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# III. **HEALTH CARE DELIVERY AND UTILIZATION**

How is the delivery of health care organized? What role do the public and private sectors play, and how far are first- and second-level providers differentiated from one another? How are providers paid, and how does this influence the organization and delivery of care? What reforms have there been to provider payments and provider organization, and with what results? Who uses health care and how much? These are the questions considered in this section.

# **_Ownership and provider payments_**

Ambulatory care in the five systems is provided largely by the private sector ( **_Table 2_** ). Differences emerge, however, in the hospital sector: the hospital sectors of Hong Kong (China) and Singapore are both largely public, while in the three social insurance systems—Japan, Korea and Taiwan (China)—hospitals are largely private. In terms of the private-public mix, then, the five systems span all four possible combinations or ownership and finance. The first-level clinics in Hong Kong (China) and Singapore are mainly privately owned and operated, and are mainly privately financed, mostly out-of-pocket. The ambulatory care clinics in Japan, Korea and Taiwan (China), like the hospitals in these three systems, are also largely privately operated, but receive large amounts of public finance through UHI reimbursement. The hospital sector in Hong Kong (China) is largely publicly owned and operated, but is financed largely (80%) out of general revenues.<sup>*</sup> By contrast, the hospital sector in Singapore, which is also still largely publicly owned and operated (more on this below), relies heavily (though increasingly less so<sup>25</sup> ) on private finance.<sup>†</sup> _Table 2: Percentage of consultations, admissions, physicians and facilities in public sector_<sup>_‡_</sup>

||Doctors<br>per 10,000<br>persons|Beds per<br>10,000<br>persons|Ambulatory<br>consultations<br>% public|First-level<br>physicians<br>% public|Hospital<br>admissions<br>% public|Hospital<br>beds %<br>public|Hospit<br>als %<br>public|
|---|---|---|---|---|---|---|---|
|Hong Kong||||||||
|(China), China|15.8|52|28%|45%|82%|86%|76%|
|Japan|20.2|129||36%||33%|20%|
|Korea, Rep.|19.4|66||10%||10%|10%|
|Singapore|15.0|28|20%||74%|81%||
|Taiwan (China),||||||||
|China|14.0|59||3%||32%|15%|
|OECDaverage|28.0|60||||||

The five systems all share a common feature, namely that their ambulatory facilities offer a wider range of services than a typical ambulatory facility in the West. In Singapore, for example, ambulatory clinics offer X-rays, clinical laboratory tests, and some rehabilitative services.<sup>27</sup> In Japan, many physician offices (one third of the total) even have a few outpatient beds.<sup>17</sup> And in Japan, as in Hong Kong (China)<sup>28</sup> , clinics offer specialist care, not just primary

> * See Hong Kong (China)’s ‘domestic’ health accounts at <u>http://www.hwfb.gov.hk/statistics/en/dha.htm.</u>

> †  No national health accounts are available for Singapore26, and I have been unable to establish the share of hospital costs borne by the taxpayer.

> ‡ Data on doctors and beds from WHO <u>http://www.wpro.who.int/information_sources/databases/core_indicators/, except Taiwan</u> (China) where the numbers are from Taiwan (China)’s statistical yearbook <u>http://ecommerce.taipeitimes.com/yearbook2004/P243.htm</u> and the OECD averages which are from OECD Health Data<sup>1</sup> .