Title

An evaluation on 2007 obstetric service policy in Hong Kong : a solution to the service-seeking behaviour of Mainland pregnant women? Shiu, Wan-yee, Ruby; Q

Author(s)

Citation

Issue Date

2007

URL

http://hdl.handle.net/10722/52547

Rights

unrestricted

An Evaluation on 2007 Obstetric Service Policy in Hong Kong a Solution to the Service-seeking Behaviour of Mainland Pregnant Women?

By SHIU Wan-yee, Ruby June 2007

Degree of Master of Public Administration The Department of Politics and Public Administration Faculty of Social Science University of Hong Kong

I, Shiu Wan Yee, attest that this thesis, An Evaluation on 2007 Obstetric Service Policy in Hong Kong a Solution to the Service-seeking Behaviour of Mainland Pregnant Women?, submitted for fulfillment of the Master of Public Administration is fully my own work unless otherwise quoted and cited.

ii

Table of Content

Content

Page

Chapter One

Introduction Introduction Undesirable Phenomena Diagnosis to the Phenomena Economic Environment Legal Ambiguity Failure of Charging Policy Government Action Framework of Study Research Questions Methodology Dissertation Plan

1 2 5 5 6 7 9 11 12 12 13

Chapter Two

Hong Kongs Immigration Policy on Mainlanders Introduction 14 Immigration Policy on Mainlander in Colonial Era 14 Entry to Hong Kong for Settlement 17 Entry to Hong Kong for Visit 18 Immigration Policy on Mainlanders after 1997 20 Contradiction between Basic Law and Immigration 25 Ordinance Immigration Ordinance 25 Basic Law 26 CHONG Fung-yung v. the Director of Immigration 28

Chapter Three

Diagnosis of the Problem from an Economic Approach Introduction Common Pool Resources Problem of Collective Actions Externalities

31 31 32 34

iii

Public Obstetric Service in Hong Kong Cost of Giving Birth in Hong Kong I) Short-term costs II) Long-term costs Benefits of Giving Birth in Hong Kong I) Fleeting from one-child policy penalty II) Advanced medical care III) Hong Kong Residency Externalities Policy Before September 2005 Policy After September 2005

38 40 41 41 43 45 45 45 46 48 48

Chapter Four

New Policy in February 2007 Introduction The New Policy Increase in Charge Defaulted Payment Prevention Mechanism Centralized Registration System Tightened Immigration Control

51 51 52 53 54 55

Chapter Five

Evaluation of the New Policy Introduction What is Evaluation Classification of Policy Regulatory Instrument Economic Instrument Information Evaluation of 2007 Policy Policy Instrument Choice of Instrument Design of Policy Conclusion

56 58 60 60 61 62 63 63 64 68 69

iv

Chapter Six

The Way Forward Introduction 71 Long-term Implication 71 Social Disintegration 72 Restructuring of Obstetric Service Policy 73 Reorienting Policy Target 73 Extending Quota Coverage 74 Increasing Charge for Couples who are both 74 non-Hong Kong residents Supportive Measures 75 I) Immigration control 75 II) Defaulted Payment Prevention System 78 Civil Education 78 Vision in Education, Housing, Medical Service and other 79 Welfare Policies Education 79 Social Welfare Assistance 81 Conclusion 82

CHAPTER ONE INTRODUCTION Introduction In the past five years, the number of Mainland women coming to Hong Kong for obstetric services has risen from 7810 cases in 2001 to 20,577 cases in the first ten months of 20061. The percentage to the number of local pregnant women rose from Before 2001, majority of Mainland women came to

16% in 2001 to 39% in 2006.

Hong Kong for obstetric services were wives of Hong Kong males. While in recent years, there was an upsurge in the number of Mainland women, whose husbands were also Mainlanders, came to Hong Kong for giving birth. Among the 20,577 Mainland

women giving birth in Hong Kong, 61% of them were married to non-Hong Kong residents. Detailed figure on the number of birth by Mainland mothers in Hong Kong appear in Annex A.

With only eight public hospitals providing obstetric services in Hong Kong, handling around 42,000 deliveries per year 2 , the large influx of Mainland women poses significant pressures on the scarce health care resources in Hong Kong. Some public

Discussion Paper on Impact of the use of Obstetric Services by Mainland Women on Public Hospital Resources by Legislative Council Panel on Health Services. (8 January 2007), LC Paper No. CB (2) 761/06-07(03). 2 Hospital booking rule for Mainland mothers, Global News Wire - Asia Africa Intelligence Wire, 2007-01-17. 1

hospitals have already announced that no further registration for obstetric services would be accepted in the first half year of 2007 due to the excessive workload they encountered due to the influx of Mainland women.3

Undesirable Phenomena There were intermittent reports on the plight of local pregnant women. Some did not

receive the same amount of prenatal checks as they used to have. Extra beds made of canvas were placed inside public wards to cater for the excessive numbers of expectant mothers who were waiting for giving birth. Some were even left in the

corridor. There were reports that that more than one woman gave birth in one delivery room at the same time. The privacy of these mothers-to-be was not

respected. Worse still, some pregnant women deliberately chose to deliver their babies by surgery instead of natural labour just to secure a stay in the hospital.4 It

was because they knew that those gave birth by surgery (elective caesarean section) were allowed to stay for maximum three nights while those had their babies naturally born (spontaneous vaginal delivery) could only stay one night in the hospital.

3 4

, Apple daily. (2006-12-8) , Apple Daily (2006-12-07) 2

Local pregnant women showed concern about deteriorating standards of care and were resentful of outsiders coming in, jumping queues, and getting services they had not wholly paid for. A group of 30 angry Hong Kong mothers marched to Central

Government Office to air their resentment in order to push the Government into taking action on November 19, 2006, which was believed to be the major factor that triggered the implementation of new measures in February 2007.

Hong Kong public medical care is funded mainly by the HKSAR government. Approximately HK$300 million revenue of Hospital Authority in 2006, 90% was government subvention. Hong Kong taxpayers generally have the feeling that

money they spent went to subsidize Mainland women instead of provide quality medical service to Hong Kong people5 as the obstetric services were provided to everyone at a highly subsidized rate regardless of the service seekers nationality.

Before the imposition of the HK$20,000 obstetric package in September 2005, the charge for obstetric services was calculated based solely on the number of days of hospitalization, prior to this, the charge was standardized across all public hospitals at a highly subsidized rate at HK$100 per day for Hong Kong residents and HK$3,300

Public money spent on medical service amounting to $32.2 billion in 2006 which was around 13% of the overall government expenditure. Sources : Census and Statistics Department. HKSAR Government. 3

per day for non-Hong Kong residents while the average cost of delivery for a pregnant woman was $12,000 to $14,000.6 The influx of Mainland women seeking obstetric What is

services imposed significant financial burden to our health care system.

more, some of these Mainland women did not settle the bill before they left the hospitals. Together with the inefficient default payment collecting mechanism, the

bad debts of Hospital Authority amounted to $2,800 million in 2005/06.7

What made the situation even worse was that many of these Mainland pregnant women did not receive any antenatal examination before they came to Hong Kong for giving birth.8 It posed considerable risks to both the mothers-to-be, hospital staff,

other patients, and the babies because illness, defects and other possible problems could not be detected before delivery. Besides, as the service seekers medical

history and the health condition of their babies are all unknown to the hospitals, this also brought risk to the hospital staffs and other pregnant women staying in the same hospital, especially when the pregnant woman has Viral Hepatitis Type B or Acquired Immune Deficiency Syndrome.

6 7

Legislative Council Meeting on November 10, 2004.

(http://www.legco.gov.hk/yr04-05/english/counmtg/hansard/cm1110ti-translate-e.pdf)

Discussion Paper on Impact of the use of Obstetric Services by Mainland Women on Public Hospital Resources by Legislative Council Panel on Health Services. (8 January 2007), LC Paper No. CB (2) 761/06-07(03). 8 In 2006, there were almost 20,000 Mainland women gave birth in Prince of Wales Hospital. More than 70% of them did not receive antenatal examination. Source : , Mingpao. (2006-12-07) & 5 16 , Singtao Daily. (2006-12-07). 4

Diagnosis to the Phenomena Economic environment Mainland women giving birth in Hong Kong is a complex issue and cannot be easily explained by one single reason. It is the result of political, economic, and social changes after the handover of sovereignty in 1997. Before 1997, when Hong Kong

was still a British colony, its economic development, job opportunities, political stability attracted immigrants from Mainland China. Hong Kong government

enacted Immigration Ordinance and imposed strict control over Mainland migrants and visitors. The purpose was to control the number of influx of Mainland China to

avoid unbearable pressure on the resources of Hong Kong.

After 1997, Hong Kong experienced an economic downturn due to Asian Financial Crisis. To revive the economy, Hong Kong government agreed to increase the

Two-way Permit quota three folds to encourage Mainland visitors traveling Hong Kong. The number of Mainland visitors increased from 2.27 million in 1997 to 4.86 million in 2001.9 When Hong Kong economy rebounded in 2003, the Severe Acute

Respiratory Syndrome (SARS) outbreak seriously hit Hong Kong retail, tourism, and catering industries. The restrictions on Mainland visitors were further relaxed by the

Immigration Department Annual Reports 96-97, 03-04. 5

introduction of Individual Visit Scheme in 2003 that allowed Mainlanders to visit Hong Kong in their own capacity (i.e., without being part of a tour group) for a maximum of seven days. The relaxation of immigration control has paved way for

the large influx of Mainland pregnant women coming to Hong Kong for the purpose of giving birth.

Legal Ambiguity Before 1997, when the people moving in and out from Hong Kong were governed by Immigration Ordinance Chapter 115 (Cap. 115), Hong Kong residents were defined as Chinese citizen born in Hong Kong if one of his/her parents had settled or had the right of abode in Hong Kong at the time of his/her birth or at any later time. With

the introduction of Basic Law in 1997, the definition of Hong Kong citizens under Immigration Ordinance was challenged as it was found to be contradictory with Article 24(2)(1) of the Basic Law which provides that Chinese citizens born in Hong Kong Special Administrative Region have the right of abode in Hong Kong. Ambiguity over the definition of Hong Kong residency was cleared on 20 July 2001 when the Court of Final Appeal ruled in the Chong Fung-yuen case that Chinese citizens born in Hong Kong have the right of abode in Hong Kong regardless of the status of their parents.

The decision of Court of Final Appeal gave all babies born to Mainland women in Hong Kong, residency in Hong Kong, which is also the main reason for Mainland women coming to Hong Kong for giving birth. They know that their babies, as

Hong Kong citizens, will have free education, healthcare, housing benefit and social welfare. Many Mainland parents have expressed that they will have their children in care of relatives in Hong Kong and to be educated in Hong Kong.10 Some said that these newborn babies would be a solution to our ageing problem while some argued that they might be the heaviest financial burden to Hong Kong society. Although

either hypothesis is anticipation, the number of babies born to Mainland women is large enough to have implication on Hong Kongs planning and policy on population, welfare, and education.

Failure of Charging Policy Another reason for the large influx of Mainland mothers-to-be was the low charge for obstetric services in Hong Kong. Health care services in Hong Kong are distributive in nature. Requests from any person, regardless of their citizenship and financial condition, would be contemplated. Fees and charges for different medical services are standardized across all public hospitals at a highly subsidized rate. The same fee

10

Authority cashes in on pregnancy policy. South China Morning Post. (2007-02-02). 7

structures applied to Hong Kong and non-Hong Kong residents alike.

Before

September 2005, obstetric service for Mainland women only costed HK$3,300 for one-day hospitalization in a public general ward. the baby delivery service. This charge has already included

The charge was so low that it could not even cover the

cost of delivery. The low charge level attracted Mainland women since they could enjoy enormous benefits including better medical care and Hong Kong residency for their children born in Hong Kong.

Despite the low medical charge, many Mainland women did not settle the bill before leaving the hospitals. In addition, there is no policy or system in place to ensure full The ineffective default payment mechanism For Mainland women, seeking

payment is made before they left.

further encouraged such free-riding behaviour.

obstetric services in Hong Kong have everything to gain, nothing to lose.

What is more, by giving birth in Hong Kong, Mainland parents could avoid the penalty for having more than one child under One-child policy. This policy was

adopted by Mainland China since late-1970s as a measure to control its population. It stipulates that each couple is only entitled to have one child. Every extra child will cost the couple around RMB80,000 as penalty. Since children born in Hong Kong

are Hong Kong citizens and will not have Mainland Hukou, citizenship, their parents would not be fined.

Government Actions The ever-increasing number of Mainland mothers giving birth in Hong Kong made the government realize the problem. It is recognized that the obstetric service charge To

for non-Hong Kong residents was set too low, causing market disequilibrium.

bring the market to optimum, the Hospital Authority introduced a new charging system as a rational basis for the allocation of resource in September 2005. Each

non-Hong Kong pregnant woman giving birth in Hong Kong will be provided with a minimum obstetric package, which included delivery and three days 2 nights of hospitalization in a public general ward. The whole package charges each service

seeker HK$20,000. Private consultation fees were also revised from fixed standard charges to pre-sent ranges to reflect variations in the complexity of the patients clinical conditions and in the expertise that might be required for treatment. As

services were provided based on medical need regardless of the patients or service seekers citizenship, requests from local and Mainland pregnant women were handled in the same manner.

The alarming figure of bad debt11 also pushed the authority to introduce measures to avoid defaulted payment. The minimum obstetric service package required all

non-Hong Kong residents to pay a deposit of $19,800 upon admission at a public hospital. However, as many Mainland pregnant women know that they would not be

denied medical service due to lack of means, they avoided paying deposit by seeking service from accident and emergency (A&E) ward when they approached to deliver. After delivery, the Mainland mothers left with their babies prematurely to evade payment. These acts pose significant risks to both the mothers and babies. There were intermittent reports that babies died due to inadequate postnatal care as the babies mothers left hospitals for avoiding payment.12

Noise from the public and the pressure groups formed up by pregnant women had pushed the government in facing the problem in a more active way. After several meetings among the Secretary for Health, Welfare, and Food Bureau Dr. York Chow, Secretary for Security Mr. Ambrose Lee, and Mainland China Authorities on the issue, the Bureau came up with some measures to tackle with the problem. Aims of the

measures are to ensure that local pregnant women would be provided with proper and

11

In 2004/2005 financial year, the defaulted payment arisen from obstetric services by Mainland women amounted to HK$1,200 million. Source : Hospital Authority : management of outstanding medical fees, Audit Commission. HKSAR Government. http://www.aud.gov.hk/pdf_e/e47ch05.pdf 12 4 , Wenweipo. (2006-12-27). 10

priority obstetric services through restricting the number of non-local pregnant women giving birth in Hong Kong to a level that can be supported by Hong Kongs healthcare system.13

Framework of Study This paper will employ market theories to explain the problem of insufficient public obstetric service in Hong Kong. The following are the major presumptions in the framework14 i) Public obstetric service is common-pool resources that are

non-excludable and subtractive. problem of free-riders. ii)

Its nature inevitably results in the

As human beings are rational and self-interested, they only see the cost imposed on them and neglect the cost imposed on the society as a whole. The problem of externalities resulted in market inequilibrium and inefficiency.

iii)

The problem of externalities can be solved by internalizing the social cost to individual through Pigouvian tax so that the consumer can see

13

New measures on obstetric services and immigration control on January 16, 2007, Press Release, www.info.gov.hk. 14 The presumptions are the summary of reference drawn from OSTROM, E., (1990), Governing the Commons, Cambridge : NewYork, Cambridge University Press, COWen, T., (eds), The Theory of Market Failure : A critical Examination, Fairfax, Va. : George Mason University Press and DUNN, W., KELLY, R.M., (eds), Advanced in Policy Studies since 1950, New Brunswick and London : Transaction Publishers (1992). 11

the real cost of their consumption. iv) One of the greatest challenges to Pigouvian tax is that the government is not able to have perfect information to set the optimal tax level.

Research Questions In this dissertation, I will ask the following questions: What makes the public obstetric services become so scarce? Why could the policy adopted in 2005 not solve the problem? Can the new policy implemented in 2007 solve the problem of Finally, can the policy mark an end to Hong

insufficient public obstetric services?

Kong peoples anxiety over Mainland womens utilization of obstetric services?

Methodology This paper employs the theoretical frameworks of common pool resource, externalities and Pigouvian tax to illustrate the problem of insufficient public obstetric service in Hong Kong in recent years. literature will be conducted on these theories. Extensive research on academic

Additionally, useful information will

be collected from newspaper, magazines, and websites, journals and reports and meeting records of Legislative Council.

12

Interviews will be conducted with representatives of interest groups, representatives of enforcement agencies and professionals such as doctors and nurses to seek their views on the feasibility and effectiveness of the new policy.

Dissertation Plan The whole dissertation comprises six chapters. In Chapter 2, the evolution of Hong Kongs immigration policy on Mainlanders before and after 1997 will be discussed. The discrepancies between Immigration Ordinance and Basic Law after 1997 will be emphasized to illustrate the reason for the influx of Mainland pregnant women after 2001. Chapter 3 will explain the Mainland womens service-seeking behaviour from This chapter will apply the Pigouvian theorem in

economic point of view.

answering the failure of 2005 policy. Chapter 4 is the detailed description of the new policy implemented in February 2007. five by applying Policy Instrument theory. This policy will be evaluated in Chapter Instead of evaluating the policy outcome,

this chapter will analyze the policy effectiveness and legitimacy by referring to the choice of policy tools and the design of policy. The last chapter will round up the

whole dissertation by proposing suggestions on the way forward.

13

CHAPTER TWO HONG KONGS IMMIGRATION POLICY ON MAINLANDERS

Introduction Hong Kong has long been an immigration city. Since the British occupation of the

territory in 1842, Hong Kong has been a favorite sanctuary for those looking for a better life.15 People from Mainland China come to Hong Kong for different reasons. Some treasure political stability while some cherish rapid economic development. At present, more than half of Hong Kong population is immigrants from Mainland China.16 From 1842 when Hong Kong became a British colony, to now, Hong

Kongs immigration policies for Mainlanders have aimed at controlling the number of migrants from Mainland China to avoid unbearable pressure on the resources of Hong Kong. Evolution of Hong Kong immigration policy on Mainlanders since 1842 is outlined in Annexure B.

Immigration Policy on Mainlanders in Colonial Era Hong Kong had no immigration control measures on Mainlanders until 1938 when the

15

CHAN, J. The Evolution of Immigration Law and Policies : 1842-2003 and Beyond in CHAN J., Rwezaura, B. (eds) Immigration Law in Hong Kong : An Interdisciplinary Study, Hong Kong : Sweet & Maxwell Asia (2004). Pp. 1. 16 Ibid. 14

population grew from 878,947 in 1931 to over 1,500,000.17 At the time, the Hong Kong Government realized that the society could not cope with the influx of people from Mainland China in terms of physical, social, and economic infrastructure. The

Immigration Control Ordinance of 1949 was enacted which provided that any person not in possession of relevant travel documents, visas or entry permit, frontier passes or certificates of residence issued under the Ordinance were illegal immigrants and would not be permitted to land, enter or remain in Hong Kong18.

Notwithstanding the introduction of the Immigration Control Ordinance, the immigration authority adopted an open door policy. How an illegal immigrant was

to be dealt with was decided by the prevailing executive policies and not by the law. Immigration officers could exercise their discretions in granting permits, with or without conditions, to allow an illegal immigrant to stay in Hong Kong. Instead of

being repatriated to Mainland, every illegal immigrant could obtain entry permit by reporting to the immigration authorities so that their stay could be regulated. One of

the reasons was that Hong Kong economy suffered badly in the fifties after the outbreak of the Korean War in June 1950. The United Nation and the United States

17

Growth of Population in Hong Kong 1841-2006. Details at Annexure C. Source : CHAN, J. The Evolution of Immigration Law and Policies : 1842-2003 and Beyond in CHAN J., Rwezaura, B. (eds) Immigration Law in Hong Kong : An Interdisciplinary Study, Hong Kong : Sweet & Maxwell Asia (2004). Pp. 1. 18 Natives of Guangdong Province were exempted from this Ordinance. 15

imposed embargoes on Mainland China and Hong Kong. Trading of Hong Kong almost came to a standstill. At the same time, political uncertainties pushed refugees

from Mainland China who brought to Hong Kong capital and industrial expertise as well as a pool of skilled, intelligent, and industrious labour. These refugees were the

major force of economic growth at that time which explained why the government adopted such a lenient policy toward illegal immigrants from Mainland China in the fifties and sixties.19

Under this open door policy, about 60,000 Chinese persons entered Hong Kong illegally between 1962 and 1972 and were subsequently permitted to stay. However, in 1973 alone, 56,000 illegal immigrants arrived from the Mainland. 20 When comparing with the total population of 4,203,700 in 197321, the figure was quite alarming. in 1974. It pushed the Hong Kong Government to impose a reached-base policy Under this policy, illegal immigrants who were arrested in the border

region or in Hong Kong territorial waters during their attempt to enter Hong Kong would be repatriated, but all others who evaded immediate capture, entered the urban areas and subsequently gained a home with relatives or otherwise found proper
19

CHAN, J. The Evolution of Immigration Law and Policies : 1842-2003 and Beyond in CHAN J., Rwezaura, B. (eds) Immigration Law in Hong Kong : An Interdisciplinary Study, Hong Kong : Sweet & Maxwell Asia (2004). Pp. 6-9. 20 Ibid. 21 Hong Kong Population Projection 1971-1991. Census and Statistics Department. HKSAR Government. 16

accommodation would be given permission to stay in Hong Kong.22

In 1979, five

years after the implementation of reach-base policy, the number of Mainlander arrested on arrival and repatriated was 89,900 while those evaded capture and remained in Hong Kong was 107,700. Some condemned that this policy positively

encouraged illegal immigrants from Mainland and led to an influx of illegal immigrants who arrived and reached base.23 This reached-base policy was thus abolished in 1980. removed.24 All illegal immigrants from Mainland China were to be

Entry to Hong Kong for Settlement Since the abolishment of the reach-base policy in 1980, the only legal way for people from Mainland China to come to Hong Kong for settlement was entry under One-way Permit (OWP) scheme. OWP scheme is a quota system introduced in 1950 with maintaining a rough balance between the inflow and outflow of people as its major objective. However, the introduction of quota was opposed by the Mainland authority as unreasonable and unfriendly act towards the PRC and its people. It

was also a sensitive political matter to have an agreement on the quota, as this might
22

CHAN, J. The Evolution of Immigration Law and Policies : 1842-2003 and Beyond in CHAN J., Rwezaura, B. (eds) Immigration Law in Hong Kong : An Interdisciplinary Study, Hong Kong : Sweet & Maxwell Asia (2004). Pp. 12-13. 23 Illegal immigrants from Mainland who successfully evaded capture and remained in Hong Kong increased from 6,600 (1977) to 28,100 (1978) to 107,700 (1979). Ibid Pp. 12. 24 The number of legal immigrants from Mainland China dropped from 107,700 in 1979 to 69,500 in 1980, the first year of the abolishment of reach-based policy. 17

constitute a tacit recognition on the part of the Chinese government that Hong Kong was not part of China. Therefore, the quota was not strictly enforced. A

compromise would be that the Director of Immigration always gave permission to land to whoever was issued an OWP. Indeed, the number of legal migrants who It reached a peak

came to Hong Kong by way of an OWP varied from time to time. of 310 per day in 1978.

It resulted in 67,495 legal immigrants from Mainland China Although the

in one single year, which was almost 250% of the figure in 1977.

British and Chinese governments reached an agreement on the daily limit of the number of legal immigrant to 150 per day in 1980, the Mainland authority, which is the issuing authority of OWPs, still changed the daily limit over time. The authority

reduced the limit to 75 per day in 1983 while it increased to 105 in 1993 to facilitate the admission of a large number of long-separated spouses and children born to Hong Kong citizens. In 1995, the quota increased to 150 per day. Since then the daily

limit remained unchanged.25

Entry to Hong Kong for Visit The restrictions over Mainland visitors were strict in colonial era. Mainlanders who wish to make private visit to Hong Kong had to apply for a Two-way permit (TWP)
25

CHAN, J. The Evolution of Immigration Law and Policies : 1842-2003 and Beyond in CHAN J., Rwezaura, B. (eds) Immigration Law in Hong Kong : An Interdisciplinary Study, Hong Kong : Sweet & Maxwell Asia (2004). Pp. 15-16. 18

from Mainland Public Security Bureau offices before entry. implemented in 1950.

TWP scheme was

Before 1997, there were only two types of endorsements, Each had strict

Tanqing (Relative visit) and Tuandui Luyou (Group visit). requirements upon application.

Relative Visit endorsement was issued for those who

went to Hong Kong for managing properties or business or visiting close relatives who were Hong Kong permanent residents. The applicant must produce proof of business and properties in Hong Kong or proof of close relatives26 living in Hong Kong, including copies of Hong Kong Identity Card, certificate of marriage, or more. upon application. For Group Visit, visitors had to join tours organized by one of the three recognized and approved Mainland tour operators. depart together as a group. They must arrive and

There was also daily quota imposed on the Group visit

endorsement. It was hard to believe that the average daily quota for Group visit was 8.3 persons for the whole of Mainland China. The daily limit increased to 1,142 in

1998, though this was still inadequate to cope with the demand.27 Mainland people coming to Hong Kong for visits before 1997 were not as free as Hong Kong people going to Mainland China for visits were.

26

Before 1997, the definition of close relative confined to parents, spouse, spouses parents and siblings. Endorsement would only be issued to those who had relatives residing in Hong Kong. 27 SHAO, Shanbo (2002), , , Pp 6-9. 19

Immigration Policy on Mainlanders after 1997 Immediately after the change of sovereign, there was no significant influx of Mainlanders, either for settlement or for visit. The 150 daily quotas for OWP still Number of Mainland visitors to The major

applied and the issue of TWP was not released.

Hong Kong decreased from 2.29 million in 1996 to 2.26 million in 1997.

reason was that the China Government did not want chaos at the time of handover and sought stability.28

It was ironic that, after the changeover of sovereignty in July 1997, political stability faded away as the issue of concern as the economy became the major focus. What

many Hong Kong people and international observers feared about intervention by Chinese authorities did not happen. The One Country, Two Systems arrangement went off to an auspicious start. Quite unexpectedly, the outbreak of the Asian Until the

financial crisis began with the depreciation of the Thai baht in July 1997.

end of January 1998, a number of Asian currencies had depreciated substantially with respect to the US dollar. remained steady at 7.75. Since Hong Kong dollar was linked to the US dollar, it As a result, all these Asian currencies depreciated with Traveling to other Asian countries became much

respect to the Hong Kong dollar.

28

SHAO, Shanbo (2002), , , Pp 20. 20

cheaper than to Hong Kong after their currency depreciation.

In the first half of

1998, the number of visitor arrivals declined sharply by 21% as compared to the first half of 1997.29 Domestic consumption shrank and the economy contracted. Hong

Kongs unemployment rate hit record levels exceeding 7% by the end of 2002.30 When compared with Hong Kong, Mainland China was less affected by the Financial Crisis. RMB's non-convertibility protected its value from currency speculators.

Unlike other Asian countries, most of the Chinas investment took the form of factories on the ground rather than securities, which insulated the country from rapid out flowing of assets and money and sharp drop in the exchange rate after the financial crisis.31 The Chinese economy was hardly affected by the financial crisis as it continued to grow at 8.8% in 1997 and 7.8% in 1998.32

To revive the economy, Hong Kong government agreed to have the restrictions on the issue of TWP relaxed. In 1998, China Government introduced Shangwu (Business visit) endorsement, which allowed visitors on business trip, who previously were required to obtain a visa upon arrival at Hong Kong. The requirements for Relative
29

LIU, Pak-wai (1998), The Asian Financial Crisis and After Problems and Challenges for the Hong Kong Economy, Hong Kong Institute of Asia-Pacific Studies, Pp. 18 30 SIU, Alan & WONG, Richard, Economic Impact of SARS : The case of Hong Kong, Asian Economic Papers 3:1 (Winter 2004), pp. 62-83. 31 With all of its foreign investment took the form of factories on the ground instead of securities, China insulated itself from rapid capital flight. RMBs non-convertibility protected its value from currency speculators. China was less affected by the financial crisis. 32 Wong, J., Chan, S., Liang, R. The Impact of SARS on Greater China Economies in Wong, J (eds). SARS Epidemic, Singapore : World Scientific Publishing Company, (2004) Pp. 13. 21

Visit endorsement were released in 2000, which allowed Mainlanders to visit their relatives who lived, worked, and studied in Hong Kong. The daily quota for Group visit endorsement increased from 1,142 in 1997 to 1,500 in 2000. The number of

tour operators in Mainland China, which undertook the application of Group visit endorsement, also increased from 3 before 1997 to 63 in 2002. 33 At present, there are in total 99 tour operators in Mainland China that can apply Group Visit TWP. All

tour operators were monitored by the China Tourism Association. The relaxation in TWP permit requirements greatly attracted tourists from Mainland China. The

number of Mainland visitors to Hong Kong increased from 2.67 million in 1998 to 6.82 million in 2002.34 Revenue from tourism-related activities increased from 142 millions in 1998 to 287 million in 2002.35

When economy started to recover again 36 , Hong Kong experienced another crisis Severe Acute Respiratory Syndrome (SARS). A professor from Guangdong

came to Hong Kong for a relatives wedding. He stayed in a hotel in Kowloon for one night in February. He sought medical treatment in Hong Kong and was admitted Not soon after, his brother-in-law

to Kwong Wah Hospital on February 13, 2003.

33

SHAO, Shanbo (2002), , , Pp.

8.
34 35

Tourism Development Board. HKSAR Government. Ibid. 36 Real GDP in Hong Kong grew at 3.4% in the third quarter of 2002 and at 5.1% in the fourth quarter of 2002. Sources : SIU, Alan & WONG, Richard, Economic Impact of SARS : The case of Hong Kong, Asian Economic Papers 3:1 (Winter 2004), pp. 62-83. 22

and 16 other people, who stayed in the same hotel with the professor, were admitted. On February 22, 2003, the Guangdong professor was certified death and was later confirmed to have died of SARS. Another patient, who visited an acquaintance

staying on the same floor of the hotel during the critical day in February, admitted to Ward 8A of Prince of Wales Hospital (PWH) and brought the index case for Hong Kongs first outbreak in PWH. Eleven healthcare staff of PWH working in Ward 8A

left on sick leave on March 10, 2003. The number of medical staff who had infected with SARS through contact with this patient increased to 139. The SARS epidemic

reached its peak on March 30, 2003 when the government issued an order to isolate Block E of Amoy Garden after 213 residents of Amoy Garden were admitted to hospital for suspected and confirmed SARS with half of the cases were from block E. On April 2, 2003, the World Health organization (WHO) issued an advisory against non-essential travel to Hong Kong and Guangdong Province.37 Visitor numbers fell throughout the Asia-Pacific region, with Hong Kongs April arrivals dropping by almost 65% compared with 2002, and those of May by almost 68%.38 By the end of the epidemic, total 1755 people were infected with SARS. 1451 were discharged

while 304 died of the disease.39 Fearing the disease might spread to the community at large; Hong Kong people refrained from many consumption activities outside their
37

SARS Expert Committee Report : From Experience to Action. Department of Health. HKSAR Government. http://www.sars-expertcom.gov.hk/english/reports/reports/reports_fullrpt.html. 38 Hong Kong Tourism Board Annual Report 2003-2004. 39 SARS. Department of Health. HK Government http://www.info.gov.hk/info/sars/e_sars2003.htm. 23

homes. The drop in demand put further pressure on the price level and worsened the unemployment problem.40

To bring the Hong Kong economy back to life, the Chinese Government further released the issue of TWP and implemented the Individual Visit Scheme. Mainlanders might go to Hong Kong as individual visitors. Individual visitors from

the Mainland were permitted to remain in Hong Kong for a period of not more than 7 days upon each entry. When this scheme was introduced in July 2003, it was opened

only to residents of Dongguan, Zhongshan, Jiangmen, and Foshan in Guangdong Province. In the past three and a half years, the scheme extended progressively, and

now covers Guangdong province and 28 other cities (Refer to Map at Annexure D). The Individual Visit Scheme has brought a significant increase in the number of Mainland visitors to Hong Kong from 8.5 million in 2003 to 12.2 million in 2004 which brought an increase in inbound tourism revenue from 70,234 million in 2003 to 91,849 million in 2004.41 The Individual Visit Scheme was successful in reviving

Hong Kong economy while it also paved way for Mainland pregnant women to come to Hong Kong for giving birth. The number of visitors from Mainland China from

1997 to 2006 is shown in Annexure E.

40

Unemployment rate increased from 7.5% in March 2003 to the highest point of 8.7% in July 2003. Source : Census and Statistics Department. Hong Kong SAR Government. 41 Tourism Board Highlights 2004. HKSAR Government. 24

Contradiction between Basic Law and Immigration Ordinance The Sino-British Joint Declaration on the Question of Hong Kong (The Joint Declaration) was signed between the Chinese and British Governments on 19 December 1984. The Joint Declaration sets out the basic policies of the People's Under the principle of "One

Republic of China (PRC) regarding Hong Kong.

Country, Two Systems", the socialist system and policies shall not be practiced in the Hong Kong Special Administrative Region (HKSAR) and Hong Kong's previous capitalist system and life-style shall remain unchanged for 50 years. The Joint

Declaration provides that these basic policies shall be stipulated in a Basic Law of the HKSAR. The Basic Law of the Hong Kong Special Administrative Region (The

Basic Law) was adopted on 4 April 1990 by the Seventh National People's Congress (NPC) of the PRC. It came into effect on 1 July 1997.42

Immigration Ordinance The definition of Hong Kong citizen was stipulated in Immigration Ordinance Cap. 115. Before 1997, the implementation of the British Nationality Act 198143, a child born in Hong Kong acquired the status of a British Dependent Territories (Hong Kong)
42 43

The Basic Law of The Hong Kong Special Administrative Region of The Peoples Republic of China. The British Nationality Act 1981 was an Act of Parliament passed by the British Parliament concerning British nationality. The Act reclassified Citizenship of the United Kingdom and Colonies into three categories relating to the right of abode in United Kingdom : British citizens who had the right of abode in the UK, British Dependent Territories Citizens who enjoyed a right of abode in the Dependent Territories and British Overseas Citizens who enjoy right of abode nowhere in the whole. Most of the Hong Kong people fell largely into the category of British Dependent Territories Citizens. 25

citizen if one of his or her parents had the same status or was settled in the city at the time of their birth. This provision was stated clearly in Schedule 1 of Immigration

Ordinance Cap. 115. It was the common understanding of the Chinese and British experts under the Sino-British Joint Liaison Group that similar arrangement would apply after 1997 and no formal agreement was made before the reunification. For

the purpose of reunification, Schedule 1 of Immigration Ordinance Cap. 115 was slightly amended upon the change of sovereign in 1997. While its meaning

remained the same which required that for a Chinese citizen born in Hong Kong to be a permanent resident, one of his parents must have been settled44 or had the right of abode45 in Hong Kong at the time of his birth or at any later time.

Basic Law However, this qualifying requirement sated in paragraph 2(a) of Schedule 1 of Immigration Ordinance does not exist in Article 24 of Basic Law. Article 24 of Basic Law states that the following categories of people shall have the right of abode in Hong Kong and shall be qualified to obtain, in accordance with the laws of the Region, permanent identity cards which state their right of abode

The term settled is defined by Para. 1(5) of Schedule 1 of Immigration Ordinance Cap. 115 as A person is settled in Hong Kong if he is ordinarily resident in Hong Kong; and he is not subject to any limit of stay in Hong Kong. 45 According to s. 2A of Immigration Ordinance Cap. 115, a Hong Kong permanent resident enjoys the right of abode in Hong Kong which are the right to (a) land in Hong Kong; (b) not to have imposed upon him any condition of stay in Hong Kong, and any condition of stay that is imposed shall have no effect; (c) not to have a deportation order made against him and (d) not to have a removal order made against him. 26

44

i)

Chinese citizens born in Hong Kong before or after the establishment of the Hong Kong Special Administrative Region;

ii)

Chinese citizens who have ordinarily resided in Hong Kong for a continuous period of not less than seven years before or after the establishment of the Hong Kong Special Administrative Region;

iii)

Persons of Chinese nationality born outside Hong Kong of those residents listed in categories (1) and (2);

iv)

Persons not of Chinese nationality who have entered Hong Kong with valid travel documents, have ordinarily resided in Hong Kong for a continuous period of not less than seven years and have taken Hong Kong as their place of permanent residence before or after the establishment of the Hong Kong Special Administrative Region;

v)

Persons under 21 years of age born in Hong Kong of those residents listed in category (4) before or after the establishment of the Hong Kong Special Administrative Region; and

vi)

Persons other than those residents listed in categories (1) to (5), who, before the establishment of the Hong Kong Special Administrative Region, had the right of abode in Hong Kong only.

27

More importantly, Article 11 of Basic Law provides that no law enacted by the legislature of the Hong Kong Special Administrative Region shall contravene the Basic Law. The authority of Immigration Ordinance was seriously challenged.

CHONG Fung-yuen v. the Director of Immigration

The Contradictions between Basic Law and the qualifying requirements provided in the Immigration Ordinance brought a numbers of judicial reviews where decisions and authority of the Director of Immigration Department were challenged. CHONG

Fung-yuen case was a classic case arguing the legal provision on the residency of Hong Kong born child to Mainland parents. CHONG Fung-yuens parents were

Mainlanders who came to Hong Kong with two-way permits on a visit in early September 1997. They were not residents of Hong Kong, permanent or otherwise.

Shortly after the parents arrived in Hong Kong, the mother gave birth to CHONG Fung-yuen on 29 September 1997. They were arrested and repatriated while

CHONG Fung-yuen stayed in Hong Kong with his grandfather who was a Hong Kong citizen. Chongs grandfather lodged a claim about Chong's status with the Director of Immigration. That was in November 1997. The Director did not accept

CHONG Fung-yuen as permanent resident of Hong Kong, and did not accept that he

28

has the right of abode in Hong Kong by referring to the provision stated in Para 2(a) of Schedule 1 of Immigration Ordinance. Chongs grandfather applied for a judicial review against the Directors decision in 1999.

The Court of First Instance ruled that the wordings in Article 24(2) (1) of the Basic Law are clear and self-explanatory enough to confer the status of permanent residents on Chinese citizens who have been born in Hong Kong. The judged state that

the words in paragraph 2(a) of Schedule 1 to the Immigration (Amendment) Ordinance enacted on 1 July 1997 : if his father and mother was settled or had the right of abode in Hong Kong at the time of the birth of the person or at any later time were in my judgment incompatible with, and contravene art.24(2)(1) of the Basic Law. They have therefore no effect to limit the

right of abode of those Chinese citizens born within Hong Kong.46

46

CHONG FUNG-YUEN v. the Director of Immigration. HACL 69/1999 29

Besides, the judges of the case had reviewed the numbers of children born in Hong Kong between July 1, 1997 to January 31, 2001, whose parents neither had the right of abode nor lived in Hong Kong at the time of birth.47 Based on the survey of 43

months, they concluded that such judgment posed no significant risk to the city and decided that anyone born in Hong Kong is Hong Kong resident regardless of his or her parents residency48. Director of Immigration lodged an appeal to the Court of

Appeal and Court of Final Appeal and were both dismissed.

The decision of Court of Final Appeal has tremendous implication on Hong Kong population policy. Once the floodgate was open, Hong Kong medical and health care and social welfare services became the big pull for Mainland mothers. Following the Courts judgment, the number of such births in Hong Kong has risen from 709 in 2000 to 9273 in 2005, a 13-fold increase. The lack of foresight of our judges brought about todays plight.

47

Between July 1, 1997 and January 31, 2001, there were totally 1991 Chinese citizens born in Hong Kong whose parents neither had the right of abode in Hong Kong nor Hong Kong residents. (CHONG Fung-yuen v. the Director of Immigration. CACV No. 62 of 2000.) 48 The Hordes at our gate by Regina Ip. South China Morning Post. (2006-12-04) 30

CHAPTER THREE DIAGNOSIS OF THE PROBLEM FROM AN ECNONOMIC APPROACH

Introduction In this chapter, the insufficient public obstetric service for local women will be diagnosed from an economic perspective. By referring to the public obstetric service as a common-pool resource, problems of collective action and problem of externalities can be used to explain the service-seeking behaviour of Mainland pregnant women. The content and effectiveness of government reactions in 2005

will be analyzed through Pigous theorem of government intervention as a solution to the problem of externality.

Common Pool Resources When categorizing a good or service, we basically ask two questions : firstly, is it possible to restrict someones access to that good or service and the second, once access is gained and consumption or use occurs, does the good or service remain available for subsequent consumption or use by someone else. For goods which is very difficult, if not impossible, to restrict someones access to the resources and becomes unavailable for subsequent consumption once it is open for access, we can

31

categorize it as common-pool resource. The most typical examples of common-pool resources are forests, pastures, and fishery grounds49. These resources are so large Furthermore, these

that it is impossible or too costly to restrict someones access.

resources are exhaustible, there will be one day when the resources be used up if open for consumption without proper management or control.

Problem of Collective Actions Standard analysis in modern resource economics concludes that when common-pool resources are open to people for consumption, the problem of collective action is common. In Garrett Hardins Tragedy of the Commons, he used behaviour of As human beings are rational and If

rational herders to illustrate the phenomena.

self-interested, people do things to advance their own goals and objectives50.

every herder can gain access to the same piece of land, they tend to add more and more animals as they receive the direct benefit of their own animals and bear only a share of the costs resulting from overgrazing. The individual is likely to neglect the impact of overgrazing as everyone thinks chiefly of his own, hardly at all of common interest.51
49

Ostrom, E, (1990), Governing the Commons : The evolution of institutions for collective action, Cambridge: Cambridge University Press. Pp 30. 50 Brickers, K.N., (2001), Public policy analysis : a political economy approach, Boston ; New York : Houghton Mifflin, pp. 5 51 Ostrom, E, (1990), Governing the Commons : the evolution of institutions for collective action, Cambridge: Cambridge University Press. Pp 2. 32

Another scholar Robert Axelrod suggested that the Tragedy of Commons could be avoided by repeated interactions and cooperation among individuals. The rationale

behind this is that individual will cooperate if they believe that gains from cooperation over time outweigh the loss in short-term benefits of not doing so. However, due to

individuals inability to trust one another, they fail to cooperate and end up competing with each other. This theory is called prisoners dilemma, which is a common

representation of the failure of self-interested individuals to cooperate due to lack of trust.

Mancur Olson in The Logic of Collective Action also suggested those human beings are rational and self-interested. Unless the number of individuals is small, or unless

there is coercion or some other special device to make individuals act towards their common interest, rational, self-interested individuals will not act to achieve their common or group interest.52 best interest. Instead, they will behave in a way that brings them the

52

Ostrom, E, Policy Analysis of collective Action and Self-Governance in Dunn W.N. & Kelly, R.M (eds) Advances in Policy Studies Since 1950, New Brunswick (USA) and London (UK) : Transaction Publics (1992), Pp 89-90. 33

The above three theories are closely related. At the heart of each of these models is the free rider problem. Whenever one person cannot be excluded from the benefits

that others provide, each person is motivated not to contribute to the joint effort and to obtain benefit without paying. Since individuals are rational and self-interested, they tend to allow others to pay for the goods so that they may free ride. participants choose to free ride, the collective benefit is not produced. If all

On the other

hand, some may provide while others free ride, leading to a less than optimal level of provision of collective benefit. The temptation to free ride, however, may dominate

the decision process and thus all end up where no one wanted to be. These models are extremely useful for explaining how perfectly rational individuals can produced, under some circumstances, outcomes that are not rational when viewed form the perspective of all of those involved.53

Externalities The irrational outcome usually appears in the form of inefficiency due to negative externalities. Figure 154 shows the effects of a negative externality. The marginal

benefit curve showing the maximum value that one is willing to pay for successive

53

Ostrom, E, Policy Analysis of collective Action and Self-Governance in Dunn W.N. & Kelly, R.M (eds) Advances in Policy Studies Since 1950, New Brunswick (USA) and London (UK) : Transaction Publics (1992), Pp 90. 54 Dahlman. C.J., The Problem of Externality in Cowen T. (eds) The Theory of Market Failure, Virginia : George Mason University Press (1988). Pp 209-234. 34

units of goods while the marginal social cost curve representing the maximum values that one is willing to forgo for the production of successive unit of goods. In a

perfectly competitive market, the efficient equilibrium is at the point of intersection of the supply and demand curves, where marginal social cost equals to marginal social benefit. The latter reflects the idea that the marginal social benefits should equal the marginal social cost, that is the production or consumption should be increased only when the marginal social benefit exceeds the marginal social cost.

However, there are situations where individual decisions are not based upon full account of true costs and true benefits. If the consumers or producers only take into

account their own private cost, they will end up at price Pp and quantity QP, instead of the more efficient price Ps and Qs. The result is that a free market is inefficient since

at the quantity Qp, the social benefit is less than the social cost, so society as a whole would be better off if the goods between Qp and Qs had not been produced or consumed. The problem is that people are buying and consuming excessively. The most typical example of externality is the problem of pollution. Producers only see

their private costs of production such as input of materials, labour cost, rent of factory, while fail to appreciate the real cost or the social cost to others such as pollutions arisen from their production and the impact of others health. As the producers

35

neglect these externalities, they tend to produce more than market optimum and induce loss to the society as a whole. Modern resource economics analysis also concludes that where number of users have access to a common-pool resource, total resource units withdrawn from the resource will be greater than the optimal economic level of withdrawal.55

55

Ostrom, E, Policy Analysis of collective Action and Self-Governance in Dunn W.N. & Kelly, R.M (eds) Advances in Policy Studies Since 1950, New Brunswick (USA) and London (UK) : Transaction Publics (1992), Pp. 86 36

One of the most frequently cited solutions to externality is government intervention by way of user charges or tax, which was suggested by Pigou in Economics of Welfare in 1921. He stated that it is desirable to make the producers or consumers take By imposing charges or tax for every unit of

responsibility for the externalities.

goods or services consumed or produced, the real cost is internalized to the producers or consumers so as to resume the market optimum. (Figure 2 refers56)

56

Dahlman. C.J., The Problem of Externality in Cowen T. (eds) The Theory of Market Failure, Virginia : George Mason University Press (1988). Pp 209-234. 37

Pigouvian theorem The Pigouvian Tax was criticized by Ronald Coase to be inefficient in solving public problem. He criticized that government is not capable of gathering perfect information to set an optimal level of charge or tax to bring marginal private cost equal to marginal social cost. Additionally, the transaction costs for formulating regulation, imposition of tax and monitoring are too high. He further suggested that when there are no costs of transacting, all externalities would be eliminated, as costless transaction opportunities will allow suitable modification of translations behaviour so that all undesirable side effects are properly internalized.57

Public Obstetric Service in Hong Kong In Hong Kong, medical services that are provided by public hospitals can be categorized as common-pool resources that are non-excludable and subtractive. Non-excludable means that it is impossible to prevent relevant people from using the resources and subtractive means that consumption by a person will impose cost on others. Some may argue that user charge excludes those who cannot afford the payment from accessing the medical services, which makes medical service a private good. However, it is in reality impossible to restrict ones access to medical care. In Hong Kong, it is the Hospital Authoritys principle not to deny medical care due to

57

Dahlman. C.J., The Problem of Externality in Cowen T. (eds) The Theory of Market Failure, Virginia : George Mason University Press (1988). Pp 209-234. 38

lack of means. Unlike Mainland China58, medical services will be provided to any person in Hong Kong who is in need regardless of their ability to pay, as human lives are paramount. The ethical concern makes public medical service non-excludable in nature. Public medical resource is common-pool resource because it is also

subtractive. Additionally Mainland mother are patients requiring addition drugs, bed, ward, medical attention from doctors and nurse, thereby imposing costs on other patients, who now received less attention from nurse and doctors and less space in the same ward. Pregnant women, who do not manage to reserve a place in public hospital or who want to have better medical care, are forced to pay more and give birth in private hospitals when the limit in public hospitals is reached.

Hong Kong public medical services are funded mainly by the government59 through revenue from taxes and sale of land.60 Patients seeking medical service only have to pay at a rate, which is highly subsidized by government. Obstetric service before September 2005 calculated on the number of day of hospitalization. Hong Kong

residents only had to pay HK$100 per day for admission to public hospital for giving birth.
58

Non-Hong Kong residents paid HK$3,300 per day.

The government

A pregnant woman about to give birth was turned away from three hospitals and a clinic in Kunming because she only had 900 yuan. Hospitals slam door on pregnant woman, South China Morning Post, 2007-04-03. 59 In 2005/2006 financial year, among the HK$300 million revenue of Hospital Authority, 90% i.e. HK$263 million was from government subvention. 60 In 2005/2006 financial year, over 70% of the total government revenue was from tax. 39

subsidized 97% and 75% respectively as the cost of delivery for each pregnant woman is estimated to be HK$12,000 to HK$14,000.61

Alternative to public medical service is private medical service provided by seven private hospitals in Hong Kong. hospitals is much higher. The charge for obstetric services in private

It ranges from HK$15,000 to over HK$100,000 (Service Those who can afford the higher

charges of seven private hospitals at Annexure F).

service charges will choose private hospitals that provide better medical treatment, a more comfortable stay, and better postnatal care.

Cost of giving birth in Hong Kong When deciding whether to give birth in Hong Kong or in Mainland, in private or in public hospital, Mainland women evaluate the costs and benefits based on their knowledge. As utility maximizers, Mainland mothers choose the option that benefits them most. They focus on their private costs and benefits while neglecting the costs

for the Hong Kong society by consumption of medical care.

61

Legislative Council Meeting on November 10, 2004.

(http://www.legco.gov.hk/yr04-05/english/counmtg/hansard/cm1110ti-translate-e.pdf)

40

I) Short-term costs Giving birth in Hong Kong involves short-term costs and long-term costs to Mainlanders. Short-term costs include obstetric service charges, which were only HK$3,300 before September 2005. they have to pay lodging. For those who have no relative in Hong Kong,

The cost of lodging ranges from hundreds to thousands. Majority of

It depends on the type of accommodation chosen by the Mainlanders.

Mainland pregnant women come from Guongdong province.62 They come to Hong Kong mainly by train. The transportation cost is rather limited. Many of these

Mainland mothers-to-be come to Hong Kong with two-way permit under Individual Visit Scheme. The application fee for a TWP together with a single entry

endorsement costs RMB120.63 However, travel during pregnancy involves risk to the mothers and babies that should also be counted as costs.

II) Long-term costs Giving birth in Hong Kong is not without long-term cost. The most important one would be forgoing hukou, i.e. citizenship, in Mainland China. Hukou system was

implemented by Mainland China government in 1955 as a measure to guard big cities

62 63

, Mingpao. (2006-12-29) Application fee fro a two-way permit cost RMB120 for a single entry while cost RMB140 for double entries. Source : Website of Division of Exit and Entry Administration Department of Public Security of Guangdong Province. http://www.gdcrj.com/wlgat/gdgry/index.htm 41

against influx of rural population.64 Under Hukou system, every Mainland China citizen is required to register to a Public Security Bureau. Hukou registration

provides the principal basis for establishing identity, citizenship, and proof of official status. Without registration, one cannot establish eligibility for food, clothing, or

shelter, obtain employment, go to school, marry, or enlist in the army.

Unlike Hong Kong, eligibility for the above benefits in Mainland is not standardized across the country. The state reserves its resources disproportionately for those Benefits allocated to urban areas are privileged over

classified as urban population.

their counterparts in countryside. Within both urban and rural spheres, there are still differentiations, for example in the allocation of social services by job status. Children of state official and military officers attend elite schools with small classes while those of workers in urban area go to neighborhood schools and the parents pay 5% of their income for tuition plus a range of miscellaneous fees.65

64

Rapid economic development in Mainland China brought significant rural-urban migration. Chinas urban population increased from 10.6% of the total population in 1949 to 14.6% in 1956, with a net gain of 34.6 million. Tiejun Cheng and Mark Selden, (1994) The Origins and Social Consequences of Chinas Hukou System, The China Quarterly. 65 Deborah Davis (1989) Chinese Social Welfare : Policies and Outcomes. The China Quarterly. 42

Benefits of giving birth in Hong Kong I) Fleeing from One-child Policy Penalty However, majority of these Mainland pregnant women regard hukou as a push instead of a pull of coming to Hong Kong for giving birth because they can flee from paying one-child policy penalty by having baby in Hong Kong.

In 1954 when the first census survey in China revealed that Chinas population was over 600 million and was growing by 2 percent yearly, Central Government officials started doubting their traditional beliefs that having large family was a good thing. As a result, the Health Ministry issued instruction to all government organizations to provide guidance to people on the concept of birth control. With the implementation of economic reform in late 1970s, the Chinese leader at that time, Deng Xiaoping, pointed out that strict adherence to population control policies was the only way out of poverty, and to realize the four modernizations66. In 1978, the Fifth National

Peoples Congress ratified the new constitution, which explicitly stipulated that the state advocated family planning. It was also the first time that family planning was

confirmed legally and became one of the fundamental duties of all citizens.67

66

Four modernizations was fundamental part of Deng Xiaopings economic reform in China in late 1970s. Four modernization included modernization of agriculture, industry, national defence and science and technology. 67 WANG, Gabe T., (1999), Chinas Populations : Problems, Thoughts and Policies, Aldershot ; Brookfield, Vt. : Ashgate. Pp. 87-94. 43

The population Control Policy in late-1970s included four parts. One is to reduce the number of children-- which advocates that each couple has only one child; it must strictly control the second birth, and resolutely prevent the third child.68 Under the one-child policy, every Mainland couple is only entitled to have one child. will be a fine for having an extra child. There

The penalty varies from city to city, from

household to household. Generally speaking, a family in Guangdong who has their second child will be fined for around RMB80,000. The Family Planning Office

claims that the rationales behind is first, to make people think clearly before having children and second, as a financial support for the government to provide education and other welfares for their children. However, entitlement to social services Having a Hukou in

depends largely on the type of Hukou and social status.

Mainland and paying the penalty will not guarantee social services especially for those live in rural area and /or without state employment.

By paying just HK$3,300 to give birth in Hong Kong, Mainlanders can evade from making the penalty of RMB80,000 to the government. Mainlanders come to Hong Kong for giving birth. It explains why so many

68

WANG, Gabe T., (1999), Chinas Populations : Problems, Thoughts and Policies, Aldershot ; Brookfield, Vt. : Ashgate. Pp. 95. 44

II) Advanced Medical Care Further, medical care and technology in Hong Kong is much more advanced than that in Mainland China. Furthermore, in Mainland, medical services are provided only They follow strictly to this rule.

when full payment is made upon admission.

Reports on denying medical treatment due to lack of means is common in Mainland China. While in Hong Kong, the service seeker can easily avoid paying deposit or

can make off without payment by approaching A&E ward and seeking service in the last minute. This is also the method used by many Mainland women to flee from The whole system attracts

making payment in Hong Kong public hospitals.

Mainlanders, as they know that they can obtain better medical service without paying a penny in Hong Kong.

III) Hong Kong Residency However, the major drive for Mainlanders giving birth in Hong Kong is the permanent residency for their children born in Hong Kong. Especially after the landmark Chong Fung-yuen case in 2001, it became clear that everyone born in Hong Kong would be Hong Kong citizen. Many Mainland mothers cherish the better

living environment and welfare for their children and thus try every mean to give birth in Hong Kong. They are attracted by the nine-year free education, public housing

45

benefits, public medical care, different sorts of allowances such as Comprehensive Social Assistance Allowance and more recently the Pre-primary Education Voucher Scheme. With only limited cost, their children can enjoy disproportionately greater benefits provided by the Hong Kong government. That makes Hong Kong quite attractive to Mainlanders.

Externalities What these Mainland mothers cannot see are costs imposed on the society upon their consumption of medical care in Hong Kong. The negative externalities associated

are not incorporated in the cost function of these Mainland mothers, but appears as costs to others in the society. The cost of delivery ranges from HK$12,000 to

HK$14,000. The difference between the charge level and the cost are borne by Hong Kong taxpayers. Besides, the large influx of Mainlanders has placed

significant pressure on the Hong Kong medical resources. As mentioned before, medical resources are subtractive in nature; consumption by one would impose cost to another. The service-seeking behaviour of Mainlanders has reduced the frequency and quality of prenatal and postnatal checks entitled to all local mothers-to-be. Saturation of public hospitals forced local expecting mothers to give birth in private hospitals. Those managing to get a place in public hospitals are forced to stay in a

46

crowded ward and give birth with another woman in the same delivery room at the same time.

Furthermore, providing education, medical care, and welfare to these Hong Kong born children to Mainland parents are not without cost. The costs are, nevertheless, shouldered by Hong Kong taxpayers. Especially after 2005, there was an upsurge in Mainland pregnant women, whose husbands are also Mainlanders, coming to Hong Kong for the purpose of giving birth. Hong Kong people show anxiety over this

situation as they feel that their contributions to the society are subsidizing children whose parents have done nothing to contribute to the economic prosperity of Hong Kong. They feel that these children free ride on the effort of Hong Kong taxpayers.

Not all of these costs were recognized by the Mainlanders.

This discrepancy

between the marginal private costs and marginal social costs of seeking obstetric services by Mainland mothers induces a loss in the overall benefit of such consumption for the whole society. irrational behaviour. Individual rational decision becomes collective

In order to resume market equilibrium, government has taken

measure to internalize the costs to the Mainlanders and tackle the problem of externality.

47

Policy before September 2005 After Hong Kong Court of Final Appeal confirmed the status of Hong Kong born child to Mainland parents in 2001, there was an upsurge in the Mainland mothers coming to Hong Kong for giving birth. The number of Mainland women giving

birth in Hong Kong in 2005 increased almost 3-fold over that in 2001. At that time, the charge for obstetric service in Hong Kong for non-Hong Kong residents was just HK$3, 300 for one-day hospitalization in public ward, with delivery service included. The private cost for Mainlander was far below the social cost of giving birth in Hong Kong. Together with the long-term benefits to their children and the relaxation of Two Way Permit (TWP) requirements, thousands and thousands of Mainlanders came to Hong Kong for giving birth. The sudden increase in the number of Mainland

pregnant women induced congestions in public ward, delivery room, pressure on medical staff and affected the quality of service provided to local pregnant women. Some local mothers-to-be were forced to pay extra to get a place in private hospitals, as the public hospitals had no vacancy left.

Policy after September 2005 Hong Kong government noted the problem and tried to regulate the situation by imposing a negative incentive, extra charge, for non-Hong Kong resident seeking

48

obstetric service in public hospital. in September 2005.

A HK$20,000 obstetric package was introduced

The package included delivery and care fees in a public ward It also came along with a deposit system that

for the first three days in the hospital.

required all Mainland pregnant women to pay HK$19,800 deposit upon admission to hospital in order to avoid defaulted payment. The rational behind was that by

increasing the price level, the cost of giving birth in Hong Kong was internalized to Mainlanders seeking the service. Another purpose was to bring the charge level of public obstetric service closer to that of private hospital, so that Mainlanders who could afford the charge might rationally decide to give birth in private hospitals in order to get better medical treatment and service in return. afford HK$20,000, they might simply remain in China. For those could not

This Pigouvian tax adopted by the government proved to be ineffective in solving the problem. In 2006, one year after the implementation of increased charge for the

obstetric package, the number of Mainland women gave birth in Hong Kong increased 30% from 19538 in 2005 to 20577 in the first ten months of 2006. The major reason It is

was that the charge was not effectively set to bring the market back to optimum.

quite ironic to set the charge at HK$20,000 when one can save HK$80,000 by fleeing from one-child policy penalty. Besides, the marginal private cost after the

49

implementation of new charge was still far below the marginal social cost.

It

coincides with the criticism over Pigouvians theorem that the government is incapable of setting an optimal level of charge or tax to attain market equilibrium.

Another reason why the package could not reduce the number of Mainland pregnant women coming to Hong Kong was that the cost could not successfully be internalized to the consumers. Although the Authority required every non-Hong Kong resident to make deposit upon admission for giving birth, there existed a loophole that allowed Mainland women to obtain obstetric service without making deposit. They knew

that Hong Kong hospitals would not deny service due to lack of means, they then sought last-minute hospital admission before delivery through the A&E ward. Furthermore, the obstetric package did not come along with new initiatives in preventing and collecting defaulted payments as many of the defaulted payments ended up as bad-debt.69 As Mainlanders can easily escape from making payment, the cost of delivery could not be internalized to them and could not bring the market to optimum.

69

The bad debts of Hospital Authority amounted to HK$2,800 million in 2005/06 financial year. Source : Hospital Authority : management of outstanding medical fees, Audit Commission. HKSAR Government. http://www.aud.gov.hk/pdf_e/e47ch05.pdf 50

CHAPTER FOUR NEW POLICY IN FEBRUARY 2007

Introduction The ever-increasing number of Mainland mothers coming to Hong Kong for giving birth has reached an unsustainable level. Public hospitals are overcrowded; existing medical staff manpower can no long cater for the increasing workload; quality of service delivery has declined significantly; duration of stay after delivery and number of postnatal checks entitled by every baby and mother have been reduced. A group

of 30 local mothers-to-be marched to Central Government Office to air their grievances over the situation in November 2006. They urged the government for

solution to ensure sufficient public obstetric service is reserved for local pregnant women.

The action by these groups of pregnant women had tremendous effect. Different pressure groups, Legislative Council members and the public have urged the government to face the problem. Speculations on the possible solutions and

development over the issue can be seen on the headline of the newspaper almost everyday. Some suggested having the Basic Law amended or reinterpreted while

51

some suggested withholding the babys birth certificate until the parents have settled their hospital charge. All were rejected by the government.

After months of meetings with Mainland authorities, Health, Welfare, and Food Bureau finally came up with a package of new measures to tackle the problem. The

official objective of the new measures is to ensure sufficient public obstetric service is available to local pregnant women. The measures include increasing the charge, a centralized booking system, and strengthening of immigration control. was tailor-made solely for Mainland women. The policy

Pregnant women of other nationalities

were not bounded by these rules. The authoritys explanation was that the number of pregnant women from other countries seeking obstetric service in Hong Kong was not common.

The New Policy Increase in Charge Effective from February 1, 2007 when the new measures were implemented, the charge for delivery in public hospital increased from HK$20,000 to HK$39,000. HK$39,000 is the minimum rate that covers the charges for the delivery (vaginal or operative) and the first three days of hospitalization in general wards for the

52

concerned delivery. An additional HK$9,000 will be charged for those who have not made a prior confirmed booking for their delivery and / or have not undergone the antenatal checkup provided by the Hospital Authority during the pregnancy. The major aim of doubling the service charge was again to make it closer to or even over the price level set by private hospitals. private hospitals. So that the Mainland mothers will shift to

The imposition of HK$9,000 additional charge was to deter It also

Mainland pregnant women from seeking obstetric service in the last minute.

encourages the Mainland pregnant women to have prenatal checks before their delivery in order to reduce the risks to the mothers, their babies, and medical staffs.

Defaulted Payment Prevention Mechanism As mentioned in last chapter, without an effective defaulted payment system, the consumers will never see the real costs of their consumption. To effectively

internalize the costs to the Mainland mothers, the Hospital Authority implemented several measures for collecting outstanding medical fees. Upon registration, the Additionally, the

Mainland mother-to-be is required to produce proof of address.

Authority will defer submission of birth data to Birth Registry for Mainlanders until outstanding fees are paid up to 42 days. Those, including both Hong Kong residents

and non-Hong Kong residents, who have outstanding fee will only be provided with

53

emergency services. payments.

Furthermore, administrative charge will be imposed for late

Finally, the Authority is also exploring the possibility of hiring

international debt collection agency for pursuing Mainland bad debts.70

Having learnt from previous lessons, the government knows clearly that the problem cannot be solved solely by increasing the service charge. People in Mainland China are getting wealthier. People who can afford HK$39,000 for giving birth to a baby are countless.71 Besides, Mainland people might still find HK$39,000 worthy as they can flee from one child policy penalty and their children can enjoy Hong Kong social welfare benefits. Therefore, the government implemented other supporting measures to ensure sufficient obstetric service is available to local pregnant women.

Centralized Registration System The Bureau developed a centralized booking system for both private and public hospitals. Every Mainland woman must make prior booking in person and settle the Priority is reserved for local women and only when extra In any case, the number of

full payment in advance.

quotas are left will be allocated to Mainland women.

70

Discussion Paper on Impact of the use of Obstetric Services by Mainland Women on Public Hospital Resources by Legislative Council Panel on Health Services. (8 January 2007), LC Paper No. CB (2) 761/06-07(03). 71 On the first day of the implementation of this new measures, totally 734 Mainland pregnant women made registration through the Hospital Authority centralized booking system and brought HK$28.6 million revenue to Hong Kong Government within in single day. Authority cashes in on pregnancy policy, South China Morning Post, (2007-02-02). 54

quota for Mainland mothers would not exceed HK$12,000 per year.

After the

Mainland women have made the reservation, a booking certificate will be issued to them. Every Mainland mother-to-be is required to produce such certificate to Entry of those Mainland women at

immigration officer upon entry to Hong Kong.

the advanced stage of pregnancy72 who have no booking would be denied.

Tightened Immigration Control The Bureau also anticipated that those who have not made reservation nor had no money might try to get through the immigration control points by concealing or disguising their pregnancy. Body check facilities and medical officers were

stationed in all checkpoints to provide advice on the physical conditions of the non-local pregnant women. Those who were found to be pregnant for more than 28

weeks and without booking certificate will be denied entry.

The new policy was put forward in January 2007 and was fully implemented in February. In spite of the rush, there was no big opposition or objection from the public, pressure groups or politician at the time it was implemented. The public generally welcomed the policy which had considerably released their anxiety over the situation.

72

To avoid dispute, the authority has defined advanced stage of pregnancy as being pregnant for more than 7 months i.e. 28 weeks. 55

CHAPTER FIVE EVALUATION OF THE NEW POLICY

Introduction According to the figure released by the Health, Welfare, and Food Bureau, the number of Mainland pregnant woman giving birth in Hong Kong public hospitals dropped significantly after the implementation of the new measures in February 2007. In the

first nine weeks of the new policy until April 4, 2007, totally 3,800 Mainland women gave birth in Hong Kong. 1,190 of them gave birth in public hospitals. 371 of them sought last-minute obstetric service from emergency wards. When compared

with the figure of the same period last year, although the total number of Mainland women coming to Hong Kong only dropped by 4%, the number seeking services from public hospitals dropped significantly by 35%. Mainland pregnant women seeking

emergency delivery service even dropped by 75%.73

By looking at the figure, it seems that the new measures have successfully shifted the Mainland mothers-to-be from public to private hospitals. Besides, the

implementation of centralized booking system together with immigration control has

73

Birth fee drop for wives ; charge for cross-border couples could fall to HK$20,000 SCMP (2007-04-17) and 4% Singtao Daily, (2007-04-16) 56

deterred people from seeking last-minute service from the emergency wards. However, since the new policy has been implemented for just two and a half months, the duration is too short to see the real effectiveness of the policy. Therefore, instead

of focusing on the output of the policy, this chapter will be the evaluation of the new policy with focus on its design and implementation.

Richard F. Elmore stated that certain types of problems predictably bring into play certain responses from policy makers; these responses are called instruments. Different policy instruments have different operating characteristics, strengths, and implementation problems. Certain instruments fit certain problems and objective better than other instruments. Therefore, it is good to know something about the

potential effects of different policy instruments before one chooses among them. The study of policy instruments then can be useful in strengthening the predictive capacity of policy analysis that would be helpful in policy design.74

As a broad policy objective is to be achieved far in the future, while the instrument choice is real and will have immediate consequence75, this chapter will evaluate the new policy by referring to the choice and design of the policy instruments.
74 75

Elmore. R.F. (1987) Instruments and strategy in public policy. Policy Studies Review. Bemelmans-Videc M, Rist R.C. Vedung E. (1998), Carrots, Sticks and Sermons, Policy Instruments and their Evaluation, USSA New Brunswish : Transaction Publishers. Pp. 41. 57

What is Evaluation? Evaluation is the systematic application of social research procedure for assessing the conceptualization, design, implementation and utility of social intervention programmes.76 Evaluation of a policy cannot do away with figures and data on the In fact,

policy outcome, which is generally referred as output / outcome evaluation.

all phases of the policy process, from problem analysis through monitoring implementation to the appraisal of the actual result of the policy can be evaluated. Apart from output / outcome evaluation, there is also process evaluation where the evaluation focuses on the process of designing and implementing of policy or programme.

When evaluating a policy, no matter output evaluation or process evaluation, there should be some criteria by which to judge the adequacy of the policy the criteria of good governance the central values of which government actions is appraised. According to Marie-Louise Benelmans-Videc, the values of good governance include effectiveness, efficiency, legality, democracy, and legitimacy77.

76

Rossi, P.H. and H.E. Freeman. 1993. Evaluation : A Systematic Approach. Newbury Park, CA : Sage. Pp. 5. 77 Bemelmans-Videc M, Rist R.C. Vedung E. (1998), Carrots, Sticks and Sermons, Policy Instruments and their Evaluation, USSA New Brunswish : Transaction Publishers. Pp. 41. 58

Effectiveness is the degree of goal-realization due to the use of certain policy instrument. instrument. It includes both positive and negative effects brought by the policy Efficiency refers to the input-output ratio of the policy instrument. It

includes the problems of implementation of the policy instrument through devised means. Legality means the degree of correspondence of administrative action in

designing and implementing policies with the relevant formal rules as well as with the principles of proper process. Democracy is the degree to which administrative

action in designing and implementing policies correspond with accepted norms as to government-citizen relationships in a democratic political order. The final value is legitimacy, which is the degree to which government choices are perceived as just and lawful in the eyes of the involved actions. These central criteria of good governance

need to be combined, while at the same time they compete or conflict, e.g. policy instruments that score high on the democracy criterion often have a price tag in terms of their efficiency. Therefore, the choice of policy instrument instruments is a search for optimum solution, a prioritizing process, and a balancing act.78

78

Bemelmans-Videc M, Rist R.C. Vedung E. (1998), Carrots, Sticks and Sermons, Policy Instruments and their Evaluation, USSA New Brunswish : Transaction Publishers. Pp. 6-9 59

Classification of Policy Instruments Nowhere in the international literature on policy analysis and public administration is to be found a uniform, generally embraced classification of policy instrument. policy instruments can be categorized in many ways. The

In this paper, policy

instruments are categorized by the degree of authoritative force or degree of constraints involved in the government effort. By such, policy instruments can be

defined as regulation, economic means, and information.79

Regulatory Instrument Regulations are measures undertaken by government to influence people by means of formulated rules and directives that mandate receivers to act in accordance with what is ordered in these rules and directives. Regulations often associated with threats of

negative sanctions such as fines, imprisonment, and other type of punishment.80

Regulation is often chosen by the governments as a policy tool because it appears to be more certain and effective as regulatory instruments define the norms, acceptable behaviour or to limit activities in a society.81

79

Bemelmans-Videc M, Rist R.C. Vedung E. (1998), Carrots, Sticks and Sermons, Policy Instruments and their Evaluation, USSA New Brunswish : Transaction Publishers. Pp. 59. 80 Ibid. Pp. 31. 81 Bemelmans-Videc M, Rist R.C. Vedung E. (1998), Carrots, Sticks and Sermons, Policy Instruments and their Evaluation, USSA New Brunswish : Transaction Publishers. Pp. 59. 60

Regulatory instruments are not without weakness.

It is argued that regulations are

ineffective in changing behaviour if there no social consensus around the government policy underlying the regulatory instruments. The effectiveness of a regulatory

instrument is associated with its legitimacy. Additionally, effectiveness also greatly depends on the nature of the policy context, which also determines the capacity of the government organization to ensure compliance.82 An illegitimate regulation might lead to non-compliance and the cost of non-compliance might even greater that the cost of the problem itself.

Economic Instrument Economic policy instruments involve either handing out or the taking away of material resources from the addressees to make it cheaper or more expensive in terms of money, time, effort, and other valuables to pursue certain actions. What makes economic policy instruments different from regulations is that the addressees are not obligated to take the measures involved. They may decide not to make use of the

government incentive, either positive or negative, because they hesitate to take the measures required to get it.83 Taking cigarette consumption in Hong Kong as an
82

Bemelmans-Videc M, Rist R.C. Vedung E. (1998), Carrots, Sticks and Sermons, Policy Instruments and their Evaluation, USSA New Brunswish : Transaction Publishers. Pp.71. 83 Bemelmans-Videc M, Rist R.C. Vedung E. (1998), Carrots, Sticks and Sermons, Policy Instruments 61

example, since cigarette smoking is hazardous to health, the government fells the need to do something to discourage people consuming cigarette. Instead of formulating

rule to totally ban the purchasing of cigarette in the market, the government imposes heavy tax on it and makes the smokers habit more expensive.

Economic policy instrument is flexible and usually has higher legitimacy when compared with regulatory instruments, as the addressee has no obligation to follow the regulation. The addressees have the right to choose. However, the

effectiveness of economic instrument must rely heavily on the relationship between the economic incentive and the policy goals. Sometimes, the addressee might

already have decided to behave in the desired way, in which case economic incentive or disincentive has been unnecessary.

Information The third type of instrument is information which influences people through the transfer of knowledge, communication of reasoned argument and persuasion. 84 Through advertisement, education, diffusion of printed material, amassing and packaging etc, citizens are informed of what is right or wrong, good or bad. How the

and their Evaluation, USSA New Brunswish : Transaction Publishers. Pp. 32-33. 84 Ibid. Pp. 33. 62

people should act and behave and what people are allowed to do.

It is worth

highlighting that information can be either a policy instrument in its own right or a metapolicy instrument in the sense that it is used to disseminate knowledge of the existence, meaning, and availability of other policy instruments.85 The former refers

to information as a policy instrument while the latter refers as information on policy instrument.

Evaluation of 2007 Policy Policy Instruments The policy implemented in 2007 is a combination of economic, regulatory, and informative policy instruments. It increased the public obstetric service charge for

Mainland women from HK$20,000 to HK$39,000. Mainlanders are not obligated to pay the adjusted service charge. They can choose not to come to Hong Kong for giving birth if they hesitated to give the amount of money or they can seek service from private hospitals in Hong Kong. The financial disincentive increased the cost of action and prompted the addressees to undertake activities that will achieve the goals of the government.86

85

Bemelmans-Videc M, Rist R.C. Vedung E. (1998), Carrots, Sticks and Sermons, Policy Instruments and their Evaluation, USSA New Brunswish : Transaction Publishers. Pp. 48. 86 Bemelmans-Videc M, Rist R.C. Vedung E. (1998), Carrots, Sticks and Sermons, Policy Instruments and their Evaluation, USSA New Brunswish : Transaction Publishers. Pp 79. 63

To avoid defaulted payment and enhanced the effectiveness of the policy, it imposed regulations requiring all Mainland obstetric service seekers make prior registration and settle full payment before delivery. Those Mainland women at their advanced stage of pregnancy without booking certificate would be denied entry. Those

seeking obstetric service without registration will be penalized for HK$10,000. To avoid non-compliance, body check facilities are put in place in border checkpoints to ascertain the health condition of pregnant Mainland women. There is also yearly quota that set the upper limit of vacancy allocated to Mainland women to ensure sufficient obstetric service is available to local women.

Many new policies in Hong Kong in recent years like to use information either as a tool or as a package. Well before the policy is put forward, there are advertisement, press release, and consultation papers to raise people attention on the subject. However, since the target of this policy is Mainland women, we do not see large-scale promotion or publicity on this policy in Hong Kong.

Choice of instruments From policy instrument perspective, policy formulation is the art of choice making. There are two factors which shape the choice of policy makers : the first one is the

64

problem identification and the second is the resources and constraints faced by policy makers.87 The decision making process is an exercise of give and take which involves the trade-offs of effectiveness and efficiency, the capabilities of implementing institution, the political and fiscal costs of selecting a particular instrument, and the different constituent pressures faced by the policy maker.88

In late 2006 when the issue received the hottest debate, different people had different focuses on the issue that led to different proposals on the solutions. Some focused on the problem of defaulted payment, some focused on the residency of the children while some focused on the quality and availability of obstetric service in public hospitals. There were suggestions to request Mainland pregnant women to pay

deposit upon entry at border checkpoints and withhold the issue of birth certificate to their children if they fail to settle the hospital bill. Some even suggested amending Basic Law to redefine the residential status of children born in Hong Kong with Mainland parents.

In January 2007, the government announced its plan in tackling the service seeking behaviour of Mainland pregnant women while no extremely authoritative measures as
87

McDonnell, L.M., Elmore, R.F. Getting the Job done : Alternative Policy Instruments, Educational Evaluation and Policy Analysis, Summer 1987, Vol. 9, No. 2, Pp 144. 88 Bemelmans-Videc M, Rist R.C. Vedung E. (1998), Carrots, Sticks and Sermons, Policy Instruments and their Evaluation, USSA New Brunswish : Transaction Publishers. Pp. 151. 65

listed above could be seen in the proposal.

Although these measures will surely

bring effectiveness and efficiency due to their degree of coerciveness, the level of legitimacy would induce difficulties in implementation. The political cost and the After NG

cost of non-compliance are so high that the government cannot afford.

Ka-ling case89 in 2002, reinterpretation of Basic Law became a taboo of Hong Kong government which was condemned to have ruined the autonomy of Hong Kong under One Country, Two System. The possibility of seeking reinterpretation was ruled

out by the Secretary for Security on the first day it was proposed.

As the policy objective is to ensure sufficient obstetric service to local pregnant women, there is no need to totally deny service to non-local women. Instead of

implementing absolute prohibition, Hong Kong government chose conditional prohibition, which granted permission to Mainland women to come to Hong Kong if they have fully settled the obstetric service charge in advance. On one hand, the prior registration requirement allow the authority better control the number of Mainland pregnant women seeking public obstetric service. On the other hand, it can reduce the possibility of defaulted payment. More importantly, the children born

in Hong Kong might become our future workforce, which will relieve the problem of

89

NG Ka-ling and others v. the Director of Immigration. FACV No. 14 of 1998. 66

the ageing population faced by the society. With the consistently low birth rate, it is estimated that by 2030, 27% of the total population will be aged 65 and above.90 Allowing Mainland mothers to give birth in Hong Kong is one of the methods in ensuring the sustainability of Hong Kong population growth.

In the meantime, the policy doubled the service charge to make the charging level of obstetric service in public hospital more inline with that in private hospitals. The

economic mean has changed peoples behaviour and successfully shifted the service seekers from public hospitals to private hospitals. Finally, the imposition of yearly quota ensured sufficient obstetric service is available to local pregnant women, which is the goal of the policy.

Regulation seldom results in uniform compliance.

There is always individuals resist

compliance if by doing so they can reap positive benefits. The government then put in place series of measures to avoid non-compliance. Apart from prior registration system to prevent defaulted payment, the authority also set up body check facilities in border checkpoint to ascertain the pregnant womens medical condition. However,

there are still intermittent reports on Mainland women gained entry to Hong Kong by

90

2006 Population By-census, Census and Statistics Department, HKSAR Government. 67

disguise or forgery.

Recently, a Mainland woman crossed the border with a forged

registration certificate that was issued by a medical practitioner in Hong Kong. Other illegal acts such as illegal smuggling of pregnant women from Mainland China to Hong Kong and overstaying in Hong Kong waiting for delivery are common. In

fact, what the government can do is to reduce the variation of behaviour to a tolerable level because the enforcement cost for uniform compliance is prohibitively high.

Design of Policy However, it is not a perfect policy; it also has its downsides. The way the policy is designed is unexpectedly insensitive which made it subjected to challenges. the policy is discriminatory in nature. Firstly,

It only applies to Mainland women. Women

from all other countries are not covered by the new policy, which means pregnant women from USA, UK, Japan, Sri Lanka, and Thailand etc are not required to make prior registration for giving in Hong Kong. They would not be any barrier from entering Hong Kong solely on the ground of pregnancy. What more, they only have to pay HK$20, 000 for giving birth in Hong Kong. Governments explanation was that non-local pregnant women from places other than China are a clear minority and would not pose threat to the Hong Kong public medical service just does not sound convincing. If the policy goal is to protect the welfare of Hong Kong pregnant

68

women, the new service charge should apply to all obstetric service seekers from all over the world, instead of just targeting Mainland pregnant women. The legitimacy of the new policy is doubtful.

Moreover, the policy was criticized for failing to take care of the real need of Hong Kong people. Among the 20,577 Mainland women coming to Hong Kong for giving

birth in the first 10 months of 2006, 39% of them are married to Hong Kong males. These Mainland women expressed that they will not pay HK$39, 000 even if they have money as they found it unfair to be treated differently. Fifty Hong Kong males who have wives in Mainland China marched to Central Government Officer on April 1, 2007 and May 13, 2007 to demonstrate against the new policy. They found it unfair as they are required to pay extra for service and welfare entitled by every Hong Kong people. Their grievance over the policy is understandable.

Conclusion The choice of policy instrument appears to have stricken a balance between effectiveness, feasibility, and legitimacy. The figure in the first three months after the implementation of policy has initially approved the policys effectiveness in reducing Mainland womens demand over public obstetric service. After the

69

implementation of the new policy, there is a significant reduction in the number of Mainland pregnant women giving birth in public hospitals. According to the figure

released in early-April 2007, among the 3,800 Mainland women gave birth in Hong Kong, 1,190 of them gave birth in public hospitals. compared with the figure of the same period last year. It dropped by 35% when The new pricing system has Besides, the

successfully shifted the demand from public to private hospitals.

registration system and immigration control have deterred people from taking free lunch.

70

CHAPTER SIX THE WAY FORWARD Introduction Judging from some key indicators of policy outcome such as the number of Mainland women giving birth in public hospitals, the implementation of the policy has been a success. In the three months after the implementation, the goal of relieving the

pressure of public obstetric service has been achieved by shifting Mainland pregnant women from public hospitals to private hospitals. The number of Mainland pregnant

women seeking obstetric service between February and April this year dropped by 37% when compared with the figure of the same period in 2006. problem really solved? However, is the

Does it mark an end to Hong Kong peoples anxiety about

the influx of Mainland immigrants?

Long Term Implication Government knows that Hong Kong people's concern is not just the availability of obstetric service. The primary worry is the implication of Mainland children's In the first nine weeks after the implementation

inclusion in our society in the end.

of the new policy, Hospital Authority received 10,170 registrations for obstetric

71

services, in both private and public hospitals, from Mainland women91.

Based on

this figure, it is estimated that the number of registration will reach twenty or even thirty thousand by the end of 2007. They are all entitled to the education, medical The

services, housing facilities, and other welfare services of Hong Kong. implication for Hong Kong resources will be significant.

In fact, the demand of From

welfare services from these newborn babies has surfaced progressively.

August 2006 to March 2007, there were 102 children born to Mainland parents applied for Comprehensive Social Security Assistance (CSSA)92. The figure might

seem trivial when compared with the total number of children born to Mainland parents every year. However, its implication cannot be overlooked. Otherwise, we

will commit the same mistake as committed by our judges in CHONG Fung-yuen case in 2001.

Social Disintegration The uncertainties faced by Hong Kong people made them worry and anxious. Besides, there were signs of deepened social disintegration after the issue became the center of discussion last year. Hong Kong residents, married with Mainland wives,

91

Birth fee drop for wives ; charge for cross-border couples could fall to HK$20,000 SCMP (2007-04-17) and 4%, Singtao Daily, (2007-04-16) 92 The applicants ages ranged from two months old to 17 years old. Source : Social Welfare Department. 72

complained that they are discriminated and are not provided with the same rights and benefits enjoyed by other Hong Kong residents. Other Hong Kong people argued

that allowing Mainland women married to Hong Kong males to give birth in Hong Kong at normal rate would expose our medical resources to exploitation.

With the short-term problem being solved, the government should focus its effort on the long term planning in order to balance the population and the resources. This

can be achieved by restructuring the current policy on obstetric services and better management of welfare resources.

Restructure of obstetric service policy Reorienting Policy Target First, the objective of the policy has to be re-oriented to meet the real need of Hong Kong people. Instead of protecting the benefit of local pregnant women, the policy

should aim at protecting the right and benefit of Hong Kong residents as a whole. The welfare of those Hong Kong residents with Mainland wives should be cared for equally. The best and simplest way in achieving this is by standardizing the service charge for all Hong Kong families. That means Mainland women married to Hong

Kong residents only have to pay HK$100 per night for giving birth in public hospitals. By doing so, the government can show its care and support to all families in Hong

73

Kong without differentiation which would definitely be beneficial to restore social harmony. As most of the opposition of the current policy was from Mainland

women married to Hong Kong residents, the above-suggested policy would gain support that is more public.

Extending Quota Coverage Secondly, to better manage the number of Mainland women giving birth in Hong Kong, the quota system should extend to cover the registration in private hospitals. Under current policy, the quota system is not applicable to private hospitals. From

February to April, there were 10,170 Mainland women registered for obstetric services in Hong Kong, 3756, around 36% of them sought service from public hospitals 93 . Without proper control, Mainland women giving birth in private

hospitals might pose unbearable pressure on the resources of Hong Kong at a later date.

Increasing Charge for Couples who are Both non-Hong Kong Residents Thirdly, for those couples who are both non-Hong Kong residents wishing to give birth in Hong Kong, as their children might be educated, living, and seeking medical

93

75%

, Mingpao (2007-04-13) 74

and welfare of all kinds in Hong Kong, they are required to pay extra as compensation to the Hong Kong government. The payment is expected to be in line with the

amount of the one-child policy penalty i.e. around HK$100,000. The aim is not to raise public revenue. The whole purpose is to reduce their incentive to give birth in Hong Kong to the minimum. Apart from protecting Hong Kong peoples benefits,

the increase in charge has the effect in screening incoming pregnant women. Those seeking obstetric services in Hong Kong would be willing and capable in paying the services, which can reduce the possibility of defaulted payment.

Supportive Measure As the charge is so high, it is very likely that people will try every possible mean to come to Hong Kong illegally. Series of measures have to be put in place to avoid non-compliance. It can be achieved by strengthening of Immigration control and

implementing a defaulted payment prevention system.

I) Immigration Control An experienced Immigration officer served in Lok Ma Chau border-crossing point revealed that in the past few months after the implementation of the new policy, Mainland pregnant women without registration certificate tried different means to

75

come to Hong Kong. Apart from the most commonly used tricks that was disguising as non-pregnant woman, there were also Mainland mothers claimed feeling unwell and sought medical treatment at the border crossing points. Immigration officers had After medical They even

no choice but to send these Mainlanders to the nearest hospitals. treatment, these Mainland women refused to leave the hospital.

threatened to commit suicide if repatriated. Some Mainlanders waited in the area between China and Hong Kong clearance counters and sought obstetric service from the border crossing point when they were ready for delivery. Few falsified

registration certificates while others became nasty when being denied entry.

The possibility of non-compliance can be minimized by strengthening the communication with Mainland and solving the problem by working in partnership. They should establish a cross-border system that cover two issues. First, if a

Mainland woman leaves Mainland China to Hong Kong, and the Mainland public security officer at clearance counter reasonably believes that she is at her advanced stage of pregnancy, the officer should not allow the pregnant woman to leave China unless the woman can produce a valid registration certificate. Second, Mainland women claim feeling unwell and seek medical service from Hong Kong border-crossing points should be handed over to the Mainland public security officers

76

who will either render medical treatment on the spot or send the women to the nearest hospitals for treatment.

The system is expected to reduce the possibility of abusing medical service due to policy loophole. However, it requires cohesive communication and cooperation

between Mainland and Hong Kong authorities. More importantly, it needs the active participation of Mainland China. China government should realize that such

service-seeking behaviour of Mainland women is not simply a Hong Kong problem; it is a cross-border problem. policy of Mainland China. The behavior poses significant impact on the population As those babies born in Hong Kong will not be counted

as China population, the one-child policy will be less effective in controlling the number of population in China.

As the whole obstetric service policy lies heavily on the effectiveness of the immigration control, Immigration Department should invest more resources in training their staffs, especially those serving in border checkpoints. Training should

focus on the authority empowered to Immigration officers under the new policy, the communication skills and the negotiation technique. The training will better equip

the officers and make them more confident and competent in carrying out their duties.

77

II) Defaulted Payment Prevention System Even under strict immigration control, Mainland mothers can still enter Hong Kong illegally. Some are illegal immigrants while some are two-way permit holders, who have overstayed in Hong Kong after the expiration of their TWP. In these cases, the

government should take actions to show her intolerance to these immigration offences and the determination in collecting full payment by criminalizing non-payment of hospital fee and charging all illegal immigrants and overstaying pregnant women with heavier penalty to deter illegal acts. Those who fail to settle full service charge before they leave the hospitals will be wanted and denied egress from Hong Kong. The purpose is to reduce peoples incentive to come to Hong Kong for giving birth illegally.

Civil Education Due to excessive negative reports by the media, these babies born to Mainland women were discriminated by other Hong Kong people that resulted in serious social segregation. The government should exert greater effort in promotion the positive image of these newborn babies by publicizing the benefits and advantages brought by them. They should be portrayed as the pillar of our society, which will be the

solution to our aging population problem in the future.

78

Vision in Education, Housing, Medical Service and Other Welfare Policies In 2006, 63% of the newborn babies were born to mothers from Mainland China and became the major source of population growth in Hong Kong. Besides, there was growing proportion of these newborn babies whose parents are not Hong Kong residents. The government should recognize the implication of the growing number of these newborn babies and their family profile to our existing and future social policies.

Education These children may seek education, accommodation, medical service, and welfare of all kinds in Hong Kong. The government should monitor the trend of the

service-seeking behaviour of Mainland women and project the demand on education, housing facilities, social assistance, and medical care in the coming decade. All policies have to be reviewed to meet the need of our next generation. The most imperative one would be our education policy. Due to the ever-declining birth rate94, totally 127 primary schools closed down between 2001 and 2006 due to the low enrollment rate. These schools are either demolished or left idle. Many teachers

lost their jobs and many students are forced to transfer to other primary schools.

94

The number of birth in Hong Kong dropped from 85,000 in 1980 to 67,700 in 1990 and to 48,200 in 2001. Census and Statistic Department. http://www.censtatd.gov.hk/showtableexcel2.jsp?tableID=004. 79

However, since 2001, Hong Kong's population has rebounded. The number of birth rose from 48,200 in 2001 to 65,000 in 2006, with children born to Mainland mothers formed the major part of the population increase. They successfully brought our population back to 1990 level. This means the whole societys demand on education will increase in the coming decade. If the government has insight and takes a

proactive role in forecasting our demand on education in the future, we might be able to avoid unnecessary chaos as such.

In the past, with our geographical layout, the demand on boarding schools was low which made the number of boarding schools limited. With the increase proportional of newborn children whose parents are not Hong Kong residents, the demand on boarding schools might increase. If these children seek education in Hong Kong, it

is very likely that they will not live with their parents. On the other hand, if they remain residents in Mainland China, it would take considerable time for them to travel to school. The government should consider either encouraging private sector to run boarding schools, which provide all in one services to these children so that their education, accommodation and catering are being taken care, or the government can provide the services by herself so that the quality of education and living environment can be assured.

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Social Welfare Assistance To better protect Hong Kong peoples welfare and avoid social resources being abused, the existing social welfare system needed to be reviewed. Under current

policy, any person who has been Hong Kong resident for 7 years or more and has resided in Hong Kong for at least one year is eligible for applying CSSA. requirements are exempted for those who are under 16 years old. These two

That means those

children born to Mainland parents are all eligible for applying CSSA on the day they are born in Hong Kong. financial test95. These children can get HK$1,955 per month if can pass the

Social Welfare Department should develop a system with Mainland

China to collect reliable information on the applicants financial situation to avoid deception of the social assistance programs. Besides, as the assistance is provided to

the Hong Kong born children only, the amount and the mode of assistance also needs to be reviewed. Furthermore, to ensure the assistance goes directly to the applicant,

government should reduce the amount of cash assistance and explore the feasibility of using voucher or direct subsidies to service providers to avoid assistance being misused.

95

To be eligible for CSSA, the applicants capital asset should not be more than HK$34,000 for single person application. 81

The government should look into far too many issues. However, it is not the purpose of this paper to list out all policies the government has to review. The objective of this section is to highlight that the government should note the significant implication brought by these newborn babies to our society. The government should extend its focus from the availability of public obstetric service to the long-term planning of social policies to ensure sustainable development of Hong Kong society as a whole.

Conclusion These newborn babies are Hong Kong residents, which is an irrebuttable truth. They

have the right to enjoy the welfare, education, and medical service in Hong Kong while they also have the obligation to contribute to the community. Whether they will become the pillar or the burden of the society depends on the governments attitude and determination in nurturing them and builds their sense of belonging towards Hong Kong that makes them recognize Hong Kong as their home.

82

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Website Census and Statistics Department. (http://www.censtatd.gov.hk) Legislative Council. (www.legco.gov.hk) Hong Kong Legal Information Institute (www.hklii.hk) Audit Commission. (www.aud.gov.hk) Social Welfare Department (www.swd.gov.hk) SARS Expert Committee (http://www.sars-expertcom.gov.hk) HKSAR Government Press Release (www.info.gov.hk/gia) Tourism Board (http://www.discoverhongkong.com) Official Website on SARS. Department of Health Website of Division of Exit and Entry Administration Department of Public Security of Guangdong Province. (http://www.gdcrj.com/wlgat/gdgry/index.htm)

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Newspaper Authority cashes in on pregnancy policy, South China Morning Post, (2007-02-02). Birth fee drop for wives ; charge for cross-border couples could fall to HK$20,000 South China Morning Post (2007-04-17) Hospital booking rule for Mainland mothers, Global News Wire - Asia Africa Intelligence Wire. (2007-01-17) Hospitals slam door on pregnant woman, South China Morning Post (2007-04-03) The Hordes at our gate by Regina Ip. South China Morning Post. (2006-12-04) , Apple daily. (2006-12-8) , Apple Daily (2006-12-07) , Mingpao. (2006-12-07) & 5 16 , Singtao Daily. (2006-12-07). 4 , Wenweipo. (2006-12-27). 4%, Singtao Daily, (2007-04-16) 75% , Mingpao (2007-04-13) , Mingpao. (2006-12-29)

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Annex A

Birth Statistics

Total Number of Birth in Hong Kong

Number of babies born to Mainland women in HK (% to the total number of births) 7810 (16%) 8506 (17.6%) 10128 (21.6%) 13209 (26.5%) 19538 (34%) 20577 (39.3%)

Year 2001 2002 2003 2004 2005 2006 (first 10 months)

Number of Births in HK 48219 48209 46965 49796 57098 52265

Family Profile of babies born to Mainland mothers

Total No. of babies Number of babies % to the total number born to Mainland born to Mainland of babies born to women women in HK Mainland women 7810 8506 10128 13209 19538 20577 620 1250 2070 4102 9273 12678 7.9% 14.7% 20.4% 31.1% 47.5% 61.6%

Year 2001 2002 2003 2004 2005 2006 (first 10 months)

Source : Discussion Paper on Impact of the use of Obstetric Services by Mainland Women on Public Hospital Resources by Legislative Council Panel on Health Services. (8 January 2007), LC Paper No. CB (2) 761/06-07(03).

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Annex B

Chronology of Major Events affecting Hong Kong Immigration Policy on Mainlanders

1841 1940 1941 1949 Hong Kong became British colony Immigration Control Ordinance introduced Second World War Immigration Control Ordinance stipulated that no person may enter into the Colony without an entry permit, natives of Guangdong province were exempted. Hong Kong Government introduced a quota system to balance the numbers of those entering into and those leaving the Colony. Outbreak of Korean War The United States imposed an almost complete embargo on Chinese trade, which brought Hong Kong entrepot trade to a standstill. Outbreak of Cultural Revolution in Mainland China Introduction of reach based policy. Abolition of reach based policy China and British governments finally reached an agreement on the daily quote of One Way Permit. Maximum 150 legal immigrants were allowed to enter Hong Kong for settlement per day. Mainland China reduced the OWP quota from 150 to 75 per day Signing of Sino-British Joint Declaration. Mainland China increased the OWP quota from 75 to 105 per day

1950

1950 1950

1966 1974 1980 1980

1983 1984 1993

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1995 1997 1997 1998 1998

The daily quota for OWP further increased to 150 per day Change of sovereignty Hong Kong hit by Asian Financial Crisis Unemployment rate of Hong Kong reached 7% Introduction of Shangwu (Business visit) endorsement for Two-way Permit. Relaxation of Tanqing (Relative visit) endorsement requirements. Court of Final Appeal ruled that any person born in Hong Kong is Hong Kong residents in CHONG Fung-yuen case SARS Outbreak Introduction of Individual Visit Scheme

2001

2003 2003

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Annex C

Growth of Population in Hong Kong (1841 2006)

8000 7000 6000 5000 4000 3000 2000 1000 0

1841 1851 1861 1871 1881 1891 1901 1911 1921 1931 1941 1951 1961 1966 1971 1976 1981 1986 1991 1986 2001 2006

Thousand(s)

Year

Source : The figure from 1841 2001 were taken from CHAN, J. The Evolution of Immigration Law and Policies : 1842-2003 and Beyond in CHAN J., Rwezaura, B. (eds) Immigration Law in Hong Kong : An Interdisciplinary Study, Hong Kong : Sweet & Maxwell Asia (2004) The figure for 2006 was drawn from Census and Statistics Department, HKSAR Government.

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Annex D

Map of Cities covered by Individual Visit Scheme in 2007

Changchun

Shenyang Beijing Shijiazhuang Dalian Tianjin Jinan Wuxi Suzhou Wuhan Shanghai Chengdu Nanjing Hangzhou Chongqing Ningbo Changsha Taizhou Fuzhou Nanchang Guiyang Quanzhou Xiamen Nanning Kunming Zhengzhou Hefei

Haikou

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Annex E

No. of Mainlanders Visited Hong Kong (1997 2006)

Million(s)
14 12 10 8 6 4 2 0

8.46 m *

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year
* Individual Visit Scheme implemented in Mainland China in July 2003.

Source : Tourism Board

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Annex F

Obstetric Service Charges in Hong Kong Private Hospitals

Service charge for Hong Service Hospital Kong residents Normal Delivery Hong Sanatorium Hospital () and HK$32,000 Caesarean Delivery HK$43,800 Normal Delivery Kong residents. charge Caesarean Delivery for Special Women Arrangements

Mainland mother

for Mainland Pregnant

Kong HK$13,800 HK$17,800 Same as charges for Hong Deposit for Mainlanders HK$50,000 ward) HK$100,000 ward) (private (general

St. Paul Hospital HK$12,500 HK$15,180 HK$30,000 HK$35,000 Additional Administrative () Canossa Hospital () HK$25,280 HK$28,880 HK$42,800 HK$488,00 Charge HK$1,000 Fee

HK$13,100 HK$16,600 Same as charges for Hong Administration HK$51,700 HK$94,100 Kong residents. HK$15,000

Adventist Hospital HK$15,800 HK$25,800 Same as charges for Hong () Hong HK$41,800 HK$85,500 Kong residents. Fee

Kong HK$13,680 HK$15,800 Same as charges for Hong Administration HK$32,880 HK$37,780 Kong residents. HK$10,000

Baptist Hospital () St. Hospital () Union Hospital ()

Teresas HK$13,000 HK15,000 HK$24,000 HK$25,000 HK$28,000 HK$33,000 HK$45,000 HK$26,000

HK$15,880 HK$18,200 HK$42,000 HK$52,000 HK$27,260 HK$34,500 HK$80,000 HK$100,000

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