many nations. Policy legitimacy encompasses public
preferences for the underlying principles of policies and the actual outcomes as perceived by citizens.
Scholarly knowledge concerning the legitimacy of health policy – a major element of modern social
policy architecture – is, unfortunately, limited. This article seeks to extend the scholarly debates on
health policy legitimacy from the West to Hong Kong, a member of the East Asian welfare state
cluster. A bi-dimensional definition of health policy legitimacy – encompassing both public satisfac-
tion with the health system and the normative expectation as to the extent of state involvement in
health care – is adopted. Based on analysis of data collected from a telephone survey of adult Hong
Kong citizens between late 2014 and early 2015 , the findings of this study demonstrate a fairly
high level of satisfaction with the territory’s health system, but popular support for government
responsibility presents a clear residual characteristic. The study also tests the self-interest thesis
and the ideology thesis – major theoretical frameworks for explaining social policy legitimacy –
in the Hong Kong context. Egalitarian ideology and trust in government are closely related to both
public satisfaction with the system and popular support for governmental provision of care.
However, the self-interest thesis receives partial support. The findings are interpreted in the context
of Hong Kong’s health system arrangements, while implications for the territory’s ongoing health
policy reform are discussed.
Keywords
Policy legitimacy; Satisfaction; Popular support; Health policy; Hong Kong
Introduction
Over the past decade, many countries have been undergoing major health
policy reforms. The fact that both the USA and China, the two largest
Author Email: jwhe@eduhk.hk
© 2016 John Wiley & Sons Ltd

SOCIAL POLICY & ADMINISTRATION, VOL. 52, NO. 3, MAY 2018
economies in the world, rolled out their national health care reforms almost
simultaneously reflects the daunting health policy challenges that most
national governments are grappling with. Soaring costs and continuous
demand for quality improvement exemplify the thorny problems testing the
wisdom of policymakers (He and Meng 2015). Health care is a people-
centred service that is ultimately paid for by the general population, so
eliciting views of citizens is essential for public accountability (Judge and
Solomon 1993). Consolidating popular support for health policy has become
increasingly critical, given the notable evolution towards growing reliance on
private expenditure, in the form of out-of-pocket payments and health
insurance contributions (Thomson et al. 2010).
These challenges have reopened the debates on the legitimacy of health
policies. As elucidated by Rothstein (2001), legitimacy ultimately depends
on both public approval of the value of certain policies and the way they
are implemented in practice. Thus, policy legitimacy encompasses public
preferences for the underlying principles of policies and the actual outcomes
as perceived by citizens. Scholarly knowledge concerning the legitimacy of
health policy – a major element of modern social policy architecture – is,
unfortunately, limited and is mainly confined to the conception of public
satisfaction. A fairly large number of empirical studies have been focused on
investigating public satisfaction with health systems, mainly in Western
countries, while a few such studies have been conducted in the developing
world (Donelan et al. 1999; Mossialos 1997; Lee et al. 2009; Bleich et al.
2009; Footman et al. 2013). However, while public satisfaction is what
ultimately justifies health policies, public acceptance of the underpinning
values provides the normative foundation and must not be neglected.
With regard to broad social welfare policies, there is a rich body of litera-
ture analyzing the legitimacy of Western welfare states. Many previous works
have found that self-interest, ideological orientation and institutional set-ups
are key determinants (Jæger 2006a; Blekesaune 2007; Van Oorschot
2000; Gelissen 2000; Blekesaune and Quadagno 2003). While these
country-specific analyses, as well as cross-national comparisons, have illumi-
nated many sources of the legitimacy of modern welfare states, two major
shortcomings exist.
First, with a few exceptions (such as Missinne et al. 2013; Wendt et al.
2010), most previous studies broadly focused on the entire social policy
regime, while little understanding has been gained as to the legitimacy of
health care, a key welfare component. Second, most previous studies were
explicitly or implicitly built on Esping-Anderson’s typological model of
Western welfare regimes (Jæger 2006b; Papadakis and Bean 1993), which
has been found to be of little relevance in explaining social welfare systems
elsewhere. East Asia, for instance, has exhibited salient, distinct features in
its approach to welfare, one for which the terms productive welfare capitalism,
oikonomic welfare states, developmentalism and residual welfare regimes have been
coined (Jones 1990; Kwon 1997; Holliday 2000). Notwithstanding the
variation in the use of concepts, it is fairly clear that East Asian economies –
especially the Newly Industrialized Economies or Asian Tigers – have their
welfare systems built on rather different ideological and policy grounds. As
© 2016 John Wiley & Sons Ltd 751
such, the patterns and dynamics of the policy legitimacy of East Asian welfare
systems may profoundly differ from those of their Western counterparts. Are
East Asians happy with their health systems? Do they support more
state involvement in health care? What explains their satisfaction and
such support?
This article is an attempt to fill the gap with an empirical study in Hong
Kong. The patterns and determinants of health policy legitimacy are
examined by analyzing data collected from a telephone survey of Hong Kong
citizens between late 2014 and early 2015. This study makes three contribu-
tions. First, it extends to Hong Kong the discussion on the popular legitimacy
of welfare state in Western countries and reveals new patterns pertinent to a
residual welfare system. Second, a bi-dimensional understanding of health
policy legitimacy is adopted and the study reveals the factors associated with
such legitimacy in a mixed medical economy. Third, Hong Kong is in the
midst of health care reforms; this study is intended to provide the territory’s
health policymakers with evidence-based recommendations that take into
account the citizens’ views.
Theoretical Background
Popular support for welfare states and predictors

The debates on the popular legitimacy of welfare states have been active
for more than three decades. Early studies mainly stemmed from fears of
a welfare state legitimacy crisis due to decreasing public support. The
‘abused taxpayer’ argument by Rose and Peters (1978) and the ‘comfort-
able middle class’ argument by Wilensky (1975) and Galbraith (1992)
warned that increasing taxation as a result of rising welfare spending would
eventually lead to the withdrawal of popular support in Western welfare
states. Other studies that followed contradicted this line of argument and
maintained that normative beliefs and social values – such as social
solidarity, duty and altruism – provided a solid motivational basis for
supporting welfare provision (Hechter 1987; Inglehart 1990). Empirical
analyses, too, found strong and stable popular support for the social welfare
systems in most Western countries (Taylor-Gooby 1999; Gelissen 2002;
Jæger 2006a).
A prominent body of the literature explains why citizens do or do not
support welfare systems. Three broad sets of predictors have been found
of explanatory relevance: self-interest, ideologies and institutions
(Blekesaune and Quadagno 2003). Originating in rational choice theory,
the self-interest thesis contends that individuals who benefit directly from
the welfare system, or who are at risk of becoming dependent on welfare
provision, tend to demonstrate greater support (Hasenfeld and Rafferty
1989; Svallfors 1997; Edlund 1999). Occupational status, age, social
class, income, gender and education have been found to be salient
predictors.
The ideology thesis refines the self-interest thesis: it is argued that there is
no direct relationship between individuals’ socio-economic status and their
752 © 2016 John Wiley & Sons Ltd
attitudes towards social welfare because this effect is mediated by their

ideological orientations (Feldman and Zaller 1992; Gevers et al. 2000).
Specifically, endorsements of social rights, party affiliations and egalitarian
ideologies have been identified as key factors associated with individuals’
support for welfare systems.
Institutions emerged as the third set of predictors from cross-national
comparative studies. Underlying the argument here is the hypothesis that
individuals’ perceptions of welfare legitimacy are shaped by the institu-
tional characteristics of the welfare state (Blekesaune and Quadagno
2003). Edlund (1999) maintained that different types of welfare regimes
generate different attitudinal patterns. This institutional set-up thesis thus
hypothesizes that universal, social democratic regimes tend to engender
greater support, whereas liberal regimes induce a much lower level of
support for institutionalized welfare. This argument has, however, been
subject to debate. Svallfors (1997), for instance, grouped eight European
welfare states according to their overall institutional structures, but found
no significant correlation. Gelissen (2000) analyzed data from 14 coun-
tries, but the findings were the opposite of what had been predicted. These
contradictory findings might have stemmed from the complex multidimen-
sionality of institutional structure that makes analytical operationalization
difficult.
Health policy legitimacy

Among the few studies available on health policy legitimacy, two have
made significant contributions. Wendt et al. (2010) rightly pointed out that
previous studies had failed to distinguish between citizens’ preferences
regarding the role of the state in health care and the level of their satisfac-
tion with the system. To be more specific, while the former reflects individ-
uals’ normative expectations and the underlying values, the latter is more
related to their experiences with the system. Echoing this notion, Missinne
et al. (2013) also embraced a bi-dimensional approach and noted that
health policy legitimacy first implied the normative belief as to whether
extensive state responsibility for health care is preferable, while the second
dimension pertained to citizens’ actual experiences of received care. Their
study, based on 24 European countries, found universally high support
for state responsibility for health care, but that satisfaction varied consider-
ably. The three sets of predictors revealed by previous studies were
included as explanatory variables. Missinne et al. (2013) found that individ-
uals were not guided by self-interested motives and ideologies alone, but
that institutional characteristics indeed explained a great deal of the
cross-national variations.
Wendt et al. (2010), too, analyzed both dimensions of health policy legiti-
macy in Europe. They found universally high public support for state respon-
sibility in health care, but satisfaction with the health system was strongly
related to specific institutional arrangements. In health systems with lower
levels of expenditure, fewer physicians and higher out-of-pocket payments,
the overall level of satisfaction tended to be lower.
Predictors of health policy legitimacy

Age, income, education and health status are often used to test the self-interest
thesis. Older individuals and those with lower incomes, lower education and
poorer health status are typically associated with greater health risks and fewer
financial resources, and they are therefore hypothesized to be more supportive
of public health care arrangements (Svallfors 1991; Van Oorschot 2000). Yet
there is the counter-argument that individuals with higher incomes and better
education may not necessarily oppose state intervention simply because of
heavier tax burdens and less individual freedom, but might also support public
programmes because socialization evokes a greater commitment to social
solidarity from the educated (Hasenfeld and Rafferty 1989). However, Gevers
et al. (2000), for example, reported that a preference for state provision of
health care in Europe was stronger among those in poor health, but no effects
from age or education were found. Missinne et al. (2013), using a different
dataset, identified having a lower income and being female as significant
predictors for the endorsement of state provision of health care.
The study by Wendt et al. (2010) further challenged the conventional
notion that people in poor health generally preferred more government-
organized health care, due to their heavier dependence on the services. Their
cross-national comparison in Europe showed that people who evaluated their
health status as poor did not support extensive public responsibility more than
healthy people did. Nor did age group, contrary to the self-interest hypothesis,
turn out to be a significant factor in this study.
Insights concerning satisfaction are also mixed. Some assert that individuals
of lower socio-economic status tend to receive care of a poorer standard,
resulting in lower satisfaction (Malat 2001; Footman et al. 2013), while others
argue that this group of people tend to have lower expectations and thus may
not necessarily be more dissatisfied (Sitzia and Wood 1997; Missinne et al.
2013). A fairly consistent pattern is the association between poor health and
low satisfaction, implying that frequent visits to medical facilities tend to reduce
the level of satisfaction (Lee et al. 2009; Wendt et al. 2010; Missinne et al.
2013; Footman et al. 2013). Middle-aged European taxpayers are also found
to be less satisfied with their respective national health systems, possibly due to
the contribution-utilization gap (Wendt et al. 2010; Missinne et al. 2013).
The second set of predictors is related to ideological dispositions. Individ-
uals who endorse the principle of equality are expected to be more supportive
of public health care arrangements (Missinne et al. 2013). Gevers et al. (2000)
found that European respondents of a politically left orientation tended to
favour stronger state involvement in health care. Footman et al. (2013) also
reported a strong association between individuals’ political attitudes and
satisfaction with health systems in the former Soviet countries. Party affiliation
has also been identified as a critical predictor of popular support for welfare
reforms in the USA (Knoll and Shewmaker 2015) and Singapore (Ng
2015). Studies in Europe have also revealed that individuals who endorse
egalitarian principles are the strongest supporters of state involvement in
health care, but are not necessarily more satisfied with the system they have
(Missinne et al. 2013).
The brief review above suggests a mixed picture regarding support for the
self-interest thesis and the ideology thesis. This inconsistency in the results
may be due to issues related to measurement, data reliability and national
context. In this study, predictors relevant to Hong Kong are tested as
potential explanatory variables in the analysis.
The institution thesis was employed by most previous researchers
attempting to analyze cross-national variations. Although it is not directly
relevant to this case study of Hong Kong, the argument does inspire thoughts
about interactions between citizens’ institutional trust and their attitudes
towards welfare. It is argued that if citizens’ experiences with the state tell
them that the government is trustworthy and fair, then support for public
welfare programmes is more likely than when their experiences with the state
feed feelings of its inefficiency and corruption (Rothstein and Steinmo 2002).
Rose (1991) elucidated: only if the state is trusted to be caring and effective
does it make sense for people to put their welfare in its hands. This argument
is reinforced by the study by Footman et al. (2013) in former Soviet nations,
which found that the respondents least trusting of the political institutions
were more likely to report dissatisfaction. In the present single-territory study,
the impact of institutional trust on Hong Kong citizens’ attitudes towards
health policy is also examined.
Noteworthily, both dimensions of health policy legitimacy may have
profound interactions. While satisfaction is understandably more related to
individuals’ personal experiences with the health system (Wendt et al. 2010),
the normative preference for state involvement may be shaped by the level
of people’s satisfaction with the system. Blidook (2008) has noted that the
formation of public attitudes towards health policy is determined by a combi-
nation of pre-formed opinions, information received externally and personal
experiences. Soroka et al. (2013) wisely distinguished public attitudes about
health policy into the distinction between personal and collective attitudes
and the distinction between retrospective and prospective attitudes. Their
analysis of secondary survey data in Canada indicated that retrospective per-
sonal assessment of the health system was still closely related to individuals’
system support, revealing the theoretical link between individual-level satisfac-
tion and normative expectations. In this study, the possible interaction
between both dimensions of health policy legitimacy is also considered.
Policy Background
Hong Kong’s social welfare system
Hong Kong was a British colony from 1842 to 1997 and became a Special
Administrative Region (SAR) of China thereafter. Known as one of the Asian
Tigers, this territory of 1,104 square kilometres and seven million people has
experienced extraordinary economic growth in the past 50 years. Despite the
recent economic slowdown, it remains among the most affluent economies in
the world, with a per capita gross domestic product (GDP) of US$56,720 in
2015. In terms of social welfare, Hong Kong (together with the other East
Asian Tigers) has been traditionally labeled a productivist/developmental
welfare regime, where economic growth takes precedence over social policy
(Holliday 2000). Social spending is carefully kept at a modest level, while
priority is given to social investment – especially in education, health care
and vocational training – in order to build a productive labour force and
maintain economic competitiveness (Midgley 1995).
Positive non-interventionism has been the overarching philosophy of gover-
nance in Hong Kong, with ‘small government, big market’ indicating the
underlying ideology. Although Hong Kong has historically abhorred the idea
of the welfare state and taken a residualist stance on social policy, the state
does intervene to a fairly deep extent, especially in public housing, tax-funded
health care and heavily subsidized education, as well as through providing
various forms of financial aid and social services for the community (Ramesh
2004). Although the system relies heavily on non-profit organizations in the
delivery of social services (particularly in family counseling, rehabilitation,
elderly care and community services), the bulk of the funding comes from
government finances. Critics, however, often point to the absence of universal
pensions and unemployment benefits and the existence of a large poverty-
stricken population. As noted by Wong (2008), Hong Kong’s welfare system
presents a complex mix of residual strands as well as principles of universalism
and social equity. Public health care, for example, is generously funded by the
government without means-testing, making it universally accessible.
Public attitudes towards social welfare in Hong Kong

Public support for welfare provision has evolved over time in Hong Kong.
Chow (1994) noted that democratic participation and welfare rights started
to become important in Hong Kong society in the 1980s, exerting increased
influence on welfare development. The past decade has witnessed an even
more vigorous surge in the demand for government provision of welfare,
propelled in part by the proliferation of interest groups formed to pursue their
welfare demands (Chan 2009). Yet, interestingly, Wong et al. (2008) noted
that, notwithstanding their stronger support for government intervention,
Hong Kong people still held major reservations about the idea of increasing
public expenditure on welfare services and were clearly reluctant to finance
social welfare through taxes.
Wong and Chau’s (2003) longitudinal study captured the dynamics of
Hong Kong people’s attitudes towards social welfare. A survey conducted in
1993 unveiled a residual welfare ideology among the respondents. The
prevalent belief then was that state intervention should not undermine the
virtues of self-reliance and family. In a follow-up survey in 2001, the pattern
appeared to have largely remained. Half of the respondents believed that
social welfare should be provided only for the economically disadvantaged
and those who could not help themselves, and that the state should come in
only as a last resort. Close to half perceived social welfare as being an
economic burden to Hong Kong. It is somewhat paradoxical that,
notwithstanding the residual orientation towards social welfare, both waves
of the survey suggested that Hong Kong people were as egalitarian as their
European counterparts.
Health care system of Hong Kong

Hong Kong outperforms most economies on key population health indicators.
Life expectancy at birth and infant and maternal mortality rates are among
the best in the world. The system that created such outstanding performance
is financed from both public and private sources, each taking on approxi-
mately a half share (figure 1). Total health expenditure now forms 5.4 per
cent of GDP, which is still considerably lower than the level of other advanced
economies. More than 95 per cent of public funding comes from government
tax and non-tax revenues, with the rest mainly being recovered from fees and
charges paid by patients at the point of delivery (Leung et al. 2005). Out-of-
pocket payments by households form about one-third of total health expendi-
ture. A smaller private contribution to financing comes from employer-provided
group medical benefits and private insurance, accounting for 7.5 per cent and
6.4 per cent of total health expenditure, respectively (Tin et al. 2012). To date,
there is no mandatory health insurance in Hong Kong.
Health spending took up 16.8 per cent of the total government budget in
the 2015/16 financial year. Government health expenditure consists mainly
of spending on public and subvented hospitals, and it is primarily targeted at
inpatient care (Tin et al. 2012). Private payments are the main source of
funding for outpatient services as well as pharmaceuticals (Ramesh 2004).
Figure 2 shows a breakdown of the sources of financing. It indicates that
household out-of-pocket payments and government subsidies account for
the lion’s share; other sources play a rather minor role.
The most salient feature of Hong Kong’s health delivery system is the
collection of independent providers, each working in their own market niche
(Gauld 2004). While public facilities dominate secondary and tertiary care,
70 per cent of primary outpatient services are provided by private clinics.
Figure 1
Sources of health financing and total health expenditure as share of GDP, Hong Kong. [Colour
figure can be viewed at wileyonlinelibrary.com]

Figure 2
Mix of financing sources of total health expenditure, Hong Kong. [Colour figure can be viewed
at wileyonlinelibrary.com]
Public hospitals provide close to 90 per cent of inpatient services. Citizens

enjoy heavily subsidized services at public facilities without means testing. In
the current fee schedule, a general outpatient consultation costs only HK
$45 (US$1 = HK$7.75) and a specialist consultation HK$100 for the first
attendance, with a HK$10 per item drug charge. Costs for inpatient care
are also remarkably low, with a HK$100 all-inclusive per diem charge. Public
hospitals are managed by the Hospital Authority, a statutory organization
answerable to the government. Public hospitals receive over 90 per cent of
their income from the authority.
Hong Kong’s health system has achieved internationally renowned perfor-
mance, with outstanding population health status indicators and high levels of
patient satisfaction. Looking only at public hospitals, a survey has shown that
they still enjoy a high level of trust (87 per cent) and satisfaction (80 per cent)
in the eyes of the public, despite some drawbacks (Wong et al. 2012).
However, the system is also confronting daunting challenges. First, rapid
demographic change and the prevalence of chronic diseases have created
tremendous pressure on financing. Government projections indicate that
elderly people will rise to 30 per cent of the total population by the 2030s.
According to the projections, total health expenditure will double by 2030
and further increase to HK$315 billion by 2033. The most alarming
message is that public health care expenditure will shoot up to almost 30
per cent of total government spending if this trend continues. This is
undoubtedly beyond what the government can afford (Food and Health
Bureau, Hong Kong SAR Government 2008).
Second, low taxes coupled with highly subsidized services give rise to the
so-called buffet syndrome. Leung et al. (2005) pointed out that the Hong
Kong population is over-reliant on public health care services. In conse-
quence, public hospitals and outpatient clinics are always overloaded. In the
outpatient sector, long waiting times have been the main problem plaguing
the system. Some patients may wait up to two years for a specialist consulta-
tion or surgery. Studies show that the long waiting times are a major reason
for patients’ non-attendance (Leung et al. 2003; Chan and Beitez 2006).
Methodology
Data
In this study a telephone survey was used to investigate Hong Kong citizens’
attitudes towards the health system and state responsibility. Designed by the
author, the survey was conducted by the Public Opinion Program of the
University of Hong Kong between September 2014 and February 2015.
Ethical approval was obtained from the Human Research Ethics Committee
of the author’s university. Random-digit dialing was used to select respon-
dents from a computer-generated random-digit dialing pool. As the popula-
tion of telephone non-subscribers is rather small in Hong Kong, the
coverage error is minimal. The survey targeted Cantonese-speaking adults
only, given the very small non-Cantonese speaking population in the city. A
total of 1,793 respondents formed the sample, giving a response rate of
72.15 per cent. The profile of the respondents and descriptive statistics of
key variables are outlined in table 1. STATA 12.0 was used in the statistical
analysis.
Dependent variables
Two dependent variables were used to represent the two dimensions of health
policy legitimacy. The respondents were first invited to rate their degree of
satisfaction with Hong Kong’s health system on a 5-point Lickert scale (very
dissatisfied, quite dissatisfied, half-half, quite satisfied, very satisfied). The item that
measured the respondents’ support for state involvement in health care was
phrased in this way, ‘There is an opinion that “the government should provide
everyone with only basic health care services and let people take care of themselves in other
aspects of health care” [Gelissen 2000]. Do you agree or disagree with this
statement?’. The set of Likert options offered was strongly agree, agree, half-half,
disagree, strongly disagree (in an ascending order of preference for state
involvement).
Explanatory variables
Three broad sets of variables were included to explain both dependent
variables. In order to test the self-interest thesis, the author first took gender,
760
Table 1
Descriptive statistics of key variables
Variable Obs. Mean Std. Dev. Min Max
Gender 1,793 1.61 0.49 1 (Male) 2 (Female)

Age 1,772 3.54 1.37 1 (18–29) 5 (60 and over)
Monthly income 1,680 1.67 0.76 1 (<HK$10,000) 3 (>HK$30,000)
Educational attainment 1,778 2.26 0.70 1 (Primary and under) 3 (Tertiary)
Subjective health status 1,791 2.51 0.77 1 (Very good) 5 (Very poor)
Public hospital user 1,793 0.33 0.47 0 (No) 1 (Yes)
Out-of-pocket burden 1,741 3.30 1.10 1 (Very heavy) 4 (Very light)
Satisfaction with heath system 1,747 3.24 0.94 1 (Very dissatisfied) 5 (Very satisfied)
Preference for state involvement 1,711 3.065 1.30 1 (Lowest) 5 (Highest)
Egalitarianism 1,573 6.67 1.56 2 (Lowest) 10 (Highest)
Distrust in government 1,593 9.94 2.49 3 (Most trusting) 15 (Most distrusting)
Source: Author’s survey.


age group (under 30, 30–39, 40–49, 50–59, 60 and over), educational
attainment (primary and under, secondary, tertiary), monthly income (under
HK$10,000, HK$10,000–30,000, over HK$30,000) and subjective
health status (very good, good, average, poor, very poor) as individual-level
characteristics.
The second set of variables was related to individuals’ personal experiences
with the health system, which are crucial in analyzing satisfaction. It was first
hypothesized that the type of health facilities that an individual used often
might affect his or her satisfaction with the entire system. The respondents
were asked to indicate the type of facilities that they visited most often when
seeking care from public hospitals/clinics, private hospitals/clinics and
pharmacies (pharmacies in Hong Kong do not act only as drug dispensers –
some also offer consultation services, especially in traditional Chinese medi-
cine). The second explanatory variable related to service utilization was the
respondents’ self-perceived burden of out-of-pocket payments. The question
read, ‘Do you think your individual expenditure on health care is heavy or
light as a percentage of total expenditure?’. The response options were too
heavy, heavy, light, very light. In analyzing popular support for public health care
arrangements, satisfaction with the existing system was included as an explan-
atory variable, in order to examine if there exists any interactive pattern
between two dimensions of health policy legitimacy.
Regarding the third group of explanatory variables, the two questions used
in Missinne et al. (2013) were applied in this study to capture the respondents’
egalitarian viewpoints. The respondents were invited to indicate to what
extent they agreed with the following statements, ‘For a society to be fair, differ-
ences in people’s standard of living should be small’ and ‘Large differences in people’s
incomes are acceptable to properly reward differences in abilities and endeavor’. A 5-point
Lickert scale was used, the options ranging from strongly agree to strongly disagree.
An additive index combining the values of the two answers was used to indi-
cate the respondents’ egalitarianism. The second item was reversely recoded,
so that higher scores pointed to a more egalitarian stance. Named ‘egalitari-
anism’, this new variable (based on the additive index) ranged from 2 to 10
in numeric value.
The final explanatory variable gauged individuals’ trust of broadly defined
government. The respondents were asked to indicate the extent to which they
trusted the Chief Executive (the head of administration of the Hong Kong
SAR), the Legislative Council (Hong Kong’s unicameral legislature), and
government officials in Hong Kong; the five response options were very trusting,
quite trusting, half-half, quite distrusting, very distrusting. An additive index was
created by summing the score of each item. The index scores ranged from
3 to 15, with a higher score representing greater distrust (variable name
‘distrust in government’).
Results and Discussion

Univariate analysis revealed a moderately high level of public satisfaction
(Mean = 3.239, SD = 0.939): 45.85 per cent of the respondents felt very
satisfied or satisfied with Hong Kong’s health system; 20.67 per cent were
very dissatisfied or dissatisfied; the rest indicated ‘half-half’. The support for
state involvement in health care provision exhibited an hourglass shape in
the distribution of the results (Mean = 3.065, SD = 1.300); a slight majority
of the respondents, 44.24 per cent, endorsed the statement that the govern-
ment should provide basic care only, while 43.48 per cent expressed opposi-
tion to it; 12.27 per cent were neutral. Residualist welfare thinking seems to
have dominated the ideology of more Hong Kong citizens with regard to
health care provision.
Almost one-third of the respondents, 33.31 per cent (N = 587), visited pub-
lic hospitals/clinics most often; private hospitals/clinics were the chief choice
of providers for 58.63 per cent (N = 1,033) of the respondents. This is an
expected result, as most Hong Kong residents tend to use private facilities
for primary care and usually do not visit public hospitals unless acute care
and/or hospitalization is needed. Health care expenditures overall appeared
not to be a major burden, as a mere 16.48 per cent of the respondents
reported out-of-pocket payment as being heavy or too heavy. The egalitarian
beliefs held by the respondents were moderately strong (Mean = 6.674,
SD = 1.561, Min = 2, Max =10). The overall trust in government was on
the low side, as reflected in the index score (Mean = 9.945, SD = 2.491,
Min = 3, Max =15).
The results of multivariate analysis are presented in table 2. The two
dependent variables were regressed separately with ordered probit models.
Model 1 was used to examine the effects of individual characteristics. In
Model 2, the respondents’ personal experiences (namely, the types of facilities
most often visited and the perceived out-of-pocket burden) were added to the
regression model to give a more complete illustration of the self-interest argu-
ment. Ideological beliefs and institutional trust were included in Model 3,
with age, health status, income and gender controlled for.
It can be seen that the oldest age group was the one most satisfied with the
health system. This is understandable, because senior citizens usually visit
public facilities that are highly accessible but charge low fees while providing
care of decent quality. This finding was reinforced by controlling for the type
of facilities that the respondents usually visited (Model 2). Clearly, users of the
public system demonstrated greater satisfaction, a finding consistent with
those of previous studies (Wong et al. 2012). Education, gender and income
showed no statistically significant relationship with satisfaction in Model 1
or Model 2, suggesting the high level of satisfaction irrespective of social
classes.
Interestingly, poor health did not necessarily lead to a lower evaluation of
the system; it was those in average health who reported significant dissatisfac-
tion. Compared to healthy individuals (who tend to report a positive evalua-
tion of the system) and the elderly (who are major beneficiaries of the
system), individuals of average health are neither healthy enough to engender
positive feelings nor too sick to be beneficiaries; but at the same time they still
bear the responsibility of supporting the system by paying taxes. Thus, as a
reflection of the contribution-utilization gap similar to the one observed in
Western countries, this finding still supports the self-interest argument, which
is also supported by the result that the respondents who reported private
Table 2
Regression results
Satisfaction State involvement
Model 1 Model 2 Model 3 Model 4 Model 5

Female 0.064 [0.057] 0.058 [0.058] 0.085 [0.063] 0.140 [0.057]** 0.096 [0.062]*
Age (‘under 30 ’ as reference category)
30–39 0.052 [0.110] 0.013 [0.112] 0.135 [0.118] 0.213 [0.109]* 0.157 [0.116]
40–49 0.045 [0.102] 0.004 [0.103] 0.088 [0.109] 0.129 [0.101] 0.063 [0.107]
50–59 0.086 [0.098] 0.108 [0.099] 0.003 [0.106] 0.277 [0.097]*** 0.188 [0.104]*
60 and above 0.402 [0.097]*** 0.432 [0.100]*** 0.287 [0.108]*** 0.399 [0.096]*** 0.316 [0.105]**
Education (‘primary and under’ as reference category)
Secondary 0.017 [0.086] 0.035 [0.088] 0.093 [0.106] 0.017 [0.087] 0.011 [0.105]
Tertiary 0.026 [0.098] 0.048 [0.100] 0.164 [0.118] 0.139 [0.098] 0.098 [0.116]
Monthly income (‘under HK$10 ,000 ’ as reference category)
HK$10,000–30,000 0.003 [0.069] 0.001 [0.070] 0.032 [0.077] 0.047 [0.068] 0.002 [0.075]
>HK$30,000 0.139 [0.092] 0.140 [0.094] 0.139 [0.101] 0.098 [0.090] 0.134 [0.098]
Subjective health status (‘good’ as reference category)
Average 0.289 [0.056]*** 0.260 [0.057]*** 0.265 [0.063]*** 0.041 [0.056] 0.014 [0.062]
Poor 0.066 [0.119] 0.102 [0.123] 0.186 [0.143] 0.166 [0.118] 0.188 [0.140]
Public hospital user – 0.144 [0.061]** 0.026 [0.069]* – –
Out-of-pocket burden (‘light’ as reference category)
Moderate – 0.273 [0.090]** 0.257 [0.101]** – –

Heavy – 0.347 [0.076]*** 0.317 [0.085]*** – –
Satisfaction with health system (‘dissatisfied’ as reference category)
Half-half – – – – 0.215 [0.069]**
(Continued)
763
764
Table 2
(Continued)
Satisfaction State involvement
Model 1 Model 2 Model 3 Model 4 Model 5
Satisfied – – – – 0.227 [0.080]**

Egalitarianism – – 0.070 [0.020]*** – 0.047 [0.020]**
Distrust in government – – 0.132 [0.013]*** – 0.049 [0.013]***
/Cut 1 1.647 [0.132] 1.280 [0.152] 3.144 [0.262] 1.392 [0.128] 0.539 [0.228]
/Cut 2 0.822 [0.127] 0.441 [0.148] 2.242 [0.256] 0.227 [0.125] 0.651[0.228]
/Cut 3 0.113 [0.125] 0.499 [0.147] 1.268 [0.253] 0.087 [0.125] 0.979 [0.228]
/Cut 4 1.856 [0.136] 2.254 [0.158] 0.551 [0.255] 0.886 [0.126] 1.788 [0.230]
Log likelihood 2074.4976 1984.1831 1656.6166 2390.2092 1947.9555
N 1,629 1,597 1,325 1,603 1,320
Source: Author’s survey.

Notes: *p < 0.10. **p < 0.05. ***p < 0.01. Standard errors are reported in parentheses.

payments as being medium or heavy were significantly associated with

dissatisfaction.
Stronger egalitarian beliefs led to higher satisfaction with Hong Kong’s
health system, suggesting that the system was most strongly supported by
those who stressed social equality. Trust of the government turned out to be
a very powerful predictor of satisfaction, greater distrust being associated with
less satisfaction. This echoes the study by Footman et al. (2013) that found
trust in political institutions not only shaped citizens’ confidence in the entire
health system, but also affected their satisfaction with the set of services
provided. This is particularly so in political systems suffering from a ‘trust
deficit’, such as Hong Kong (Cheung 2013).
The second dependent variable was regressed on two sets of explanatory
variables in a phased fashion. Model 4 tested the self-interest hypothesis with
personal characteristics while Model 5 included ideology- and trust-related
variables. Satisfaction with the system was included in Model 5 to examine
whether individuals’ satisfaction with the health system had an impact on
their support for extensive governmental provision of health care. As pre-
dicted, females were associated with greater support for extensive public
provision, as their lower socio-economic status coupled with their emotional
characteristics makes them supporters of extensive public provision of care
(Svallfors 1997; Edlund 1999; Missinne et al. 2013). The age groups of
50–59 and 60 and over demonstrated significant opposition to the state-
ment that government should provide basic care while leaving individuals
to take care of themselves in other aspects of health care, a finding in line
with the self-interest argument.
Contrary to what the self-interest thesis may predict, subjective health did
not explain individuals’ support for more government-provided health care
in Hong Kong. Education and income had no statistically significant relation-
ship with the dependent variable. These results provide additional evidence
from East Asia for the argument that the health care arena is characterized
by a high level of solidarity, and public support for the system is largely inde-
pendent of income or social class (Gelissen 2002). Popular support for
governmental provision of health care in Hong Kong appears to be a
phenomenon largely unrelated to socio-economic or health characteristics.
As shown in Model 5, when controlling for other personal-level variables,
those who were more satisfied with the existing system tended to prefer more
state involvement. Although the statistical analysis was not able to determine
the direction of the causal arrow, there is very likely a mutually reinforcing
relationship between the two dimensions of health policy legitimacy. It has
been argued that the legitimacy of welfare states does not rely only on public
trust in the entire system or its underlying values but also on people’s trusting
the implementing agencies (such as hospitals and nursing homes) to be
capable of delivering various services (Rothstein and Steinmo 2002). The
result here suggests that the good performance of Hong Kong’s health system
has contributed a great deal to the reinforcement of health policy legitimacy.
Similar to the results shown in Model 3, a more egalitarian ideology and trust
of government were associated with greater support for extensive state
involvement.
Conclusion and Implications

To the best of the author’s knowledge, this article is the first study to examine
the legitimacy of health policy in a Chinese society. The aim was to extend to
Hong Kong, a member of the East Asian welfare state cluster, the scholarly
debates on the legitimacy of welfare states in the West. A bi-dimensional
definition of health policy legitimacy – encompassing both public satisfaction
with the health system and the normative expectation as to the extensiveness
of state involvement in health care – was adopted. Based on analysis of the
data collected from a telephone survey of adult Hong Kong citizens between
late 2014 and early 2015, the findings of this study demonstrate a fairly high
level of satisfaction with the city’s health system, but popular support for
government responsibility presents a clear residual characteristic, in contrast
to the patterns observed in European nations.
The body of the analysis was focused on examining the predictors of
both dimensions of health policy legitimacy. The self-interest argument
and the ideology argument were considered in the analysis; trust of govern-
ment was also included as a potential explanatory variable. Multivariate
analysis suggested partial support for the self-interest argument in the Hong
Kong context. The elderly demonstrated higher satisfaction with the system
and greater support for governmental provision. However, neither good
nor poor health status showed any significant relationship with either
dimension of legitimacy. In contrast to the findings from European
countries (e.g. Gevers et al. 2000; Missinne et al. 2013), Hong Kong
citizens appear to demonstrate a higher level of social solidarity in health
care, which may have been shaped by the institutional legacy of the public
system. Yet, to what extent the Chinese culture has played a role warrants
further studies in the future.
One important finding that emerged is that users of public hospitals were
associated with higher satisfaction, which in turn reinforced the support for
state involvement. Although private providers play a substantial role in pri-
mary care, the backbone of Hong Kong’s health system is, arguably, its tax-
funded public facilities. The highly equitable and accessible provision of care
greatly enhances the legitimacy of the whole system, reinforcing the argument
that public hospitals are a valuable governmental tool that can help achieve
various social policy goals, if properly used (Ramesh 2008). The SAR
Government has reaffirmed with the public its strong commitment to con-
tinue to run the public hospital system with high standard, notwithstanding
its plan to strengthen the private components in both financing and provision.
The ideology argument received stronger empirical confirmation in the
Hong Kong context, with greater egalitarian view leading to higher satisfac-
tion and stronger preference for extensive state-organized health care. This
echoes the mainstream argument that ideology is at the core of health policy
opinion formation (Schlesinger and Lee 1993; Gelman et al. 2010). Health
care is different from other social policies because of its more universal impli-
cations in the sense that nearly all citizens experience directly the operation of
the system (Schlesinger and Lee 1993), and therefore, this is an arena where
strong solidarity is usually observed.
Another significant finding is that distrust of the political institutions seems

to undermine health policy legitimacy. The politics of Hong Kong in the post-
handover era have been increasingly characterized by a blend of anti-Beijing
sentiments, rising local identity and calls for greater democratic space, as can
be seen in the recent social movements. The political dynamics have left clear
marks on social policies. As Ramesh (2012) insightfully pointed out, the lack
of full political legitimacy in this liberal semi-democracy has made meaningful
social policy reforms difficult. This study, too, provides new evidence that
distrust of the government is significantly associated with lower satisfaction
as well as with less support for governmental provision of health care.
Hong Kong is in the midst of health care reforms. Central to the reform
agenda is correcting the public-private imbalance of Hong Kong’s health
system by promoting greater private responsibilities. The middle- and high-
income segments of the society, in particular, are encouraged to shoulder
more costs by joining a proposed voluntary health insurance scheme and to
utilize private services. However, the promotion of greater private responsibil-
ities introduces the risk of jeopardizing health policy legitimacy, given the
positive association between high level of public satisfaction and the use of
public hospital services in Hong Kong. The resolution of this tricky situation
therefore requires not only professional expertise in health policy per se, but
also excellent social acuity on the part of policymakers. Health policy reforms
are in essence a political process, and this is particularly so in Hong Kong. As
pervasive distrust of the government is the main instability factor in the
territory’s public governance, the window of political opportunity for reforms
is narrowing (Cheung 2013). The success of health policy reform thus hinges
on astute political management of public opinions and the creation of more
popular policy discourses. As such, a more thorough appreciation of the
public’s views on health policy and the health system as a whole is of critical
importance.
Acknowledgements
This study was funded by the Telephone Survey Funding Scheme of the
Department of Asian and Policy Studies, the Education University of Hong
Kong. The author is very thankful to Kee-lee Chou for inspiring this study.
Valuable comments from M. Ramesh and Jiwei Qian are gratefully
acknowledged.
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SOCIAL POLICY & ADMINISTRATION ISSN 0144-5596

Public Satisfaction with the Health System and Popular

© 2016 John Wiley & Sons Ltd

Popular support for welfare states and predictors

attitudes towards social welfare because this effect is mediated by their

Health policy legitimacy

Predictors of health policy legitimacy

Public attitudes towards social welfare in Hong Kong

Health care system of Hong Kong

© 2016 John Wiley & Sons Ltd 757

Public hospitals provide close to 90 per cent of inpatient services. Citizens

Descriptive statistics of key variables

Variable Obs. Mean Std. Dev. Min Max

Gender 1,793 1.61 0.49 1 (Male) 2 (Female)

Source: Author’s survey.

© 2016 John Wiley & Sons Ltd

Results and Discussion

Satisfaction State involvement

Model 1 Model 2 Model 3 Model 4 Model 5

© 2016 John Wiley & Sons Ltd

Moderate – 0.273 [0.090]** 0.257 [0.101]** – –

Satisfaction State involvement

Model 1 Model 2 Model 3 Model 4 Model 5

Satisﬁed – – – – 0.227 [0.080]**

Source: Author’s survey.

© 2016 John Wiley & Sons Ltd

payments as being medium or heavy were signiﬁcantly associated with

Conclusion and Implications

Another signiﬁcant ﬁnding is that distrust of the political institutions seems

© 2016 John Wiley & Sons Ltd 767

768 © 2016 John Wiley & Sons Ltd

© 2016 John Wiley & Sons Ltd 769

770 © 2016 John Wiley & Sons Ltd

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Moderate – 0.273 [0.090] 0.257 [0.101] – –