FREE MARKET, AND CONFUCIAN FILIAL PIETY: AGEING POLICY, GOVERNANCE AND AGED CARE IN KONG

by

Wai Lim Wong

A thesis submitted in fulfillment of the requirements for the degree of Doctor of Philosophy

School of Social Sciences and International Studies University of New South Wales 2012 Abstract

This thesis aims to explain the shaping of the aged care policy in from 1948 to 2007. The British Colonial government borrowed the concept of community care from the United Kingdom in 1973 and ageing-in-place in 1994 to support the development of its ageing policy. Prior to 1973 provision was mainly family and society-based. Between 1997 and 2007, the Hong Kong Special Administrative Region government continued to support policies associated with the colonial government but also emphasised the centrality of family support drawing on Confucian filial piety.

The problem under investigation is the contradiction implicit in Hong Kong’s social care policy for older people. The focus on Confucian filial piety and reliance on family care means that there is little provision of care in the community by the government. This thesis argues that the aged care policy in Hong Kong is more than a policy about material provision and that it engages with Hong Kong Chinese and promotes a narrative that normalizes family care as a duty and responsibility. The shortage of home places, together with government subsidies for some of the residents and providers, has greatly encouraged the development of private aged-care. The quality of this sector is very varied.

This thesis employs a three-stage analysis - which covers policy papers, the process of policymaking and the process of implementation. Newspaper and television reports on the aged care industry are also examined.

The theoretical framework draws on political economy, cultural and moral economy, Foucauldian govemmentality and Rose’s ethopolitics analysis. These perspectives provide a framework for explaining how filial piety or familial support prevails in Hong Kong, in relation to Hong Kong’s welfare system and its strong commitment to the free market and a balanced budget. Originality statement

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I am fortunate to have had Associate Professor Helen Meekosha and Dr. Alan Morris as my thesis supervisors. Without their inspiration, time, patience and good humour, my thesis would never have seen the light of day. I am also grateful to Associate Professor Raul Pertierra for the development of the research proposal, Professor Ann Daniel for her suggestion to compare Confucius’ and Foucault’s writings, Dr. Diana Olsberg for her insights into policy analysis, and Dr. Andrew Davidson for reminding me about the politics of governance in Hong Kong. I am particularly grateful for Dr. Alan Morris' unfailingly support during the final stage of the writing-up. My wife Suk Man and son Chi Yan have both been lovingly supportive and I am very thankful to them. Lastly, and with deep respect, I would like to dedicate this thesis to my late parents, Wong Man Ho and Wong So Shun, my late father-in-law, Chan Kit, my mother-in-law, Lai Wai Pin, and to all the elderly people in Hong Kong, who have shown me the spirit and meaning of life. Table of Contents

Part I Ageing policy, residential care and welfare Page governance

Chapter 1 Ageing theories, welfare governance and some 1 theoretical considerations

Chapter 2 The characteristics of Hong Kong political and 27 welfare systems

Chapter 3 Cultural legitimacy and Hong Kong ageing policy 53

Chapter 4 Research methodology 86

Part II The development of ageing policy in Hong Kong: a historical review 1948-2007

Chapter 5 Pre-community care policy period (1948-1972) 104

Chapterö Community care policy period (1973-1986) 138

Chapter 7 Community care and commercial care period: phase 182 one (1987-1997)

Chapter 8 Community care and commercial care period: phase 212 two (1997-2007)

Chapter 9 Conclusion 244

Bibliography 249 List of Appendixes

Appendix 1 A list of selected events in newspapers and television 304 programmes

Appendix 2 Social services expenditure as a percentage of GDP, 307 1967-2009

Appendix 3 The Five-Year Plan of community and home services 308 1979-1987

Appendix 4 The Five-Year Plan of community and home services 309 1988-1996

Appendix 5 Residential and community support services for the 310 older people 1998/99-2007/08

Appendix 6 Elderly Commission Study on Residential Care 311 Services for Elderly, 2009

List of Tables

Table 1 Residential care for the older people 2009 72

Table 2 The relationships of aged home, family services and 130 public assistance

Table 3 The distribution of the 60 & over population between 140 1971-1986

Table 4 The distribution and the increase of 60-64, 65-69, 141 70-74 & 75+ age cohort

Table 5 Types of elderly news in Ming Pao Daily from 1999 238 to 2006 Exchange rate

According to the linked exchange rate system, is pegged to the US dollar at the fixed exchange rate of 7.8 since 10/1983, and 7.75 since 9/1998

1 US$ = HKS7.8 (since 10/1983)

1 US$ = HKS7.75 (since 9/1998)

Source: Hong Kong Monetary Authority Part I Ageing Policy, Residential Care and Welfare Governance

Chapter 1 Ageing Theories, Welfare Governance and Some Theoretical Considerations

Introduction

This thesis is a study of the historical development of the aged care policy in Hong

Kong from 1948 to 2007. The study covers both the British colonial administration from just after the Second World War in 1948 to 30 June 1997, the return of Hong

Kong to China, and the administration of the Hong Kong Special Administrative Region

(HKSAR) under the principle of ‘one country two systems’ from 1 July 1997 to 2007.

The key features of aged care policy in Hong Kong are care in the community and ageing-in-place. The policy emphasises that older people should live in the community and considers residential aged care as the last resort. This thesis aims to understand the forces underpinning the formation and development of this policy. It will also examine the relationship between the provision of community support and residential aged care, and the arguments of tradition, family and the virtue of self-reliance. I will examine the four periods of its development: the pre-community care period (1948-1972), the community care period (1973-1986), and the community and commercial care period, phases one (1987-1997) and two (1997-2007).

This thesis consists of two parts. Part I Chapter 1 is about ageing theories and welfare governance, and outlines some theoretical considerations. Chapter 2 is about social policy, legitimacy and Hong Kong society. In Chapter 3, I will examine cultural legitimacy and Hong Kong ageing policy with ideas and arguments from Chapters 1 and 1 2. Chapter 4, which concludes Part I, is about methodology. The first four Chapters in

Part II are about the historical development of ageing policy in Hong Kong. Chapter 5 is

about the pre-community care policy period, Chapter 6 is on the community care period, and Chapter 7 is concerned with community and commercial care phase one. Chapter 8 is about community and commercial care phase two after the to

China. The last chapter in Part II is Chapter 9 and is the concluding chapter of the thesis.

In this chapter, I will first introduce a recent user group’s petition concerning the provision and quality of residential care for older people, and physically and mentally disabled people, a long-neglected social welfare issue. This is followed by an introduction to3 Hong Kong as an ageing society, including a discussion of the demographic and ageing policy context. Secondly, I will explain the different kinds of ageing theories, with a focus on those that will be used in the analysis of the ageing policy. Lastly, I will conclude the chapter with a brief discussion of ageing theories and social policy.

On 7 July 2009, an inaugural ceremony of a united front demanding an increase in government-subsidised residential care homes for older people and physically and mentally disabled persons in Hong Kong was launched. The united front was composed of ten self-help groups of which five were physically and mentally disabled persons’ parents’ groups, one was a carer group for mentally disabled persons, two were policy and rights groups for the elderly, two were rehabilitation groups, and 17 were social welfare non-government organisations (NGOs). Three hundred people attended the inaugural ceremony, where they condemned the government for the acute shortage of

2 government-subsidised homes. Representatives from different self-help groups spoke of the hardship facing families and seven legislative councillors showed up to support the groups and their cause. The united front was formed because of abuse and the shortage of residential places for the elderly and the physically and mentally disabled. It also argued that the legislature had governed the operation of residential homes for the elderly since 1996, but not homes for physically and mentally disabled persons. After the meeting, the group - with a of 11,800 signatures - marched to the Labour and Welfare Bureau to petition the government to speed up the provision of residential care for the two groups. In the statement presented to the government, it says that between April 2005 and February 2009 there were 8142 older people on the waiting list for care and attention homes (C & A homes)1, a facility for older people who require less than 2.5 hours of nursing care per week, and only 1866 of them had been placed. Of the remaining 6276, about three-quarters had died while waiting for admission.“ The situation for the physically and mentally disabled group was even worse. It would take

1 Aged homes in Hong Kong are classified according to the care needs of the elderly. They include hostels (for people with self-care ability), homes (for those with self-care ability and those requiring assistance), C & A homes (for those requiring less than 2.5 hours per week of nursing care), nursing homes (for those requiring more than 2.5 hours per week of nursing care) and infirmaries (for those who require constant care). All these aged homes are government-sub vented. There are also private aged homes which the government finances through the Bought Place Scheme (BPS), Enhanced Bought Place Scheme (EBPS) and the social security scheme. Nearly 70 per cent of those in residential care are in private homes. There has been no provisions for new hostels since 2003 and the current ones will be phased out.

2 Some of those on the waiting list may have been staying in private homes and waiting for a place in the government-subsidised homes run by NGOs. The waiting list may not be an absolute accurate indicator of the exact number of people with genuine needs, but it shows the large pool of people in need of the service. In the 2005 thematic household survey on long-term care, 2.8 per cent (65+) had an intention to move into an aged home and 90.9 per cent planned to move into a subsidised residential care home (an NGO home) (Census and Statistics Department, 2005: 55). 3 an average of six to eight years for a home placement and for some of the severely

mentally disabled people, the waiting time was 12 years. This was an unfortunate

situation, especially for the severely mentally disabled whose families have to shoulder

the burden of care. What has gone wrong with social policy and social welfare planning

in Hong Kong? As a newly industrialised economy (NIE) in East Asia, Hong Kong

started social welfare planning in 1965. By 2009, it had four decades of experience. It was clear that this long tradition and experience in welfare provision had barely improved the living conditions of the groups in question. The lack of provision raises several key questions. How did the government contribute so little to the provision of community support and residential care services? Is this a financial or cultural issue?

How could the family and the private residential care sector become the major providers of care? What kind of welfare regime exists in Hong Kong?

In the case of older people, which are the focus of this thesis, it was not the first time that social workers and service users had petitioned the government for the provision of good quality residential care. Older people and concerned groups had petitioned the government on different occasions for different kinds of provisions since the late 1970s.

Petitions had been used mainly because of the bureaucratic of government departments, making applications difficult, or the shortage of provision.

The number of petitions varied from year to year and usually there were only a few a year, depending on the urgency of the incident. There were more petitions in the late

1970s and 1980s than in the 1990s, and there was an increase in the 2000s. If there are too many petitions, the impact on the government is minimised and they are described by the mass media as a nuisance rather than an expression of real concern. From the above situation, one might conclude that all the petitions had been futile.

4 The structural lack of supply of provisions for older people was not only a cause of

concern leading to street petitions and public assembly, as described above; it was also

part of the tradition of gerontological research in Hong Kong. This was because many

of the studies were service provision oriented so that researchers, such as academics or

social workers, could use the findings to justify an increase in services. It was like an

audit of public provision in the form of action-oriented research. In a systematic review

of 56 research reports about older people in Hong Kong, Law (2001) notes that

government reports on ageing were published in the late 1960s and the mid-1970s and it was not until the early 1970s that there was research on the elderly and ageing population. He also notes that this research and the surveys were of a descriptive nature, and the findings were usually presented in 'the simple frequency distribution format'

(Law, 2001: 63) and 'most of the samples are from public housing estates, members of the elderly centres, and the instituitionalised aged’ (ibid.).

Taking into consideration the key feature of the mainstream gerontological research tradition in Hong Kong, I will examine the issue from a different perspective. I will begin the study from a historical viewpoint to find out how the shortage of provision can have so little impact on Hong Kong society.

I argue that the ageing policy in Hong Kong is not only a policy about service provision for older people, but is also a . There was no formal ageing policy between 1948 and 1973, and the care of the old was mainly based on the traditional

Chinese culture of care by the family. Those who did not have families to take care of them would turn to religious and NGO-based aged homes for help. Thus, care was a

5 combination of family and charity care in the traditional cultural sense. In 1967, when

Hong Kong was recovering from social riots, the then Hong Kong government was

eager to show the Hong Kong people that, - unlike the previous government, the new

government was a modern and caring one. Hence, the wording of the title of the ageing policy, 'care in the community' gives the formal provision of aged care a sense of modernity. The policy argued that it would 'make the least demand on community resources, whether these be finance, skilled manpower or accommodation' (Working

Party on the Future Needs of the Elderly (WPFNE), 1973: 15). Thus, it was economical in nature and suited the fiscal culture of the Hong Kong government of maintaining a balanced budget. The literal meaning of 'care in the community' or 'domiciliary care'

(ibid.) when translated from English into Chinese expresses the traditional Chinese of familial care of older people. These four different senses of culture — traditional (familial and charity care), modem (Western modernity), fiscal (Hong

Kong’s regime of economic truth) and literal (translation of the cultural ideal of Hong

Kong Chinese ethnicity) — have had an interlocking effect on the development of residential care and community support services for the old in Hong Kong.

I will examine a range of ageing theories to explain the values behind Hong Kong society and the ageing policy it pursues. Before this, I will outline the demographic stmcture of Hong Kong and provide background information related to the 'care in the community' policy.

Hong Kong as an ageing society: demographic and ageing policy context

According to the 2006 By-census, Hong Kong’s population was about 7 million, of whom 12.4 per cent (0.85 million) were 65 plus (Census and Statistics Department, 6 2008). The life expectancy was 79.5 years for males and 85.6 years for females. As a

point of reference, in 2006 in Japan the life expectancy for males and females was 70.0

and 85.8 years respectively. In Singapore, in 2006 the life expectancy of males and

females was 78.9 and 82.8 respectively (Chau & Woo, 2008: 12). In Hong Kong, more

than half of the elderly were living with their families, though there was a growing trend

among old people either to live alone (11.6 per cent) or with their spouse only (21.2 per

cent) (Census and Statistics Department, 2008: 45). The figure for the aged care home

population was about 10 per cent, increasing from 6 per cent in 1991 (Chau & Woo, 50).

This was high compared with Japan (3 per cent), Australia (6 per cent), the United

States (6 per cent), and the United Kingdom (5 per cent) (ibid, 50- 51).

The high percentage of older people in residential care in Hong Kong was a result of many factors. First is the increase in life expectancy. Those aged 85 and above comprised the highest percentage of all the age groups in 2006. About 23.5 per cent of males and 39 per cent of females lived in non-domestic households in 2006 (ibid. 50).

The second factor is the lack of community support services, meaning the elderly have difficulties staying in the community (Wong, Yu & Tsoi, 2002). Thirdly, there is the attitude of not receiving formal services until family care is exhausted, and therefore people usually only turn to residential care when the family finds their aged relatives too difficult to cope with. Fourthly, there is a shortage of female carers at home as women’s employment rates have risen. In addition, not all female family members want to care for their older relatives at home. Fifthly, there is the question of the housing conditions in Hong Kong. Due to the lack of space, wheelchair-bound people are not able to get around easily and admission into an aged care home is their only solution.

7 Lastly, there is a group of older people suffering from senile dementia who cannot be

cared for by their families.

The ageing policy of 'care in the community' was first brought to Hong Kong from the

United Kingdom (UK) in 1972. According to the Working Party on the Future Needs of

the Elderly (WPFNE), the government aimed to have 'an overall strategy, and a

comprehensive and coherent policy for the ageing' (WPFNE, 1973: 15). The report

goes on to say that the reason for the adoption of the policy was based on 'the similarity

between the UK and Hong Kong and that both groups of applicants for residential care

would remain in their community if services were provided ' (ibid. 16). If this was the

case, it was the suggested similarity of the residential contexts more than the differences

that gained acceptance. The success of the 'transfer' of the community care policy was based on similarity rather than difference. In fact the residential context in the UK was quite different from Hong Kong in a number of ways, such as population density, spatial difference, land utilization and development control (Booth, 2003: 81 &

185-186). However, the meaning of ‘care in the community’, as will be argued in

Chapters 3 and 6, resembles the familial care of Hong Kong Chinese tradition. The implication is that the policy engages with the identity of the Hong Kong Chinese people and they take it as natural and normative.

In comparing the stages of social welfare development between Western economies and newly indistrailised economies (NIEs) such as Hong Kong, La Grange and Lock (2001) note that 'the Anglo-European model can be broadly characterized as having shifted from minimal welfare provision to a Keynesian model of welfare and social democracy in a post-industrial model' (ibid. 28). In the case of NIEs (such as Hong Kong), they

8 'can be characterized as having proceeded directly from pre-Fordist to post-Fordist

welfare regimes without the intermediate Fordist phase’ (ibid.). They further note that

'there is much in common between a Confucian and post-Fordist model of welfare

which helps to explain the apparent seamlessness of the transitions', and 'in South East

Asia, governments do not find themselves in the uncomfortable position of seeking to

reduce benefits because they never provided them in the first place' (ibid.).

From the institutional perspective (Thelen, 2003: 217), ageing policy in Hong Kong

suffered from the path-dependency of cultural values which was common among East

Asia countries (Fu & Hughes, 2009: 15). From the point of view of administration, the policy facilitated or consolidated 'the best government possible within Chinese political tradition' (Tsang, 2004: 206).

The following is an examination of ageing theories, which illustrates the dynamics of ageing policymaking.

Ageing theories, the modern and the critical

In this section I aim to assess the different kinds of ageing theories and to see how they explain the development of the aged care policy in Hong Kong covered in Part II.

Ageing theories are not just explanations of growing and being old; they are about social and political relationships constituted by social policy and welfare philosophy

(Biggs, Lowenstein & Hendricks, 2003; Estes, Biggs & Phillipson, 2003; Bengtson,

Putney & Johnson, 2005; Powell, 2006; Bengtson, Gans, Putney & Silverstein, 2009; Fu

& Hughes, 2009). There are several traditions in the explanation of ageing and its related processes, reflecting the assumptions of individuals, family, government, work 9 and responsibility. In the case of my examination of Hong Kong’s ageing policy, five

different ageing theories can be identified: the functionalist, political economy, moral

economy, cultural economy and Foucauldian gerontology theories. These ageing

theories can be divided into two types — the modem functionalist and the critical perspective3. The former consists of the functionalist theory of disengagement and

activity, while the latter includes political, moral and cultural economy and Foucauldian

gerontology. There is a close relationship between ageing theories and ageing policy.

Ageing theories are like social and political theories that have the characteristic of mirroring the reality of society, reflecting the treatment of older people as manifested through the implementation of the ageing policy.

The modern functional theory of ageing

There are two key functionalist theories of ageing: disengagement theory and activity theory.

Disengagement theory and modern gerontology

Disengagement theory is in the 'first generation' of gerontological theories, and one of the few theories of ageing constmcted for and by gerontologists (Achenbaum, 2009: 31).

It was developed in the late 1.950s by a group of gerontologists associated with the

Committee on Human Development at the University of Chicago (Phillipson, 1998: 15).

The seminal study focused on a panel of people aged 50 and over who were interviewed

3 Several of these ideas have been discussed in Wong, W.L. (2007) 'The resilience of personal economy of ageing: an examination of the productivist welfare capitalism of Hong Kong \ Journal of Comparative Social Welfare, 23:1, pp. 81-88. 10 for several years in the large metropolitan centre of Kansas City, Missouri, in the US

(ibid.). Disengagement theory (Cumming & Henry, 1961) involves several elements;

two of which are useful in the present examination. First, during the ageing process, the

older person disengages from their social life, work and society, thus allowing them to

prepare for their last stage of life, that is, death. Second, disengagement from work —

retirement — makes room for the younger generation to take over. However, the theory

has been criticised on empirical, theoretical and logical grounds (Passuth & Bengtson,

1996: 15).

Disengagement theory assumes a natural process of exclusion of older people from society (Estes, 1979) as 'legitimating a form of social redundancy among the old'

(Phillipson, 1998: 16) and it is by nature a theory of'acquiescent functionalism', that is, the tendency to attribute problems of ageing to individual adjustment rather than to structured inequalities (Townsend in Estes, Biggs & Phillipson, 2003: 15). It operates

'from a structural-functionalist perspective' and 'argues that those who enter old age should be gradually phased out of important social roles to maximize the functioning of a stable society' (Hughes & Heycox, 2010: 75-76). As a whole, the theory 'was immune to mediating circumstances or variations by race, ethnicity, gender, or class'

(Hochschild, 1975 in Achenbaum, 2009: 32). Despite all the critiques of the theory, it has had a profound effect and 'it has provided a theoretical rationale for early retirement in the private and public sectors over the past several decades' (Estes, Linkins & Binney,

2001: 25) and 'it continues to resurface as gerontological commentators regularly note'

( Dannefer, D. & Kelly-Moore, J.A., 2009: 406).

11 Activity theory and successful ageing

Activity theory arose in response to disengagement theory (Achenbaum, 2009: 32). The

theory insists that old age can be a lively and creative experience and that idleness not

ageing hastens illness and decline (Katz, 1996: 123). Activity theory argues that

successful ageing can be achieved by maintaining the activity patterns and values

typical of middle age into old age (Bond, Briggs & Coleman, 1990: 30). In contrast to

disengagement theory, it argues that the more active elderly people are, the greater their

satisfaction with life. The central criticism of activity theory is its idealistic nature,

because it is unrealistic to expect all people to be active and maintain a middle age

pattern of life (ibid.). It is also criticised for neglecting structural issues such as class,

income and housing, and for its continuing focus on individual ageing (Estes, Linkins &

Binney, 2001: 27; Katz, 1996). However, it has stimulated the development of several

social psychological theories - including continuity theory and successful and

productive ageing. The theories of successful and productive ageing have been

challenged for ignoring health and economic disparities as mentioned above, and 'some

elders do not wish to take on fresh challenges' (Achenbaum, 2009: 32). Activity theory as expressed in the form of successful ageing is challenged for focusing:

on a narrow elite group and defining ageing in White male, middle class

terms, thereby labeling some as successful, while marginalizing women, the

poor and people of color ... and by its use of the term successful,

unintentionally stigmatizing some elders, including the disabled, as

'unsuccessful' or 'losers' (Leedham & Hendricks, 2006: 32)

12 Though disengagement and activity theories originated in the US, they are no strangers

to a liberal economy like Hong Kong. In an attempt to evaluate gerontological studies in

the US so as to re-engage with basic questions about ageing and social life, Hagestad

and Dannefer note that there is a strong trend of microfication in concepts and theories

of ageing in the US. They say there is:

a concentration on psychological characteristics of individuals in

micro-interactions and as a result, macro level phenomena of central interest

to social scientists, such as social institutions, cohesion and conflict, norms

and values, have slipped out of focus or have been rendered invisible (ibid.

4).

In similar vein, in Hong Kong it is taken for granted that individuals will take responsibility for themselves and their opportunities in life.

Critical perspectives on ageing

Political economy of ageing

The rise of the political economy of ageing was mainly due to the neglect of the fact that ageing is a differentiated process which encompasses class, gender and ethnicity. It was also 'an explicit attempt to counteract the then prevailing functionalist paradigm in social gerontology' (Walker, 2005: 816). Besides, it 'highlights awareness of the structural processes and constraints affecting older people ... the larger political and economic context that structures the experience of ageing' (Ozanne, 1997: 236). The political economy of ageing challenges the mainstream functional theory of ageing in

13 three areas. Firstly, the basic argument of this perspective is the structural dependency of ageing which describes the development of a dependent status resulting from restricted access to a wide range of social resources, particularly income. This is reflected in the large numbers of older people who live in (Townsend, 1979;

Bond, Briggs & Coleman, 1990: 34). It also challenges the view of 'growing old as a period dominated by physical and mental decline, an approach known as the biomedical model of ageing' (Phillipson, 1998: 17-18). Secondly, it challenges the 'alarmist' or ' apocalyptic' demographic view that 'the burden on public expenditure is a result of an ageing population' and thus 'blaming old people obscures problems relating to the capitalist system and the subsequent political choices' (ibid. 19). Thirdly, the status of old people cannot be analysed in isolation from other societal forces and phenomena, and the power of the state, business, labour and the role of the economy are of central concern (Estes, Linkins & Binney, 2001: 40-41).

There are three major criticisms of this approach. One is that 'it is too structurally deterministic, leaving no room for individual agency' (Phillipson, 1998: 20). Secondly,

'it underplays the impact of gender in status and power, and the effects of the cumulative oppression faced by women' (ibid). Thirdly, there is little or no attention given to 'the moral and existential issues faced by older people' (ibid.). In addition, the daily life of old people and their resistance to tackling life tasks are not fully dealt with

(Phillipson, 1998: 139). The key concern of the political economy perspective addresses the redistributive aspect of income, salary and retirement protection, the question of retirement equity among the employed. The political economy of ageing continues to play an important role because it can highlight the fact that the low-income group is composed of old people who are either under-paid or unemployed and without income

14 protection. Taking into account globalisation and development, Walker (2005) draws

our attention to the international political economy of ageing and globalisation.

Townsend (2006) proposes that a dimension of human rights offers a framework of

rigorous analysis and anti-discriminatory work.

In Hong Kong, there are many instances that illustrate the usefulness of the political

economy perspective. Retirement protection is an example. Except for Hong Kong’s civil servants, who can enjoy their retirement with a secure income, the majority of

Hong Kong people do not have workplace retirement protection. It was only in 2000 that a mandatory provident fund (MPF) scheme was established and it will take some years before it has an impact. Due to insufficient retirement protection, the majority of older workers try to stay in the labour market for as long as possible (Chou, 2009: 105).

Some continue to work in China and some become security guards at residential and commercial buildings, 'earning a living until forced to retire' (ibid. 106). The Hong

Kong labour market is a good reflection of the political economy approach.

In terms of methodology, Estes (2001: 1-3) takes a broad view of the perspective of political economy. She considers it the core of analysis and at the same time supports its theoretical roots in the areas of conflict, feminist and critical theory as well as . She calls this the multilevel analytical framework (ibid). She also supports and attempts to merge and blend the political economy of ageing with the moral economy of ageing. This is an area, which I will examine in later sections.

15 Moral economy of ageing

Building on the work of the historian E.P. Thompson (1971), the moral economy

perspective has brought attention to the social norms of reciprocal obligations and

relations and their role in the social integration of old people. Moral economy refers to

issues of fairness and custom, the consensual assumptions about reciprocal obligations

and social nonns in society. Moral economy recognises that not all human exchanges

can be entered into cost-benefit equations. It shifts the emphasis from individual

motivation to the system of reciprocal relations, and allows us to go beyond the political

and economic sphere in a narrow sense and into an analysis of the moral structure of the

economy and polity themselves. The moral economy of ageing usefully distinguishes between use and exchange values, the former referring to needs-based, public interest

and empowerment-oriented values, while the latter refers to those goods maximising satisfaction regardless of social distribution. Use values can promote the formation of moral economy. The moral economy of ageing is about structuring society so as to maximise the possibilities of a decent life for all (Estes, Linkins & Binney, 2001: 42-43;

Minkler & Estes, 1991, Hendrick, 2005), and modem retirement system can be an illustration (Kohli, 1987).

However, moral economy has been criticised for being too idealistic and for offering a one-dimensional account of a multidimensional process (Gilleard & Higgs, 2000: 22).

Theories of moral economy have developed largely as part of the political economy of ageing and they aim to solve problems highlighted by the political economy perspective.

Therefore, all these understandings of the moral economy of ageing neglect ethnicity and women’s standpoint. However, Estes’s (2001) multilevel framework of analysis includes ethnicity and the female perspective. An example is the study by Maynard & et

16 al. (2008) of women in later life, in which the authors examined the interdependence

and moral economy of kinship among women from different ethnic groups in the UK.

Another example is about the moral economy of female migrants in the US (Ong, 2006:

199). Moral economy analysis can be at the kinship-based micro scale as well as the

societal-macro level.

Moral economy has much to offer as an analytical framework and it can be a mediating concept linking other ageing theories of economy. Awareness of the moral dimension of growing old has become an important issue both within political economy and through influences from within the humanities (Phillipson, 1998: 21). Tao notes that, in Hong

Kong, 'according to the Confucian moral thesis, not only are human relationships essential to our realization of our humanity, but to our family relationships' (2004: 137).

In a sense the practice of filial piety, which in Hong Kong is an important aspect of the familial care of older people, is a kind of moral economy (Maynard & et al., 2008; Ong,

2006). This is also about the normative basis of receiving public welfare, involving questions such as the ‘deserving’ or ‘undeserving’ and how much old people should receive from the government to ensure a decent living.

Cultural economy of ageing

The study of the cultural economy of ageing is a recent academic topic (Tulle-Winton,

1999; Gilleard & Higgs, 2000; Katz, 2005). It emerged from the recognition of postmodern culture and the post-traditional society in the late 1990s (Tulle-Winton,

1999). It represents the in the study of the political and moral economy of ageing (Gilleard and Higgs, 2000). The cultural economy of ageing is critical of commercial culture and the dominant discourse of successful ageing associated with the 17 individual governance of one’s body (Tulle-Winton, 1999: 290). Ageing has become

complex and differentiated, and there are now a variety of ' of ageing', such as

ageing and (Blaikie, 1999) and ageing of ethnicity (Torres, 2006: 231).

However, the emphasis on the cultural aspect of ageing is considered a narrow cultural

critique of ageing (Walker, 2006: 59) and is inadequate in terms of both evidence and

theory (ibid. 71). This is because it is an 'over-estimating agency in replacing political

economy with a culture of personal identity' (ibid. 70).

Not directly relating to social gerontology but to the development of the study of

cultural and political economy (CPE), Jessop (2004) and Best and Paterson (2010)

argue the usefulness of the cultural political economy perspective. Taking into account

the social and political changes over the last few decades, Jessop’s concept of CPE

relates to critical semiotic analysis, while Best and Paterson aim to rediscover the

unacknowledged role of culture in the writings of classical political economists. All reflect the adjustment of the cultural lens of political economy in order to have a better view of our times. A cultural political economy of ageing perspective sounds useful considering the interplay between culture and politics, especially with regard to the meaning of language.

Given these cultural, economic and political changes, Tulle-Winton (1999) argues that underlying much contemporary gerontological knowledge is a debate about the most appropriate framework within which to understand the social and cultural position of the old in any given society. Tulle-Winton is in favour of an analysis of how culture and consumption are given more importance than the political economy of structured dependency. There are certainly strengths in the explanation of ageing through its

18 cultural lens but there is a danger of being over-deterministic. In other words, it would

be an act of over-determination to reduce all explanation to the cultural factors. This is

the reason why this thesis examines and seeks to explain ageing policy from different

perspectives. This is a view termed by Bass as the integrated view of ageing analysis

(2009: 360).

The debate about whether political economy or cultural studies offers a better

explanation of society has been taking place for some time (Kellner, 1997: 102).

However, it is only recently that the debate has occurred in the field of critical social

gerontology. In an examination of consumerism and the remaking of the state-citizen

relationship, Clarke notes that 'political economy operates with a residual or “thin”

conception of the social: those domains of life that are “extra-economic” and subsidiary

to the dynamics of economic forces and their conflicts' (2006: 92). The debate between

political and cultural economy with a focus on the 'social' is summarised in Walker

(2006). Walker notes that according to Gilleard and Higgs, cultural economy means

'anti-ageing technology' and 'staying young' culture, thus reducing it to a question of agency, and in political economy 'older people themselves are not isolated, atomized individual agents or subjects focusing only on their own identities, but interacting with and changing the social structure' (Walker, 2006: 76). Walker argues through the theoretical basis of the social against the background of social quality (ibid. 71-76) which 'provides a methodology for understanding the constant tension between structure and agency in everyday life, including over the life course' (ibid. 76) to reconcile the debate between the political and cultural economy of ageing.

19 The debate between agency and structure has special implications in the analysis of

aged care in Hong Kong. There, given the subordination of social policy to economic

policy, it is useful to see how the political economy perspective can shed light on the

analysis of ageing and economic inequality. On the other hand, not everything is

determined by political economy. How individual agency as subject of him/her or

his/her own family can be a result of cultural or moral forces other than political

economy is worth probing. The multilevel approach as proposed by Estes (2001) is

useful in considering other forces of importance and at the same time not losing sight of

the economic factor in the understanding of ageing policy.

A brief summary of the three economies of ageing

A brief summary of the three economies of ageing is helpful here. Vincent (1995)

remarks that there has been a dialectical progression advancing the understanding of the

social position of the elderly. He argues that the first generation theories

(disengagement and activity) are individualistic and psychological in orientation. Their antithesis came with the second-generation theories (political economy of ageing), such as age stratification and structured dependency within a social structural framework.

The third-generation (moral economy of ageing) or synthesis theories are those that can bridge both structure and action (Vincent, 1995: 171). In the next section I discuss the fourth generation of ageing theory, Foucauldian gerontology.

Foucauldian gerontology

Foucauldain gerontology is different from the above-mentioned perspectives in the sense that it is not a single-track theory of analysis but has multiple entry points. As I have noted above, Estes’s multilevel analytical framework (with the political economy 20 perspective as the core) is multifocal and does not rule out the possibility of examining

the position of old people from different angles. In this regard, this viewpoint is close to

Foucauldian gerontology.

The implication of Foucauldian gerontology is particularly significant for a

contemporary neo-liberal society and its policymaking. Foucault only mentioned old

age a few times in his writing, yet there is much food for thought in his work in terms of

ageing analysis. What is important for this thesis is that the Foucauldian economy of

ageing (Biggs & Powell, 2001) explores the themes of power, subject and body from the genealogical standpoint. It traces the issue from its starting point.

Foucauldian writings are mostly about 'power, knowledge/controF and the processes and techniques by which the government manages the population through health and social care provisions. In Foucault’s later writings, there is increasing evidence of what might be termed an ‘optimism of resistance’, that is, people have in themselves the power to resist domination, and in particular domination by the state (Biggs & Powell,

2001).

It was not until recently that there has been an increasing use of Foucault’s writing in ageing studies (Powell, 2006; Biggs, & Powell, 2001; Wang, 1999; Katz, 1996). In one of the pioneer works of Foucauldian gerontology, Katz in his analysis of gerontology as a discipline notes that:

the technologies of workhouse and old people’s homes, the development of

pensions and retirement, and social surveys (feeding an alarmist

21 demographer which fuelled the demand for control) created the ‘elderly’ as

a problem group and the ‘retiree’ as a category of old, poor and dependent,

receiving benefits as the state determines but unable to ‘earn’ them as a

productive member of a capitalist economy (1996: 6-7).

Governmental approach: governmentality and ethopolitics

Foucault’s work on governmentality has had a major impact on policy studies. In

addition to the governmental analysis of social policy (Marston & McDonald, 2006),

Rose (2001, 2007) also argues for ethopolitics, the politics of behaviour. In this thesis, I

will use both governmentality and ethopolitics to analyse the development of ageing

policy in Hong Kong.

Governmentality

The employment of governmentality in policy analysis unravels the complex character of the relationship linking state and non-state forms of governance. The key concern of governmentality is how modem forms of government shapes the conduct of others and the conduct of selves (Marston & McDonald, 2006: 1). Governmentality refers to the two processes of state power: the individualising and totalising forms of power

(Foucault, 1982: 213). It refers to the twin processes of societal management according to both the micro (the conduct of selves on the personal individual level) and macro (the conduct of others at the group and society level). The analysis incorporates not only the actions and structures of the state, but also all the complex ways in which selves and population are managed, directed, ordered and administrated, for example in families, in

22 schools, in communities and in workplaces. The state-centred mode of analysis has been questioned by a growing number of policy researchers (Petersen et al., 1999; Fischer,

2003; Dean, 1999 in Marston & McDonald, 2006: 3). The intention of the governmental approach is to bring a different mindset to analysing the state sector so as 'to reposition how we think about power and authority in late modem societies' (Marston &

McDonald, 2006: 3). In its application, 'govemmentality serves as a conceptual scaffold to support' and 'directs us to explore the moral codes in operation, the language used, the attributes of participants marked as ethically significant' (ibid. 4). Cruikshank (1999) notes that social welfare programmes in the US are 'technologies' for the formation of citizenship. Thus:

The 'technologies of citizenship formation' illustrate how the 'powerless

group', 'group at risk' and 'passive welfare dependent' are either

encouraged or not so gently coerced to take up certain ethical dispositions

associated with self-reliance and responsibility (Marston & McDonald, 2006:

4).

Govemmentality can be mechanical and reduces the analysis to merely political programming (Rose, 1999; Dean, 1999; Mckee, 2009). Treating it as a Foucauldian effect, Powell argues that govemmentlaity 'may be a totalizing discourse but in practice it is complex and differentiated, dynamic and fluid' (2006: 110). He also argues that 'it needs to be thought of as permanently incomplete and dependent on an enormously diffuse system of action which itself is the aggregate or structural effect of innumerable interpersonal and organizational transactions' (ibid.).

23 Ethopower

In response to the debates about the Third Way in politics in the UK and the US, Rose

suggests that 'what is most significant is the emergence of a new politics of conduct that

seeks to reconstruct citizens as moral subjects of responsible communities' (2001: 1).

Rose says that 'the person whose conduct is to be governed is believed to desire

personal autonomy as a right, but autonomy does not imply that individuals live their

lives as atomized isolates’ (ibid. 4). He continues, 'they are understood as citizens, not

of societies as national collectivities, but of neighbourhoods, associations, regions,

networks, , age groups, ethnicities, and lifestyle sectors — in short,

communities ' (ibid.). He also distinguishes ethopower from discipline and biopower,

saying that:

if discipline individualizes and normalizes and biopower aggregates and

socializes, ethopower works through the values, beliefs and sentiments

thought to underpin the techniques of responsible self-government and the

management of one’s obligations to others' (Rose, 2001).

In ethopolitics, 'life itself, in its everyday manifestations, is the object of adjudication, the community-civility game' (ibid. 5). For critical gerontology, the relevance of ethopolitics is the moral code regarding caring, the mundane everyday life activities.

Rose notes that 'moral order cannot rest on legal codes enforced and upheld by guardians; it is embodied and taught through the rituals and traditions in the everyday life of communities' (ibid. 9). In Hong Kong, familial care of older people or the practice of filial piety constitutes a kind of successful ageing intermingling with self-

24 perfection and the familial ideal. It can be argued that ethopolitcs is a process of

meaning making or value preference based on a conceived notion of one’s social groups.

Filial piety and the Hong Kong community care policy for old people are clear

examples. My observation is that ageing policy is a policy based on symbolic goals more than serious provisions. It reflects the limits of the capacity of the Hong Kong

state. Paradoxically, it is also due to the symbolic meaning of the policy that the state

can reach the people, as Shue notes in The reach of the state (1988).

Conclusion

Ageing is a multifaceted phenomenon, not only because older people are not an homogeneous group, but in the case of Hong Kong there is also the influence of socio-historical forces. It is because of multiple factors that the two main traditions of explaining ageing - either as an outcome of individual adjustment, as argued by disengagement and activity theories, or the structural dependency thesis of the political economy of government policy - are inadequate in providing an explanation of ageing and its relationship with policymaking in Hong Kong. To go beyond this binary view of ageing, individual or structural, though each has its own disciplinary contribution, an alternative multilevel approach is needed to reconcile the differences between these two views.

The examination of power relations is absent in the first paradigm of ageing as disengagement and activity. The main focus of the second, third and fourth paradigms of the political, moral and cultural economy of ageing is power relations and how the political, economic and cultural determine ageing and older people. However, they do

25 not usually account for how individual agency interacts with the structural constraints.

The fifth and sixth paradigms of Foucauldian ageing theories of govemmentality and

Rose’s ethopolitics can provide an explanation of how individual agency interacts with the ageing policy. Govemmentality and ethopolitics both possess a mediating property with 'the potential to mediate between the individual and the stmctural and to help us understand the genesis of social action' (Williams, Popay & Oakley, 1999: 172).

At the beginning of this chapter, I noted that ageing policy in Hong Kong represents four different cultural perspectives. These 'cultural dimensions' constitute different

'regimes of truth' relating to the question of legitimation. The next chapter is about the characteristics of Hong Kong political and welfare systems. In Chapter 3,1 will examine cultural legitimacy and Hong Kong ageing policy.

26 Chapter 2 The characteristics of Hong Kong Political and Welfare Systems

Introduction

One of the purposes of studying social policy is to explain why government takes

certain directions and not others. Therefore, we need a theoretical framework to guide

the analysis — a set of hypotheses about what drives policy (Feena, 2004: 123). In this

chapter, I outline some of the key features of Hong Kong society relevant to an

examination of the development of the aged care policy. In the second part I will

examine the residual, liberal and Confucian dimensions of the Hong Kong welfare

regime. In the conclusion I will review the use of the term ‘state’ in relation to welfare provision in Hong Kong.

In my analysis of the welfare model in Hong Kong, I argue that in order to understand

Hong Kong’s welfare system we need to examine the issue of legitimacy. Legitimacy refers to the acceptance of authority by the general public in the Weberian sense.

Governments can step down if the administration is not accepted by the people. The

Hong Kong government as a legitimate authority could be even more vulnerable due to its politically dependent status as a British colony between 1841 and 1997 and a special administrative region of the People’s Republic of China (PRC) since 1 July 1997.

There has been a lot of research in the area of legitimisation in Hong Kong (Scott, 1989,

2010; Cheng, 1992; Leung, 1996: 20; Aspalter, 2002: 20; Ngo, 2002; Goodstadt, 2007:

20; Sing, 2009) but seldom do these works examine legitimacy from the perspective of the development of ageing policy in Hong Kong. This thesis attempts to fill such a gap.

27 This chapter argues that the production of economic and cultural citizenship is part of

the normative foundations of Hong Kong society. Economic citizenship is normative

because the Hong Kong government emphasises economic development far more than

the development of civil and political rights. People who work hard and are

economically active and 'are the kind of people the Hong Kong government considers

as the model citizen’ (Lam, 2005: 314). This is an important dimension in the

understanding of the development of the aged care policy in Hong Kong. The lack of a

state-supported retirement system means that citizens have to make their own

preparations for their retirement.

The formation of cultural citizenship in Hong Kong has a policy and administrative background. In the early days of the British colonial government, Hong Kong

established the Secretariat for Chinese Affairs, which was the means of communication between the government and the Chinese population of the colony. Through the

Secretariat, government policy was explained and the views of the locals could be collected. It advised government on questions involving Chinese law, customs and opinion, how to administer charitable funds, the protection of women and girls, and the licensing of Chinese hotels, boarding houses, Chinese restaurants and permits for

Chinese celebrations (Secretariat for Chinese Affairs, Annual Report, 1951). A Social

Work Office was set up in the early 1950s and the Social Welfare Department (SWD) in

1970. Policy documents published by the SWD, such as the White Papers on social welfare development, mentioned Chinese tradition, family values and the virtue of self-reliance. Over the years these became the typical arguments of the Hong Kong government on Chinese culture in Hong Kong. Since 95 per cent of the Hong Kong

28 population is ethnic Chinese, people would consider the social welfare policy as a

cultural policy, hence the implied relationship between culture and welfare.

Three kinds of relationship exist between culture and welfare, and these relate to the

ethics of family, charity and self-reliance. These relationships constitute the welfare

sphere of Hong Kong. Firstly, social welfare in general, and ageing policy in particular,

is explicit that personal problems should be kept within the realm of the family or social

networks. There is 'the idea that a person will never find his true fulfillment unless

within the family context' (Liu, 1985 in Chow, 1987: 37) Hence, one’s own family is

regarded as paramount. As we will see later, this thinking of one’s family as the priority

affects the consumption of aged home services. Secondly, in Chinese culture, social

welfare has always been considered charity work and is meant for the unfortunate and

lesser beings. This is the case with charity and welfare organisations relating to the

Buddhist, Taoist, Catholic and Christian traditions as well as independent NGOs, and in

Hong Kong they provide residential aged care facilities.

On the other hand, there is Confucian thinking, which says that 'the unfortunate should be taken care of so as to enable them to have the opportunity to strive for perfection'

(Chan, 2004: 111). Therefore, there is a flourishing network of charity organisations, philanthropic activities and NGOs in Hong Kong. Thirdly, because social welfare is for the less fortunate, welfare assistance is stigmatised. Therefore, avoiding stigmatisation has the effect of promoting self-reliance and less dependence on welfare. The close relationship between welfare and culture has reinforced the 'Chinese concept of welfare' and the Chinese identity. In practice, for example, a social security applicant

29 has to pass both the income and assets tests before being eligible and this could involve the applicant’s children making a declaration of their inability to support their parents.

Citizenship is implied here as the outcome of a long process of social welfare and ageing policymaking. It is a kind of relationship between the government and its people that has been constructed and expressed as the collective identity of the Hong Kong

Chinese. The outcome of the policy has the implication of producing the cultural ideals of the Hong Kong Chinese.

Hong Kong residual welfare model, legitimacy and citizenship

For the British colonial government, legitimacy was always a central issue (Scott, 1989,

2010; Chan, 2004: 102; Sing, 2009; Yu, 1996: 416, 2007:166). This is because colonialism, the occupation of land and the ruling of its people by a foreign power, is by its very nature a lack of legitimacy. Scott (2010) argues that the Hong Kong British colonial government faced an enduring crisis of legitimisation. This crisis of legitimacy continued when the PRC took over the administration of Hong Kong in 1997. After

Hong Kong was returned to China, it was governed under the 'principle of one country, two systems' and the authority governing Hong Kong had to be accepted by the general public. The Hong Kong government continued to face a legitimacy deficit (Goodstadt,

2007; Sing, 2009).

There is also a close relationship between the Hong Kong welfare model and legitimacy, because financially Hong Kong has the ability to provide more welfare and yet the government is constantly advised not to exceed its budget. This is because during the

30 days of the British colonial government, colonies were required to spend within their

proposed budget. After 1997, a rule was written as an article of the Basic Law, a

'mini-constitution' governing Hong Kong. It states that:

The HKSAR [Hong Kong Special Administrative region] shall follow the

principle of keeping expenditure within the limits of reserves in drawing up

its budget, and strive to achieve a fiscal balance, avoid deficits and keep the

budget commensurate with the growth rate of its gross domestic product.

(Article 107, Basic Law, HKSAR)

There is a strict fiscal policy in place so that even if money is available, it would not be

spent. For the 'unspent accumulated funds from the past budget surpluses, they are held

in the government exchange and invested in a manner which ensures a high degree of

liquidity' (Latter, 2007: 51). The government has established an Exchange Fund under the Currency Ordinance of 1935 (later renamed the Exchange Fund Ordinance) (Hong

Kong Annual Report, 2008: 93). In 1976, the government began to transfer its fiscal reserves to the Fund. The Fund’s primary statutory role is to affect the exchange value of the Hong Kong dollar, by preserving capital, providing liquidity to maintain financial and currency stability and generating an adequate long-term return (ibid). In 2006, the total equity of the Exchange Fund was HK$1176 billion with foreign reserves amongst the highest in the world (Latter, 2007: 81-82). On December 31, 2008, the Exchange

Fund’s total assets stood at $1557.7 billion (Hong Kong Annual Report, 2008: 93). This is an unusual practice and Hong Kong was described as a 'productivist state' (Holliday,

2000). A table showing social services expenditure as a percentage of GDP from 1967 to 2009 is attached in Appendix 2.

31 Due to this structural financial constraint, the Hong Kong government has to find ways

to solve the ongoing demand for welfare and has to justify its inaction whenever there

are demands for welfare provision. In the field of social welfare and social policy in

Hong Kong, legitimacy can be of a non-material nature and can include, for example,

the value of virtuous behaviour. This concerns the moral basis of authority (Scott, 1989:

327, 2010), that is, whether the action of the government is justifiable on the basis of

right or wrong. In the present case, the development of aged care policy in Hong Kong

is justified by values such as duty and deservedness and they are based on an ethics of

care towards one’s older family members.

The politics and administration of Hong Kong

King (1975) notes that the colonial government maintained its legitimacy by co-opting the elite sector of the society, most notably Chinese business people, and later the grassroots. The appointment of major Chinese business people to the legislative and executive structure helped fonn a 'synarchy' of colonial bureaucrats, British merchants,

Chinese elites and the grassroots. King describes this process as 'the administrative absorption of politics' (1975: 422-39). In doing so, the colonial government

'administerised' politics and constructed a 'synarchy' between Chinese business elites and colonial bureaucrats. Through the influence of these leaders in Chinese society, the colonial government managed to pacify potential opposition to colonial rule (Ma, 2007:

24). King’s argument implies that there was collaboration between the coloniser and the elites. This way of theorising Hong Kong society is expressed in the writings of Hui

(1999: 42), Carroll (1999, 2005) and Law (2009).

32 Hui also notes that one of the key features of collaboration between the coloniser and

colonised were the compradors in early Hong Kong (1999: 42). According to Hui:

they were indispensable actors and made colonial dominance possible. Far

from being simply subordinate partners of European powers and merchants,

they played a very active and lucrative role in the collaboration, often

benefiting more in economic terms than the imperialist powers and foreign

merchants (ibid.).

Yee talks about 'the comprador system that grew out of today’s Asian capitalism' (1992: xvii).

This particular kind of collaborative relationship between the British ruling class and local Chinese capitalists sheds light on the understanding of the development of social welfare and its related institutions in Hong Kong. Kuah-Pearce and Hu-Dehart argue that within a colonial structure, the British administration left the various ethnic communities to handle their own socio-cultural, economic and political affairs, resulting in little interference in all aspects of community and individual life (2006: 11). The

Chinese community was thus able to function as an imperium. in imperio (ibid. 55).

Thus 'the permission of the sovereign state to let the governed act according to their rules and customs maintained and sustained the relationship between the government and the society' (ibid.). One example is the Tung Wah Group of Hospitals, which has provided a whole range of services to the Chinese community in Hong Kong, South

China and overseas since the early days of Hong Kong (Sinn, 1989). It is still an active

33 NGO in Hong Kong providing medical, education and social services. In a study of the

history of the Tung Wah Group of Hospitals, Sinn (1989) argues that it is a political

institution rather than an ordinary social welfare NGO. The Tung Wah Group of

Hospitals is able to solve problems of local Chinese and in a way promote political

stability. It is a local philanthropic organisation with no religious background.

From the viewpoint of production of welfare, the provision of aged service involves a

process of co-production. It is the 'partnership between people who rely on services and

the people and agencies providing those services' (Hunter & Ritchie, 2007; Wilson,

2000, 1994). Co-production in respect to self-care or familial care is a process involving

the formal, the informal, the NGOs and the commercial sectors.

In the field of ageing policy during Tung Chee-hwa’s administration of the Hong Kong

Special Administrative Region (HKSAR) from 1997 to 2005, in conjunction with the process of de-colonisation there was also a process of re-nationalisation that Tung argued was important for traditional Confucian familial values (Chiu & Wong, 2005;

Hill, 2009 in Fu & Hughes, 2009: xvi). For ’s administration (for this study, the period is from 2005 to 2007) the idea of conventional familism is also strong

(Policy Address, 2005-2006: 45). In addition, Tsang’s administration 'vowed to govern with “people-based” principles, to cultivate a sense of harmony and to safeguard core values such as freedom, equality, and the rule of law' (Chan & Chan, 2009: 104).

Despite differences in their views towards social welfare, both the British colonial and the HKSAR governments were not very different in relation to their values towards family, community, sense of self-reliance and tradition. The lack of universal suffrage and Hong Kong’s semi-democratic political structure means there was a continuation of

34 the alliance of the ruling class and capitalists. Senior government officials and business

leaders depict welfare as basically alien to Hong Kong and bad for its people (Goodstadt,

2009: 38). Ironically, the available evidence shows that no such welfare expectations

were typical of Hong Kong people (ibid.). Apart from strong opposition from some

grassroots organisations and the post-1980 youth groups, the demand for change and

welfare reform has made little progress. There is a lack of intellectual framework in any

fundamental social welfare reform.

One of the most persistent features of the campaign for improved social welfare was the

fight for an increase in social security payments (known as the Comprehensive Social

Security Assistance Scheme (CSSA) in Hong Kong) above the present meagre safety net standard. In 2006, the median income was HK$ 12,000 per month and the social security payment per person was about 40 per cent of the median income, that is, around

HKS4800. However, when the HKSAR government came into office it claimed that social security payments had been increased and were more attractive than wages (Chau

& Wong, 2002).

After the withdrawal of the British, the HKSAR government firmly committed to remaining a low-spending and low-taxing economy (Li, 2006; Latter, 2007/ This has continued to the present period. The lack of a proper welfare structure means the government can continue to implement a low tax rate. In 2007-08, profits of unincorporated businesses were taxed at 16 per cent and profits of corporations at 17.5 per cent, while no one needed to pay more than rate of 16 per cent of the salaries tax (Hong Kong Annual Report, 2008: 61).

35 Due to its size, land in Hong Kong is a precious commodity sought by property

developers. This has direct impact on the development of aged homes, which require

land and buildings. In other words, the capitalist class is resistant to social welfare

development, if not anti-welfare. Therefore, any discussion of social welfare

development in Hong Kong cannot be separated from an examination of its economic

system and the nature of its capitalist class. The working class and low-income group

are not totally passive, but their actions are not effective enough to bring about

improvement in their livelihood. Besides, not all working class belong to their unions,

and the unions are of different political orientations and may have different views

regarding social issues. In 2008, Hong Kong’s labour force comprised 3.65 million

people - 53.4 per cent men and 46.6 per cent women (Hong Kong Annual Report, 2008:

124). Declared membership of employee unions over the previous five years remained

around 670,000 and the trade union participation rate was around 21 per cent over the

same period (Hong Kong Annual Report, 2008: 130). The unemployment rate decreased

from 4 per cent in 2007 to 3.6 per cent in 2008 (Annual Report, 2008.124). Despite the

different political orientations of the trade unions, one common concern was the

establishment of a minimum wage benchmark to be implemented in 2010. The hourly rate of the minimum wage would begin at HK$23. Because of insufficient retirement protection, the majority of older workers strove to stay in the labour market for as long as possible, earning a living until they were forced to retire (Chou, 2009: 105-6). In a survey among 2003 older adults, it was found that although 56.6 per cent of them had retired, only 3.4 per cent had really done so. For most retirement was of a forced nature e.g., due to poor health or no job opportunities (ibid). There is also the prevailing value of self-reliance among some older people, and they prefer to work as scavengers rather than rely on government support. Scavengers are mostly female and their number is

36 estimated to be around a few hundred to a thousand (Lou, 2007; Li, Chiu & Wong,

2006).

As noted above, Hong Kong is basically in a state of legitimacy deficit (Cheng, 1992;

Goodstadt, 2007; Sing, 2009) and the government gains its legitimacy partly because of

its economic achievements, and partly because it has deliberately created credibility

with its citizens in policymaking by employing experts and consultants (Scott, 2010).

The Hong Kong government has not produced a Marshallian status of citizenship which

emphasises civil and political rights, but instead has produced the Hong Kong style of

economic citizenship whereby economic growth and low tax were seen as the key

features driving policy (Lam, 2005: 314). In the former instance, experts and

consultants were standard practice in aged care policymaking, which will be illustrated

in Part II of the development of aged care policy.

The Hong Kong economy

The labour market in Hong Kong was interrupted by the oil crisis in the mid-1970s, the

Asian financial crisis in 1998 and the Severe Acute Respiratory Syndrome (SARS) epidemic in 2003 and later. The unemployment rate decreased from 4 per cent in 2007 to 3.6 per cent in 2008, while the under-employment rate fell from 2.2 per cent in 2007 to 1.9 per cent in 2008 (Hong Kong Annual Report, 2008: 124). In 2008, the per capita income of Hong Kong was US$30,900 per annum, which was one of the highest in Asia

(ibid. 41 )4.

4 In 2009 the gross national income per capita among Hong Kong and its neighouring economies was: Australia (US$43,770), Japan (US$37,870), Singapore (US$37,220), Hong Kong (US$29,826), Korea (US$19,830), Taiwan (US$16,392). Source: International Monetary Fund, 2009. 37 It has been argued that Hong Kong’s economy consists of five key characteristics: 'a

greater focus on growth than on inequality; the “fertilizer” role of the government; a

pro-growth political regime; an open economy that at the same time promotes internal

economic consistency; and the pursuit of capitalist market disciplines' (Li, 2006).

Economism accepts income inequality, arguing that it is due to differences in the

individual’s endowment, and it holds that economic security is the more relevant goal

(Li, 2006: 11). Due to this and its growth-oriented developmentalism, that is, to take

economic growth as its major goal of development, Hong Kong is regarded among East

Asian societies as practising productionist welfare capitalism (Holliday, 2000; Holliday

& Wilding, 2003: 165) and is seen as a capital investment state together with Singapore

(Tang, 2000). In short, Hong Kong has adopted a strong neo-liberal approach. The

emphasis is on keeping the state’s role to a minimum and strengthening the role of the

market.

In their discussion of the East Asian welfare model, White and Goodman observe that:

in the west, neo-liberals point to East Asian success in achieving high levels

of popular welfare without high levels of government expenditure or a large

bureaucracy, and laud the spirit of individual and group responsibility and

the crucial role of the family in providing social welfare and social services

(1998:4).

My research looks at these factors in Hong Kong in the context of ageing policy.

38 Money, fear and moral panic as welfare constraints

I argue that there are three reasons for the Hong Kong government to pursue its social

welfare policy model. The first relates to Hong Kong’s economism and its principle of

prudent financial management. The second relates to fear, and the third to moral panic.

Firstly, as mentioned, the Hong Kong government is careful about not overspending, so

as to maintain a low tax rate and ensure a surplus. This has been the case since

becoming a British Crown Colony in 1841 (Endacott, 1973) and continued after 1997

when Hong Kong was returned to China as a special administrative region (Tung, 1997).

In 2008, John Tsang, the Financial Secretary said he would 'continue to manage public

finances prudently by keeping expenditure within limits of revenues, maintaining a low

and simple tax regime, and following the direction of - “market leads, government

facilitates”' (Tsang, 2008: 14). These three principles of government underpinning the management of the British administration are now written in the Basic Law.

Secondly, as Hodge remarks, the lack of a systematic and humane way to tackle social problems in the early days of Hong Kong was also due to fear — the fear of finding

Hong Kong swamped with demand if relief was too generous and humane (1981: 6).

One official report says that 'indiscriminate and lavish aid afforded in Hong Kong to destitutes would practically act like a magnet attracting professional beggars to Hong

Kong where money is more plentiful than anywhere in the province of Canton' (ibid.).

The third reason relates to the potential consequence of undermining 'the moral tone, the thrift and frugal industry of the Chinese' (ibid. 7). This resonates with Rimlinger, who states that 'in the eyes of mercantilists, widespread poverty could be looked upon

39 not as a problem in itself. It may be considered as positive because it can be a means to

keep the masses industrious' (1971: 18). In the case of Hong Kong, where social

welfare provisions are minimal and means-tested, people have to try not to depend on

welfare but to find work for themselves. In 1991, the Social Welfare White Paper

(SWWP) emphasised the self-reliance of the people and argued against developing a

'dependency culture'. It says:

Hong Kong welfare programmes have been designed and developed

cognizant of the innate local values of concern for the family, commitment

to self-improvement, self-reliance, mutual support and generosity,

reluctance to be dependent upon welfare', respect for social order and a

combination of ingenuity and resourcefulness (Hong Kong Government,

1991).

It is not surprising to find that a review of the Hong Kong welfare system observed that the government’s main purpose was to prevent dependency on the CSSA (Chau &

Wong, 2002: 211). It should be noted that Hong Kong does not have a contributory social security system, rather a means-tested one that started in 1971. The MPF for the employed was not established until 2000. One of its inherent weaknesses is that it is a saving-contribution scheme that will take time to mature and become fully operational.

The scheme depends on a small sum of money being deducted monthly from one’s pay, and the employer contributing accordingly. There is no unemployment benefit in Hong

Kong except for basic social security provision (about HK$4000/month). Applicants have to keep looking for work until they can prove they are unemployable and then they can receive support. Some are encouraged to do volunteer work so as to maintain a

40 work ethic. There is also the Employee Retraining Scheme and the Training Programme

for the Middle-aged. Students attending the Employee Retraining Scheme receive an

allowance and in the latter scheme, middle-aged participants are given a training

allowance of HKS1500 per month for up to three months (Hong Kong Annual Report,

2008: 128).

The different dimensions of the Hong Kong welfare system

There are several ways of describing the Hong Kong welfare system. In this section I

will examine the residual welfare model, the liberal welfare regime and the Confucian

welfare state.

Residual welfare model

Titmuss’s (1974) classic study of the social division of welfare is based on the standpoint of distinguishing between welfare provision by government, welfare provided by one’s workplace and welfare provided by one’s family and non-governmental agencies. Titmuss uses the concepts institutional redistributive, industrial achievement-performance and residual welfare to describe the three common welfare models (1974: 30-31). The institutional model refers to the granting of entitlements to all, based on the principle of universal redistribution. It operates through the taxation system. The industrial achievement-performance model is about social needs being met on the basis of merit, work performance and productivity. Residual welfare is based on means-testing and selective transfer for the most marginal sectors of the population. According to this classification, Hong Kong is a residual welfare system.

The residual welfare model is:

41 based on the premise that there are two 'natural' (or socially given) channels

through which an individual’s needs are properly met: the private market

and the family. Only when these networks break down do social welfare

institutions come into play, and then only temporarily ... The theoretical

basis of this model can be traced back to the early days of the English Poor

Law and finds support in organic-mechanistic-biological constructs of

society advanced by sociologists like Spencer and economists like Friedman

and Hayek (Titmuss, 1974: 30-1).

However, whether Hong Kong’s welfare provision is residual by nature is contestable.

McLaughlin (1993) notes that Hong Kong has a residual model of welfare provision,

and Chan (1996) argues that Hong Kong is a welfare state because 50 per cent of the population is living in public rental and subsidised housing, there are nine years of free education, and health and medical services are primarily free for the poor and needy.

Hong Kong is a residual model in terms of social welfare provision (provisions under the SWD) but not with housing, education and medical and health services, which are more universal. On the other hand, in terms of operation, most of the provision is organised by NGOs (Aspalter, 2002). The government is committed to not getting directly involved in provision. Thus, in terms of provision, Hong Kong is not entirely a residual model, but in terms of government thinking it is residual by nature.

Liberal welfare regime

Esping-Andersen’s (1990) welfare regime theory differs from Titmuss’s welfare model, taking on board class stratification and market commodification. Instead of using the term ‘welfare model’, he employs the concept of a regime to refer to the ways in which 42 welfare production is allocated between state, market and household (Esping-Andersen,

1999: 73). The three types of welfare capitalism he identifies are: the 'liberal' welfare

regime with the archetypical examples being the US, Canada and Australia; the

‘conservative’ welfare regime (corporatist-statist legacy) which is represented by

Austria, , and Italy; and lastly, the ‘social democratic’ welfare regime

which can be found among the Nordic countries. This classification was based on ideal

types and Esping-Andersen later modified it to incorporate the shortcomings of the

three worlds welfare regime theory, and included the fourth world welfare regime (1999:

73 & 88-94) in which Antipodean, Mediterranean, East Asian and Families and Welfare

Regimes all have a part to play.

The proportion of gross domestic product (GDP) for social welfare spending in Hong

Kong is under 20 per cent. In 2007-08, spending on welfare in Hong Kong represented

14 per cent of the GDP (Latter, 2007: 50). More than 60 per cent of spending on social welfare is allocated to public assistance or the CSSA, and the remaining allocation goes to the elderly, family services, youth, rehabilitation and correctional services.

Hong Kong has similar features to the liberal welfare regime because means-tested assistance is common, there are the beginnings of some insurance coverage, there is a greater role for the welfare market and the government searches for cheaper alternatives.5 Benefits are mainly for a low-income clientele, usually new arrivals, the

5 The dominant message is to discourage people from depending on welfare through means-testing, and through mass media to dramatise the story of the undeserving poor, fraud cases and the importance of Hong Kong spirit (self-reliance). The shopping centres in the public rental housing estate is run by a private company with the aim of enhancing their commercial value. Private universities are encouraged and medical insurance schemes are beginning to develop. Some government subsidies for the NGOs are allocated on a competitive basis. 43 unemployed, the middle aged and the elderly. Entitlement regulations are severe and

benefits are typically modest and are often associated with stigma. In an examination of

the social security system in Hong Kong, Chan and Bowpitt found that the rules are

strict and replace social security payments with 'workfare', thus forcing a large number

of poor citizens out of the welfare system (2005: 62). Old people who want to apply for

social security support are required to have their children declare that they are not able to support their parents. Thus, income support from the government carries a stigma.

There is not a universal state pension system in Hong Kong and pensions are only available to civil servants. Social security payments for the old are of three kinds: the old age comprehensive social security scheme (60+), the normal old age scheme (for

65-69) and the higher old age scheme (70+). The first is a full payment (around

HKS4000 per month) and is means-tested. Neither the second nor third are means-tested, and the amounts are HK$1000 and HKS1200 respectively. The latter two are also known as 'fruit money', meaning they are a supplement for old people to buy fruit.

On the other hand, the state encourages the market, either passively — by guaranteeing only minimum support — or actively, by subsidising private market schemes

(Esping-Andersen, 1990: 26). In Hong Kong, aged homes receive different kinds of financial support from the government, and the development of the aged home market is partly a product of the amount of government funding. There are the Bought Place

Scheme (BPS), Enhanced Bought Place Scheme (EBPS) and CSSA payment and the

Disability Assistance. The government also allocates government premises and private providers can tender for a contract to run a home in them.

44 According to what has been outlined above, Hong Kong is by and large a classic liberal

and residual welfare system (Chiu & Wong, 2005; Lee, 2005, 2009). The family, the

voluntary sector and the market have been encouraged to take primary responsibility for

the delivery of welfare. We have here a highly complex set of relationships that govern

private and public welfare provision within a residual framework (McLaughlin, 1993:

106).

The liberal nature of Hong Kong social welfare can be demonstrated by the present

situation and the small public assistance programme instituted in 1971, together with a

rather larger, but ungenerous system of allowances for the elderly and disabled. Public

health care was virtually free before 2003 but the outpatient department was usually

crowded and the queue for specialist consultations would take 6 months to 12 months or

more. The state was, however, a major provider of primary and secondary education.

The overall social welfare expenditure amounted to less than 20 per cent of public

expenditure (Latter, 2007: 39)

Administratively, the provision of social services and social welfare in Hong Kong

belongs to different branches of government. Social services in Hong Kong include

education, housing, medical and health services and labour and manpower, and they are

in different government branches. Their scope of provision is more comprehensive than

social welfare. Social welfare in Hong Kong refers to those services provided by the

SWD. It provides family, youth, elderly, correction and rehabilitation services. It also runs a social security scheme and a licensing office for the operation of homes for the aged.

45 Hong Kong is often characterised as a residual welfare regime (Wilding, 2007; Yu,

1996, 2007; Aspalter, 2003; Chan, 1998, 2005; McLaughlin, 1993), but according to

Wong (1995a) this is questionable. She argues that ‘residualism’ may be too limited to

capture the welfare landscape and the local model is a 'hybrid’ system with different

principles underpinning the major social services. Wong continues that 'there is a mix

of rights-based, universal services (health, education and old-age allowance) to social

subsidy of housing for the largely low-income sectors or groups displaced by urban

development, and the safety net of need-based tight budget provisions in public

assistance' (Wong, 1995a: 249).

To further elaborate on the hybrid nature of the Hong Kong welfare system, it can also

be said that in some areas there is massive state provision — for example housing and

education, there is state funding but most schools are run by non-state bodies (Wong &

Chau, 2002; Wilding & Mok, 2001; Chan, 1996). Most social care is provided by NGOs

(Aspalter, 2001, 2006). It is frequently stated that no one shall be denied the health care

he or she needs because of a lack of means, but most health care is provided by general

physicians in private practice. Public sector health care, though free to the needy, has

long waiting lists for specialist consultations and there are long queues at out-patient

departments. Fees are now charged for expensive prescription drugs. Social security provision is limited to a narrow residual social assistance scheme (Wilding, 1996, 2007).

Pearson argues that the Hong Kong situation clearly demonstrates that it is helpful to use the concept of the ‘welfare state’ as a blanket term to include all social policy programmes (2005: 211). Given the debate over what constitutes the 'welfare state', how it operates and which countries are considered to be one (Esping-Andersen, 1990),

46 it may be more appropriate 'to treat the idea as a socially constructed ideal to which

some states strive to aspire and others try hard not to emulate' (Pearson, 2005: 211).

The Confucian welfare state

There is also the suggestion that Hong Kong is a Confucian welfare state (Jones, 1993),

and that the Hong Kong government is the custodian of traditional values (Chiu &

Wong, 2005; Walker & Wong, 2005: Ikies, 2005; Olson, 2006). This is the point to

which I now turn. The 'Asian miracle' has created strong academic and political interest

in the role of the state in the economic rise first of Japan, and then of the East Asian rim

counties, like South Korea and Taiwan as well as the city-states of Singapore and Hong

Kong (Rieger & Leibfiried, 2003: 241). The particular East Asia formation of social

policy is often explained with reference to cultural factors (Ramesh, 2004: 5). Jones

coined the term ‘Confucian welfare state’ (CWS) as another composite category to add

to the three theories of welfare regime mentioned above. According to Jones, the

Confucian welfare state:

is comprised of conservative corporatism without (Western-type) worker

participation; subsidisation without the church; solidarity without equality;

laissez-faire without libertarianism. An alternative expression for this might

be 'household economy' welfare states — run like the traditional, Confucian,

extended family (Jones, 1993: 214).

Jones (1993) also argues that social security arrangements in East Asia constitute a discrete 'Confucian' regime in which education is emphasised and low priority is accorded to statutory social security. She added that parents are mostly taking care of

47 their children’s educational development and they try to help their children study as

much as they can even if the government gives them no support (ibid.). As a whole, the

explanation of Asian cultural society is idealistic and positive, without considering

negative aspects such as the caring role of women. Walker and Wong found the label

'Confucian welfare states' ambiguous (2005: 4) and Hill and Hwang were not able to

accept Jones's (1993) emphasis on the influence of Confucianism (Hill & Hwang, 2005:

146). One of the dimensions of the debate is concerned with whether the CWS is an

independent or a dependent variable in the policy analysis. In my view it is an

independent variable in the welfare analysis because it has a relatively strong impact on

the policymakers in Hong Kong. From the standpoint of a protective pillar, it is also an

independent variable because in reality the family has been the key provider of services.

In addition, in my analysis, I find the CWS is an outcome of a long tradition in policymaking, emphasising the role of family and thus neglecting the positive

contribution that the residential care sector and community support services have made.

It is culture with a capital ‘C’ and is the core matter embedded inside the path of dependency. Strictly from the Confucian way of thinking, there is an implied hierarchical relationship in the CWS composed of the three bonds and five constancies,6 thus politically it is a soft form of authoritarian government.

6 The proper Confucian human relationships ensure that the authority of the ruler is over the minister, the father over the son and the husband over the wife as in the 'three bonds', and that the supreme importance of the five basic human relationships (father/son, ruler/minister, husband/wife, older brother/younger brother, and friend/ffiend) are recognized, as in the 'five constancies' (Tu, 1993: 26).

48 The persistence of traditional family and community structures has meant that people in

the region usually have not had to turn to the state for support, as is the case in Western

countries (Ramesh, 2004: 5). Another implication is that the familial orientation of

social norms and government policy have stunted the growth of statutory social welfare,

and 'private social investment' undertaken by Asian families calls for a departure from

a state-centred view of the welfare state to 'Confucian welfare societies' (Wad, 1999: 33

in Ramesh, 2004: 5). That is to say, the sense of self-reliance or privatism is so strong

that it hampers the fonnation of a social protection scheme for all, and it also indirectly

facilitates the growth of social inequality. In the case of ageing policy, the traditional

Confucian values that emphasise family responsibility for the economic support of older

family members have served to slow down the development of social security

provisions (Olson, 2006: 71). There are different kinds of community service units,

centres for older people that provide services such as daily activities assistance and

group and community support. Due to the short supply of community services for the

elderly, most families take up the caring role; however, there is a connection between

caring for one’s aged parent and the shortage of services. In effect, there is a two-way relationship. The argument of the aged care policy promotes and facilitates the formation of a cultural citizenship (Stevenson, 2003). Confucianism is used as a form of political legitimation to justify restrictive social policies (Walker & Wong, 2005: 4).

Hence the pro-growth and 'pure' economic-prone states are also known as productivist welfare capitalists (Holliday, 2000) characterised by subordination of social policy to economic policy. In economic terms, Tang (2000) describes the Hong Kong welfare regime as a 'capital investment state'. I have mentioned earlier that there is a kind of

49 economic citizenship, the army of labour of the productivist state of Hong Kong

(Holliday, 2000; Wilding & Holliday, 2003).

In summary, one group of writers supports the culturalist view of Hong Kong as a

Confucian welfare regime (Chiu & Wong 1999, 2005; Tao, 1991, 2004; Chan, 2004;

Rieger & Leifried, 2003; Lin, 1999; Jones, 1993), while others argue that it is a

productivist welfare regime (Holliday, 2000), and yet others a 'capital investment

welfare state' (Tang, 2000). These very different interpretations can be grouped into two

broad perspectives: political economy and culturalist. Referring to Chapter 1 on ageing

theories, I note that there are both the political and cultural economies of ageing. It is

useful to examine the political economy perspective together with the cultural lens.

Before concluding this chapter, I would like to review some of the questions relating to the use of the tenn ‘state’. Firstly, due to its colonial history and currently being the

HKSAR of China, the word ‘state’ may not be an appropriate term to describe Hong

Kong. There is the issue of the lack of political sovereignty, which means lack of representation in making social and political decisions. This relates to the question of what power the Hong Kong government has. On the other hand, the influence of global social policy or processes of globalisation has an impact on the local state. Considering that Hong Kong is a dependent political entity, it may not be appropriate to see social provision as having a relationship with citizenship, which implies a notion of social or political rights. If this is the case, the entitlement to social provision is not a right-based conception but just a desired activity (Ho, 2004: 33).

50 Secondly, since welfare provision may not only come from the state, it would be rather

misleading to call Hong Kong a welfare state. In fact, most welfare provision is of

mixed mode, composed of formal, quasi-formal, informal and commercial sector

contributions. Wilson (1994) notes the co-production of ageing policy and that self-care

is also an important aspect. Given the lack of adequate provision, the contribution of the

family members and the lay sector are significant (Hunter & Riche, 2007).

Thirdly, the welfare state would ideally mean redistribution, social justice and equality,

in other words, it addresses the positive end-result of the universal welfare state (Mau &

Veghte, 2007). However, Walker & Wong (1996) point out that Titmuss, a pioneer in

the study of social policy, used quotation marks with the words ‘welfare state’.

Therefore, its application is elastic (ibid.). It could be debatable whether Hong Kong is

really a welfare state, given its poor record in combating poverty and its

semi-democratic political structure, yet it has made housing, education and medical and

health services available to the needy.

Fourthly, authors use the term ‘welfare state’ inconsistently. This is the most debatable

aspect (see Chan 1996, Aspalter 2001, 2006, Wilding & Mok, 2001, and Jones 1993 on the Confucian welfare regime). In order to include the dimension of NIEs and growth in developing societies in the discussion, the term ‘developmental state’ is used. In this context, Hong Kong can be considered a politically developmental state but not an economically developmental state. This is because Hong Kong’s economic system is well developed but its political structure is not. According to Tang, Hong Kong is a

'quasi-developmental state' (2000: 33). All these descriptions relate to the 'who', 'what' and 'how' factors that influence the development of social welfare in Hong Kong, hence

51 the impact of social policy. What is the impact of the state as the key variable affecting social welfare development in Hong Kong?

Conclusion

Hong Kong has been enjoying economic success; however, despite this success, social expenditure remains low. As will be illustrated in the case of aged care, there has been minimal expenditure over the last four decades. The Hong Kong government has been making use of Chinese familial ideology to support its aged care policy. It is an expression of cultural citizenship, and so family responsibility is the norm rather than the exception. Familial rather than government responsibility is seemingly taken for granted. However, it can be critically examined through an understanding of the shifting context of welfare relations, as I have discussed above. Welfare governance and legitimation have been so intermingled over time that it is necessary to examine the interplay between the micro and the macro dimensions as well as the formation of the welfare subject regarding filial piety. All the neo-liberal practices put forward by the government, which contribute to the construction of the value preference of self-reliance and the autonomous subject of the model citizen with self-care capacity as its ultimate goal, require critical examination. These are the areas I will examine in the next chapter.

52 Chapter 3 Cultural Legitimacy and Hong Kong Ageing Policy

Introduction

In the last chapter I noted that Hong Kong’s residual welfare system is a result of the

powerful ideology which says that there must be a balanced budget and a low taxation

regime. In terms of welfare provision, Hong Kong has always had a policy of fiscal

austerity. The reasons for the budget-driven approach to welfare were introduced in the

last chapter. Other factors that are used to justify budget austerity are the fear of

attracting migrants from Communist China and the spread of a welfare dependency

culture (Hong Kong Government, 1965, 1991; Leung, 1999, Pearson, 2005; Ngan, 2007:

128).

This chapter is divided into four parts. Firstly, I will continue to examine the relationship between ageing policymaking, tradition and cultural legitimation, which forms the basis of cultural citizenship in Hong Kong. Secondly, I will outline the background as well as the community support and residential care provisions. Thirdly, I will examine Hong Kong Chinese Confucian familism and its relationship with service provision. In the conclusion, I will outline four hypotheses to be examined in this thesis.

Aged care policymaking, tradition and cultural legitimation

Complexity of home care, social welfare, culture and identity

In regard to policy for the ageing population, Hong Kong is perhaps on a par with the southern European countries where public provision for older citizens is minimal

53 (Baidock & Ely, 1996; Ferrera, 2005) and familial (Naldini & Jurado, 2009). It is

therefore useful to stress at this point that familism is not something unique to Hong

Kong society, but it is important to show how the government has been using familism

in governing Hong Kong society. There is a strong connection between welfare

provision, policymaking and culture in Hong Kong.

As mentioned in Chapter 2, social welfare is a multi-faceted phenomenon. In Hong

Kong there is a shortage of provision and aged people are often quite reluctant to apply

for social welfare services7. In an examination of the community care policy for older persons, it was found that the formal services experienced low usage levels (Yeung,

Chow & Lee, 2003: 103). In terms of gender, there is a poor rate of participation among males attending older people’s centres (Li, Chiu & Wong, 2008). In a study of help-seeking behaviour (Chiu, 2002), it was found that residents preferred to solve their own problems. Most respondents did not seek help from more than one source, and stigma was attached to those receiving welfare.

7 Social welfare services refer to services provide by the SWD, mainly at personal service levels such as social security assistant, family casework, youth and older persons, probation, correction and rehabilitation work. Social services in Hong Kong include housing, medical and health and education. The Hong Kong government has always faced the question of how to meet the demand for social welfare services while operating under financial constraints. It discouraged people from depending on welfare by adopting the following strategies. First, there was always little government provision of services. Because of its limited provision, services are not publicized. Second, bureaucratic measures, such as means-testing, discouraged welfare consumption. Low levels of assistance and complicated application procedures probably undermined the concepts of welfare rights and suppressed the public’s expectations about welfare. Third, the practice of seeing welfare dependency as an irresponsible act and social security as a poor substitute for employment has had an effect. 54 From a different but related perspective, Baldock and Ely describe home care (in Hong

Kong, this is known as the home help service of the community support services) as

'suffering from the paradox of complex mundaneity' (Baldock & Ely, 1996: 202). This

is because 'home care is culturally and emotionally loaded, and accepting it requires

important adjustments in self-image and identity’ (Baldock & Ungerson, 1994 in

Baldock & Ely, 1996: 203) and 'people with similar disabilities will not be similarly

satisfied with the same solutions' (ibid. 203). Burau, Theobold and Blank (2007: 33)

note that:

Home care, then, is a highly complex activity that includes not only a wide

range of different tasks but also transcends the distinction between formal

services and informal relationships. The former links home care governance

to the dynamic of policy making and different approaches to governing,

whereas the latter links hoem care governance to the wider family and

gender structures in society.

There is no doubt that care (for others and being cared for) is an important lifespan dimension and, at the macro-level, the 'paradox of complex mundaneity' is also useful in the understanding of residential care admissions (see Chapter 6). In addition, the mundaneness of the ordinary and everyday experience of social care is important to the study of citizenship because 'the experience of citizenship is also located in (the) relationships, processes and practices of service provision' (Lewis, 2004 in Clarke &

Fink, 2008: 227).

55 In relation to citizenship studies, social care as an everyday activity is constantly dealing

with one’s identity and is 'refracted through the experience of citizenship' (Kershaw,

2008: 44) as an act of citizenship (Isin & Nielsen, 2008: 2). This is similar to Rose’s

comment that 'citizenship should be studied at the level of practice' (1999: 226). These

observations are useful in the examination of the relationship between cultural

citizenship and ageing policy in Hong Kong.

Isin and Nielsen (2008) differentiate between formal and substantive citizenship.

Formal citizenship is about social, civil and political rights based on legal status (ibid. 2) and it is the conventional Marshallian view of citizenship. In responding to globalisation and new social transformations, substantive citizenship is about ' practices of making citizens — social, political, cultural and symbolic' (Isin in Isin & Nielsen, 2008: 17). It is citizenship without the formal entitlement of rights. Substantive citizenship is based on how a person acts according to his or her own subjectivity and identity. The performance of these acts, be they social, political, cultural or symbolic, are claims to formal citizenship status. In sum, substantive citizenship is the condition of the possibility of having a formal citizenship status (ibid.).

In an attempt to elaborate on 'acts of citizenship', Turner theorises acts of citizenship as

'acts of piety' in the religious world. Piety 'refers to habitual acts of reverence and obedience, and hence it is the habits or habitus of the pious' (Turner, 2008: 124 in Isin and Nielsen, 2008). Piety 'creates a hierarchy of values or grace' and 'a person’s inspirational worth is measured in terms of acts of piety' (ibid. 123). Acts of piety therefore often represent a challenge to the secular world (ibid.). Turner also highlights

56 acts of piety as empowering people and they 'characteristically involve some challenge

to the existing order or “city”, that is, the secular city' (ibid. 125).

In connection to the concept of habitus, he draws comparison with Bourdieu’s work

Distinction (1984). He notes that 'habit' is derived from 'habitus' and suggests that 'our

dispositions and tastes are merely routine' and 'acts of piety' do not simply reproduce

habits, but rather challenge existing arrangements both secular and religious (Turner,

2008: 125). Turner also illustrates a parallel set of arguments from the work of

Confucius and Mencius (ibid.). 'Within a cultivated and disciplined self, character is

expressed unintentionally through a virtuous disposition' (ibid. 126). In this research,

filial piety is an example of an act of piety, an act of virtuousness. The act of piety is

similar to ethopolitics as discussed in Chapter 2.

The act of citizenship is about the meaning behind one’s action and it has a close relationship with government provision and its policy (Lockhart, 2001; van Oorschot,

Opalke & Pfau-Effinger, 2008). Theorising acts means investigating everyday deeds that are ordinarily called politics (Isin & Nielsen, 2008: 2). In this research, I use substantive citizenship as the tradition of caregiving and self-reliance as claimed by the government, rather than as a process of claim-making, as argued by Isin and Nielsen

(2008). In this chapter I examine ageing policy and Chinese Confucian familism and argue that ageing policy in Hong Kong reflects traditional norms and values.

57 Government policy, tradition, legitimacy and citizenship

Policymaking in Hong Kong is mostly a top-down process (Phillips & Chan, 2002: 18;

Scott, 2010), and legitimacy plays an important role in the process. In order to

understand the forces underpinning ageing policymaking, it is useful to compare other

social service policymaking such as education and housing. In the context of education

policymaking, Cheng (1992) argues that Hong Kong Chinese put great faith in

empiricism, such as scientific measurement and overseas consultants, who they see as

impartial, knowledgeable, and able to provide up-to-date measures to improve services.

On the other hand, legitimacy is premised on the Hong Kong government’s strong

record of economic growth and other types of freedom (except political), such as

expression and mobility, which are relatively absent in China. Cheng’s conclusions are

relevant in the case of policymaking for the aged, especially with regard to the

involvement of overseas experts and local consultants. In an examination of the

curriculum development process of the history subject in Hong Kong, Vickers notes that

by the 1980s, the practice of looking to British precedents had become largely

institutionalized (2005: 134). On the whole, there is little participation from the

grassroots or user groups.

In the field of ageing policymaking, the major force of legitimation comes from the policy objective of community care borrowed from the UK in 1973. The Hong Kong government has used Hong Kong Chinese Confucian culture to legitimate its community care policy (Hong Kong Government, 1973; 1994: 50). It can be argued that the community care policy for older people is similar to the Chinese philosophy of the care of older people which implies that aged care is a family responsibility rather than the government’s (Hashimoto & Ikies, 2005; Holroyd, 2001; Ngan & Leung, 2001; Lui,

58 Lee & Mackenzie, 2000; Chi, 1999: 13-14; Chong & et al. 1999: 81; Ngan & Kwan,

1995; Chong & Kwong, 1994: 211). In other words, the coupling of Chinese Confucian

values and services for older people — especially with regard to the residential care

sector — has given the government a narrative to hold families responsible for their

elderly relatives (Shi & Fu, 2009; Olson, 2006; Hashimoto & Ikies, 2005: 442; Walker

& Wong, 2005:215; Keith et al., 1994: 56).

The government’s success in implementing the ageing policy is not just a matter of

cost-saving and it goes far beyond material aspects. The aged-care policy provides a

way of thinking about how one should act. It is a community practice in which realisation of one’s cultural identity is possible. There is a hint of Hobsbawn and

Ranger’s (1983) argument about 'the invention of tradition' here and, in this sense, in

Hong Kong 'rituals connect the present to the past’, and thereby encourage a sense of

'rootedness' in the community (Chan, 2001: 503).

In a study of Chinese business groups in Hong Kong and political change in South

China, Chung observed that Hong Kong’s polity and society requires 'tradition' and

Hong Kong businessmen refer to China for 'tradition' rather than

(1998: 16). There are two observations to be made here. The first, in relation to Chung’s view, is national identity. The second is Tu’s view of cultural China (1994).

In relation to national identity, Carroll (2005) also notes that as early as the 19th century, there was already a group of people in Hong Kong who considered themselves to be

Hong Kong belongers. However, Ku (2009, 2004) says that before the mid-1980s, there was a touch-base policy, which meant that if a new arrival from China reached the

59 boundary of the city then they could automatically become a Hong Kong citizen. This is

the relationship between migration policy and 'formal' citizenship mentioned above.

In public housing provision, in the early days of Hong Kong, there was little trust

between the locals and the British government and the construction of a public housing

project somehow contributed to the administration gaining some trust from the locals

(Smart, 2008). Smart describes this as the construction of social citizenship through

housing provision. In a similar vein, Ip (2004) emphasises that resettlement estates

brought a special kind of citizenship expansion in the form of cultural cultivation.

In relation to cultural cultivation the idea of a 'cultural China' as noted by Tu (1994) is

useful for the analysis. According to Tu, the concept of cultural China 'is not a

pre-given term, but rather arises as a result of a continuous interaction of three symbolic

universes' (1994: 13). The first consists of , Taiwan, Hong Kong and

Singapore, that is the societies populated predominately by cultural and ethnic Chinese.

The second consists of Chinese communities throughout the world which - tend to

define themselves as members of the diaspora. The third symbolic universe consists of individual academics who try to understand China intellectually and bring their

conceptions of China to their own linguistic communities. I argue that it is through the understanding of cultural China that the formation of the ageing policy in Hong Kong can be understood. That is to say, the cultural tradition of familial care as the cultural ideal of the overseas Chinese diasporas is considered as an appropriate behaviour as an act of piety.

60 From the anthropological view of Chinese society in South China, Siu (1990) notes that

cultural construction and identity-building in China relies on the writing and the

recycling of tradition. In the colonial studies of India, Dirks (2001, 1997) also discusses

the process of the policing of tradition, that government policy preserves and maintains

tradition like the police in the keeping peace and order in a community. In the present

case, the ageing policy helps to generate and re-generate the cultural meaning of being

Chinese and thus, serves the purpose of maintaining the practice of tradition as in the

aspect of policing. Tradition in the present study is about fdial piety, intergenerational

solidarity and self-reliance, the spirit of relying on oneself, one’s social network, and

not on the government. It is through the symbolic meaning of the policy that the lack of

provision is legitimatised.

The relationship between tradition and the implementation of government policy is a close one, especially when tradition is assumed to be familial responsibility. This also raises the question of families caring for their ageing parents when service provision is inadequate. One of the key explanations, as mentioned above, is low motivation in seeking outside help. Another explanation is the prevalence of 'acts of filial piety', which people take up as a duty or responsibility. How would this 'fixity of tradition'

(Giddens, 1991) of familial responsibility and self-reliance be maintained?

Chatterjee (2004) notes that the Western concept of the universal citizen and civil society cannot provide an adequate analysis of a post-colonial society like India. He argues that there is a major hegemonic difference between citizens and populations, nationalism and the politics of ethnicity, and the rise of the govemmentalisation of the state 'that are produced by the modem imaginings of community' (Chatterjee, 2004: 5).

61 The govemmentalisation of the state means that the state regime 'secures legitimacy not

by the participation of citizens in matters of state but by claiming to provide for the

well-being of the population' and 'governmental techniques that have promised to

deliver more well-being to more people at less cost' (Chatterjee, 2004: 24). Chatterjee

refers to Anderson (1998) who argues that there are the unbound and bound serialities;

the former corresponding to nationalism and the latter to the politics of ethnicity

(Chatterjee, 2004:5). Another difference between bound and unbound serialities is that

'unbound serialities are potentially liberating. Bound serialities, by contrast, can operate

only with integers' (ibid.). Integer is used here to refer to a population group sharing

entirely the same expectations, aspirations and meaning of life. Chatterjee further

explains that:

This implies that for each category of classification, any individual can

count only as one or zero, never as a fraction, which in turns means that all

partial or mixed affiliations to a category are ruled out. One can only be

black or not black, Muslim or not Muslim, tribal or not tribal, never only

partially or contextually so (ibid. 5-6).

Woodiwiss also notes that the politics of the governed 'has [been] done in India not by constituting individuals as autonomous subjects as in the west, but constituting them as members of what are often termed “communities” such as castes, tribes, or ethnic groups for its own governmental purposes' and that 'the state has actually ruled on the basis of its own presumed sovereignty' (2004: 176).

62 The continuous employment of the term 'care in the community' in ageing

policymaking in Hong Kong over the years has the effect that 'a bound seriality of

govemmentality can create a sense of community' (Chatterjee, 2004 in Woodiwiss,

2004: 176). The key difference between the cases of India and Hong Kong is that

governmental practice involves different communities in India, and in Hong Kong

governmental practice targets the whole society. It thus provides a unifying effect in the

organisation of the society. The different Chinese ethnic groups in Hong Kong each

have their own orientations and yet they share a belief in the importance of filial piety

and familial values. The presumed of family virtue in caring for the old

and their self-reliance are crucial for one’s identity, which provides meaning for one’s

everyday life and plans for the future.

In sum, in addition to low motivation in seeking outside help, the of

familial care and the ageing policy of community care have a synergetic effect in pressuring the people to care for their ageing parents. Cultural citizenship can be

summarized as 'the right to belong to a broader community in ways that are felt by the individual and recognized by others, as well as to the responsibilities to protect the dignity of that community' (Fong & Murphy, 2006: 2).

The background and context of ageing policy of Hong Kong

In this section I will examine the kind of ageing policy the Hong Kong government is pursuing, the context of provision and the relationship with the Hong Kong welfare model. I argue that if the Hong Kong government chooses not to fully support ageing services it will look for other methods to meet needs.

63 This assumption differs from laissez-faire economic policy and political

non-intervention philosophy, but is in line with the argument that the Hong Kong

colonial state is not a neutral actor (Ngo, 1999: 9). In other words, the Hong Kong

government is an interventionist state and is not relying solely on the market for a

solution. This is also the case with the Tung (1997-2005) and Tsang (2005-2012)

administrations. Throughout its indirect rule, the government has been actively

constructing the welfare sphere. 'Culture' has been employed in the production of the

ageing policy.

The ageing policy in Hong Kong is in two tiers: the community support service, also

known as the community care policy, and the residential care service. It should be noted

that ‘residential care service’ here refers to institutional care and is mainly provided by

NGOs and the private sector. Unless otherwise stated, the ‘private sector’ refers to the

for-profit commercial providers. The government does not treat community and

residential services in the same way, and the differing funding strategies results in

uneven development. I will briefly outline the community support service and the

residential service.

Community care policy and its support services

Hong Kong is primarily a Chinese community, with 95 per cent of its population ethnic

Chinese. Traditionally among the Chinese, caring for the aged has been recognised as a family responsibility. Those without family support are usually cared for by religious and charitable organisations (Sinn, 1989; Lethbridge, 1978). These organisations have a long history of offering refuge to the elderly and the destitute.

64 Until the 1960s neither the government nor the social welfare sector gave services for

the elderly any significant attention. Most of the provision was by religious and local

charity organisations in the form of institutions. In the early 1970s, problems associated

with the lack of, or inadequacies in, family care and the growing needs of the elderly

began to surface (Kwok, 1997: 23-4). This was partly due to the impact of Hong Kong’s

early industrialisation, and urbanisation, its demographic profile and the changing role

of the family. In 1971, 293,273 were 60 and over, which was 7.4 per cent of the total

population of 3,936,630. Among this cohort, 111,431 were male and 181,843 were

female; 31 per cent were still employed; and 28,009 were single. Of these single people,

10,713 were male and the remaining 17,296 were female (Working Party on the Future

Need of the Elderly, 1973: 2, 4, 5, 7). By 1972, 33,910 of the 51,267 public assistance

recipients were 60 and over (Kwan & Chan, 1986: 187).

Some of those seeking help were elderly single people who came from China to work and did not want to return to their home towns. Others had been left behind by their children who migrated overseas. In 1972, the Hong Kong government set up a working party to examine the future needs of the elderly. It recommended a wide range of services including social security, housing, medical and health, welfare, transport, and employment (Working Party on the Future Needs of the Elderly, 1973). The priority for development were those services contributing to the broad aim of 'care in the community', to enable the elderly to remain in the community and in their own familiar places as long as possible (ibid. 15). Over the years the aim has been to provide support services to older people staying in their own homes, in the form of meals on wheels, escort services to visit physicians, home cleaning and bathing. These support services include neighbourhood aged centres (which provide social and recreational activities);

65 district aged community centres (which provide a range of services including

counselling, home help, social and recreational activities, community education,

networking for older people, bathing, laundry and canteens); day care centres (which

provide personal, nursing and paramedical care for the senile older people); home help

services (which provide meal delivery, personal care and escort services); home care

(which provides in-home services); meal services (delivery only) and facilities like a

holiday camp and some coach services. Most of these services have a waiting list of a

few months to one year. Recipients have to go through a need assessment. There is a

planning ratio for each of the services and there has always been a shortfall and service

gap (Kwan, 2007). About 1 per cent of those who were 65 and over were receiving

community support services in 2001 (Chi, 2001). As mentioned earlier, there are several

reasons why social welfare services have a relatively low priority among potential users.

There has always been a comprehensive range of services, but in reality the number of

services has been few and unevenly distributed. Therefore, there is the contradiction that

the policy has a well-addressed goal but this is not matched by the provision of services.

It should be noted that no service area is able to meet the projected demand, and the

areas of multi-service centres, social centres, day care centres and home-help services

are all falling short. The projected demand is calculated according to an estimate of the needs of the population. However, the government either lacks the political will to reach its target or faces lack of co-operation from the different government departments.

Since 1973, the community care policy has been reviewed and reaffirmed several times in policy papers such as the Green Paper Services for the elderly in 1977; the White

Paper Social welfare into the 1980s in 1979; the White Paper Social welfare into the

66 1990s in 1991; the 1994 working group report; and the Deloitte report in 1997. The

'ageing in place' policy and long-term-care policy (Report of the Working Group on

Care for the Elderly, 1994) both have implications for the community care policy,

especially so in the case of ageing in place. The basic principle of provision, since the

establishment of the HKSAR government, has been to provide senior citizens with a

sense of security, a sense of belonging and feelings of well-being and self-respect (Tam,

1998). With the re-engineering of community support services in April 2003, which

aimed to eliminate service duplication and provide a more responsive service

infrastructure to address the changing needs of the elderly, Home Help Teams were to

fonn Integrated Home Care Services Teams (IHCSTs) to enhance their ability to take

care of the frail and disabled aged in an integrated and holistic manner (Kwan, 2007:

573). Services are means-tested. Three tables showing the number of community

support and residential provisions can be found in Appendix 3, 4 and 5. The first two

tables in Appendix 3 and 4 are based on projected figures from the Five-Year Plan review exercise. Since 1998 the exercise was not in operation. In Appendix 5, I used

figures from the government’s monthly digest of statistics to illustrate the number of provisions from 1998 to 2008. These are actual figures.

In financial terms, the community care policy is cheaper than institutional care because care provided by the family in the community is not included, and therefore is supposed to be free of charge. Besides, the latter is provided on a 24-hour basis. Critics say that the inadequate supply of community support services is an excuse for limiting public spending rather than genuinely developing a comprehensive approach to enabling elderly people to live independent and satisfying lives in the community (Kwok, 1997:

24). Chau (1997: 4) says that critics of the community care policy such as Chow (1987)

67 and Yeung (1992) argue that the government has used it as a cheap alternative to

institutional services, while Ngan and Kwok (1994) argue that the caring responsibility has shifted from the government to the family. Chau claims that 'the Hong Kong

Council of Social service has gone as far as saying that community care in Hong Kong has become “family care”, or even “care by women”' (Hong Kong Council of Social

Services, 1994 in Chau, 1997: 2). It is the structural shortage of these provisions that triggers such comments. Regarding the caring capacity of families, Chui (2008: 173)

also notes that 'older people cannot rely upon their grown-up children to live with them and take care of them'. However, Wong (2008: 199) and the government report A literature review' of family policy in four East Asian societies (Central Policy Unit, 2009) note that family in Hong Kong remains intact.

Since the community care policy is close in meaning to family care, it implies family responsibility and filial piety (Hashimoto & Ikels, 2005; Ngan & Leung, 2001; Chong

& et al. 1999; Ngan & Kwan, 1995; Chong & Kwong, 1994; Keith et al. 1994; Yeung,

1992). People accept the policy as culturally appropriate because families practise the notion of family care (Ngan & Leung, 2001: 17). In government documents on community care, the term ‘domiciliary care’ is also referred to and printed next to the term ‘care in the community’. The term ‘domiciliary’ (the Chinese character jia) is translated as ‘staying at home’. The translation gives further weight to the family care of older people being a legitimate policy option.

68 Residential care service and types of homes

Due to the government’s preference for the community care policy, residential aged

care has been considered a lesser option. One survey (Hong Kong Health Care

Federation, 2009) reported that more than 80 per cent of the 1000 respondents preferred

to live alone rather than be admitted to an aged home. In a domestic household survey

of 27,400 older persons conducted by the Census and Statistics Department in 2005,

97.2 per cent did not intend moving to a residential care home, and for those who

answered in the affirmative, 2.5 per cent said they would prefer to stay in subvented

residential NGO home (financially subsidised by the government) and 0.3 per cent

preferred private residential care (Census and Statistics Department, 2005: 55, 89). In

2006, 10 per cent of those who were 65 and over lived in homes for the elderly. In 1991,

there were only 6 per cent (Chau & Woo, 2008: 50-1). In Australia, by comparison, in

2006 only 6 per cent of those 65 and over were in non-private dwellings (ibid.). In 2006

in Hong Kong, there were 49,210 places (68 per cent) in the private residential sector

and 22,899 places (32 per cent) in NGO homes. On average, the charge for NGO homes

is about HKS2000 (per month), while in the private sector the range is from HKS5000

to HK$20,000 (per month). The waiting time for NGO homes ranges from 31 months to

40 months and for the private sector it is about 9 months or less. The admission process

for the NGO homes is quite selective due to the limited places available, and it is usually the very frail and most vulnerable who find their way in. In Hong Kong, given a choice, people enter a home only when they are too frail to take care of themselves. On the whole, older people do not usually consider homes as an alternative living arrangement, mainly because they fear extreme social isolation or are reluctant to make changes and adjust to unfamiliar conditions. In a study on mobile phones, aged homes and family relations in Hong Kong, respondents indicated that elderly people enter

69 homes for reasons such as their health, poor or non-existent family relations or

insufficient living space at home (Wong, 2006: 181).

As mentioned previously, prior to the beginning of fonnal community support services,

religious and charitable agencies had long been involved in the care of the aged in

homes. From the late 1960s, after the 1967 riots, voluntary agencies started to bring in

overseas experience and experiment on a limited scale with hostel services in the form

of group housing for old people on the first and second floors of public housing estates.

After the 1973 working party report was published, it was suggested that the

construction of NGO aged homes stop for two years to determine the effect of the care

in the community policy. However, the proposal was never implemented. Since then,

there has been a prolonged period of insufficient supply of residential care places and

with an increased ageing population who required residential care, the private aged

home market began to emerge.

The different kinds of institutional facilities include hostels (mainly for those who are

capable of self-care - but hostels are being phased out), aged homes (for the less capable

and with meals provided), nursing homes (for those requiring personal and limited nursing care) and lastly, infirmaries (for those requiring regular nursing and medical care). These facilities are government funded and managed by NGOs.

Some of the homes’ quality of care is substandard, particularly those that belong to the private home sector where profit is important. In 1995 an ordinance was introduced and the government also introduced different subsidies and financial measures — such as the BPS, EBPS and one-off Financial Assistance Scheme — to improve the quality of services. If the home operators wanted to receive a financial subsidy from the 70 government they had to meet certain quality standards in order to qualify. The

government thought that subsidies were an incentive for the operators to improve their

service quality. The residents could apply for the CSSA, which is means-tested. These

government subsidies mean that the private residential home market is not an entirely

free market as is claimed.

In 2001, there were about a million people aged 65 and over and about 30,000 places

were available, less than 3 per cent of those aged 65 and over. Waiting lists were long

and the average waiting time could be up to 30 months (Social Welfare Department,

Annual Report, 2003). It was, therefore, not surprising that one-quarter of those on the

waiting lists passed away before getting a place.

Leung observed that in 2002, some 5800 places were under the BPS, while there were

21,600 CSSA recipients living in private homes with their fees being paid by the

government (plus another 26,300 such CSSA recipients in subsidised homes) (2004: 90).

Altogether, the government was subsidising a total of 53,600 places or 76.6 per cent of

all places (ibid.). In other words, the government was still the major financial underwriter of the residential care sector, contrary to the belief that the private sector is independent. The government spends more resources on the residential care sector than the community care sector, which it claims has top priority. This policy has many contradictions. As for the amount of financial subsidy, which includes homes and community care services, and payments under the CSSA, in 2004-05 the annual recurrent expenditure was HK$3,206 million (Kwan, 2007: 570).

In 2006, 10 per cent of those 65 and over stayed in institutions, as compared to 6 per cent in 1991 (Chau & Woo, 2008: 50). Paradoxically, an estimation of aged home 71 admissions in Hong Kong indicates that they are higher than their counterparts in Japan,

Singapore, the UK and the US. A study commissioned by the Elderly Commission

(2009) found that almost 1 in 15 persons aged 65 or over in Hong Kong lives in an aged care home. The report said that the high institutionalisation rate in the city might be due to reduced family size and the limited space in Hong Kong flats. There are about 700 homes for the elderly across the city, offering 72,955 bed spaces. Sixty-two per cent are run by the private sector, with the rest subsidised by the government. There are 25,000 elderly people waiting for places in government-subsidised homes, and the waiting time for home admission is between 22 and 40 months (South China Morning Post, 6

January 2010). Please refer to Table 1.

Table 1. Residential care for the older people 2009 Total number of homes 700 (72,955 places) Commercial private homes 62 per cent NGOs homes 38 per cent Waiting list figures 25,000 persons Waiting time 22 months to 40 months

Source: Elderly Commission’s Study on Residential Care Services for the Elderly, 2009:14

Hong Kong Chinese Confucian familism and filial piety

In this section I will explain Chinese Confucian familism, filial piety and their relationship with the ageing policy. Since there is a close relationship between the ageing policy and the care provided by the family in Hong Kong, I will examine these and their relationship with ageing studies.

72 Hong Kong Chinese Confucian familism

The goal of Confucianism is to achieve harmony with the world and nature. Based on

this, there are sets of rules that are intended to maintain harmonious and proper

relationships. Among them is the formulation of 'three bonds' and 'five constancies'.

These are the different kinds of personal relationships constituted according to the

relationships with the political leader, family and friend. The 'three bonds' aim to

ensure the authority of the ruler over the minister, the father over the son, and the

husband over the wife. The 'five constancies' determine the conduct between

ruler/minister, father/son, husband/wife, older brother/younger brother and

friend/friend.

Confucianism places great emphasis on filial piety. One of the teachings on filial piety is:

Nowadays for a man to be filial means no more than that he is able to

provide his parents with food. Even hounds and horses are, in some way,

provided with food. If a man shows no reverence [to his parents], where is

the difference? (Analects Book II: 7 in Lau, 1992: 13)

Confucius defined nine acts involved when adult children practise filial piety towards the elderly: providing care; not being rebellious; showing love, respect, and support; displaying courtesy; continuing the family line; promoting fraternity among siblings; advising parents; concealing parents’ blunders; and displaying sorrow for parents’ illness and death (Lam, 2007: 64).

73 Mencius described eight features of filial piety: supporting, respecting, taking care,

minding, showing courtesy, pleasing, abiding by righteousness and procreation (ibid.).

These nine acts and eight features describe the proper behaviour and attitudes of adult

children towards the aged. Over the centuries these scriptural guidelines have shaped

the expectations and behaviour of countless parents and children (Ikels, 2004: 4).

Present-day filial piety is modified and is less formal and ritualised. For instance, in the

old days, there were rules regarding what a son should do when his father passed away.

A son could not shave or bath for a week, amongst other things, in remembrance of his

father. This is no longer the practice.

Another important aspect of Confucian thinking which is still popular and people

always use, say and meditate on is a quotation from the Great Learning:

Wishing to rectify their hearts, they first sought to be sincere in their

thoughts. Wishing to be sincere in their thoughts they first extended to the

utmost their knowledge. Such extension of knowledge lay in the

investigation of things. Things being investigated, knowledge became

complete, their knowledge being complete, their thoughts were sincere.

Their thoughts being sincere, their hearts were then rectified. Their hearts

being rectified their persons were cultivated. Their person being cultivated,

their families were regulated. Their families being regulated, their states

were rightly governed. Their states being rightly goveemed, the whole

kingdom was made tranquil and happy (Legg, 1971: 358-9).

Value is placed on the family as a whole and not on individual members, and thus, family is viewed as more important than the individual. Family relationships are

74 hierarchically structured, especially with regard to the relationship between father and

son, which is placed above all others (Hsu, 1971), and have been criticised as being

primarily patriarchal (Lee, 2003).

In Hong Kong, the family ideology has been heavily promoted in social services

(McLaughlin, 1993), as in the case of the ageing services mentioned above. In regard to

Hong Kong’s residual welfare system, Chiu and Wong (1999) argue that its brand of

residualism has been strongly supported by traditional Chinese family values,

selectively manipulated by the colonial government. The notion of self-reliance, in the

sense of family residualism, is taken to mean family reliance, where family is regarded

as both the first and perhaps the last port of call for any responsible citizen (ibid. 78).

Where the primary responsibility for the provision of care and welfare is assigned to the

family, it is in reality assigned to the women (Jones, 1990: 221-2; Kwok & et ah, 1997:

252-6 in Lee, 2003: 5). Without adequate labour protection, social security and welfare,

familism became a practical strategy of survival for individuals who were left to fend

for themselves (Lee, 2003: 5). This observation also supports the arguments of Salaff

(1981) and the 'centripetal family', and Lau (1982) and 'utilitarian familism', that Hong

Kong’s Chinese familism was an adaptation to the colonial condition which forced individuals to rely on familial networks as their safety net (Lee, 2003:7).

Traditionally, the Chinese family is patrilineal. This is still the case today. The oldest male is the head of the family, even if he is very old and economically inactive. The experience is that he and his elderly wife live with their offspring and are cared for by their adult sons and daughters-in-law. However, only a handful of local elite and very rich households can attain the ideal cultural norm of a multi-generational household. In

75 his book, Trust, Fukuyama observes that the nuclear family has been much more

common in China, even among traditional peasants in the countryside, than many

Chinese themselves believe (1995: 90). Despite the increase in nuclear families (Wong,

1972, 1974) and higher life expectancy, and the fact that ties among family members

may have been weakened, filial piety in Hong Kong on the whole remains intact (Wong,

2008). To summarise, Hong Kong Chinese Confucian familism is to some extent what

Kinnear and Graycar argue is the ‘hidden welfare state’ in Australia (1983: 79-80 in

Fincher, 1989: 110) or what Gough (2004: 28) and Wood (2004: 49) argue is the

informal security welfare regime in developing countries.

Filial piety and the care of ageing parents in Hong Kong

Comparing Japan and China, and to an extent Hong Kong, Hashimoto and Ikels state

that filial piety refers to the practice of respecting and caring for one’s parents in

old-age, based on a moral obligation that children owe their parents (2005: 437). This

practice is not unique to Asia, as virtually all world religions recognise filial obligations

of some form as an important moral value. However, the practice of filial piety is often

especially associated with East Asian societies, because of the strong historical influence of Confucianism, which articulated the doctrine as the centerpiece of the moral order of society. The practice of intergenerational reciprocity of respecting the old is described as xiao and is considered the most important value among all virtuous deeds. Three ideological sources bolster filial piety in Hong Kong: Confucianism, familism and the norm of reciprocity (Kwan, Cheung & Ng, 2003: 15 in Lam, 2007:

66).

Wong and Chau (2006) found that the notion of filial piety remains strong in a modem

Chinese society like Hong Kong. They also found that a relational approach to filial 76 behaviour, with its emphasis on 'felt obligation', seems to offer an apt interpretation of

the motivations when children care for their parents (Wong & Chau 2006: 600). This

approach also supports Liu’s (2000) social psychological approach to the normative

understanding of intergenerational care-giving in China and Hong Kong.

Chow (2001) examined the three levels of the practice of fdial piety: providing parents

with the necessary materials for the satisfaction of their physical needs and comfort;

paying attention to parents’ wishes and obeying their preferences; and behaving in a

way that makes parents happy and brings them honour and the respect of the

community. The survey findings indicate that the majority of the respondents thought it

their responsibility to satisfy the material needs of their parents (Chow, 2001: 134). The

value of filial piety is still upheld by most Hong Kong people as a value they should

treasure and practise in appropriate ways (Chow, 2001: 135; Wong, 2008).

Similarly, Holroyd argues that the Hong Kong Chinese daughter’s intergenerational

care-giving obligation is a result of Hong Kong Chinese culture. Unlike most other

researchers, she includes the dimension of government policy as part of the Hong Kong

cultural model (Holroyd, 2001: 1127). She also looks at the psychological process

involved in the internalisation of obligations. Holroyd’s study is quite similar to Wong

and Chau’s (2006) and Liu’s (2000) mentioned above. The key research question in

Holroyd’s study was 'in what way do caregiving daughters actively constitute their obligations? ' One of the respondents replied by saying:

77 I think that as a woman and a daughter it is very important to care for your

mother. This kind of care should not be questioned as it is bom within you,

and others expect it of you (Holroyd, 2001: 1132).

However, the respondent also explained that there was no one else to care for her

mother because of the Hong Kong government’s policy towards care of the elderly

(ibid.)

In contrast, in-depth interviews of 50 aged persons in a public housing estate found that

they received relatively poor informal support from adult children (Ng, Phillips & Lee,

2002: 150). Elderly people who do not live with their children received the poorest

infonnal support, while elderly people living with children received the best infonnal

support. In general, the shorter the geographical distance from adult children, the more

infonnal support the aged received, especially in tenns of day care, and psychological

and financial support. The caring capacity of the Chinese family cannot simply be

assumed, nor can the assumption be made that in the future filial piety will guarantee the provision of assistance. This study confirmed Lam’s (2007) work, showing that the practice of filial piety could encounter structural constraints and these are usually in terms of living arrangements and family income.

There is little research on care-giving among the sandwich generation in Hong Kong

(Lam, 2007: 64). The ‘sandwich generation’ refers to those who have to take care of their ageing parents and their own children (ibid.). A quantitative study from a random sample of 503 sandwich generation respondents in a telephone survey (CATI system) and 20 qualitative interviews was conducted in order to understand how the sandwich generation perceive and practise the care-giving role and the difficulties they encounter.

78 The results show that the strength of filial piety values can be regarded as the primary

factor determining the respondents’ care-giving performance (ibid. 77); in other words,

the extent to which they have internalised filial piety values influences the degree to

which they care for their parents. In this research, the author reported that:

respondents may regard the provisions of care to their elderly as a justified

action since the adult children had been taken care of by their elderly and

they should do something in return (Lam, 2007: 70)

This aspect of the study is consistent with Wong and Chau’s (2006), Holroyd’s (2001)

and Liu’s (2000) studies. The second factor is structural constraints, such as living

arrangements and family income, and the third is the ability of the care-receivers to take

care of themselves.

A questionnaire survey of seven cities in China including Hong Kong (sample size 5512,

with 1539 Hong Kong respondents) indicated that the more modem a city, and the more

education one receives, the less one acknowledges filial piety. This finding fits with the modernisation thesis. Compared with the other six Chinese cities, the perception of filial piety in Hong Kong was the lowest (Kwan, Cheung & Ng, 2003: 113). In addition, in

Hong Kong older people had a very high expectation of government support (ibid. 6). A city with greater filial piety in practice had a lower expectation of government support.

Filial piety and government support for the old, therefore, appear to be mutually exclusive. Undoubtedly, filial piety in practice reduces people’s need for community and government support (ibid.). In an examination of aged care in China, Ikels reports that the provision of long-term care is essentially the responsibility of the family (1997:

452). Ikels further explains that 'while this responsibility has its roots in traditional

79 values that emphasise filial obligations to one’s parents, it is equally grounded in the

contemporary political economy of China due to the restructuring of the state economy

to a market one' (ibid.). It is in the similarity between neo-liberal thinking and

traditional familism that the latter has gained its new legitimacy.

The relationship between social services and filial piety

From the above examination, two key features emerge: the relationship between the

care-giving role of the family and the provision of social services. This section

examines the relationship between social services and filial piety.

It is clear that the values of Confucian filial piety provide the basis for defining the

intergenerational relationship culturally. However, one also has to note the insufficient

services, both in kind and in cash, which mean that old people have to turn to their infonnal networks, that is, their children, for help. The inadequate supply of public provision for the aged deprives them of the opportunity to make the choice — of whether to stay home or to enter an aged care home. When comparing who will care for tomorrow’s elderly in the East and the West, Bengtson and Putney observe that in contemporary East Asian nations, traditional norms of filial obligations are reinforced by the general unavailability of publicly supported programmes for the aged (2000:

270). Thus, children have to look after their parents, as there is often no alternative (Fu

& Hughes, 2009).

It is not surprising when examining the living arrangements of the aged in Hong Kong to find that for decades the government appeared to take family care of the old for

80 granted, and provided few public services. In recent years the situation has improved,

but only to a limited extent. Therefore, the Hong Kong family remains the chief aged

care institution, a state of affairs reinforced by the lack of government policy on aged

care in terms of adequate social security and community care facilities (Lee & et al.,

2001: 272-3). According to the 2004 Census Survey (Census & Statistics Department,

2005), among persons 60 and over (a total of 985,700 which is 14.6 per cent of the

population), 55 per cent required assistance or had caregivers and 45 per cent had no

caregivers. Of the 55 per cent, 37 per cent were cared for by their children and 27 per

cent had their spouse as their major caregivers. Another 23 per cent received care from

domestic helpers or a nurse, and 13.2 per cent received help from relatives, friends or

neighbours (Chau & Woo, 2008: 58).

Hashimoto and Ikels make a similar observation regarding the relationship between

social policy and family care in colonial times — Hong Kong was relatively free to

maintain or change its practices so long as they did not interfere with trade or threaten

the British administration (2005: 442). The British were happy to support the notion that

the family was the best setting for the Chinese elderly and used it to justify the policy of

'care in the community' while failing to develop support services for these caring

families. The shortage of services had the effect of keeping the families industrious.

In Hong Kong, unlike Japan, China or Singapore (ibid. 439, 441, 442), there is no legislation that stipulates that children must support their parents. However, the insufficient supply of public provision, the formal requirement of children’s consent not to support their parents in applications for social security payments, and the argument behind the community care policy for the aged have the same effect as law in the

81 regulation and sanction of intergenerational reciprocal behaviour. As I pointed out

earlier, the Hong Kong government, like any government, has always needed legitimacy

to rule, and it makes use of the cultural appeal of filial piety to legitimise an ageing

policy that does not consume too many financial resources. In other words, the ageing

policy can be seen as an outcome of the politics of cultural legitimisation (Chow, 2002:

2).

A recent study on welfare dependency and the Chinese family in the UK found that

Chinese families tend to rely upon each other for support and resources rather than on

the government, even though assistance is available (Chan, Cole & Bowpitt , 2007).

Although the study is not directly related to filial piety, it sheds light on the

'self-reliance' or 'social isolation' of Chinese people, either as a result of cultural

socialisation, the language barrier or diversity in behaviours around seeking help; all

have a close relationship with policymaking and the wider societal network.

Conclusion

From the above discussion on Hong Kong Chinese familism, filial piety and their relationship with service provision, two important implications follow. First is the

cultural prescription effect (Haber & Gratton, 1996: 81) of the policy which results in

family care as a substitute for government support (Keith et al., 1994: 258). The community care policy capitalises on norms, customs and tradition. It is also a prescriptive theory, highlighting the importance of the practice of family solidarity and caring. It conveys what Putnam describes as the spirit of the importance of social networks and social capital (2001). In other words, the covert meaning is one of social cohesion. The second implication is a result of the cultural prescriptive effect which

82 generates the psychosocial and psycho-cultural dimension of intergenerational

reciprocity, as discussed by Ho (1996), Liu (2000), Holroyd (2001) and Wong and Chau

(2006). The psychosocial and psycho-cultural dimension of family caregivers and

receivers constitute the process of the formation of citizenship, the acts of caring. It

provides an explanation of the context of reciprocity of familial care-giving, - one

element of which is the cultivation of a Hong Kong cultural citizenship.

In an attempt to link social policy, ageing and social theory, Estes, Biggs and Phillipson

note that 'ageing policy allows the release of resources and gives permission for

professional intervention' (2003: 3-4) and allows for a definition of 'the relationship

between social responsibilities and age' (ibid. 5). Ageing policy also has 'a symbolic

function in the creation of social spaces that encourage certain forms of behaviour and

sanction others' (ibid. 362). The care in the community policy for older people in Hong

Kong is an example. The word ‘community’ is highly symbolic, with a range of meanings. For instance it could mean self-help, family care or government support services, and it does not draw a distinction between who should be helping and the kind of help that they will provide. In Hong Kong, old age is not only a cultural space, but a political one. For example, as mentioned above, the community care policy provides 0a framework for the allocation of resources, fosters filial piety and affects the development of homes for the aged.

Based on the discussion so far, I propose four hypotheses:

83 1. The low priority given to the development of social welfare in Hong Kong is a

result of the practice of economic rationalism. Thus, social welfare policies are

residual in structure and people have to rely on help from their family for care.

2. The low priority given to social welfare in Hong Kong is a result of low cultural

expectations based on collective welfare and family, rather than societal orientation

(incorporating the influence of Confucianism and filial piety).

3. The low priority given to social welfare in Hong Kong is a result of a long history

of self-reliance and not looking to the government for help (incorporating the

influence of Confucianism and filial piety).

4. The low priority given to aged home provision in Hong Kong is a result of

government policy’s emphasis on community care, that is family first and aged

home second (incorporating the influence of Confucianism and filial piety).

The above hypotheses are based on the research assumption that if aged care policy is a result of the interplay between the political and economic spheres (the political economy perspective which reveals the amount of adequate or inadequate supply of resources), then it cannot be justified as a cultural or moral one (cultural and moral economy perspective). In the next few chapters I go into more detail and discuss whether culture, as represented by tradition, filial piety and self-reliance is an independent variable, whether government policy is an independent variable, and my research methods.

If policy shapes our everyday understanding of ageing, it is important to discover which pathway it promotes (Daatland & Biggs, 2006: 99). The three chapters in Part II will

84 examine the historical development of the Hong Kong aged care policy from 1948 to

2007. I use an historical account to illustrate the policy in practice.

Before Part II, I outline my research methodology for the thesis.

85 Chapter 4 Research Methodology

Introduction

In this chapter, I will firstly explain the research aims and questions, the different

periods for the present research, and the materials for the analysis of the ageing policy

in Hong Kong. Secondly, I will outline the methodology for the research and lastly,

mention the limitations of the research.

Research aims and questions

In Chapters 1, 2 and 3,1 note that the core methodologies for research on family care of

old people (Cheung & Kwan, 2009; Cheng & Chan, 2006; Cheung, Kwan & Ng, 2006;

Kwan, Cheung and Ng, 2003; Ngan & Leung, 2001) ageing provision (Cheng, 2009;

Chou & Leung, 2008; Lee & Lo, 2005; Law, 2001; Chow, 2001; Kw'ok, Luk, Lau &

Woo, 1998) and ageing policy (Kwan, 2007; Chan & Phillips, 2002; Chi, 2001; Leung,

2001) in Hong Kong have been survey questionnaires or research of a quantitative nature. These methodologies have been able to identify the service provision gap and critique the shortcomings of the policy. However, they do not by and large examine the social and political forces underpinning the making of ageing policy, and they neglect

o the historical context.

8 An exception is Lee’s work. Lee, J.J. (1997) ‘The development of gerontological social welfare policy in Hong Kong: a brief history’, in Lam & Au (eds.) Social Work in Hong Kong: reflections and challenges, Hong Kong: Department of Social Work, The Chinese University of Hong Kong, pp.71-106. (in Chinese) There is an increasing trend in using qualitative method such as case study and focus group in researching later life in Hong Kong, e.g. Cheng, Chan & Chan, 2008; Wong & Chau, 2006; Ng, Phillips & Lee, 2002; Holroyd, 2001. There are also studies with a combination of quantitative and qualitative method, e.g. Lam, 2007. 86 The social and political forces refer to the actions of the government in response to its

conception of the ageing society, its related philosophy of provision, the cultural beliefs

of familial care and the financial implications. There are also the organized activities

such as petitions by concerned groups in response to the policy-making and individual

older citizens as welfare users. Given the lack of a comprehensive examination of these

social and political forces contributing to the shaping of the development of ageing

policy in Hong Kong, this thesis aims to examine how can the

ageing policy be implemented with the least provisions and yet successfully counter

resistance from concerned groups. It also aims to examine the relationship of the

community care ageing policy, the shortage of NGO homes and the private commercial

sector. Lastly, it aims to explore how citizens, more especially the older population, views and response to ageing policy in the different periods.

In each of the four historical periods the following research questions will be addressed:

• Did the Hong Kong government perceive ageing as a problem and if

so, what were its proposed solutions?

• What were the dominant government and media perspectives?

• In each period was there any resistance and activism by concerned

groups regarding the policy-making? If there were such actions

were they successful?

• What kind of welfare model was in operation during the four

periods?

The four historical periods reviewed in this study are explained in the next section.

87 The periods under study and the three-stages of analysis

In order to account for these questions, a general historical perspective will be outlined

as the basis for discussion.. There are several ways of formulating an historical

discussion regarding the development of the ageing policy in Hong Kong. One approach

is to analyse the different periods of development according to the four Social Welfare

White Papers published by the British Colonial Administration in 1965, 1973, 1979 and

1991. These White Papers were published to address the changing contexts of the Hong

Kong society and can be seen to represent summary accounts of the official views about

social distress and the amount and requirement for state involvement during the

different periods.

Another approach is to analyse the development of the ageing policy according to the

trajectory of the social security system in Hong Kong. Social relief work including

social assistance begins in 1948 immediately after the World War Two. In 1971 a public

Assistance Scheme was formed and subsequently expanded and changed its title to the

Comprehensive Social Security Assistance Scheme (CSSA) in 1993. In 1997 a Portable

Comprehensive Social Security Assistance Scheme was introduced to provide an option

for elderly people to continue to receive the CSSA after they had chosen to move permanently to province. Since August 2005, the Scheme has been extended to Fujian Providence (Hong Kong Annual Report, 2006).

In this thesis, I shall examine the different periods according to the development of the community care policy for older people. The applicability of the notion of community care as a watershed in dividing up the different historical periods can take into consideration the different Social Welfare White Papers as well as the operation of the

88 Public Assistance Scheme and its subsequent Comprehensive Social Security

Assistance Scheme. It can also shed light on the peculiarities of the social structure of

Hong Kong in aspects of family, work and charity ethics. The background of this

community care policy has its root in the 'discovery' and the 'idealization' of family

care, which in turn has had a direct impact on the development of the residential care

policy for the older people.

The period under study is divided into four periods according to the development of the

community care ageing policy in Hong Kong and the political administration of Hong

Kong. These phases are: the pre-community care policy phase (1948-1972); the

community care policy phase (1973-1986); and the community care and commercial

care policy phase under the British colonial administration (1987-1997) and the

HKSAR administration of China (1997-2007). The reason for using the year of the

publication of the community care ageing policy document i.e. Report by the Working

Party on the Future Needs of the Elderly (1973) as a chronicle divider or historical boundary between 1948 and 2007 is because the term ‘community care’ has been the key word in the history of the development of ageing policy since the publication of this

Report in 1973. It should be noted that the planning and debate of this policy started in

1973 and yet the first time this term appeared in Social Welfare White Paper was 1979.

In this research I choose 1973 instead of 1979 for three reasons. Firstly, as mentioned above, the planning and debate regarding this policy started right after the publication of the working party report in 1973. Secondly, the public assistance scheme began in 1971 and became fully operational in 1973, supporting older people living in the community.

Thirdly, the community care policy for older persons was part of the community

89 building programme in the early 1970s when Hong Kong was on the road to

modernisation after the riots of 1966 and 1967.

In each of the four periods, apart from a general description of the socio-economic

context relevant to an understanding of ageing policy in Hong Kong, I will outline and

examine the development of the aged care policy according to a three- stages analysis.

Firstly, government policies (e.g. working party reports, Green and White Papers) are

examined. Secondly, there is an examination of departmental implementation, strategies

and programmes (e.g. review reports, committee meeting minutes, consultative reports),

and finally the operations of these programmes are assessed in terms of the principles

and content of the ageing and welfare policy papers. This part of the analysis will draw

on newspaper reports, and other documents such as minutes of the Legislative Council

(Hong Kong Hansard), and Elderly Commission’s report. In order to have an alternative

view of government actions, media reporting is included in the analysis.

In the following section, I describe the materials used for the analysis of the ageing policy in Hong Kong.

Policy papers, archival documents and reports

This thesis employs five kinds of documents in the analysis of the ageing policy. Firstly, there are 16 government documents outlining the philosophy of planning and implementation of the ageing policy from 1948 to 2007. These include four Social

Welfare White Papers published in 1965, 1973, 1979 and 1991. There are one Green

Paper on social security published in 1977 and another one on elderly service also published in 1977. There are one Working Party report on elderly service published in

90 1973 and one Working Group report in 1994. There is one programme Plan of Services

for the Elderly published in 1982, a Report of the Central Committee on Services for the

Elderly published in 1988, and one Report on Community and Residential Provisions

for Older People in 1997. There is the 2002 Audit Commissioner Report on residential

care for the older people and the minutes of the Legislative Council Welfare Panel on

residential care services for the Elderly (Legco, 31 July 2005). Secondly, there are 24

Annual Reports (between 1948-54 (consolidated report) and 1977-1978) and 16 yearly

Five-Year Plan Reviews (between 1979-1980 and 1997-1998) both from the Social

Welfare Department, and a 1950 annual report from the Secretariat for Chinese Affairs.

Thirdly, there are the 1997 and 2005 Annual Policy Address by the Chief Executive of

the HKSAR government, and the 2008 Financial Secretary’s Budgetary Speech.

Fourthly, there are minutes from the meetings of the Social Welfare Advisory

Committee (SWAC) held in 1973, 1986 and 1988, and the minutes of the meetings of

the Legislative Council recorded in Hansard in 1965. Fifthly, there are reports from the

NGO sector such as Hong Kong Council of Social Services, Hong Kong Christian

Service, Association for the Rights of the Elderly, and a few joint papers by the government and the NGOs.

Lastly, there was one consultancy study on residential care services for the elderly

(2009) initiated by the Elderly Commission (Appendix 6). Even though this report was published outside of the period under review, its recommendations are similar to previous reports and it provides additional information and evidence regarding the government’s argument of community and family care.

91 Analysis of government policy papers

According to Scott (1990) and Wharton (2007: 80-81), using documents as the basis for

the analysis we need to consider the questions of authenticity, credibility,

representativeness and meaning. The government documents for this analysis are

authentic and they are an expression of the standpoint of both the Hong Kong British

colonial and HKSAR administration. However, I note that for example in one of the

examples cited regarding the practice of community care ageing policy in Asian

societies in the 1979 Social Welfare White paper may not be accurate as it seems. I will

return to this point in Chapter 6. Prior (2003: 122) notes that 'documents have content,

and content requires analysis'. He further notes that 'rather than focus on the 'meaning'

of a word, sentence, paragraph or document, it is far more fruitful to ask what is

referenced within the documents' (ibid). The idea of referencing is useful in the present

analysis. Referencing is used in two ways here. One is the referencing of meanings

among the different kinds of policy documents. It is useful to see how particular

meaning or values such as family values are referred to among the different policy

documents in different periods of time. Another way is to examine how the content of

the policy refers to other welfare economies outside Hong Kong. In different policy documents, the Hong Kong administration would use outside examples either to justify

change or to maintain its status quo. Basically, the documents are analysed according to how the government portrayed the ageing population and its counter measures. In the review of literatures in Chapter 2 I note that there are two broad perspectives of writings about the nature of Hong Kong’s welfare system, and the political economy and the cultural economy perspectives. The analysis will examine these documents and look for particular themes and analyse them historically in the political economy, moral and cultural economies of Hong Kong. These are important documents for the analysis

92 because, they are about how to develop a modern welfare system against the backdrop of the culture and tradition of Hong Kong. The Hong Kong government has all along been sensitive to matters that might involve traditional Chinese customs and practices

(Scott, 2010: 9). Since these policy papers are relate to the culture and tradition of Hong

Kong, they reflect the mode of thinking, the mode of ruling, the ruled and governing9.

In the case of policy for older people, there are a few policy audiences. There are social workers, medical doctors, nurses and academics. There are professional organisations such as medical organization, and action groups which employ social action strategies with the aim that the government will accede to their requests. Finally there are

9 During the 150 years of colonial rule of Hong Kong, the administration had attempted to implement a number of policies relating to what is now described as the field of health and social care. Among these events two are well-known. The first event is the issue of the abolition of the Mui Tsai system (child servant) during 1917-1941. It was referred to as a colonial melodrama, the construction of 'Chinese customs' and the Hong Kong government built a case against any compulsory system of registration of transferred children (Pedersen, 2001: 169-170). The event provides an opportunity for woman activists in England to speak of their rights which led to the formation of the matemalist movement. Po Leung Kuk (the Society for the Protection of Women and Girls) was able to stop the government policies from moving too far in advance of opinion (Lethbridge, 1978: 96). Another organization, the Anti-Mui Tsai Society was feeble and never made any headway against the entrenched opposition of the Chinese elite on whom the Hong Kong government relied (Miner, 1987: 189). The second event is about the improvement of the sanitary conditions around 1982 when the Sanitary Bill was introduced after Chadwick conducted an investigation. It proposed to demolish houses and to set up a sewage system. The locals were not in favor of the Bill because of the interference with Chinese customs. It was passed in 1887 but in a diluted form (Sinn, 1989: 160). Commentators noted that local inhabitants saw the proposed Bill as an excuse for the government to 'collect' their houses rather than for the improvement of sanitary conditions. A plague took place in May 1894. The care of older people is another example. The HKSAR government is no different from the colonial administration in terms of the use of tradition as governance.

93 individual citizens. Their responses, to an extent, depend on the nature of the policy and

whether they are affected.

The analysis of the statistical figures that can be found in the annual reports of the

Social Welfare Department, and the yearly Five-Year Plan Review also by the Social

Welfare Department were also useful sources. Based on the figures presented in the

annual reports between 1948-1954 and 1976-1977, I have compiled a Table on the

relationship between the aged home admissions, family service due to old age and

residential care and older people as public assistance applicants. The relevant Table

(table 2) is presented in Chapter 5. From the yearly Five-year Plan Review report

between 1979-1980 and 1995-1996, I have complied two tables based on the demand

and planned provision of both the community-based and residential care. The

community support services are the home-help services, multi-services centres, day-care

centres and social centres. The residential care services are the hostels, homes and care

and attention homes. The table (in Appendix 3) is based on figures between 1979-1980

and 1987-1988, and the second table (in Appendix 4) is based on figures between

1988-1989 and 1995-1996. After 1997 the HKSAR government no longer undertook the five-year planning review exercise, and therefore the figures for community and residential care are not available.

However, the Hong Kong Monthly Digest of Statistics (HKMDS) also provides figures for the analysis. From the HKMDS I have compiled a table (in Appendix 5) on the relationship between the types of community and residential care services, the total number of users and the 65+ population figure from 1998-1999 to 2007-2008. The ageing policy papers and the social welfare white Papers provide an explanation of the philosophy and standpoint of the Hong Kong administrations, while the yearly

94 Five-Year Plan Review is an exercise of planning by numbers. It aims to see whether

the calculation of demand and its actual provision of specific services have been met.

The making of policy in Hong Kong has a long tradition and can be traced to the early

years of the British colonial administration. Every year the British administration

published an annual report and most of the departments such as the Social Welfare

Department also published an annual report. The Special Administrative Region

government also followed this tradition. The annual policy and financial budgetary

addresses are published and widely circulated at different government district office and

can be download from government’s websites. I was able to access this material because

almost all policy papers are open to the general public.

The Hong Kong government’s policy documents are valuable sources of information as

they explain the position and the orientation of the Hong Kong government regarding proposed policy initiatives. The 'semi-democratic' polity of Hong Kong historically means that one reliable source of information about the Hong Kong government is the reading and analysis of the published policy documents. The government also uses policy papers to initiate a process of consultation (Endacott, 1973, Scott, 2010).

However this does not mean that the government was unaware of the sensitivity of certain documents and some are restricted. Secrecy is always present and is strategically subtle. An attempt was made to secure minutes of the Social Welfare Advisory

Committee regarding some of the discussion of the welfare reforms in the late 1970s and the early and mid 1980s but this was unsuccessful. The enquiry was made during the early 2000s. Some minutes from the Social Welfare Advisory Committee are

95 accessible within the social welfare community, however.10 Therefore, the present

analysis is based on documents that are open and accessible to the public.

As to the layout of the policy papers such as the Social Welfare White papers in Hong

Kong, they mostly follow the pattern of describing the socio-economic conditions of

Hong Kong, the philosophical standpoint of the government, the proposed changes in

policy and, the future outlook.

Newspaper reports and television programmes

News reports of older people are an important source of information. Newspaper reports

illustrate the problems facing older people either living in the community or in older

people’s homes. Drawing on newspaper articles, I use these individual case reports

between 1980 and 2007, and they are examined with the focus being the impact of the

policy, and how the goals of the ageing policy have been met or, if they have not, why

not. I also categorise the individual cases according to their common theme. Cases between 1999 and 2006 in one newspaper, Ming Pao Daily are categorised and

organised according to their six themes so as to provide an overall view of the effects of the ageing policy. The themes of the cases will be explained below and in Chapter 8.

The print media plays an important role in the daily life of ’ daily life and 'they are [Hong Kong people] nowadays served by 15 local daily newspapers' and 'the media play very important roles in Hong Kong politics' (Chan & Lee, 2007:

10 Grateful that some of the minutes are available from the Office of the Hon. Y.F. Hui, a director of the Hong Kong Council of Social Services and, a representative of the social welfare sector in the Legislative Council. 96 155). Due to the semi-democratic political structure of Hong Kong, dating back to the

British colonial administration, newspapers have always been one of the key

government channels for accounting for policy actions (Miners, 1998). Likewise,

newspapers in Hong Kong are a platform for different political and interest groups to

express their opinions (Law, 1997; Miners, 1998; Chan & Lee, 2007). Editorial column

of newspapers can serve as the voice of the general public on government policy and

questions relating to the provision of care (Miners, 1998: 269). After the handover in

1997, Hong Kong government officials 'lamented that “Hong Kong is governed by the

media”' (Chan & Lee, 2007: 155). Newspapers have different political orientations.

Broadly speaking there are five in Hong Kong and they are the pro-mainland China

newspapers such as Ta Kung Pao, Wen Wei Po and China Daily (Hong Kong Edition);

there are those that support the Hong Kong government and the PRC establishment such

as ; there are those that support Hong Kong locals such as ;

those which appeal to the middle-class, such as Ming Pao Daily and South China

Morning Post; and there are also the pro-Taiwanese nationalistic newspapers such as

China Times and United Daily News imported from Taiwan.

In this research I used different newspaper reports such as the English language newspaper such as South China Morning Post, Standard, and the Star, and the newspaper such as Wah Kiu Yat Pao, Sing Tao Daily, Ming Pao Daily, Tin

Tin Daily News and Apple and Oriental Daily. There is also a news story from the

Netvigator News. Wah Kiu Yat Pao (no longer available) and Sing Tao Daily are newspapers which carry government announcement. Tin Tin Daily News (no longer available), Apple and Oriental Daily are popular newspapers which have high circulation figures. They are all locally owned except Sing Tao Daily which used to be

97 owned by the daughter of a Malaysian Chinese. The analysis of these newspaper stories

can be found in Chapter 6, 7 and 8. The analysis is based on stories about older people

as case studies to illustrate how the government handles the issues of ageing and how

society reacts. There are 4 case studies in Chapter 6 and 12 in Chapter 7. In the period

ageing between 1999 and 2006, I have compiled a table according to themes from Ming

Pao Daily. The stories are categorized into 6 types and they are (1-) ageing policy, (2)

aged homes, (3) societal concern towards older people, (4) social events and incidents

(such as demand for the increase of provisions and social inclusion), (5) accidents (such

as suicide, hurt, traffic accidents and abuse) and (6) health. There are altogether 1433

news stories during this period of time and the analysis can be found in Chapter 8. The

categorization of the news reports are carried out manually.

Throughout the period of the study, there were only two or three English newspapers

and South China Morning Post has the longest history. Both Ming Pao Daily and South

China Morning Post are recommended as standard reading for secondary school students and for their daily subscription due to their authenticity and reliability in news reporting. The Ming Pao Daily newspaper stories were downloaded from the Hong

Kong’s digital Wisenews website. The website of the Wisenews electronic Chinese newspaper clippings can be located in any public library or universities’ libraries.

These two newspapers are both owed by overseas Chinese. Ming Pao Daily is owned by

Tiong Hiew King, a Malysian Chinese who bought it from Louis Cha, a Hong Kong resident. The South China Morning Post is owned by Robert Kuok Hock Nien who is also a Malaysian Chinese. Both of them are China supporter.

98 Four television programmes were also used. They are: (1) 'Bought Place Scheme for

private residential aged care operator' aired in TV Jade Channel (Chinese) in 12 June

1987, from The Pearl Report series produced by the Hong Kong Television

Broadcasting Company Ltd, Hong Kong; (2) 'Older people in Hong Kong' aired in TV

Jade Channel (Chinese) in 11 May, 1989, from The Pearl Report series produced by the

Hong Kong Television Broadcasting Company Ltd; (3) 'Older people in Hong Kong

and China' aired in TV Jade Channel (Chinese) in 20 October 2003 from The Pearl

Report series produced by the Hong Kong Television Broadcasting Company Ltd, and,

(4) 'Home Horrid Home' aired in 20 July 2008 in TV Pearl Channel (English) from The

Pearl Report series produced by the Hong Kong Television Broadcasting Company Ltd.

All these programmes are produced by TVB, the Hong Kong Television Broadcasting

Company Ltd., and can be found at the multimedia learning centre of the Hong Kong

Baptist University library. Hong Kong Television Broadcasting Company Ltd. is a

Hong Kong based company and the key proprietor is Sir Runrun Shaw, a Hong Kong

Chinese resident.

The choice of methodology and multilevel interpretative framework

In Chapter 1 I noted that, in addition to the perspective of the political economy perspective on ageing, through which one can critically examine the relationship between ageing policy and Hong Kong capitalism, the moral and cultural economy of ageing perspectives can also contribute to the explanation of the normative foundation of later life in Hong Kong. In addition, I will use Foucauldian gerontology in the analysis, as mentioned in Chapter 1. The approach is quite similar to Estes's multilevel analytical framework gaining strength from examining a combination of different

99 factors such as 'financial and post-industrial capital and its globalization, the state,

sex/gender system, the public and citizen11, and the medical industrial complex and the

ageing enterprise (Estes, 2001: 3) with political economy analysis as its basis (ibid.l).

The strength of Estes’s framework is that it helps us to look beyond one single level of

analysis especially because the phenomenon of ageing is a multidimensional

developmental process (Hennessy & Walker, 2011) and a single level analysis cannot

do full justice to the complexity of the ageing world. Besides, Estes’ approach is of

particular interest to the present examination because of the use of a political economy

perspective as the basis of the multilevel analytical framework. Hong Kong has long

been characterized by having its social policy subordinated by economic policy. Aged

care policy has never been a priority.

In this study, the levels of the multilevel interpretative framework are the different

levels of focus of the different kinds of ageing theories as explained in Chapter 1. The political economy perspective emphasizes how economic rationalism has dominated policy-making in Hong Kong for many decades. The cultural economy represents

Chinese welfare culture (Orientalism) such as familial care and self-reliance, and the

Western culture (Occidentalism) of modem welfare as state provisions and its intervention. The moral economy represents the level of ethic of care at both the kinship and societal levels. In the micro-kinship level, moral economy represents the 'morality of reciprocity, mutual obligation and protection' (Ong, 2006: 199; Maynard & et al.,

11 According to Estes at the level of the citizen and the public, the framework incorporates an examination of the meaning of citizenship and the rights and benefits of citizens granted by the state through public policy (Estes, 2001: 3). 100 2008), and the moral character of old-age provision (Bode, 2008: 108; Kohli, 1987),

service provision equity, or in E. P Thompson (1971) notion of the 'economic justice' at

the macro-societal institutional level.

I will also use Foucualdian gerontology’s govemmentality and Rose’s ethopolitics in

the explanation and examination of the development of the ageing policy in the four

periods. In the application of the term govemmentality, I aim to examine the ageing

policy of Hong Kong from the aspects of individualizing and totalizing forms of power

(Foucault, 1982: 213). They are the ' twin processes of societal management according

to both the micro (the conduct of selves on the personal individual level) and the macro

(the conduct of others at group and society level) as outlined in Chapter 1. At the policy

level, it is a ' form of activity aiming to shape, guide or affect the conducts s of some people or persons ' (Gordon, 1991: 2). I will examine the practice of govemmentality at the levels of the socio-cultural and political processes. For the individualizing process it is the conduct of selves in the aspects of self-reliance and self-perfection at the micro-level. In this study, they are kinship filial piety behaviour and older people who try not to depend on government for a living. For the totalizing process it is the conduct of others as the management of the population, the shaping of older people and their families through different kinds of assistance schemes and screening measures in the application for assistance and support.

The practice of govemmentality is a framework of explanation. In order to come to an understanding of this explanation, it is useful to relate it to the goals and aims of a society and aspirations of the individuals. Goals, aims and aspirations are best represented by values or the ethos of a society. Ethopolitcs is about how the meaning of

101 value can have the effect of bonding people together. The combination of

govemmentality and ethopolitcs helps to illustrate how the community care policy for

the old people representing the norm of filial piety of care giving and 'is a process of

meaning making or value preference based on a conceived notion of one’s social

groups' as mentioned in Chapter 1 above. The basic assumption is that the role of social

values plays an important part in a particular context of Hong Kong (Ngo, 2000: 148).

Liu also notes of the role of values plays in the shaping of ageing policy in China and

East Asia societies (Liu, 1998, 2000). The practice of ethopolitcs provides a context for

the understanding of the practice of govemmentality in the development of ageing

policy in Hong Kong.

Ethopolitcs is about value analysis and has a close relationship with explanations about

the cultural and moral economy of ageing. In this study, cultural economy is more about

values relating to 'tradition' and 'modem welfare intervention' and moral economy is

about kinship familial values and distributive justice. This is a cultural analysis and is based on the interpretation of how ageing policy has its impact on the family, and how

ageing policy indirectly produces or sustains cultural specific behaviour in the tradition of Hong Kong Chinese.

Limitations of the research

The main source of the analysis, however, is based on an analysis of government documents and newspaper reporting over the last five decades in Hong Kong. The study compares and contrasts the research findings with other research reports and written material, work which is primarily interpretative and reflects the author’s subjectivity.

This has always been a challenge with explanation when meaning interpretation can be 102 diverse. However, I have tried to overcome this through a multi-level interpretative framework. Another limitation is the small number of newspaper cases and its general nature.

In the next three chapters of Part II, I will examine the development of ageing policy between 1948 and 2007, to illustrate how different forces are at work in the shaping of ageing policy in Hong Kong.

103 Part II The Development of Ageing Policy in Hong Kong: A Historical Review 1948-2007

Introduction Part II

In this section, Chapters 5, 6, 7 and 8, reviews the development of ageing policy in

Hong Kong with emphasis on residential care. Since aged care homes have always been

regarded as a last resort or refuge when the family system fails, due attention will be

given to the family in the discussion. An examination of the historical accounts reveals

the trajectories of welfare provisions, their development and the policy frameworks

which underpinned Hong Kong ageing programmes from the period following the

Second World War until 2007. In Chapter 5, I explore what I call the pre-community

care policy period. In Chapter 6, I examine the community care period and in Chapter 7

and 8, the community and commercial care period is assessed.

Chapter 5

Pre-community Care Policy Period (1948-1972)

Introduction

This phase covers the period 1948 to 1972. I have called it the pre-community care policy period because prior to 1972, there was no formal provision of community services. In 1973 there was a proposal for community support services and the subsequent implementation of an array of formal services supported by the government such as social, multi-purpose and day-care centres for the elderly, canteens, home-help services, counselling and community education (Working Party on the Future Needs of 104 the Elderly, 1973). However, during the 1948-1972 period, aged care was primarily a

personal and family matter. The following discussion is a three-level analysis. Firstly, I

examine the goals and objectives of the government policy paper; secondly, the

implementation of the program and strategies; and thirdly, the operation and evaluation

of the programme.

For the first stage of analysis, I will examine annual reports of the Social Welfare

Department. For the second stage of the analysis, I will examine the 1965 Social

Welfare White Paper, the minutes of the Legislative Council (Hansard) about the debate

of the aforementioned White Paper and Lady Williams’ Report on social welfare

development in 1966. In the third stage, I will examine some NGOs reports and also the joint policy paper by the Hong Kong government and the Hong Kong Council of Social

Services in 1969, the Hong Kong Christian Service report in 1969 and the Hong Kong

Housing Society in 1972. In addition, statistical figures from the annuals reports of

Social Welfare Department regarding the older people as users, problems they are

facing and the kind of provision will also be used in the analysis.

This chapter first outlines some of the relevant background information, such as the

China factor, NGOs, aged homes, group homes and the welfare philosophy, followed by the population structure and the housing issue. Secondly, I have divided this period into two phases: the first one is between 1948 and 1965 and the second is between 1965 and

1972. I will examine the discussion of population ageing mainly from annual reports of the Social Welfare Department, the Hong Kong government’s Annual Reports, a consultant report on social welfare in Hong Kong, the first Social Welfare White Paper from 1965, minutes from the Legislative Council, and some NGO reports. The chapter

105 will conclude with an analysis of the Hong Kong government’s provision from the

standpoint of political, cultural and moral economies, the government of tradition,

virtue, and 'a problem of people': the politics of proper conduct and values, and a

conclusion.

The NGO sector, China factor and Hong Kong British Colonial Government

It should be noted that the role played by the voluntary organisations in Hong Kong is

like NGOs elsewhere; that is, these organisations provide different kinds of social

services both tangible and intangible to different users such as young people, the

mentally ill, people with a disability, older people, families and other disadvantaged

groups. They are voluntary organisations in the sense that members of the management

boards are not employees of the organisations, and work on a voluntary basis. In Hong

Kong the social workers and administrative and support personnel such as clerks and

office assistants in these NGOs are salaried, with monthly payments from subvention

given by the Hong Kong government. ‘Subvention’ is a tenn used in Hong Kong to

describe the amount of money given to NGOs by the government in the form of

subsidies. Unlike NGOs elsewhere, the Hong Kong NGOs are the major providers of direct services with subvention from government. Politically, NGOs in Hong Kong are

'bridges' between the Hong Kong government and the Chinese community (Castells,

Goh & Kwok, 1990: 130) or ‘friends’ and critics of the Hong Kong government (Lui,

Kuan, Chan & Chan, 2005). Some of the traditional NGOs that are still in operation are the Kaifong Welfare Association (local residents of the same neighbourhood), Tung

Wah Group of Hospitals, Po Leung Kuk (children’s and women’s protection agency) and Little Sisters of the Poor Aged Home. Some of the new ones working for older

106 people are, for example, the Hong Kong Society for the Aged, Senior Citizens Home

Safety Association and Hong Kong Alzheimer’s Disease Association.

The 1965 Social Welfare White Paper and the 1969 Position Paper were both significant

in terms of the structure of provision and as a blueprint for the future, laying the

foundation for what is now described as ‘the mixed economy of welfare provision’ in

which the NGOs play an important role in the direct provision of services.

During this period, Hong Kong witnessed two major riots, one in 1966 and another one

in 1967. The 1966 riot was caused by 'a lone student on hunger-strike over a projected

fare increase' (Jones, 1990) of 5 cents by the Star Ferry Company which runs the ferry

service between Hong Kong Island and Kowloon peninsular, a major transport route.

The social and economic causes of the 1967 riot were overcrowding, the struggle to maintain a living, and police corruption (Carroll, 2009). Working conditions at that time were poor, and welfare provision was in an appalling state. From the standpoint of the government, the riot had a close relationship to young people and the family, and the

Commission of Inquiry Report (1967) stated that 'there is evidence of a growing interest in Hong Kong on the part of youth and a tendency to protest at a situation which their parents might tacitly accept' (Commission of Inquiry Report, 1967:129 in Castells, Goh and Kwok, 1990:135). This remark to some extent reflects the mentality of the government in considering the Hong Kong family as part of the governance of Hong

Kong.

In addition to the social and economic factors, the 'eight months long 1967 riots with protracted clashes between police and protestors, total casualties were 51 people dead

107 and 832 injured' (Goodstadt, 2005: 78) also had political aspects. The 1967 riot has

been described as a watershed in the postwar (Cheung, 2009).

What is relevant to this research is that many of the most 'progressive' reforms of

colonial Hong Kong occurred in the wake of the 1967 riot (Smart & Lui, 2009: 147),

such as the 10-year housing scheme, provision of medical and health services and

universal free education for nine years.

After the riot, the new policy under Governor Murray MacLehose, who was governor

from 1971 to 1982, later known as the MacLehose decade, benefited from astute

publicity campaigns. The Governor was conscious of the political uncertainty of the

colony and thought it important to boost public confidence and to secure hegemonic

leadership before China raised questions about Hong Kong’s political status (ibid. 159).

A series of community building exercise was launched at that time.

Aged homes, group homes and the welfare philosophy of government

In the 1948-1972 period Hong Kong society had developed its own organised services

for the elderly. Most were in the form of institutions or group homes and some were offered by charity organisations. Group homes were known as Chai-Tong, which is literally translated as ‘vegetarian hall’, and were residences for single, vegetarian women. These homes were self-funded. A few religious sects ran Chai-Tong, catering for retired amahs, working maids and factory girls. As sect members aged, the

Chai-Tong became homes for the elderly (Topley & Hayes, 1968; Social Welfare

Department, 1983). There were also female domestic servants who never married and wanted to live together after their retirement, but not in the Chai-Tong. They bought their own shelters, either houses in the countryside or apartment buildings on Hong

108 Kong Island or the Kowloon peninsular. These group homes were self-organised and

self-funded. It was estimated in 1977 that between 7000 and 10,000 old people lived in

Chai-Tongs (Elderly Service Green Paper, Social Welfare Department, 1977: 21).

However, in 1983 there were 76 Chai-Tongs and 21 ffiends-living-together elderly

households with a total population of 1703. Of the 1703 residents, 93.5 per cent were 60

years old and over (Hodge, 1980; Social Welfare Department, 1983). Hodge notes that:

vegetarian halls provide for members a substitute family, and with this roles and

statuses that are to be found only within the social complex of patriarchalism and

filial piety. Aged members thereby receive help, fellowship and honour, and, since

they are usually given work within their limitations, even if it is only tending the

altars, they retain their self-respect. In everyday life the members address each other

in kinship terms borrowed from the family (1980: 54).

In the 1948 to 1972 period, local organisation such as Kaifong, neighbourhood-level

welfare association would provide help to individuals or families in distress. Hodge notes that Chai-Tongs:

like the kaifongs and others, will in time be linked more closely with social

welfare services, helped with subventions and staff training, and become parts

of a network of neighbourhood level mutual welfare and community

organizations' (ibid. 55).

In contrast, there was always a group of people, especially males, who had families in

China but wanted to settle in Hong Kong or, who due to their family relationships, they

109 preferred to stay in an aged home or bedspace apartment (Chow, 1983). During this

period, the only formal provisions for the elderly was home provided by religious

groups and NGOs.

According to government reports, the general attitude of the government in this period

towards aged care was based on the assumption that the Chinese family had a strong

support system and that the old were well cared for by their families. This stance also

maintained the view that the government would only render support to those who did

not have any assistance. This position is clearly stated in all the Social Welfare

Department’s Annual Report published during this period, as well as in the first Social

Welfare White Paper in 1965. For example in the 1954-55 Annual Report, it states that

'care for the aged in Hong Kong was in the main well-provided for within the strong

family system of the Chinese' (1954-55: 19). These views have been held consistently

since then, and give tremendous support to the state in its selective involvement in the provision of organised institutional care for the aged. The work of the Secretariat for

Chinese Affairs in family dispute conciliation work (Social Welfare Department,

Consolidated Report 1948-54: 15) was recorded in most of the annual reports of this period. The relationship between the Secretariat and the SWD was close, and the

SWD’s precursor, the Social Welfare Office, was first established in 1947 as a

12 The Secretariat for Chinese Affairs is the medium of communication between the government and the Chinese population of the colony. All communications of a general character from Chinese individuals or from classes or bodies of Chinese are addressed to the secretary for Chinese Affairs and forwarded by him to the Government, which in turn replies through him. The Secretariat is required to advise Government on questions involving Chinese law, customs and opinion; to act as an adviser to Chinese in distress and as and unofficial court of arbitration in Chinese disputes, mostly of a family nature. By statute the Secretariat is given powers for the protection of women and girls and the legal guardianship of girls under the age of twenty-one' (Secretariat for the Chinese Affairs (1951), 49-50 Annual Report: 7) 110 specialised sub-department of the Secretariat, dealing with the protection of women and

girls, suicide cases, the destitute and relief work (ibid. 3).

Population structure and the housing issue

Hong Kong’s early population growth was based on immigrants from China, and young

males tended to migrate more than other groups in the population (Lo, 1992: 30). It is

not surprising to find that the age-sex structure was extremely unbalanced in Hong

Kong’s early days and gradually evened out as the years went by. The sex ratio, which

is normally expressed as the number of males per 1000 females, was 1348 in 1931,

1029 in 1961 and 1033 in 1971. For the general population, in 1931, 70 per cent was

between 15 and 64, and 2 per cent was aged 65 and above. In 1961, those aged between

15 and 64 was 57 per cent, and 3 per cent for the 65 and above group. In 1971, those

aged between 15 and 64 was 69 per cent, and the 65 and above group was 5 per cent. In

1931, 49 per cent of the population was married, while the figures for 1961 and 1971 were at 64.9 per cent and 59 per cent respectively (ibid. 34).

Due to limited space in Hong Kong and ever-increasing migration from China, there was always a shortage of housing. The Hong Kong government has had to deal with the problem of overcrowding, which has been endemic since the founding of the colony.

This is well described in the 1956 Hong Kong Annual Report as 'A problem of people'

(Hong Kong Annual Report, 1956 reprinted in Hodge, 1980). This statement requires some elaboration. It relates to 'the problem of a vast immigrant population' (Hodge,

1980: 38) with no signs of stopping, and 'it proved no solution to the basic human and social problem' (ibid. 48). Also, the report was meant for those who wanted the Hong

111 Kong government to provide decent welfare for its people, because the population was

2.5 million in 1956 and increasing by 70,000 per annum. It was stated that the

'population in Hong Kong has always run ahead of the services available’ (Hong Kong

Annual Report, 1956: 1) and that there was 'a general apathy towards social problems

amongst a population which for the most part might not be expected to think of Hong

Kong as 'home" (SWD Consolidated Report 1948-54: 2). In the context of the concerns

of de-colonialisation and the incongruity between 'the sweatshops of the East' and its

booming economy, 'a problem of people' can be seen as an excuse for the immense

difficulty of carrying out any immediate social reform.

According to another account provided after the Second World War by Bray (2001), a

retired civil servant, Hong Kong was a devastated city with no working utilities or

public transport. The population was thought to be about 600,000 and five years later

was estimated to be about 2.5 million. The great majority was young men and women

aged 25 to 35 and their children. There were very few elderly people. Housing was a

great problem that no government could solve it. So in the usual Hong Kong way, the people themselves solved it (Bray, 2001: 16-17). As noted above, there were older people staying in vegetarian halls. Hodge, based on Yap’s Ageing and mental health

(1960) in Hong Kong, notes that 'most vegetarian halls are organized along particularist lines, drawing their members from the same part of China or sometimes from the same lineage (Hodge, 1980: 54). In other words, people tend to seek help from their own folk of their native town or villages. In Suicide in Hong Kong, Yap (1958) also notes that in the year 1953-54, among 145 male suicides, 16 of them were aged between 60 and 76 and above. Among the female cases, there were 14 out of the 118 cases in the same cohort. In other words, there was already a group of older people in Hong Kong

112 committing suicide during that time, and the 'suicide rates in old age are not compatible

with the somewhat romantic view often expressed that old age in Chinese culture is a

period relatively free from stress' (Yap, 1958: 45).

As the population continued to grow with both natural increase and immigration (legal

and illegal) in the post-war years, squatters proliferated and the population density in

urban areas rose (ibid. 39). On Christmas Day 1953, a fire at Shek Kip Mei got out of

control and in one night left 53,000 people homeless (Castells, Goh & Kwok, 1990;

Bray, 2001; Smart, 2006). In 1954, the government committed to the provision of

housing which involved the resettlement of the squatters and the construction of

low-rent public housing. Between 1955 and 1965, a total of 848,609 units of

accommodation was completed (Castells, Goh & Kwok, 1990: 21). The provision of public housing after the fire is considered a striking contradiction of urban policy

(Castells, Goh & Kwok, 1990: 1; Smart, 2008: 220). Castells, Goh and Kwok note that paradoxically, while social reform and housing provision was 'stabilizing the political scene in Hong Kong, social programmes actually triggered a series of social movements' (1990:140). Similarly, Smart (2008) notes that in the 1950s the Hong Kong colonial government had deep suspicions about the reliability of the indigenous population and concerns about internal security resulted in a dramatic expansion of social welfare programmes. As noted in Chapter 3, Smart argues that the provision of public housing as a massive squatter resettlement programme into a broad-range public housing programme illustrates the complex cultural and geopolitical processes that transformed distrust into a dramatic escalation of elements of social citizenship (2008:

220).

113 The involvement of the government in housing provision constituted a radical departure

from every aspect of its previous policy. The unofficial members of the Executive

Council (the highest decision-making political structure in Hong Kong composed of the

Governor and appointed unofficial and official members) were rigorously opposed to

any building of government housing because of fear of further influxes (Bray, 2001: 17).

The was often caught between pressure exerted on him by the

UK government for toeing the social policy line in the 1940s and 1950s, and appeasing

the legislature which always opposed such a move (Faure, 2003). The 'public housing

project meant direct responsibility using public funds and its own constructional

resources' (Hong Kong Government, 1956: 48-49), implying that the government meant to tackle social reform within its own strengths and limit. The outcome of this policy has the effect of fostering a sense of belonging to the Hong Kong government, hence the cultivation of citizenship (Lam, 2005; Smart, 2008).

The period of study in this chapter is divided into two phases: the first phase covers the period from 1948 to 1965 when the first Social Welfare White Paper was published; and the second covers the period from 1966 to 1972, prior to the publication of the second

Social Welfare White Paper Social welfare in Hong Kong: The Way Ahead (1973) and the report by the Working Party on the Future Needs of the Elderly in 1973.

Pre-community care policy period: phase one (1948-1965)

In this section I will argue that even though it might appear that, according to official records, it is only in recent years that an increasing number of old people need institutional care, in fact, since the end of the Asia Pacific War in 1945, when the

114 British government resumed its colonial sovereignty in Hong Kong, a persistent feature

of institutional aged care was that vacancies were few and waiting lists were long. This

section of the thesis will focus on the reports published by the Social Welfare

Department.

In the first post-war consolidated social welfare report of 1948-1954, it was recorded

that the then North Point Relief Camp 'remained a complicated combination of an

orphanage, a home for the aged, a transient destitute’s reception center, and an asylum

for desperate cases of many other kinds' (SWD, Consolidated Report, 1948-1954: 22).

Explanations in the report as to why older people were there, were that they were too

frail to flee during the Japanese occupation, either alone or with their families, or that

they had no families to return to in the already war-devastated country or, even if they

had families, they were unwilling to return. This is understandable, because only those who were physically or mentally not capable of living on their own or with their

families would want to stay in the relief centre. In subsequent reports, the institutional aged care situation was far from satisfactory. The second annual report published in

1954 states that there were three old people’s homes operated by different religious organisations — Catholic, Buddhist and Tao — and that each of the homes had about

100 residents. Due to demand, a site was allocated to a charity organisation for the construction of an additional home to accommodate 100 old people (Social Welfare

Department Annual Report (SWDAR), 1954: 19). In 1956, the Annual Report states that there were aged people with nobody to support them and there were no vacancies in any of the homes (SWDAR, 1956: 21). The 1957 Annual Report says that the waiting lists for homes for the aged had swelled considerably (SWDAR, 1957: 19). In the following year, the Hong Kong Jockey Club donated $100,000 to the Sin Tin Tao Home

115 to build an extension to house about 150 old people (SWDAR, 1958). By the early

1960s the shortage of homes for the aged was a standard entry in all the SWDARs.

Following are some of the extracts from the annual reports between 1960-1961 and

1963-64. It should be noted that the mention of aged homes links with the family.

The Annual Report of 1960-1961 says that 'two new homes for the aged were being

built, while progress was made in the extension of 3 existing homes'. It goes on to say

that 'As most Chinese families still feel a strong sense of obligation towards the aged,

old folks are encouraged wherever possible to remain with their families' (SWDAR,

1960- 1961: 20).

The 1961-1962 Annual Report begins with: 'One of the most encouraging features in

the field of social welfare was the increasing support for positive and constructive

measures to help people to remain independent self-respecting citizens' (SWDAR,

1961- 1962: 1). It states ' On the whole, the care of the old people in Hong Kong is not

such a large and difficult problem as elsewhere, mainly because of the traditional

concept of the importance of the family and the strong sense among Chinese of respect

for, and obligations towards, the aged' (ibid.: 21-22). It goes on to say 'But there are

always a number of old people without relatives in Hong Kong or with families who

lack the resources to provide for them, and there has never been enough accommodation

for them in the existing homes for the elderly' (ibid.: 22). The report states that as a projection, there were altogether 1750 places by 1964 (ibid.).

116 The 1962-1963 Annual Report also emphasises the importance of the family: It

comments:

Chinese culture has traditionally attached great importance to the care of the aged

members of the family. Consequently, the care of the old people in Hong Kong is

happily not such a large and difficult problem as elsewhere. It is important that the

changes in values and attitudes brought about by industrialization and urbanization

should not have the effect of weakening the strong sense of respect for, and

obligations towards, the aged felt generally by the Chinese people' (SWDAR,

1962-1963: 22).

It also says:

There has never been enough room in the existing homes for the aged to

accommodate all who need care. The Sin Tin Tao Home for the Aged was

expanded and the St. Mary Home at Aberdeen was opened by the Little Sisters of

the Poor during the year, providing a welcome increase in accommodation of over

500 (SWDAR, 1962-63:22).

In the 1963-64 Annual Report, it continues:

with the increased expectancy of life, quite apart from other considerations, the

number of old people who are without relatives in Hong Kong, or have families

which lack the resources to provide for them, is certain to increase, and there has

117 never been enough room in the existing homes for the aged to accommodate all

who need care (ibid.: 21).

It also says that there were 9 homes with 611 places and the size of homes ranged from

100, to 400 and 450. However, at the beginning of the report it states that:

it will demonstrate the falsity of two frequently expressed opinions — the overseas

opinion that Hong Kong is only interested in its industrial success and not solving

its social problems; and the local opinion that social workers spend their time in

talking or writing theory, or indulging in jargon or comment about what social

work is instead of getting down to a productive job of work — highly productive in

terms of human values (SWDAR, 1963-1964: 3).

It may seem unusual to come across such a remark, but the tension between the problems caused by industrialisation and urbanisation and the inadequate supply of welfare provisions can be strongly felt and, it countered the local view that the work carried out by social workers was not productive.

In the same report it repeats that ' Chinese culture has traditionally attached great importance to the care of the aged members of the family. Consequently, the care of the old people in Hong Kong ought not to be such a large and difficult problem as it is elsewhere' (ibid. 21).

118 In the 1964-1965 annual departmental report, it says:

Chinese tradition has through the centuries attracted great importance to the care of

the aged members of the family. Consequently, the care of old people in Hong

Kong ought not to be such a large and difficult problem as it is elsewhere

(SWDAR, 1964-65: 24).

It continues that 'it is important that changes in values and attitudes brought about by

industrialization and urbanization should not encourage any weakening in this strong

sense of respect for, and obligation towards, the aged' (ibid.).

The repeated emphasis on the importance of the family as a primary care of the elderly

is noteworthy. It was used to justify low priority given to aged care. This may also be

because the Hong Kong government was preoccupied with a whole series of problems

during the early days of post-war reconstruction. Means and Smith (1985) in the study

Evacuation and elderly people in the Second World War provide a useful comparison in

the UK. They argue that little attempt was made to directly help those older people most

'at risk' and, rather, attention was focused on those who might have the capacity to disrupt civilian morale through complaints. The aged, the infirm and the bedridden were evacuated from the shelters and therefore separated from their families and familiar environment. At that time, 4000 old people were transferred from London.

They argue that the slow overall growth of services at that time could only be understood in relation to the usefulness of frail old people as participants in either economic production or in the reproduction of a new labour force. They add that the

119 deeply held views about family responsibility and the ‘natural’ caring role of women

shaped provisions for the elderly (Means & Smith, 1985: 86, 1998: 148; Means,

Richards & Smith, 2008:14). In their search for a more comprehensive explanation for

neglect of services for the 'Cinderella' group of elderly people, Means, Richards and

Smith say there is no single answer and a number of strands can be identified (2008: 40).

First, there is the political economy approach of the capitalist mode of production;

second, questions relating to the complex role between institutional and social control;

third, the central concern of government to encourage informal care and the knock-on

consequences of the neglect of community-based services; and fourth, the cultural

stereotype about ageing and disability. These four explanations echo the reality of Hong

Kong’s situation and especially so with the cultural stereotype factor, which tolerates

the neglect of services.

Taken as a whole, the pre-community care policy first phase laid the framework for the pattern of provision under which the state allocated the land, the Hong Kong Jockey

Club provided some financial support and the voluntary sector managed the day-to-day operation of the home. This model of provision reflects the Hong Kong government’s minimal involvement in the direct provision of services.

Immediately after the Second World War, the Hong Kong economy grew strongly. In less than a decade, it began to make its name in the world market as a small but dynamic exporter of manufactured goods, principally in textiles and clothing. Thus, during the 1950s Hong Kong had already established itself as a manufacturing centre of some importance (Youngson, 1982: 5). It was described in the Economist as 'a show window of capitalism in the East' (ibid. 7). Between 1950 and 1955, almost half a

120 million people entered Hong Kong from China, and in 1961 the population reached 3.1

million (of which 3 per cent were 65 and over), an increase of 1.1 million or over 50 per

cent in 11 years. Part of this was a result of the post-war baby boom, while most of the

increase was the influx of returnees or refugees from China. Some of the migrants

brought capital and expertise with them, and some of the most successful examples

were the Shanghaiese entrepreneurs who owned cotton mills (Wong, 1988).

The spectacular economic growth was not, however, without cost (Scott, 1989: 72).

Chow Sui-man argues that there was little redistribution of income between 1957 and

1966 (ibid, footnote 136). The workers’ standard of living did not materially improve,

and conditions in many factories were reminiscent of Dickensian England (ibid. 73).

Scott points out that on social welfare issues, the government did almost nothing before

1960, preferring to leave social welfare in the hands of voluntary agencies. The

provision of social services, other than housing, was very limited and improvements in

social policy and labour legislation were minimal or largely cosmetic (ibid.). Scott describes the lack of social provision as a social debt, which has expanded enormously through years of inaction (ibid.). The persistent shortage of home places for the aged is an example.

The government was aware of the impact of rapid industrialisation upon Hong Kong society. As noted above, the 1963-1964 SWDAR states that 'it will demonstrate the falsity of the overseas opinion that Hong Kong is only interested in its industrial success and not in solving its social problems'. In the following year, a draft of the first Social

Welfare White Paper (SWWP) was prepared. This is discussed below.

121 Pre-community care policy period: phase two (1965-1972)

The second phase of the pre-community care policy period began in 1965 when the first

SWWP was published. For the first time, the Hong Kong govemmenfs welfare

philosophy was made known to the public. In relation to the provision of welfare in

general, the paper says that organised social welfare services should be arranged in such

a way so as not to accelerate the breakdown of the natural, or traditional sense of

responsibility such as by encouraging the natural family unit to pass on to social welfare

agencies — public or private — its moral responsibility to care for the aged or infirm

(SWWP, 1965: 5).

The 1965 SWWP contains what today would be labelled ‘neo-liberal thinking’ such as

the limited role of the government in service provision, the involvement of the market in

service provision, and the self-help ethos of the individual and family. In this White

Paper there is a separate section on voluntary agencies and private agencies', which may be referring to the private-commercial sector. This aspect of private or commercial

agencies (SWDAR, 1982) also comes up in the next phase, which will be examined in

Chapter 7. Its relevance here is to show that the commercial side of the Hong Kong model of aged residential care provision had long been considered, just as it had occurred in the fields of education, housing and medical and health care (Scott, 1989,

2010; Goodstadt, 2009; Smart, 2006;; Vickers, 2005).

In his examination of government funding of voluntary social services, Jones (1978) notes the subtle differences in the way that the voluntary sector has been described. The implication is that from the very beginning in 1965, it appears that incorporating different providers in the provision of services — other than the state and the non-profit

122 making voluntary agencies — was considered. In other words, the market would also

take part in the provision of services.

The implementation of the 1965 White Paper was supported by the 1969 Position Paper

where the government also states that it had no plans to enter into the field of operating

homes for old people (Social Welfare Department & Hong Kong Council of Social

Services, SWD & HKCSS, 1969).

The first Social Welfare White Paper in 1965

The 1965 White Paper highlighted the fact that Hong Kong should continue to make provision for minimum public assistance (SWWP, 1965: 4, 8) with careful

consideration of the potential effects on the economy (ibid. 7) and to help those who were dependent on others to acquire or recover their ability to be independent and to contribute to their own support (ibid. 9). The paper spelt out difficulties facing Hong

Kong, such as the high density of population, it being the end of the road for most inhabitants, the lack of natural resources and limited space. It is the end of the road for most of the residents because of their inability — either legally or financially or both — to leave Hong Kong. In response to the limitations facing Hong Kong in the development of social welfare services, the paper explicitly talks about the usefulness of the family. It states:

It is of the greatest possible importance that social welfare services should

not be organized in such a way as to make it easier for socially disruptive

influences to gain over the community, or to accelerate the breakdown of

the natural or traditional sense of responsibility — for example by

123 encouraging the natural family unit to shed on to social welfare agencies,

public or private, its moral responsibilities to care for the aged or infirm

(ibid. 5).

Also in relation to the family, it states that:

Chinese social traditions and values maintain a strong hold, even in urban

Hong Kong, and are likely to persist, especially those which were originally

based on a sound practical knowledge of Chinese family and social needs

(ibid. 6).

The paper also painstakingly continues to express the positive aspect of the Chinese family in relation to Chinese traditions and values and says that ‘Chinese social traditions and values maintain a stronghold, even in urban Hong Kong, and are likely to persist’ (ibid. 6). In explaining the role of the government in relation to the family system it says that it will:

... help families to remain intact as strong natural units and to care (and not

to abandon) their children and handicapped or aged members. The

individual should be seen as a member of a family unit, for which there is

no real substitute in the development of children as citizens. The constant

endeavour should be to rely to the maximum extent on the natural family

unit, to strengthen and help the family to cope with its members rather than

removing them to institutional care; and to induce families to assume extra

responsibility by the adoption or 'boarding out' of orphans' (ibid. 10).

124 The paper also expresses the view of the government in relation to local organisations,

saying:

Hong Kong is fortunate in always having a large number of Chinese

organisations which generously contribute in work and money to many

forms of social services, particularly in the fields of education and medicine,

as well as in other traditionally Chinese approaches to social welfare.

Insofar as these groups may be enlisted further in the total social welfare

effort, they constitute a very important asset (ibid.).

Towards the end of the paper it concludes with a cautious note that provision of welfare

services depends on the fact that ‘the economy continues at its present rate of growth’

(ibid. 14). It further explains that Hong Kong has virtually no natural resources and ‘at the moment Hong Kong has reserves equivalent to six months gross expenditure’ and

‘its commitments could increase enormously at a time of recession’ (ibid.) In other words, it implies that social welfare provision could be a financial burden and an extra cost to bear if there was a slow down in economic growth.

During the debate on the White Paper in the Legislative Council, a few members expressed doubts concerning the official view of welfare. One member mentioned, in mocking terms, that it would be unkind to change the title of this paper to 'The Aims and Policy of the Financial Secretary on Social Welfare in Hong Kong' (Minutes of the

Legislative Council, Hong Kong Hansard, 12.5.1965: 302). With regard to how intact the Hong Kong family was as a viable caring unit, there was suspicion that the

125 government was simply 'passing the buck' (ibid.), meaning that the government was evading its responsibility. There were also disagreements concerning the control imposed on the voluntary sector and therefore a revised version was produced which recognised the contribution of the voluntary agencies.

In 1966, a year after the publication of the White Paper and on the eve of the 1967 riot,

Lady Gertrude Williams, a social work educator from England, was invited to Hong

Kong to examine the feasibility of welfare provisions. She expressed concern about the

Hong Kong living and working environment as well as the social support stmcture.

Taking into consideration the prevailing attitudes towards the family as the most appropriate source of support and the part played by organised welfare, Williams pointed out that social provision and family responsibility may not be mutually exclusive (1966: 13). She also remarked that 'old age plays a comparatively minor part as a cause of need for help, but is likely to become increasingly important in the near future' (ibid. 21, 22).

The Annual Report of the SWD issued later in the same year did not directly mention this, but says:

... old people who are without relatives in Hong Kong, or whose families

lack the resources to provide for them, are certain to increase and the

welfare of the aged folk is likely to become a community responsibility

(SWDAR, 1966-67:40).

126 It continues:

... there has never been enough room in the existing homes for the aged to

accommodate all who need care ... the care of old people in Hong Kong

ought not on the face of things to become such a problem as it is elsewhere

(SWDAR, 1966-67: 39-40).

Some remarks in Lady Gerutude Williams’s report were expressed in the 1969 Position

Paper, ‘An Appreciation of the Social Welfare Needs of Hong Kong’ (SWD & HKCSS,

1969: 39-40). It summarises the uncertainty of working out the two different views. On

the one hand, some families were no longer able to take care of their elderly, compelling

them to rely instead on community resources. And, contrary to what was said in the

SWDAR published in 1966-67, the problems facing the old or ageing in Hong Kong were likely to be aggravated by the absence of social security benefits which included the assurance of adequate income for the necessities of life (SWD & HKCSS, 1969: 92).

It also says that 'some old people who were waiting for admission into a home had difficulties in shopping or obtaining rations from welfare centres' (ibid. 99).

In terms of institutional care, it states that the government had no plans for entering into the operation of aged care homes (ibid. 97). Subject to any major new departures that might follow the acceptance of some form of a social security scheme, the role of the government was to encourage agencies and associations who were interested in and able to operate homes for the old through land grants, capital grants from the Lotteries Fund, financial assistance of a recurrent nature, reimbursement of rates and training facilities for staff (ibid.). The report states that at some later date (not until 1994), legislation

127 should be enacted to regulate and register aged care homes, with special attention to the

standard of operation (ibid. 99).

As a point of reference, it was not until 1994, after a period of 25 years, that the

Residential Care Homes (Elderly) Ordinance was enacted. It came into force on 1 June

1996 but was given a period of grace of three years for operators to improve the

standard of provision. In the meantime, licences were granted to the qualifying homes

and Certificates of Exemption were issued to those that wanted to improve.

There is no description of the conditions of older people, traditional values, family

support and social change in the 1968-1969 report. Instead, there are statistics showing the number of elderly receiving family services, referrals for home admission, public

assistance and the names of aged homes on subvention. The change in the description or discursive practice of aged care from text to statistics will be examined next.

The statistical figures about aged home, family service and public assistance

There were brief descriptions concerning aged problems, and no statistical reports, from the period 1948-54 to 1957-58. Starting from 1958-1959, there are statistical reports on the number of elderly people requiring residential care. By 1961-62, the figures indicate the number of old people in residential care, the maximum capacity and the number of homes. By 1967-68, there is a separate table concerning the nature of family services which included family problems on the basis of elderly parents, and the number of referrals to elderly institutions. There is no record of residential care between

1969-1970 and 1972-1973. In 1971 the Public Assistance Scheme started the Old Age

Allowance, and in 1972-73, there was a drop in the number of applicants for old aged

128 homes from 652 to 305 (SWDAR, 1972-73). This shows that the lack of financial

means caused some older people to enter residential care. The relationships that can be

shown from the statistical tables published in the annual reports of the SWD regarding

aged home admission, family services and public assistance scheme is compiled in

Table 1. The years of operation represented in Table 1 are between 1948 and 1977. The

reason for stretching beyond this phase of the pre-community care policy period from

1973 to 1977 is to have a slightly longer view of the aforesaid relationships. On 1 April

1972, the monthly scale of assistance was raised from HK$70 to HKS110 for a single person, for members of a family, from HK$50 to HK$80 for each of the first three members, from HK$40 to HK$65 for each of the next three and from HK$30 to HK$50 for each additional member. There were rent allowance and long- term supplements

(ibid. 21). In 1972-73 52.1 per cent of public assistance application is older people.

129 Table 2 The relationships of aged home, family service and public assistance Year 1948-1954* (no statistical report, only written report) 1954-1955 1955-1956 1956-1957 1957-1958 Number Cap. Homes 1958-1959 955 1959-1960 994 1960-1961 1001 991 7 1961-1962 1093 1412 7 1962-1963 1340 1581 7 1963-1964 1505 1611 9 1964-1965 1649 2007 9 1965-1966 No record Family Services 1966-1967 1936 2236 11 Old Aged age(1) home(2) 1967-1968 1958 2266 12 4960 218 1968-1969 2002 2285 13 2174 442 1969-1970 No record 1238 420 1970-1971 u 1001 539 Public Assistance Scheme 1971-1972 ll 2825 21 1005 652 (Older Total applicants) applicant 1972-1973 a 3000 21 1369 305 52.15% 13509 1973-1974 2650 3000 24 1248 572 52.99% 19283 1974-1975 3000<3) 26 1011 611 51.97% 27407 1975-1976 3000(3) 27 1093 542 54.70% 29608 1976-1977 3000(3) 29 1573 1105 61.34% 36883<4) Key: * : Consolidated report a) Casework counseling cases Number : numbers in care (2) Aged home referral figures Cap. : maximum capacity (3) Moratorium on building aged home Homes : number of aged homes: (4) Estimation

Source: Social Welfare Department Annual Report, from 1948-54 to 1976-1977 130 During this period, nearly 60 per cent of welfare work was carried out by the voluntary

sector and as late as 1966-67, of every dollar spent by voluntary welfare agencies,

nearly half came from overseas (International Conference of Social Welfare Paper,

HKCSS, 1972). As Hong Kong society became prosperous, voluntary agencies received

less and less overseas funding. Local organisations such as the Kaifong Welfare

Association and also local neighbourhood organisations gradually played a diminishing

role. However, longstanding charities such as the Tung Wah Group of Hospitals still

play a key role in Hong Kong, a point to which I will return.

In reality, throughout this period, a major area of work of the family service unit of the

SWD was counselling and home referrals for the elderly (SWDAR, 1987). In 1971, with the introduction of the Public Assistance Scheme, applicants for homes dropped to half as the cash allowance enabled many to continue to live where they were (SWDAR,

1971). However, with the implementation of public assistance, the situation became more complicated as to whether or not applicants for the aged homes applied out of a residential need rather than for financial reasons. Thomson (1983, 1991) notes a similar trend in the UK, that when financial assistance was rendered to the needy, the rate of home admissions dropped simultaneously. By the late 1960s and before 1972, some of the demand for home places was met through the Housing Authority and Housing

Society instead of the SWD. This opened a new chapter in residential services for the old. In 1969, the first elderly hostel with a capacity of 120 places was set up in a public housing estate as a joint venture by a group of eight voluntary organisations with support from the Housing Authority, the SWD and the Medical and Health Department

(Hong Kong Christian Services News, 1986). By 1971, the Housing Society also started to provide flats for old people on an experimental basis. It converted 10 small rooms to

131 house those living alone in the Society’s flats when younger members moved out. In

other words, families with one or two elderly people living in a flat were moved to these

small units (Hong Kong Housing Society (HKHS), 1972). Considering the housing

demand in Hong Kong, the exercise was to make use of available flats and therefore, as

an indirect outcome, they were converted to flats for the elderly.

The perception of ageing provision: a summary of the interpretation of political,

cultural and moral economies of ageing

In Chapter 2 I mentioned that there is 'a strict fiscal policy in place so that even if

money is available, it would not be spent' and 'the Hong Kong government is careful

about not overspending, so as to maintain a low tax rate and ensure a surplus'. This kind

of financial management is typical of the outcome of a political economy perspective of

which the political institution determines the performance of the economic policy.

In this period, at the level of the political economy perspective, for example, remarks

from the 1963-64 Annual Report, minutes of the Legislative Council Meeting and the

1965 Social Welfare White Paper support this view. The Hong Kong government does not perceive or admit that ageing is a problem and portrays it as a familial responsibility

and housing need. The government stresses the supposed connection between organised welfare provision and the breakdown of the community and family system (Social

Welfare White Paper, 1965: 5). This is a typical example of the use of a cultural and moral cause to justify not providing welfare. However, comparatively speaking, the pressure to speed up social welfare development in the field of housing and education comes from the metropolitan London and overseas commentators rather than from the

Hong Kong government.

132 Quite early on there is already a gender or a familial division of residential care in

Hong Kong. Single older men who are relatively independent may enter NGOs homes

and for the single older woman they may enter vegetarian halls. Female halls are more

common than male because of the vulnerability of women in traditional Chinese society.

There is also a group of domestic servants who are unmarried and have worked as

domestic servants throughout their life. When they reach old age they share a flat with

other sisters or enter the vegetarian halls. These institutions are not only good examples

from the perspective of cultural economy of ageing they are also a good illustration of

the moral economy of ageing of which reciprocity is their normative basis. Cultural and

moral economies of ageing are primarily about collective conscience and they are

traditionally deeply embedded.

In the annual reports published in this period, there are several standard citations and they are the claim of the availability of the tradition of self-reliance, familial care and traditional organizations which are good social supportive network.

The government of tradition, virtue and ‘a problem of people’: the politics of proper conduct and values

As we can see value occupies an important place in the government documents and the policy debates. The kinds of values are mostly about tradition and ritual of everyday life and they are difficult to dispute. Around 1965 during the pre-community care policy period, when the idea of development and human betterment ran high in the Western world, there was a general tendency for people in Hong Kong to urge the government to devise a plan to tackle massive poverty and injustice. Hong Kong at that time was

133 known as the 'factory of the East', as I have mentioned previously. The discrepancy

between the pace of economic development and the development of social welfare was

especially so in the 1960s. However, to recap, the Hong Kong case may be different in

two aspects. First, there was 'a large number of people using Hong Kong as a domicile

of convenience but whose loyalty and emotional investment lay elsewhere' (Hodge,

1973: 207). Second, in social affairs, the Chinese preferred to evolve their own

associations and were not particularly interested in government social welfare policies

(ibid.). In other words, even though they were living in extreme poverty, the local

inhabitants would try to tolerate their poor living conditions. There was also the

argument that better welfare in Hong Kong would attract more people, as I have

mentioned in Chapter 3.

This did not mean that the Hong Kong government was free from its duty to improve

living conditions. In fact, Hong Kong had been under the watchful eye of Western media, as well as groups such as the Fabian Society of England, which had members working in Hong Kong (England, 1976). Also, support for more welfare provision came from 'overseas experts' such as Lady Williams’s report (1966) The Feasibility of Social

Welfare Provision and Allied Topics. Lady Williams’ report was published a year after the first Social Welfare White Paper (1965). According to the government’s annual reports, old people’s homes were bursting with residents and waiting lists were long.

Hence, the government had the difficult task of working out how to dismiss the argument of not taking care of the poor and needy. In order to counter this attitude and not to get involved in any immediate and direct service provision, the government’s intention is best illustrated by its argument that the elderly problem ' should not be viewed as a problem as elsewhere' (SWDAR, 1963-64: 21, 1964-65: 24). This shifting

134 of attention away from the international scene, which justifies its 'inaction', is validated

by the claim that Hong Kong is a unique society. The difference between Hong Kong

and elsewhere (the West) justified legitimisation that said the problems of Hong Kong

were different and less significant than other places. It should be noted that the Hong

Kong government was not addressing ordinary people in the streets. The argument of

the politics of the difference aimed at colleagues within the policymaking circle or

overseas commentators. This was not the first time that the Hong Kong government

accounted for its 'inaction' (Scott, 1989) regarding the planning and provisions of social

welfare in general, and older people in particular. The argument of Williams’s report on

ageing implied the demographic alarmist perspective, and the government’s argument

of the politics of the difference is just the opposite, downplaying the importance of the remark in the report.

Another explanation arises from reading the 1965 White Paper as noted above, and that is the argument of the virtue of tradition and the family system in Hong Kong.

Pennycook notes that 'colonial government used to construct the native Other as backward, dirty, primitive, depraved, childlike, feminine, and so forth' while 'the colonizers, their language, culture and political structures [were seen] as advanced, superior, modem, civilized, masculine, mature and so on '(1998: 129).

In this particular instance, instead of arguing for a 'civilizing process' as Pennycook implies, the Hong Kong government emphasizing on the value and the availability of self-sufficient person and self-supporting family, with the implication that Hong Kong people can solve their own problems without the government. On the contrary, far from the argument of a society of virtuous people, there is also the view of 'a problem of

135 people' (Hong Kong Annual Report, 1956), arguing that the problems can not be solved

overnight when facing a huge population like Hong Kong. Here, behind all these

competing claims, is the justification of control of the population.

The argument of 'virtuous people' legitimates its non-involvement in the welfare sphere

and it is a practice of cultural governance, to govern according to an assumed norm.

There is a process of the production of cultural citizenship.

Conclusion

The shortage of homes for older people has been a feature of Hong Kong society ever

since the end of World War II. The general attitude of the government towards aged

care was based on the claim of family responsibility found among the Hong Kong

Chinese. During this period the pattern of provision was pluralistic. The government

allocated land and financial subvention. The Hong Kong Jockey Club, a government

approved gambling establishment, generated funds or profit from betting, and gave part

of theii proceeds to charitable causes. These funds provided some financial support, and

there were also private and individual donations gathered by voluntary organisations.

The residential care needs of the elderly were also expressed as a housing need, so the

Housing Department and the Housing Society, as well as the Social Welfare

Department, also participated and provided a small number of homes specifically for older people. The other key obstacle was the budgetary constraints, as I have mentioned in Chapter 2 and above.

136 Overall, the Hong Kong government has been very reluctant in its direct involvement, maintaining its minimal role and relying on the NGO sector and the family. The government has been very keen to promote the self-sufficient individual and self-supporting families. In terms of ageing policy, it is the 'confirmation' of a cultural economy of ageing.

137 Chapter 6 Ageing Policy and Community Care Policy Period: 1973-1986

Introduction

This chapter covers the period from 1973, when the Report of the Working Party for the

Future Needs of the Elderly (WPFNE) was published, to 1986 and the publication of the

Code of Practice for Private Homes for the Elderly. In this period, the second and third

Social Welfare White Papers were published in 1973 and 1979 entitled Social welfare in

Hong Kong: the way ahead and Social Welfare into the 1980s respectively. I divide this community care policy period into two phases and Phase One (1973-1979) is about adapting UK models of community care in Hong Kong while Phase Two (1980-1986) is about interpretation and implementation of these models.

In this chapter, firstly I will provide a concise introduction to the social, political and demographic background of the period, and an introduction to the background of social welfare, the community care policy and the providers. In this 3-stages analysis, in the first stage I will analyze the second and third Social Welfare White Paper (1973 & 1979) and the Report of the Working Party for the Future Needs of the Elderly (WPFNE,

1973). In the second stage, I will examine the debates among service planners as illustrated in the 1974 review report of the 5-year Plan for Social Welfare Development,

1973-1978 - Review. I will also analyse four policy events with the aim of illustrating the interpretation of community care during the implementation of the policy. At the end of the second stage, I will examine the condition of residential care, private home surveys and its related issues. In the third stage, I will examine the different levels of the development of the Hong Kong ageing policy through the use of the explanation of the

138 political, cultural and moral economies of ageing. Finally, I will arrive at conclusions

about this period of community care.

Social, political and demographic background of the period

During this period, Hong Kong entered a new phase of social welfare development.

With the appointment of Murray MacLehose as governor in 1972, the scope and

quantity of provision widened substantially, the new financial subvention system for the

NGOs was formed, and there were attempts to emphasise the ideas of a caring

community, for example in the field of community development projects and aged

services, and social integration with rehabilitation services. The emphasis on a caring

community was largely to avoid political uncertainty resulting from riots and social

disturbance in the late 1960s. Intentionally or unintentionally it would also serve the

purpose of promoting caring among the people. In the context of Hong Kong, the

meaning of a caring society echoes the Confucian ethics of care. From then on, Hong

Kong society gradually opened up to modem thinking about provision, mainly as a

result of the colonial relationship with the UK.

Apart from a few intervals of economic uncertainty, such as the global oil crisis in 1973

and the signing of the Sino-British Joint Declaration regarding the future of Hong Kong in 1984, Hong Kong’s economy continued to grow at a rate of around 5 per cent per annum. The unemployment rate was around 2 per cent for most of the period. By 1977,

Hong Kong had already transformed itself into a financial centre, and in the late 1970s and early 1980s a sizeable middle class had emerged. The establishment of the

Independent Commission Against Corruption (ICAC) in 1973 also gave Hong Kong’s colonial administration a new image, as well as further legitimisation. In 1985, the first

139 members of Hong Kong’s Legislative Council were elected. There is not universal suffrage and Hong Kong remains a semi-democratic society (Sing, 2009). In 1971, 1976,

1981 and 1986 the percentage of the population aged 60 and over were 7.4, 9.0, 10.2 and 11.5 respectively (Report of the Central Committee on Services for the Elderly,

Social Welfare Department, 1988: 11). The increase in the 60 and over cohort from 1971 to 1986 is shown in the following table:

Table 3 The distribution of the 60 and over population between 1971 and 1986.

1971 % 1976 % 1981 % 1986 % Total 3,936,630 100 4,402,990 100 4,986,560 100 5,935,997 100 population Population 293,273 7.4 398,180 9.0 507,018 10.2 618,156 11.5 aged 60 + Median 21.7 23.9 26.0 28.6 age Source: Report of the Central Committee on Services for the Elderly, 1988: 12.

However, the 75 and over age group has shown consistent increases and is shown in the following table:

140 Table 4 The distribution and the increase of 60-64, 65-69, 70-74 and 75 + age cohort.

Age Group 1971 1976 1981 1986 60-64 40 39 36 34 65-69 25 25 27 26 70-74 18 17 18 19 75+ 17 19 19 21 Total 100 100 100 100

Source: Report of the Central Committee on Services for the Elderly, 1988: 12.

The increasing proportion of people aged 75 and over suggests that there was an

increased demand for residential care.

Social welfare, the community care policy and its providers 1973 - 1986

For the first time, with the full implementation of the Public Assistance Scheme in 1973,

the government found itself with responsibility for the financial support of old people

who were no longer in the workforce. For a government like Hong Kong, which

stressed its enabling role rather than that of a direct provider, this really was a new

chapter in the history of welfare provision (Jones, 1981: xiv). Community care for the

aged was the guiding objective throughout this phase. As I discussed in the last chapter,

in 1973 the basic rate for an individual applicant began at HKS110 a month and there

was a sliding scale of assistance for families, HK$80 for the first three members,

HK$65 for the next three and HK$50 for any additional members. The assistance level

for a family of five (the average size) would have been between HK$400-HK$500 a month, compared with median family income of HK$672 a month, and the mean family income of HK$919 a month, according to the 1971 Census (Heppell, 1973: 229).

141 According to Heppell (ibid.), the architect of the scheme, it was quite a generous

scheme at that time.13 The scheme had a family means test and everyone in the

household was counted, with the exception of married sons with their own families (ibid.

228). In addition to the income maintenance basis, the scheme also had special needs

allowances, the 'vulnerable group approach' (ibid.) targeting the severely disabled and

the elderly infirm in the form of Disability and Infirmity Allowance. All older people

(those 75, and subsequently those 70 years of age) were presumed infirm, and there was

to be no means test, and the allowance was set at half the standard assistance rate (Jones,

1990: 219, 261 n.34). In 1979, the Old Age Allowance was introduced for those aged 70

and over, and the Old Age Supplement for those between 60 and 70. Neither group was

allowed to receive the Disability Allowance. The third category of assistance included

the Traffic Accident Scheme and the Criminal Law Enforcement Accident

Compensation Scheme.

Different kinds of community support services were being planned and scheduled for

implementation. The community support services included mainly multi-purpose

centres for the elderly, social centres and day care centres. Multi-purpose centres provided meals, laundry and bathing facilities, home help services, social groups and outdoor activities. Social centres mainly focus on social work groups and group activities and outings. Day care centres provided a range of personal care, rehabilitation and recreational services on a non-residential basis. However, while the government stressed the importance of community support services, at the same time it reduced the

13 Heppell is from the UK government and he is responsible for the development of the social security system in Hong Kong. Whether the Scheme is generous is a matter of debate. In order to discourage applications and in order not to create a dependency culture in Hong Kong the level of assistance remained at subsistence levels. 142 amount of subvention for community care support services for the elderly in the form of

social centres and multi-purpose centres.

During this period, numerous policy papers were produced. There were two SWWPs:

Social welfare in Hong Kong: the way ahead published in 1973 and Social welfare into

the 1980s published in 1979. There were Green Papers for aged services and social

security entitled Services for the elderly and Help for those least able to help themselves, both published in 1977. There was also the first Five-Year Plan (1974), which was a joint planning and review exercise between the government and NGO sectors.

The publication of the 1973 SWWP was recognised as a clear sign that social welfare had come of age in Hong Kong, reflecting the fact that the government accepted ultimate responsibility for the provision of satisfactory social welfare services (SWWP,

1973: 3) because of decreased overseas support for the voluntary agencies and NGOs

(Jones, 1981: xiv). At least, this was the view of the voluntary sector. In the intervening years, the government’s keenness to balance its budget and its general attitude towards welfare spending meant that the relationship between the government and voluntary sectors was not always good. Sometimes it was fair and sometimes there was a mixture of loyalty and frustration, depending on the background of the particular NGO.

Following is an observation about this relationship:

in the eyes of the powerholders, civic organizations are both friends and

enemies. They can be effective agents between the state and the market in

meeting the emerging needs of the local populations; however, in

articulating those interests and opinions, civic organizations, particularly

those excluded from power sharing, quite often become vocal critics of the

143 government. They are therefore agents both of cooperation and opposition

(Lui, Kuan, Chan & Chan, 2005: 59).

In the conclusion of the last chapter (Chapter 5), I note that the pattern of provision is

pluralistic. In this phase, in addition to the NGOs, the private-commercial sector also

participated in the provision of services. It grew over time with market demand and as a

result of growing legitimisation accorded to it by the state. By 1986, judging from the

policy papers regarding elderly services and welfare provision in general, it is clear that

there were considerations regarding the role of a private-commercial welfare sector and

the desire to put forward a fee-charging policy (SWWP, 1973 & 1977). This policy was

mentioned in the 1973 Working Party Report and was supported in the 1974 Five-Year

Plan Review, the 1977 Social Security Green Paper (SSGP) and the 1979 SWWP. It

finally surfaced in the fourth SWWP, Social welfare in the 1990s and beyond. There,

the government introduced the idea of NGOs and regarded the private-commercial

sector as on a par with the voluntary agencies. In fact, the role of the

private-commercial sector was noted in the first SWWP (1965), and it has also been a

feature of provisions in the field of education and, medical and health care. The

commercial residential sector for older people is a late-comer among service providers.

Following is a brief introduction to the two SWWPs published during this period.

Social Welfare White Paper 1973

The second SWWP (1973) is called Social welfare in Hong Kong: the way ahead, it contained little discussion of tradition, family or self-reliance. The paper consists of about 100 paragraphs and only two are about the individual and families (SWWP, 1973:

7). These two paragraphs are in Chapter 3 under the title ‘community development’ 144 (ibid). This arrangement reflects the social or political atmosphere of the time, because

the government wanted to introduce a new era after the eight months of riot in 1967 and

the feelings of uncertainty. At that time, the use of the word ‘community’ was quite

common in government documents: community hall, community centre, community

development projects and, in services for the elderly, care in the community was the

most common. In fact, the word ‘community’ is not a familiar one in Hong Kong, but

there was a modem sense of Western kind of social welfare, and it was a new face that people wanted to see. In the White Paper, it states that:

it would be a matter for great concern if, because the provision of social

welfare services has improved in Hong Kong, there was a corresponding

feeling that such matters could be left to the government and voluntary

agencies to settle. Individual, family and community concern for those

needing help is of no less importance than previously, indeed perhaps of

more importance, as needs and expectations develop in response to the

changing pattem of Hong Kong’s economy and society (1973: 7, para.

3.11).

The paper continues:

such concern should be expressed not simply in helping one’s own family or

immediate community, but in accepting responsibility for the wellbeing of

the community as a whole. The community, therefore, should help to ensure

that adequate services are available where they are needed, and that once

available they are used to their fullest extent (ibid. para. 3.12)

145 The White Paper notes that it focuses mainly on the NGOs and their contribution to

Hong Kong’s community. It expresses the government’s commitment to social welfare

development and continues to stress that the importance of the family has not lessened.

In this White Paper, the role of the private organisation was not mentioned, as can be

found in the 1965 White Paper. One explanation is that the government is more willing

to assume more responsibility on its own than to rely on the private commercial sector.

Social Welfare White Paper 1979

The third White Paper (1979) is called Social welfare into the 1980s. Compared with

the other three SWWPs, this is a 'technical' one with a focus on how to deliver services.

It discusses the social security system, means-testing, fee-charging and private services.

It states that:

an elderly person who receives both public assistance and an old age

allowance, but who pays nothing or very little towards their care and

maintenance in an aged care home, would obviously be better off than one

who is to be looked after by their family. This would be unjust and would

conflict with the government’s objective of promoting care of the elderly in

the community (SWWP, 1979: 24).

The argument put forward during the debate between the government and the

Association for the Rights of the Elderly (ARE)14 about aged home residents (as will be

14 ARE was formed in 1979 as part of the community work of the Society for Community Organisation, a NGO sponsored by some church foundations in Europe. ARE was first formed as a response to the incident of the maltreatment of older people staying in the Little Sisters of the Poor Aged home in 1978. Membership of ARE was mostly social workers, university academics, and some older people. During the 146 explained in the next section) was based on this part of the paper. The government was

consistent in the implementation of the fee charging policy and thus was quite

authoritative in asserting its own stand even though there was opposition from the

public.

In the area of elderly services the White paper also mentions that 'an exception has been

made to include health and housing services' (ibid. 6), indicating the importance of a

joint effort in the provision of services as individual government departments tend to

work within their own departments rather than as a team.

In relation to the concept of care in the community, the White Paper states that:

the concept of care in the community was well tested in both Western and

Asian communities and was found to be most effective in meeting the needs

of the elderly (ibid. 14).

This is typical kind of the legitimation practice of the Hong Kong government in policymaking. In fact, the statement that it was 'well tested in both Western and Asian communities' may not be as straightforward as it seems because the claim was not supported by evidence.

first formative year, two of the members were part-time employee from the Society for Community Organisation, the rest were volunteers. The key work of ARE during the 1980s was to 'inform' the public of the insufficient community and residential provisions for older people through social action such as petitions and coalitions with other NGOs. It also conducted survey on elderly provisions as its action strategy. In the 1990s and 2000s, ARE gradually became more of a consultative organisation than a social action oriented one. Kwan (1987) argues that there is a positive relationship between ARE and the development of social welfare service for the elderly in Hong Kong between 1979 and 1987. 147 The third SWWP also contains discussion about the financial capability of the government. The paper states that social security is an increasing and open-ended question, and that it is not unreasonable for those who receive benefits to be asked to make some contribution to the cost of services they enjoy. There was a growing demand for nev/ and better services and because overseas aid was no longer forthcoming, the government had to make social welfare services available; but they could not be unlimred (ibid. 24).

In rela'.ion to older people and indigenous organisations such as burial societies (known as Pak Kam Wui) and credit unions, the paper notes that:

the popularity of Pak Kam Wui appears to be declining in view of increased

social security benefits and better welfare facilities. Nevertheless, these

schemes are known to have a fairly wide membership amongst the poorer

sections of the community. The Government is gathering more up-to-date

information [as to] whether legislative controls are necessary (ibid. 17).

Pak Kam Wui and vegetarian halls were local developments which were forms of social protection. They gradually disappeared when modem forms of welfare were eventually organised.

148 Phase One 1973-1979: the adaptation of the UK models of community care in the planning of ageing policy

The 1973 Working Party Report on the Future Needs of the Elderly

In 1972 a working party was set up in Hong Kong to examine the role of the

government regarding the care of the old. The purpose of the Working Party for the

Future Needs of the Elderly (WPFNE) was twofold: 1) to identify the needs of elderly

people and to assess their future demands on social services; and 2) to recommend how

these demands should be met, taking into account other competing claims on

government and voluntary resources (WPFNE, 1973: 1). The report concludes that,

given there is always a limit to expenditure on welfare, the cost of improved services for

the elderly must be met by the community (ibid. 73). It says that it is important to make

this quite clear at the outset. In effect, a portion of the cost should be recovered by

charging, or be met from non-government sources.

In 1973, a report was published which recommended community care for the old. It points to other countries, and in particular the UK, where the concept of 'value for money' had found favour and operational costs were often guided by that principle. A study in the UK published around that time by the Institute of Municipal Treasurers and

Accountants entitled ‘Care of the Elderly’ based on a cost-benefit analysis, concluded that care in the community is a feasible alternative to residential care, especially when there are factors other than severe incapacity (WPFNE, 1973:16). The report also states that there was no reason why the UK findings should not apply to Hong Kong, especially in view of the high resource costs of land and buildings for purpose-built residential care (ibid. 16). In other words, the costs of community support services were

149 less than those of residential care. However, the analysis does not include any of the

costs of caring as bear by the carers, usually the family members of the old people.

The report says that the right approach was to concentrate on 'care in the community',

or domiciliary care. This means that services should be aimed primarily at enabling the

elderly to remain for as long as possible as members of the community at large, either

living by themselves, or with members of their families, rather than providing care in

residential institutions outside the community to which they are accustomed (WPFNE,

1973:15). In retrospect, it is this piece of social policy, 'care in the community' that has

remained a strong feature of the policy landscape.

Debate among the service planners

In the working party report it states that no special study was undertaken regarding the

application of the concept of 'care in the community' in Hong Kong. But, it suggests

and concludes that the UK findings would very likely be borne out because of the cost of land for institutions (SWD Five-Year Plan Review, 1974: 4). In order to see the effectiveness of care in the community, it recommended a moratorium on the establishment of new homes, for say two years, until it was possible to assess the effect on the demand for places in such homes (ibid. 22).

Another argument was based on the assumption that old people in need of residential care and not yet admitted to homes would be put at 'risk' on a controlled basis, having to fend for themselves, with some financial help and backed by support services. There were arguments both for and against 'care in the community' but the concept was endorsed for two reasons. One was the argument which was in favour of the trend in

150 many countries, not only with old people but with families in general, to preserve the

'unit' as long as possible. The second was argued on purely humanitarian grounds, that

most old people in reasonable health would prefer to continue to maintain their lifestyle

rather than to disrupt it by removal to an institution: it was not only cruelty but in many

cases would bring about a deterioration in both physical and mental health (ibid. 4). It

raises the question: what about older people who cannot be cared for at home? The

answer is that theoretically if they got ill they would probably end up in hospital. In the

early 1970s, there were very few ageing-in-place facilities such as home-help service

and day care centre for the older people (details in Chapter 3).

It was also argued that the moratorium on the construction of future homes that did not

provide care and attention facilities, as proposed by the working party, was considered

unrealistic or impractical, taking into consideration the widely expressed need and long

waiting lists for homes. Besides, it had implications for a number of aged homes that

were already in operation. In fact, two years would be quite insufficient to allow for the new measures to have an effect (ibid. Annex: 5). In fact, the moratorium was not implemented as proposed. However, it was felt that such homes (homes for people with self-care ability) should in fact be phased out and replaced by care and attention homes and infirmaries. Infirmaries are provided for the chronically ill who no longer require intensive medical treatment but nevertheless require longer-term hospitalisation. Since the health of residents in care and attention homes gradually deteriorates infirmary units were set up in non-hospital settings, such as care and attention homes. Care and attention homes were for older people who require nursing care for less than two and a half hour in a week and in an infirmary they require more than 2.5 hours of nursing care.

151 Social security payments: a question of fairness

The relationship between the provision of social security and community care is a close

one because financially it assists the elderly to remain in the community. A review of

social security policy was conducted simultaneously with the community care policy.

The review questioned whether the elderly staying in institutions should receive public

assistance, given competing priorities for support (ibid.). Many old people living in

NGO aged care homes were receiving infirmity allowances. The review continued, to

say that the elderly in institutions were in effect enjoying shelter but otherwise they

needed to look after themselves, such as preparing their own meals. If this was the case,

it was argued, then the concept of 'care in the community' seemed to run adrift. On one

hand, the government provided a benefit to help an old person to remain in his or her

own home while at the same time providing the same benefit for those who received

'care' in an old people’s home, whether it was financially supported by the government

or not. Therefore a strong plea was made in more than one set of representations for

extending the allowance to those presently excluded because they were housed in

certain institutions. In other words, the government supports the view that aged home residents should not expect to receive the Infirmity Allowance because they were also on benefits. The Infirmity Allowance was meant for those 75 and above. While this was the view of the government and, there were people who were in disagreement because staying in aged home, without one’s family members would require extra allowance to make ends meet.

The core of the matter lay with the mandatory constraints on the welfare budget and the increasing number of applicants for financial assistance. Since the implementation of the Disability and Infirmity Allowance Scheme in 1973, 33,000 old people had

152 benefitted from the Disability and Infirmity Allowance Scheme and new applications

were still coming in at the rate of 1500 a month (ibid. Annex E. 1). This is a significant

number, taking into consideration that this was the first year that the Hong Kong

government committed public funds to social welfare. Given the financial constraints,

the review argued that it was difficult to justify extra expenditure in general, and, even

if a compelling case could be made for increased benefits, they surely had to go to those

who received no help within the scope of the Disability and Infirmity Allowance

Scheme, for example, those who were chronically sick and widows with young children

(ibid. 2). Moreover, under the guise of priority and fairness, it further concluded that the

scheme was judging the need for services on their merits, bearing in mind that the needs

of the elderly will undoubtedly grow over the years, as a result of natural population

increase, and the potential immigration of large numbers from China. The above

argument was put forward in the Elderly Services Green Paper (1977), the Social

Security Green Paper (1977) and the third Social Welfare White Paper (1979).

Elderly residents of institutions, if eligible for the allowance, would be receiving a double subsidy. However, this distinction did not appear to be generally accepted by the public, who regarded it as unfair discrimination against those who were in residential accommodation, frequently not by choice but by necessity. A small allowance would be welcomed by these people and should alleviate the process of social disengagement and isolation, which often accompanies residential care.

The Social Security Green Paper, instead of using the term 'double benefit' used

'duplicate', and said that:

153 At present the allowance is not payable to those in residential institutional

accommodation ... this might duplicate Government help, since the person

concerned was living in accommodation provided by the Government,

directly or indirectly with the aid of Government funds (Social Security

Green Paper, 1977: 17).

All these arguments were justification for the implementation of the revised social

security scheme and the new NGOs unit cost subvention (subsidy) system as

recommended in the 1977 Elderly Services Green paper. The new system required the

service users to make some contribution to the cost of services they receive.

The Elderly Service Green Paper says that if elderly people in institutions became

eligible for the Old Age Allowance, then this should take into account the fees to be

charged in subvented institutions and hence the subvention required (Elderly Service

Green Paper, 1977: 7). The new unit cost subvention policy required that the sum of subvention to the NGOs homes should be deducted according to the number of residents on the Old Age Allowance or similar allowances. This measure became effective just before the implementation of the new NGO subvention system in the early 1980s.

Government subsidies and commercial providers

Looking beyond the scope of government provision, the Social Security Green Paper devoted a chapter to 'the relationship between social security and social welfare services'. It explored the possibility of encouraging non-government financed services

(private services) and replacing government financed services with individual cash subsidies. It concluded by saying that there were objections in both principle and

154 practice to a change to reliance on private welfare services, paid for by the user of the

service who would be helped through a system of individual subsidies (Social Security

Green Paper, 1977: 40).

However, in another section of the working party report titled ‘An experiment in

developing non-government financed services’, it states that in spite of the objections to

relying on private welfare services, it may be advisable to encourage, in appropriate

fields, the growth of non-government financed services through providing subsidies to

private operators. The reasons given were firstly, that if it were practical it could be

achieved without draining the resources of the government financed sector, for example,

trained manpower. Secondly, it allowed government-financed services to concentrate on

other forms of social welfare. Thirdly, there was greater freedom of choice offered by

the new arrangements and thus, reduced stigma among those who might resent having

to seek public assistance. Finally, private welfare providers would become more

accountable because those paying for the service would feel free to go elsewhere if dissatisfied (ibid. 40-41).

Private services were suggested as an alternative to government financed services in social welfare just as in education and medical and health services. For example, far fewer home-helpers than amahs were employed; and there were privately run nurseries as well as government-assisted nurseries. So far, there had been no attempt by the government to encourage the private sector in aged care. However, private services in aged care existed in response to market demand. Their location was a matter of chance rather than according to need. The provision of other private welfare services outside the government social welfare planning machinery was also haphazard (ibid. 39). The

155 report also says that it would be wise to carry out some practical tests and that child

centres and homes for the elderly would seem to be suitable for testing. The aim of the

experiment would be to see whether a workable system could be developed under which

the client is charged for the cost of the service and an allowance to cover that charge, or

part of it, is added when calculating entitlement to public assistance (ibid. 41).

While the government was trying to work out a plan for the needy based on its

budgetary constraints, struggling with tapping into more revenue or restricting its

criteria of eligibility, the government conducted a survey to calculate the allocation of

care and attention home places for the elderly (Wong, 1987: 4). According to this

survey, the projected demand for care and attention homes was between 4 and 8 places

per 1000 people. Over the years, this has proved to be inadequate and

private-commercial aged homes were set up to fill the gap (ibid.).

Private welfare provision and state subsidies did not materialise until the mid-1980s. It was only then that the Hong Kong government began to admit to the role taken up by the private-commercial sector by giving limited support through the social security scheme. In the eyes of the private home operators the support from the government was limited. It is because one of the major sources of their income is from the social security payment and, the rate of payment was basic.

During the implementation of the new subvention system for the NGOs in 1978, the first elderly home ‘incident’ occurred in one of the oldest Catholic homes for the aged.

There were reports of abuse and residents being obliged to hand in their public assistance money as 'voluntary donations' to pay for the operational costs of the home.

156 This incident sparked off the formation of a group concerned about institutional care for

the old. This group later evolved into the Association for the Rights of the Elderly

(ARE).

The next section of this chapter will show how the implementation of the community

care policy met resistance, and the discrepancy between the discourse of the policy and

its implementation.

Phase Two 1980-1986: interpretation and implementation

Introduction

Phase Two of the community care policy period covers its implementation in 1980 to the issuing of the Code of Practice for Private Home Operation in 1986. The Social

Welfare Department in Hong Kong is the key government organisation responsible for the planning and implementation of welfare programmes, and it underwent departmental re-organisation in 1979 and expansion in 1980. In this period, the government and ARE, the social activist group for the rights of the old, had different interpretations of community care. The NGOs also joined hands with ARE in arguing for decent provision of services for the elderly.

In this section, I will first examine the interpretation of the term ‘community care’.

Secondly, I examine the four policy events and two studies on private aged homes.

These four events (two in 1980 and two in 1982-3) serve as case studies to evaluate the outcome of the implementation of the community care policy and to shed light on the

157 study of its implications for the development of modem social welfare and Hong Kong society. The two private home studies in 1983 by both the government and NGOs (ARE and HKCSS) illustrate the residential aged care situation in this period. The concluding part aims to highlight the contradictory nature of how the policy was explained and how it was put into practice. I note that the policy of community care is not consistent with what v as implemented. Thus, it raises doubts as to the intention of the government.

Interpretation

Differing interpretations by the government and the NGOs affected the implementation of the community care policy, alternatively known as ‘care in the community’ or

‘domiciliary care’. It is therefore necessary to have an understanding of the term in the

Hong Kong context. ‘Community care’ has a range of interpretations (see for example

Walker, 1982: 19; Chow, 1992; Chen, 1996; Symond & Kelly, 1998; Hugman, 1997;

Means, Richard & Smith, 2008). Understanding the translation of the term from English to Chinese is also problematic. Given the unique situation of Hong Kong prior to 1997, government policies were written in English. Only those that warranted a translation were given an equivalent. The translation of law from English to Chinese is an example.

Translation can be complex and raise ambiguities. This is especially so with cultural understanding of the linguistic differences. Therefore, value orientation and preference determines the understanding of the words. The meaning of the policy on community care depends on the implicit meaning behind the terms ‘family’ and ‘care’. However, the translation of ‘community care’ into Chinese turns out to be ‘domiciliary care’. It could mean providing care in one’s abode or residence. 'Domicile' in the Chinese language can simply mean ‘one’s residence’ or ‘where one stays’. It can consist of two words ‘community’ and ‘care’. ‘Community care’ is translated as 'care in one’s

158 domicile', which can mean family care because of the use of the Chinese word ‘jia’

(family) which has a distinct meaning of ‘one’s family’ (Chinese version of the policy,

1973: 16-17). In terms of Chinese culture, the word ‘family’ is a powerful discourse. It

is also associated with the word hwo’ (filial piety) (Chen, 1996: 7; Schneider & Wang,

2000: 210; Ikels, 1997, 2004). In terms of governance it helps to 'preserve' or

'construct' an identity of Hong Kong Chinese people. Such an attitude affects aged care

policies and programs because of the 'enforced altruism' in community care (Davis &

Ellis, 1995: 136). As government policy papers state, 'the services aim to promote the

well being of the aged through care in the community and by the community' (SWD,

1979) and, 'care not only provided by one’s family but also includes the government

and those who were concerned with the old people' (SWD, 1982). In retrospect, the

government has been consistent in its application of the meaning of the term as ‘familial

care’. Considering the SWD was previously the Secretariat for Chinese Affairs, it is not

surprising to see the practice continue (Bray, 2001: 14). This happens because, to a

certain degree, there is a logical transfer of the way of dealing with local affairs which

has been affected by the preoccupation with 'the Chinese family'.

Introduction to the case studies: land constraints, unit rate subvention and classification of services

The four cases chosen for examination are related to land constraints, the unit rate of subvention and the classification of services. Due to the size of Hong Kong (1095 sq. km. or 423 sq. miles), the availability of land has always been a problem (Poon, 2005).

Private sector housing is costly and it will be shown in the next chapter that some developers and building owners used their premises to create private homes for the old.

159 The government generates high income from the sale of land; there are no material

resources in Hong Kong of greater value.

In the private housing sector, there are cage homes and partitioned flats. Cage homes are

rented bunk beds in older buildings and districts. They get their name from the wire

cage that covers the bed. Partitioned flats consist of different households staying within

the same flat and separated from each other with partitions, usually made with wood. It

is quite common to find older people and new arrivals from China staying in cage

homes and partitioned flats. There have common toilets and kitchens shared by a dozen

or more people in area of around 700 sq. ft. (According to the Society for Community

Organisations, there were 100,000 cage homes and partitioned room residents in 2009.)

Therefore, in the field of social welfare, land constraints have been a major obstacle in

the implementation of residential projects. With land being scarce and an increase in the

frail elderly with intense personal care needs waiting for aged home admission15, it is

not surprising to find that priority for the allocation of available sites has been accorded

to care and attention homes rather than hostels (SWD, 1980: 78-79). Cases 2 and 3 below both relate to land constraints though they are of a different nature. The two case

studies illustrate the differential treatment of two organisations in building homes for the elderly. In other words, the involvement of the government in the provision of homes is not at all laissez-faire.

15 According to the 5-Year Plan Review published by the Social Welfare Department (1980) in 1977 there was a provision of 316 care and attention home places with a demand for 1621 places and with a shortfall of 1305 places. In 81/82 there were 375 care and attention home places with 704 applicants on the waiting list (Leung, Chan, Lee and Cheng, 1993: p. 11). 160 The government implemented the unit rate subvention system in 1979 (SWD, 1980: 79).

It affected the amount of money given to a home and its residents. Prior to the

implementation of this system, the amount of money given to homes did not take into

consideration the number of residents receiving social security. Unit cost subvention

means the government takes into account the number of residents who are on social

security. In other words, the home would receive less financial support than before,

depending on the number of residents who were social security claimants. Case 1 is

concerned with the implementation of the unit rate subvention. Case 4, in 1983,

illustrates how aged care was not considered an essential service and only a ‘necessary’

one (SWD, 1983: 211). From then onwards, the government fully finances essential

services but for services of a necessary nature, it will only finance from 70 per cent to

80 per cent depending on the type of service. The difference between these two

categories is that for Category II services NGOs have to raise money from other sources for the delivery of a set of standard of services. The outcome and the actual implementation of the policy are contrary to the essential nature of the argument for community support provisions. The NGO service providers were very critical of the policy and they felt cheated because of the change in the subvention policy. NGOs have to make ends meet and were surprised to see the withdrawal of financial support for the care- in-community ageing policy. In 1983-84, 27 types of services belonged to

Category I, essential services as 'opposed to desirable but non-essential' which include for example, emergency relief, family casework, family life education, day creches, homes, hostels, care and attention homes, day care centres and home-help. There were eight types in Category II services, among them multi-service elderly centres, social centres for the elderly and social and recreational services for the disabled (ibid.

210-211).

161 Case 1. Protest against fee charging 1980

This incident happened in June 1980 when fee charging for aged home admission was

first applied. The context here is the operation of the unit cost subvention system as

mentioned above. In Chapter 5 I noted that the social security scheme for older Hong

Kong residents was established in 1973, and by 1980 there were 145,502 aged persons

receiving benefits. In 1980, the population of those 60 and over was 474,000. Therefore

about 30.6 per cent of those who were 60 and over depended on social security. This is

a substantial proportion. In 1980, the numbers of elderly in the three different kinds of

aged institutions were: 930 residents in hostels, 3235 in homes and 375 in care and

attention homes, with a total of 4540 residents. Elder homes are facilities for older

people with independent living ability and residents in care and attention homes they

require less than 2.5 hours of nursing care. The figure for institutional care, therefore,

was 0.95 per cent (based on 4540 of the 474000), which is about 1 per cent of the 60

and over population. This is a small number and it is evident that most elderly people

stayed with their families. However, as we can see in the 2000s, the number of older people in care has increased quite substantially.

Action by concerned NGOs and the response from government

When fees were first introduced, ARE petitioned the government saying that elderly people who were staying in homes were poor, without the care of their families, and since they had all contributed to the development of Hong Kong’s economy they deserved to enjoy their fair share of the prosperity. Seven old people representing 1000 aged home residents staged a four-hour sit-in outside the SWD headquarters, demanding that the government abandon proposed fee increases. The government argued that social security payments were adjusted every year according to the rate of 162 inflation, and the petition was turned down. In the long run, the elderly who were living

in institutions would be better off than those staying with their families. If fee-charging

was not going to be implemented, it would eventually attract more elderly people to

leave their families and turn to institutional care. This was against the objective of care

in the community. Thomas Lee, the Director of Social Welfare, said that 'charging fees

could restore dignity to welfare recipients' (South China Morning Post, 8.7.80). The

government was arguing that it was unfair to those elderly people living in the

community if the environment and conditions of aged homes were better. ARE did not

press for further action.

Analysis of Case 1

The heart of the matter is not only the amount of money recovered from fee charging,

but the disciplining of the family so that a welfare-oriented dependency culture would not be able to flourish in Hong Kong. In addition, there was also the practical consideration of having a system that was equal for all applicants so as to iron out any possibility of people receiving a double benefits. In fact, home places are not free but the amount of payment varies between the types of homes, provider background and user background. The increase in fees for the three kinds of institution was: 20 per cent for hostels (from HK$35 to HK$42), 15 per cent for homes (from HK$200 to HK$230) and 50 per cent for care and attention homes (from HKS200 to HK$300) (ARE petition letter, 20.6.1980). However, the increased public assistance of 26 per cent could not satisfy all the residents because of the different kinds of fees they were paying and the medical services some received (South China Morning Post, 7.6.1980; Standard,

27.6.1980; The Star, 27.6.1980).

163 Following the 1978 elderly home abuse incident, the group concerned with the elderly

institutional care policy evolved to fonn the ARE (ARE, 1979). ARE was composed of

some older people but mostly social workers who worked with the aged as well as some

social work academics from different universities. The prime concern of the group was

to press for the rights of the elderly. The pressure group also reflected the concern of the

postwar baby boomers on questions relating to welfare and the livelihood of ordinary

people.

Case 2. Priority for an expatriate home

Another incident in the same year involved the first English-speaking expatriate home

in Kowloon Tong, which was set up by the China Coast Community (CCC). According to the Very Rev. Sidebotham, the purpose of CCC was to meet the needs of the growing number of retired expatriates for whom there were no suitable provisions within the existing social welfare structure (South China Morning Post, 27.2.80). At the home’s opening ceremony, Lady Carter, wife of the then Chief Secretary, said that residents came from different backgrounds but they had similar problems: substandard accommodation, high rents, inflation and declining mobility (ibid.).

The residence was bought at a cost of HKS5.96 million and was made possible through a donation from the Royal Hong Kong Jockey Club of HK$3 million, with a similar amount in the form of a bridging loan from the government repayable over 10 years. At that time, the home accommodated eight persons and the plan was to construct a new wing for 50 more residents. The residents had to contribute around HKS2500 a month to cover recurrent expenditure, but for those who had limited financial resources, the community would look for donors to sponsor them.

164 At that time, the monthly rental for an ordinary resident in the voluntary sector was

around HK$100 and there were 42,000 elderly people on waiting lists16. This expatriate

aged home incident caused widespread discussion in the newspapers (Wah Kiu Yat Pao,

27.2.80). The incident was about differential treatment between non-English local

residents and English speaking expatriate residents and the principle of financial support.

At a press conference, the SWD representative said the home was a self-financing one

and that the loan for the home had to be repaid. Besides, the policy of the government

was to take care of the vulnerable. And when asked about the shortfall of home places

as stated in the Five-year Plan Review, the representative explained the delay had to do

with the building site and the geotechnical aspects of the land (Sing Tao, 18.3.1980).

Case 3. Low priority for an interested Christian organisation building a home

In January 1982, a welfare society called the Hong Kong Christian Mutual

Improvement Society expressed its discontent regarding the government’s procedure and attitudes towards the allocation of a site for the construction of a care and attention home. The Society first applied for land in 1975 and the government agreed to allocate an area of 18,200 sq. ft in Tuen Mun in the New Territories. But a year later, the Society was told that the government had to retain the land for development, and allocated another site in the same area. The Society then raised HKS2.5 million and, when ready to begin construction, was told again that the geotechnical aspect of the land made it unsuitable for construction. The Society was given yet another area but had to wait for

4 According to the 5-Year Plan Review (1980), in 1979 the shortfall of hostel, home, and care and attention home places were 2960, 660 and 1285 respectively. The total shortfall was 4905 places. The figure of 42,000 as reported by the newspaper was of different calculation method. Nevertheless, even if one considered the shortfall from the government’s figure of 4905, it is already a high figure. 165 at least two years before the land would be available. Finally, in 1981 the Society was

asked to give up the project and instead of running a care and attention home, the SWD

asked the Society to run a hostel in the same area (South China Morning Post,

18.1.1982). It would be the problem with the land, objections from some local people,

or that the Society had demonstrated its financial ability but not the expertise in running

a care and attention home.

Analysis of Cases 2 and 3

These two cases reflect the diversity of the residential care needs among different

socio-economic ageing groups. The government policymaking process had little

flexibility in meeting these groups’ needs, especially in dealing with different

government departments such as the SWD, and the land and building departments.

Aged homes are expensive projects and not many NGOs wanted to or could afford to

participate. It was unfortunate in Case 3 that the organisation faced so many hurdles and

was not able to get support. However, during the same period, another Christian

organisation was able to provide accommodation places for older people in temporary housing areas (SWDAR, 1983-84). The problem of scarcity of land is obvious and it is a structural obstacle in the development of homes. Perhaps it is not only the question of the availability of land, the preference of the government and the backgrounds of the organizations are even more significant.

Case 4. Insufficient funding for a community support service

The fourth case also occurred in 1982, during the implementation of the new subvention system. In this new subvention process, when community support services for the

166 elderly were categorised as necessary but not essential (SWD, 1982), 68 social centres

and 7 multi-purpose centres had their subsidy reduced by 20 per cent and 15 per cent

respectively. The financial implication was that for each of the social centres, the

voluntary agency involved had to raise HK$45,000 and for multi-purpose centres,

HKS 100,000, in order to keep the services going. Taking the number of affected centres

into consideration, it would cost the government around HK$4 million. However, ARE

said that since the government had a surplus of HKS100 billion there was no reason to

implement such a plan (Tin Tin Daily News, 8.6.1982).

This measure apparently contradicted the objective of community care because a social

centre at the neighbourhood level can facilitate the development of a support network,

which is crucial to the philosophy of community care. In addition, ARE said that the

funding measure could discourage potential NGO providers who would like to open

centres for the elderly as well as agencies presently providing services who would withdraw. Also, the new subvention measure would cause some agencies to charge their users for the service. Social centres mostly only charged a few dollars for the annual membership fee, and for the different kinds of activities (Ming Pao Daily, 8.6.1982).

However, the explanation given by the SWD was that social centres for the elderly were recreationally oriented and therefore they were not essential (SWD, 1982). It continued to say that home-help and day-care services, and parts of the multi-purpose centres, were fully subvented, while social centres, attached to multi-purpose centres as well as those which operated on their own, were only getting 70 per cent subvention (ibid.). As mentioned above, home help (for example meal delivery service and house cleaning) and day-care services were classified as essential, while social centres, whether attached to a multi-service centre or independent, one could only be funded 70 per cent.

167 Action 1: coalition among NGOs

In response to the subvention measure, the HKCSS organised a working group

composed of some NGO agency heads or representatives with the purpose of asking the

government to review the policy. The group agreed that joint action for the elderly

should be taken in the following sequence. First, all social centres and multi-purpose

centres for the elderly would present the subvention situation to elected members of

their District Board. District Boards are local constituencies composed of elected and

appointed members. Simultaneously, the clients would be encouraged to write to the

District Board members. Second, a letter signed by all agencies would be sent to the

leading newspapers revealing the agencies’ joint declaration to oppose the restriction on

social centre services for the elderly. Third, the representatives of the centres would

approach the Secretary for City and the New Territories Administration and un-official members of the Legislative Council. It would be a joint action organised by social

centres and multi-purpose centres (ARE, June, 1982).

Action 2: social centre survey

ARE also conducted a consumer survey among elderly people who were members of social centres. It covered the whole of Hong Kong, and aimed to look into consumer opinions regarding the usefulness of the service. The findings showed that members of the elderly centres were satisfied with the service, and found it useful (ARE, 1983).

However, in a reply to the HKCSS, the SWD explained that after consultation with the

Social Welfare Advisory Committee they did not believe that any useful purpose would be served in carrying out a review at that stage. As a standard cost for services had been worked out and the aim was to fully implement the new scheme, any review should wait until the scheme had come into full operation (SWD, 1983). 168 Response from government

At an official opening ceremony in 1983, the Director of the SWD who had just

returned from the Vienna Conference on Concern for the Aged, said that from society’s

point of view, each family was expected to solve its own problems. But at the same time,

when the situation was far from perfect, government as well as society should also

realise that they had a responsibility to assist families to take care of the aged. This was

probably why the policy on the elderly emphasised community care and why it was well

explained in the publications on social welfare, that is, the SWWP of 1979 (Wah Kiu

Yat Pao, 1983). In fact, the government was not addressing the issue of underfunding of

community support services for the older people; it was just repeating the philosophy

and principles of the ageing policy.

Before the viewpoint of the then Director of the SWD was made public (mainly through the newspapers), the ARE had petitioned the government, urging for more provisions for the older needy in terms of expanded residential places and full financial support to aged centres (ARE, 1983). The HKCSS also joined in the argument for full subsidy to centres for the elderly. After the public announcement of the government’s viewpoint, there was no further action from either ARE or the HKCSS. When the government insisted that what it was doing was correct, the opposing forces did not take further action. Confrontation usually resulted in a one-off single event rather than as a series of events, which is why social action in Hong Kong is regarded as polite politics (Ho,

2000).

169 The condition of aged residential care in Hong Kong: private home surveys

In 1983, through recurrent revenue generated from the selling of Lunar New Year Gold

Coins, the government purchased private flats and converted them into shelter housing

for 800 old people. At that time, due to the political uncertainty of the future of Hong

Kong, many newly constructed buildings were left vacant. During this period, some

land developers converted their properties into private homes for older residents. In

1983, the HKCSS and ARE organised the first seminar on private homes. One of the

speakers, who was also an aged home owner, said that due to the unclear attitude of the

government, the private-commercial sector could not involve itself financially too

deeply for fear that if there was a change of policy, the cost of building conversion and

facilities purchased could not be recovered (HKCSS & ARE Aged Home Seminar,

1983). This was one of the key difficulties in running private homes.

At the same meeting, ARE presented a survey of 29 homes. For the first time, a sketch of the private-commercial sector became available. There were extreme variations among homes, especially in terms of size, ranging from 5 to over 100 residents, while charges ranged from between less than HKDS2000 to more than HKDS4500 per month.

The difference in charges has two aspects. First, the types of room — single or shared — and secondly, whether the resident had good self-care ability or was bed-ridden. Most of the homes admitted males and females, while two homes took female residents only, and two even admitted handicapped young people.

The survey also reported the general environment of homes as crowded; some did not have sitting rooms or partitions, were poorly equipped, and poorly ventilated, which was very unpleasant during the humid and hot summer months. There were also rigid

170 regulations regarding the movement of wheelchairs or use of telephones for free local

calls, etc. Sixteen of the homes had no fire precaution measures. In terms of staffing, all

the owners said they had qualified staff, but it was found that most homes did not have

sufficient numbers of staff. Most of the staff were from China and worked either in a

two-shift or three-shift system. The two-shift system consisted of a 12-hour a shift and

the three-shift system was an 8-hour shift. It was also doubtful as to whether homes

employed extra staff when there were fresh intakes (ARE, 1987).

Since a steady number of cases of death among residents of private homes were being brought before the coroner’s court, it was recommended that the government consider compulsory registration of private homes (South China Morning Post, 5.11.85). People suffered from neglect, mainly due to a personal care worker’s lack of skill in caring for residents; the application of restraints in the form of tying residents up at bed-time was common; and it was especially so among those who were suffering from senile dementia and the home did not have enough manpower to keep an eye on them. The government could no longer ignore the situation and, in line with its conventional practice, the initial response of the state towards private care became an issue of issuing a voluntary code of practice. Eventually, the Voluntary Code of Practice for Private

Home Owner was issued in 1986, with amendments in 1988 and 1999.

Issues and implications relating to the interpretation and implementation of the community care policy

The issuing of the Code of Practice signifies the appalling quality of care in private homes at this time. I will discuss private homes in detail in the next chapter. In this

171 period, three important aspects are worth exploring. First is the question of the time-lag

regarding the implementation of the community care policy and the aged home policy.

In the last section I noted that the WPFNE (Working Party on the Future Needs of the

Elderly) was set up in 1972 because of the absence of an ageing policy in Hong Kong.

The idea of community care was introduced, and the working party recommended a

moratorium on the development of aged homes for two years in order to see the effect

of care in the community. In a review, the moratorium recommendation was rejected.

From the government annual reports, I found that the figures given for the number of

home places remained at 3000 between 1973-1974 and 1976 and 1977. The figures can

be found in Table 1 in Chapter 5, showing the relationship of aged home, family service

and public assistance.

This was only the beginning of a series of policies that turned out to be unfavourable to

older people but was consistent with the government’s enabler role (Gilbert & Gilbert,

1989; Lloyd-Sherlock, 2004: 120-121). There was a discrepancy or poor coordination between the implementation of the policy and the effect it had on the service users.

Some policies needed time to gain momentum so as to have a cumulative effect.

However, even if the provision could reach the user on time, the level of assistance would still be inadequate. On the other hand, provision of the community care policy was not launched not until 1979. These services included multi-purpose elderly centres providing home-help services, canteens, meals on wheels, individual counseling and group work, and social and day-care centres. And, older people who would not benefit from community support services prior to 1979 had to turn to aged homes for help. The lack of NGO homes left service users with little choice other than to enter a private home.

172 Second, the shortage of home places, and especially in NGO homes, directly or

indirectly caused the emergence of the private home sector, and there was a need to

regulate the private homes based on the Code of Practice because of poor quality care.

Third, the population of those 60 and over in 1980 was 474,000, and the total number of

home places was 4540, as noted above. Based on the 1980 population figure and the

number of home places in 1980, only 0.95 per cent of those 60 and over were aged

home residents. According to the 1982 Programme Plan, the official shortfall figure was

2581 (SWD Programme Plan, 1982: 240, 243). This is a significant number, and the

shortage of NGO elderly home places meant that it was inevitable that private aged care homes would be built to fill the shortfall. Added to this is the cultural factor of the aged not easily accepting services, as I have discussed in Chapter 3.

The political, cultural and moral economies of ageing

In the last period we note that vegetarian hall of local religious sect and unmarried female domestic worker4s retirement accommodation arrangement are gradually no longer a feasible retirement option for some of the older people in Hong Kong. In this period, we also note that Pak kam Wui (Social Welfare Department, 1979: 17) an indigenous credit union system is also diminishing, and the Hong Kong government has taken up a more active and directive role in welfare provision.

In the last period we note that the Hong Kong government argues that older population and its related issues 'should not be viewed as a problem as elsewhere' (1956). In this period the Hong Kong government no longer considers the issue from this standpoint and argues that the best approach to the issue is the concept of care in the community

173 because it 'was well tested in both Western and Asian communities' (1979: 17). Like its

first argument in the 1956, the legitimacy of the 1979 argument is also based on

overseas countries. But, the difference is that the former argues not to follow other

countries while the latter argues just its opposite. However, the 'official knowledge' of

this claim that the concept of care in the community is well tested in Western and Asian

communities as argued in the 1979 may not be as straightforward as it seems.

In this period, the different levels of the political, cultural and moral economies are at

work with some variations as compared with the pre-community care policy period.

This period can be described as the zenith point of the implementation of the

community care policy because of the direct 'confrontation' between the government,

the NGOs and action groups. The government, NGOs and action groups are relied on

different kinds of explanation for their actions and to justify their legitimation. In tenns

of the three economies of ageing, moral economy has a better explanatory edge over the political and cultural economy of ageing.

The political economy of fee-charging for residential care is at its full swing as expressed in the government’s argument that 'if fees were not recovered from the residents, that in the long run people in residential care would be better off than those staying with their families.'

The background of the fee-charging incident is a result of a prudent fiscal policy. The justification for fee charging is not purely on this ground of political economy. It relates to the moral economy of the equity or fairness of service provision i.e. who is more deserving than the others. However, the moral economy argument of maintaining the

174 financial status of older people in residential care of not exceeding those who are

staying with their families would have the effect of strengthening the cultural economy

of ageing.

The argument of the action group Association for the Rights of the Elderly (ARE) was

also about deprivation, but of an absolute nature. The Association for the Rights of the

Elderly was on the side of the residents rather than with those older people living with

their families in the community. The argument of absolute deprivation was based on the

value that for those living with their families were better off socially, because they are

close to their family members, than those who lived alone in aged homes. Interestingly,

ARE 's standpoint was based on the assumption that residential care is a second choice to the family. The action taken by ARE would strengthen the importance of familial care.

The government was not using the argument of family, but instead was using economic fairness to justify its position on charging fees. The government also spoke of choice and the sense of respect and dignity of paying for social services, thus to some extent, the government was extolling the position of consumer sovereignty. This is consistent with the government’s economic philosophy and its political economy standpoint.

In this period in referring to the comment made by the Financial Secretary in the 1976

Budget Day Speech to the Legislative Council, Hodge (1976) notes that:

at a time of economic recession it would be reasonable to expect families

whose bread-winner is unemployed to seek Public Assistance, at the end of

175 November 1975 such families accounted for under 6 per cent of the caseload.

However, those claiming low earnings as a cause for their seeking public

assistance on economic grounds have increased from 14 to 25 per cent. This

suggests that people do not choose to stop working and live on welfare, but

continue to work even when they cannot obtain sufficiently remunerative

employment (1976: 9).

Here the Hong Kong population is portrayed as 'the quality of people' instead of ' a

problem of people’ (Annual Report, Hong Kong Government, 1956). However, in this

period there was a lack of community support services and older people living in the

community received a flat rate of about HK$ 100-200 of Infirmity or Old Age

Allowance. In similar way, older people represent ‘a people of quality’ more than ‘a

problem of people’ because of not demanding from the government for an improvement

of living conditions and yet able to face their daily hardship.

During this period the implementation of the Public Assistance Scheme brought in the

fee-charging strategy, which could claw back some of the social security money from

the older residents, but the message was quite contradictory. In the provision of

community support services, multi-purpose elderly and social centres were categorised as necessary but not essential, thereby suffering a setback in subsidies. The government, while promoting community support services, was reducing expenses for community support provisions.

Moral and cultural economy of ageing as a form of governmentality

Open confrontation between the government, NGOs and action group regarding older people’s welfare began to surface during this period. The emergence of the ARE,

176 represents the coming of age of a long over due concern on the welfare rights of older

people. The coalition between NGOs, the Hong Kong Council of Social Services

(HKCSS) also represents the pressing need of the issue. It is a simple step to have Hong

Kong of Social Services, concerned NGOs and the Association for the Rights of the

Elderly joining together to urge the government to improve the welfare system. This is

because the actions of ARE are considered by some NGOs and to certain extent, the

HKCSS as radical and 'anti-government'. Having a label of a 'radical' in this period

would lose the status of getting financial subvention from the government. The issues

relating to the new subvention system are of pressing concern that it’s the appeal of a

moral economy of fairness which triggers the formation of a coalition or else NGOs

could be quite passive and to follow the government’s instruction though maybe

involuntarily. The willingness to participate in the action is a result based upon a moral

sense of justice for the needy older people. Following E.P. Thompson (1971) the action represented a kind of bread riot in modem Hong Kong.

The community care ageing policy in Hong Kong is a family-centered policy with assumption that different kinds of community support sendees are available. However, in reality, the actual service provision for family support is minimal. Means-testing and quota system were also in place to limit the number of users. The minimal provision of services has the implication of self-help or help coming from one’s family or social support network. However, there is also the phenomenon that even if services are available, people may still not want it as noted above.

The relationship between policy and provision is complex. Policy can result in actual provision and it can also be a symbolic of perceived social values. Social values play an

177 important role in the shaping of policy in Hong Kong (Ngo, 2000: 146). In fact, ageing

provision is not the only provision in limited supply. Similar situations can also be

found among the family services in this period. In an examination of the welfare policy

in Hong Kong, one clear indication is that it is a practice of the government that '[it] did

not offer welfare benefits to relieve the pressure on the family. Instead it launched an

ideological campaign to promote family obligations and duties' (McLaughlin, 1993:

127). The government through the

'Family Life Education campaigns ...[so as] to improve the quality of family life,

to prevent family breakdowns and to promote interpersonal relationships and

social consciousness ..with slogans such as 'Building a Happy family', 'Honour

Your Parents', Love and Care Help Build Up a happy Family' and Responsible

Parenthood' (ibid.).

For older people 'they were advised on how 'to adapt to the changes of ageing and learn to get on with the younger generation" (Jones, 1990: 222 in McLaughlin 1993: 127).

This advice is closely related to the values of active, successful and productive ageing.

In this period, when news about the poor quality of care in the residential market started to appear in newspapers and television, the government asked the proprietors to exercise self-discipline. However, when the argument of 'self-discipline’ was not effective, a

Code of Practice was issued for guidance. Things did not seem to run smoothly and there were more complaints than expected. To a certain extent, the residential care sector was ungovernable and undisciplined for the users, their families and the government. The operators are more resistant and able to dominate due to the shortage

178 of services. In this sense, the community care policy was more effective than the

regulation of the quality of care of private aged homes.

The shortage of home places was mentioned in Table 1 in Chapter 5. During this period

due to the shortage of home places, the government tried to increase the number of home places in the following manner. In 1979, the first care and attention home was set up for the frail elderly; in 1980 the first English-speaking expatriate home was set up in

Kowloon Tong; through revenue generated from the sale of Lunar New Year Gold

Coins in 1984, the government bought 80 private apartments for 480 old people

(SWDAR, 83-84: 28) in Sha Tin and a further 23 flats were bought in Wan Chai to house 115 old people (ibid. 29). Also, in the same year, an NGO organised facilities for short-term accommodation for elderly people urgently in need of accommodation while waiting for long-term placements in five temporary housing areas (ibid. 28) and one public housing estate (Five Year Plan Review, 1983: 83). As an interim measure, small infirmary units of 20 places each were established in three homes (ibid. 85). During this period the government tried to find different solutions for its shortage of home places.

Also, private homes for the elderly were established because of the insufficient services offered by government.

Conclusion

In this phase, the social security system was further developed and a subvention system for the NGO sector was established. In the course of these developments, community care was interpreted differently as ‘care in the community’ and ‘care by the community’: these are excuses that the government used to defend fee-charging and its funding policy regarding both institutional and community support services. Looking back, the

179 working party was in fact given a most difficult and perhaps impossible task to devise a

policy with little finance, a situation quite similar to what has been described as

'squaring the welfare circle' (George & Miller, 1994, Wong, 2008). Looking at the

background of those who were in the working party, participation was by an elite,

which was composed of NGO agency representatives and church leaders. The

chairperson was Mr. T.S. Heppell, an Assistant Director of the SWD, who was on

secondment from the then Department of Health and Social Services in Britain. He was

the chief architect of Hong Kong’s new social security system. Based on his planning

experience, Heppell wrote a paper entitled, 'Social Security and Social Welfare: A New

Look' published by the Journal of Social Policy in two parts (Heppell, 1973). It

painstakingly explained the particular situation of Hong Kong, highlighting the benefit

of a simple and minimal administrative framework and the ‘vulnerable group' approach,

as well as emphasising the 'new' social security scheme as 'Hong Kong solutions for

Hong Kong problems'. He thought it could be viewed as an alternative approach for others to consider. He also notes that the calculation of benefits in Hong Kong is

family-based, and the scheme for older people is non-means tested.

Another member of the Working Party for the Needs of the Elderly, Mr Lok Man-Bun, said in an article published in the Hong Kong Journal of Social Work that the working party was an example of popular participation in planning comprising representatives of relevant organisations and government departments (Lok, 1972: 25). In the summary of comments received by the working party (SWD, Five-year Plan Review, 1974:

Appendix B), it said that 42 responses came from a spectrum of interested bodies and agencies including government departments, voluntary organisations, hospitals,

Kaifongs (local neighbourhood organisations) and rural committees. The participation

180 was quite limited and restricted to agency heads and community leaders, with no or very little grassroots input. This was also the case with the membership of the Elderly

Commission which was established almost 30 years later in 1997. To some extent, ARE also had professionals as core members, with only some elderly representatives from the community. The process reflects a gradual shift from a state-centred perspective to a society-centred perspective (Chan, 1996) and a move from bureaucratic politics to populist social policymaking (Jones, 1985: 1) and to a combination of bureaucratic and populist social policymaking.

181 Chapter 7 The Community Care and Commercial Care: Phase One, the British Colonial Administration (1986-1997)

Introduction

This chapter covers the period from 1986 to 1997 and stretches from the British colonial

administration to the Hong Kong Special Administrative Region (HKSAR) of the

People’s Republic of China (PRC). I have called this the community care and

commercial care period because there was a continuation of practice of the community

care policy from the previous period and, simultaneously, a rapid development of the

private residential sector for the old. The period is divided into two phases: Phase One,

the British administrative phase, is from 1986 to 1997 and Phase Two, the HKSAR

phase is from 1997 to 2007 which will be covered in chapter 8.

In this chapter, as to the 3- stages analysis, I firstly explore the waiting list for NGO

aged homes, the code of practice (Hong Kong government, 1986) as a guideline for

good home care, and the relationship between Hong Kong’s free economy and the

private home sector, the views of the Social Welfare Advisory Committee, a private home survey conducted by the government, and another one by the Association for the

Rights of the Elderly (ARE). During this period some important documents were produced, and in the second stage I will examine: the fourth SWWP published in 1991, the Working Group Report on Care for the Elderly in 1994 and the Study of the Needs of Elderly People in Hong Kong for Residential Care and Community Support Services by Deloitte, Touche and Tohmatsu International in 1997. Lastly, in the third stage, I assess 4 types of private home cases as reported in the newspapers in order to see the effectiveness of the provision. In the conclusion, I examine the Hong Kong welfare

182 regime in the context of filial piety, ethopolitcs and the relationship with the ageing

policy. The main argument in the chapter is that despite the different kinds of

government policy on the development of provisions for the aged, the traditional notion

of aged care by the family and the commercial sector were still the key providers.

Before proceeding to the 3- stages analysis, I will begin with a summary how ageing

policy and the private home sector developed in this period.

A summary of the development of the private home sector

In this period, the community care policy was dominant and was reaffirmed in the

White Paper in 1991, the Report of the Working Group on Care for the Elderly in 1994,

and the Deloitte and Touche report on the needs of the elderly (1997). Here, it is also

worth mentioning the 2009 Elderly Commission Report on residential care, even though

it is not in the period of this study, because it vividly portrays the image that '... in oriental culture, the elderly love to stay with their families instead of spending their time in elderly homes' {South China Morning Post, 6.1.2010). This illustrates the continuity of the notion that the family should be the primary carer for the elderly.

Despite the emphasis given to community care there was very little expenditure on community care services. The resultant lack of community support services to keep old people at home and the shortage of aged home places provided by the government 1 7 triggered the mushrooming of private commercial homes. In the mid-1980s, old people

17 According to the Five-year Plan Review in 1986, there were 14 multi-service elderly centres with a shortfall of 10 such centres; there were 111 social centres with a shortfall of 72; there were 50 home-help teams and the shortfall was 189; and there were 8 day care centres and a shortfall of 16. For residential services, there were 5871 home places and the shortfall was 590 places; there were 1434 care and attention home places and the shortfall was 1057 places. 183 in Hong Kong and their families were facing a lack of community support services and

had little choice when looking for an aged care home. This chapter aims to show that

the private residential home welfare policy was not effective and that the welfare market

was marked by 'scandal' and unnecessary harm to aged residents. The role of the Hong

Kong government as a regulator was not successful. Since the NGO voluntary sector

took up most of the care of the less dependent old, due to its admission criteria, the

private commercial sector admitted those who were frail and infirm as well as those

with dementia. The assessment mechanism had the effect of directing the healthy

service users to NGO homes and the frail and difficult ones, such as old people

suffering from senile dementia, to the private commercial sector.

The waiting list and the estimation of needs

In the last chapter, I noted that the government purchased 80 flats from a private developer to accommodate 480 elderly people. With the support of Helping Hand, an

NGO providing residential care only to the elderly, they made temporary accommodation available to about 400 old people, and through the Housing Society they also arranged rooms for the aged. However, these measures did not meet the residential needs of the old, and the shortage of home places encouraged business people to open private residential homes.

It is useful to understand the relationship between the waiting list for NGO aged homes, social security payments and private homes. As I mentioned in the last chapter, there were primarily four kinds of homes for the elderly. There were hostels for those who were able to live independently (phased out in 2003). Elderly homes were for those who could not live independently in the community, however they were capable of personal

184 and nursing care and could either cook their own meals or eat meals served by the

homes. Care and attention homes admitted elderly people who needed no more than two

and a half hours of nursing care per week. And, an infirmary accepted only those who

needed more than two and a half hours of nursing care per week (there were infirmary

units in both hospitals and care and attention homes, and there were also long-stay

hospital (infirmary) care services). By the early 2000s in addition to hostels, aged

homes, care and attention homes and infirmaries, there were nursing homes which were

located between the care and attention homes and the infirmaries. Nursing homes

provided services like those in care and attention homes together with rehabilitative

services, social support and personal care, not only for those with physical disabilities

but for those with mental disabilities (Chan & Phillips, 2002). The term ‘nursing home’

was introduced by the 1994 Working Group report and has been used regularly since

1997. These definitions are by no means without their problems and are misleading because nursing hours needed by older persons cannot be measured precisely and can vary from time to time.

In 1988, there were 7000 people on the official waiting list for aged homes (Chow,

1988). Therefore, the government had to make up for its prolonged inaction by improving the aged home places planning ratio, especially for the care and attention homes. The planning ratio for aged home admission improved from 4 places per 1000 people aged 65 and over in 1979, to 8 places per 1000 in 1988 (Chow, 1988: 1). In mid-1988, the government was able to subsidise 1500 care and attention home places, and 1000 infirmary places (ibid.). Given the severe shortage of government subsidised home places, many awaiting admission had to rely on their families or move into private

185 homes. Those living alone would most likely have to move to a private home if they

could not take care of themselves and if they could afford it.

In 1985, in the care and attention home waiting list review report (Review of Clients,

1985: 7), it was found that among the 2187 applicants, 719 (32.8 per cent) were living

alone, and 576 (26.3 per cent) were already in an aged home but were waiting to be

transferred. Among the 576 applicants already in institutions, 400 were from subvented

homes and hostels, 28 from transit shelters, 142 from private homes and 6 from Chai

Tong (vegetarian halls). In the 1988 review report on the care and attention homes

waiting list, Chow (1988: 51) argues that the central waiting list is unreliable because

among the 7000 applicants, about a quarter were no longer in need of care and attention

placement; they had either moved or were away from Hong Kong and their need still

had to be ascertained. Also, some had passed away while waiting for placement. The

SWD also said that many elderly people were not waitlisted, being unaware of the

service or withdrawing their application when learning of the severe shortage.

An important finding of the survey conducted by Chow is that when those staying in

private homes were asked whether or not they would enter a care and attention home provided by government should a place be made available, many answered in the negative (Chow, 1988: 52). Despite the poor image of private homes, some residents pointed out some of the advantages of private homes such as being smaller, being less like an institution and residents having more freedom in deciding their own way of life

(Fan, 1988; Chow, 1988: 53). This is an important observation of the role that a private home can play meeting the needs of some consumers. Relatively speaking, the services provided by NGO homes are of better quality and they are far more accountable than

186 the private sector homes. It is because NGOs homes have better staff and resident ratio

and their buildings are usually purposely-built. The paradox in Hong Kong is that not all

private services offer good value or quality. When the demand is great and government

regulation is indeterminate then the outcome of the quality of care is generally average

to poor.

The Code of Practice and governmental financial supportive schemes

From 1986 onwards, a private home was defined as a ‘business operation providing

residential accommodation with personal and nursing care services for old people in

private buildings and charging fees for the services’ (Code of Practice, 1986: 3). It

should be noted that the development of private homes during the early stages suffered

from a lack of resources and infrastructure. In sum, the regulation and governance were

weak. A private home is not simply a physical shelter, it also requires health and

nursing care staff. Like any facility, it requires safety standards such as fire exits and hygiene protocols. The private homes, although commercial businesses, required

financial support from the government. Residents in private homes can apply for the

Disability Allowance or Higher Disability Allowance and can pay these to the home operator as home fees, or to community nursing services. Through the Bought Place

Scheme (BPS) and Enhanced Bought Place Scheme (EBPS) the government also bought places from the homes. This was in the range of 1000 places. In 1986, the

Voluntary Code of Practice for Private Owners was issued and it was amended in 1988 and in 1999. The Code of Practice outlines the requirements and standard of care provision. A Bill for private homes was drafted in 1993 and was passed it into law in

1994, and revised in 1995.

187 As with NGO home residents, private home residents receive social security payments.

In 1986, residents could apply for the Higher Disability Allowance and in 1988 for the

Attendance Allowance (Chow, 1988: 54). With the introduction of the Bought Place

Scheme in 1989, private aged homes were directly financially supported by the

government for the first time. The BPS, underwritten by the Lottery Fund, was a new

initiative in the field of elderly services, but was an old practice in the field of education

(Sweeting, 1993: 130, 2005). The insufficient supply of places in both government and

subsidised schools led to the government buying places for students from the private

sector. Also, due to the shortage of health care workers in private aged homes, the

government implemented a scheme in 1991 to import health workers from Mainland

China. The government also supported the training of health care workers through the

NGOs.

Laissez-faire sentimentalism and reluctant interventionism

The early days of the private home sector were chaotic, with so many malpractice cases that the government instigated a voluntary registration scheme for the fast-growing commercial sector. However, in looking further along the development of the commercial sector, it should be noted that it was not only in the early days that scandals were the norm rather than the exception.

The malpractice cases were mostly problems relating to poor management of homes and abuse, as will be explained in the next section. As I mentioned, legislation took prominence in this phase compared to the previous two periods. It should be noted that the legislation meant to regulate the standard of care was not effective. Also, during the

188 early phase of development, the government’s attitude towards the private home care

sector was passive and only remedial when problems occurred. The government was

laissez-faire in its policies, leaving the matter in the hands of providers with different

backgrounds and motives, not necessarily those who were familiar with the provision of

social and health care. It was only when reports of poor food, improper use of restraints

and lack of privacy among the residents began to appear regularly in the news that the

government started to look for ways to tackle the problems. The government eventually

intervened by issuing the Code of Practice and said that the best solution to the problem

was to have self-regulation and self-discipline among the private home operators

(Minutes of Social Welfare Advisory Committee, 16.2.1988). In fact, the government

was facing a dilemma because the lack of NGO residential facilities meant that closing

substandard homes down would leave residents with nowhere to go.

Hong Kong government’s free economy and the private home sector

It is useful at this point to highlight the philosophy of the Hong Kong government’s economic policy and to show its compatibility with the private home sector. This would explain some of the difficulties facing the development of the sector.

According to the Heritage Foundation in the US, the Hong Kong economy is regarded as one of the least regulated economies globally (Wong and Luk, 2007). Public sector expenditure was 22.2 percentage of GDP in 2004 (ibid 187), and it does not have a general sales tax, minimum wage law (before 2011), antitrust or fair competition laws

(ibid, 181). During the early 1970s, the fundamental guiding principles behind the government’s financial and economic policies did not change despite the economic

189 take-off (Tsang, 2004: 171). Miners notes that the economic policy of the Hong Kong

government has hardly changed in its essential features for more than a hundred years

(Miners, 1989: 105). As seen in Chapter 2, the strong emphasis is on economic

development and maintaining a fiscal policy of a balanced budget and surplus reserve

(Holliday, 2001) The staunch support of the role of the market and minimal government

intervention as principles for the organization of society resembles the main features of

the 19th century laissez-faire liberal political economy thinking (Barry, 1990:9). In

laissez-faire economic terms, Hong Kong promotes 'a high degree of individual

economic freedom and liberalism, and an absence of severe government intervention'

(Li, 2006: 17). Laissez-faire economic philosophy considers individual freedom and

ownership as paramount. It also believes that government has some responsibility to

make 'provisions for those unable to participate in the free enterprise system' but not to

an extent that important elements such as 'individualism and work ethic are eroded by

social policies and redistributive fiscal policies (Haddon-Cave, 1984: xv). In this regard,

Esping-Andersen notes that in the eyes of laissez-faire popularizers such as Smiley or

Martineau 'social protection caused moral corruption, thriftlessness, idleness, and drunkenness’ (1990: 41-42). This kind of 'moral corruption' thinking can be easily

found in the pages of the social welfare white papers and ageing policy papers and they have played a significant role in the safeguarding of these values.

For the term laissez-faire, Bremridge, a Financial Secretary in Hong Kong in the 1980s considers it as an insulting term (Bremridge, 1984: xi). His successor Haddon-Cave describes it as a policy of 'positive non-interventionism' (Haddon-Cave, 1984: xiv) that the Hong Kong government practices selective intervention whenever it deems necessary.

190 The private home market is a latest development as compared with other social services

such as education, housing and medical and health, and with social welfare service such

as child care service. The availability of labour and skills, building and capital and some

support from the government all contribute to the development of the sector. The policy

of private or commercial aged care is compatible with the economic policy of the Hong

Kong government.

It is, therefore, no surprise to find that according to the minutes of the Social Welfare

Advisory Committee (SWAC), the key social welfare advisory body in Hong Kong, the

policy aimed at the private sector was 'positive', providing services (to the aged and

their families) and at the same time keeping them in business (SWAC, 1988). Concern

was expressed about whether an allowance should be paid to residents in private aged residential homes as was the case in the voluntary (NGO) sector. The Social Welfare

Department confirmed that this was already the practice, but the arrangement was not widely publicised and was only made available if the client could not cope with their situation despite the provision of home help and other services (SWAC, 1986). The

Higher Disability Allowance was paid to assist with expenses entailed in maintaining constant care and attention for those in private homes.

By 1988, the commercial care sector was already a key stakeholder in residential aged care, providing more than half of the home places for the elderly. Therefore, even if problems did arise in the sector, the government had to tolerate them because of its inability to take up the work of the private commercial sector. From this angle, it was a policy of toleration or at worst indifference to 'commercial exploitation' coupled with a

191 policy of commercial compromise. The subsidy to private homes was also contentious

because of the argument that the government was using public money to finance

privately run commercial activities. Overall, the policy succeeded in creating a sphere of

care that was not directly accountable. As in the previous two periods, the Hong Kong

government was reluctant to involve itself in the direct provision of residential care for

the old. However, it is not accurate to say that the government did nothing and left the

matter in the hands of the families needing care. As mentioned above, through the

Higher Disability Allowance subsidies were available to these families but the scheme

was not publicised and the general public usually did not know it was available.

Private home survey by the Association for the Rights of the Elderly in 1986

In 1986, two surveys on private homes were carried out, one of which was conducted by

the Association for the Rights of the Elderly. The other was conducted by the SWD.

With the assistance of the Association of Private Home Owners, ARE distributed an

80-item questionnaire to 96 homes out of a total of 192. Some of the background data regarding their clients were made available. Among the 443 respondents of private home residents, 27.1 per cent were aged between 60 and 74 and 72.9 per cent of respondents were aged 75 years old and above (Kwan, 1988: 4). More than half of the homes had 40 residents, while a little more than a quarter had less than 20. More than two-thirds of the residents were females and all had lived in Hong Kong for more than

40 years. Sixty per cent of the residents had been sent to the homes by their families.

Twelve per cent entered homes after discussing the matter with their families, and 12 per cent made their own decisions. Before admission, 70 per cent were staying with their families while the remaining 30 per cent were living alone. In terms of kinship, half of the respondents had family members and 18.5 per cent were entirely without

192 relatives. Ninety per cent entered a home because no one could take care of them. More

than half of the respondents had been residing in private housing, while 25 per cent had

been living in public rental housing. Over half had weekly visits by their relatives and

15 per cent had visitors every month, with the frequency of visits depending on the

amount of medical attention they needed. In terms of financial support, 66.8 per cent

were being paid for by their immediate families, 11.7 per cent by their relatives and 14

per cent were on public assistance. Sixty per cent of the residents paid HKS2500 or

more a month for their places and 20 per cent found it difficult to pay the charges. More

than 60 per cent of the respondents required more than five hours of medical care in a

week. Over half required some assistance, 26.2 per cent were capable of self-care and

17 per cent were totally dependent.

Private home survey by the Hong Kong government in 1986

The government also conducted its own survey of private aged residential homes in

1986 with the aim of determining how the operations complied with the standards of the

Code of Practice in terms of the category of occupancy (according to care and attention home and infirmary), monthly charges, standard operating cost, space requirements,

staffing, and safety and fire precautions. Since this was the only survey conducted by the government and was meant to be the yardstick for the design of home standards, a detailed account is given below.

The 192 homes, which had a total capacity of 6823 beds, were occupied by 5204 clients.

According to the categories of self-care, meal service, care and attention, the infirm, the intellectually disabled and mentally ill, it was found that 52 per cent required care and attention and 17 per cent needed comprehensive care and were accommodated in an

193 infirmary. (As noted earlier, care and attention homes mean that people staying in them require less than two and a half hours of care per week, and infirmaries are residential facilities for those who require more than two and a half hours of nursing care per week.)

The average monthly fee was calculated to be HK$2195, with the lowest monthly fee of

HK$450 in a home operated by a workers’ union, while the highest fee of HK$ 12,000 was charged by a home in Kowloon where private rooms were available. The fee is mainly determined by the level of personal and nursing care offered to the residents, the physical environment and the location of the home. Based on the calculated average monthly charges of HKS2195, operating a home of 40 places (the average size of a home) in accordance with standards set by the code and based on different geographic locations, allows a profit margin of 20 per cent against the standard operating cost

(Kwan, 1988: 85).

The survey was concerned with two types of staffing — nurses and personal care workers. More than 78 per cent of the homes employed nurse’s aides while only 16 per cent had registered or enrolled nurses. 'Nurse’s aides' are unqualified nurses and

China-trained nurses, while registered and enrolled nurses are those with qualifications recognised by the Hong Kong Nursing Board. Under the general category of ‘nursing staff, which includes both groups, 78 per cent of the homes provided adequate staff.

The survey concluded that the majority of homes complied with the staffing ratio of

1:20 for nursing staff. Personal care workers were at the ratio of 1:7 residents, and 43 per cent of the homes complied with the standard. Government subvention-subsidised homes with care and attention cases were provided with personal care workers to attend to the daily living needs of frail old people, such as feeding and bathing, whereas self-care and home cases were not provided with personal care workers. It was

194 suggested that personal care workers be exempted in private homes for self-care and

meals. It should be noted that in the planning discussion session action was taken to

reduce the threshold of the requirement for the social and health care human resources

standard for private homes. The minimum standard for manpower is one of the major

reasons why malpractice is no stranger to the private home. This will be shown in the

next section. The salaries of experienced nurses and skilled personal care workers are

high in Hong Kong.

Under the code, the Director of Fire Services recommended that old people’s homes

should not be situated higher than 12 metres above ground level. Seventy-eight per cent

of homes met this requirement. Only 90 homes (50 per cent) were considered to have an

acceptable standard of fire-fighting equipment, exit routes and fuel storage. The survey

also suggested that homes located in the New Territories should be accessible by a

4.5-metre wide paved road for emergency vehicles. The survey also covered areas like health care services, equipment and furniture, social care, and business registration, but they were not closely examined. With regard to health care provision, most homes observed the requirements on general hygiene and sanitation, except for physical check-ups of residents prior to admission and scheduled visits by a registered doctor.

The reason given was that such practices would increase their overheads, thus undermining the profitability of homes. In the area of social care, little information was gathered on the kind of programs and activities organised for the residents. Shortage of staff was experienced in some homes while indifference to the need for social care was noted in others. Lastly, those homes without business registration were to be notified. In

1987, 23 out of the 192 homes (12 per cent) did not have business registration.

195 In the review of the Code of Practice, doubts were raised regarding the proposal to

reduce standards in order to aid compliance, as this would be a retrograde step and

therefore consideration would be given to fee assistance and ‘buying’ places from the

private sector. The Social Welfare Department warned that it could not commit the

government to such proposals but said that a subsidy scheme for NGOs, such as

Helping Hand, indicated a possible assistance model (SWAC, 1988).

The review also resolved the disagreement regarding space requirements. It proposed

that two standards should be adopted: one for homes with care and attention places and

the other for non-care and attention places. It also agreed that the ultimate objective was

to legislate, but care should be taken in deciding when and how to do this. In the review,

the Director of the SWD remarked that legislation should be seen as the stick to

accompany the carrot of voluntary registration and incentives. She noted that while

there was nothing wrong in making money from providing homes for older people, they

had to offer value for money and decent care, and legislation would ultimately be the

only way to ensure this (SWAC, 16.2.1988). Lastly, it was suggested that the

Association for Private Home Owners participate in the drafting of the legislation for

their own operation. In 1988, after the completion of the review, the Registration Office

of Private Homes for the Elderly (Licensing Office) was established to provide advice

and guidance to operators of private homes for the elderly in accordance with the Code of Practice.

Due to the frequent exposure of private homes in the news during the review, a company called the Nanhoi Oil Mass-Establishment Development Company submitted a proposal to the SWD to seek a land grant from the Shenzhen Authority, People’s

196 Republic of China, to build a private home for 1240 old people, expected to come from

Hong Kong. This proposal added a new dimension to the care of Hong Kong’s elderly,

which involved the question of whether social security payments should continue for

those who had left the territory for more than 90 days. The abandonment of the 90 days

rule finally came into effect in April 1997. The Nanhoi Oil Mass-Establishment

Development Company plan never materialised.

Based on the findings of the 1987 SWD survey, the government worked out a

categorisation of the types of care provided by the private sector. In August 1989, the

SWD announced the details of the experimental Bought Place Scheme of residential

places in private homes, and operators were invited to participate. Speaking at a press

conference, the Assistant Director of Social Welfare said that $30.6 million from the

Lotteries Fund had been allocated to buy up to 500 places (2 per cent) in private old people’s homes in a two-year period. He commented that the primary objectives of the

scheme were to provide financial incentives for existing homes to improve their

service’s standards and to encourage the setting up of new homes to create additional places for elderly people (South China Morning Post, 11.8.1989). The amount for the

500 places was not meant to pay for the individual residents who were staying in the homes, but was a sum of money given to the homes.

The Bought Place Scheme was important to the home owners because it would provide them with secure financial assistance and profits. The week before the meeting, a television station aired a programme on private homes, and owners were interviewed regarding their experiences and aspirations. The general message was that a private aged home operation is not as easy as it seems and owners were looking forward to the

197 government’s financial support of (Television programme, TVB, 12.6.1987). There was

a strong feeling of disappointment from owners who were not on the BPS. They felt

they were being cheated because the financial assistance was too little and merely

cosmetic. However, even if the subsidy was not a huge sum, most if not all the operators

would like to join the scheme. One operator complained about a substandard home

listed on the BPS which was not attended by a physician, had many empty places and in

which a resident committed suicide by hanging herself. It should be stressed here that

80 per cent of the residents in private aged homes were recipients of public assistance

(Cheng & Chan, 2003:411).

However, the SWD was not the only government department dealing with the

commercial home sector. The Department of Fire Service, Building Department,

Immigration Department and the Ambulance Services were also involved in the

operation of homes. The participation of these government departments was to ensure

the quality of care in aged care homes.

The Fourth Social Welfare White Paper 1991

The fourth Social Welfare White Paper (1991) Social Welfare into the 1990s and

Beyond was the last SWWP published during the British administration. Unlike the other three SWWPs, it uses the term ‘dependency culture’ which was popular in the US and UK. It argues that:

the challenge for Hong Kong is to improve the services without creating the

sort of dependency culture that has emerged in some developed

industrialised societies, a phenomenon that removes the incentive to work

and undermines the productive engine of the economy (1991: 14). 198 It goes on to say that:

The Hong Kong welfare program has been designed and developed with

cognizance of the innate local values of concern for the family, commitment

to self-improvement, self-reliance, mutual support and generosity,

reluctance to be dependent upon 'welfare', a high respect for social order

and a combination of ingenuity and resourcefulness (ibid. 14).

Regarding Chinese culture it says that:

The roles of social networks are part of the Chinese culture and tradition and

have always existed in Hong Kong. They are most clearly demonstrated in

the role of the family as the primary providers of care and welfare and by

the contributions of clansmen associations, neighbourhood organisations

and volunteers (ibid. 18).

The paper also says that the concept of fee-charging should be expanded and argues that it allows clients or users to make a contribution and discourages misuse of services (ibid.

42).

Report of the Working Group on Care for the Elderly 1994

The Working Group on Care for the Elderly 1994 was the second report of recommendations for the development of aged services (SWD, 1994). The first was published in 1973 and it is interesting to note that the ideas in these two reports are similar, except they have new wording. In the section under ‘basic principles and policy objectives’ it says that the working group evolved the following concepts as pivotal to the provision of services:

199 • the dignity of elderly persons: the dignity of older persons in society must be recognized and respected; • ageing in place - care in the community: appropriate support should be provided for older persons and their families to allow old people to grow old in their home environment with minimal disruption. The concept of 'ageing in place' otherwise known as care in the community is key to the existing philosophy of providing services for elderly persons. This has served us well in the past; • continuum of residential care and integration of service: where it is not possible to enable older people to 'age in place', a continuum of care is to be provided with minimal duplication of services; • people based approach and partnership between the public, subvented and private sectors must be encouraged and recognized {Report of the Working Group on Care for the Elderly, 1994: vii and viii).

It also states that 'in Hong Kong, the family remains the chief provider and supporter of

elderly people and the Chinese have traditionally relied on themselves and their families

for assistance in times of need (ibid. 50). This report differs from the one in 1973 in that the argument of the 'caring for the elderly by family members within a family context' is explicit (ibid. ix). It continues to say that 'the philosophy of care in the community has served us well in the past', reiterating the second point above.

The report also suggests having a nursing home that can provide an intermediary type of service between the care and attention home and the infirmary, and that the infirmary units in care and attention homes should be phased out eventually (ibid. xv). It proposed building seven nursing homes with a total of 1400 places scheduled to be opened in

1997 (ibid. 104).

200 Another related interest is fee charging. The report said that it would follow the 1991

White Paper’s suggestion to further develop fee charging. By doing so it would allow

well-off clients to pay for a service they need and were prepared to pay for. It also

discouraged the misuse of subsidised services (ibid. 154).

Voluntary registration and its aftermath 1988-1997

The quality of care in the private home sector relies on the observation of the Code of

Practice and the Residential Care Homes (Elderly Persons) Ordinance, 1994. The Code

of Practice is voluntary and does not have any binding legal power. In a sense, the

coercive power of the ordinance resembles the Code of Practice because both were

made ineffective for a period of three years up until 1999. This was justified by the

argument that if the government went too far, it would drive substandard homes out of

business, and the residents would be made homeless. The short-term measure was to

issue a license for homes that complied with the standards of the Code of Practice, or a

certificate of exemption, which would last from a few months to a year. Homes with

certificates still had to make changes, including improving fire safety and reducing the number of residents, in order to be granted a full license. In June 1996, 69 of the 595 homes registered had been granted licenses. Another 506 were given exemption certificates lasting from a few months to a year. The situation did not improve much during this period.

Cited below is a summary of 12 incidents that took place between 1988 and 1997 (with one case in 1998 and two cases in 1999) which give a glimpse of the reality of service provision during the operation of the voluntary Code of Practice. These cases were reported in the press and most were from the private homes, with a few from the NGOs.

201 One of the reasons why most malpractice cases were found among the private homes

was because proportionately 70 per cent of home places were in the private sector.

Secondly, the private home sector was at the receiving end of cases that NGO homes

refused to admit. Thirdly, private homes were far more concerned with running costs

and profits while the NGO homes were backed by the government and the community

groups that sponsored them. Lastly, NGO homes employed qualified and trained staff

whereas the private home sector could not attract qualified people or made little effort to

employ trained staff.

Senile dementia cases

Case 1.1

In March 1988, an 85-year-old man was found chained to his bed in a private home.

The supervisor and two nursing staff were charged with assaulting the resident. Initially,

the three staff were acquitted because the crime did not amount to a willful or reckless

use of force. However, due to public pressure, the case was given another trial on the

grounds that there was no provision for an institution to chain up a person night after night. The owner explained that the old man was demented and unmanageable and since admission he had been suffering from irrational outbursts of violence and conducting dangerous acts to himself and other residents. They tried to isolate him once but he broke a window and escaped from the home. The only solution was to provide restraining devices. Cloth strips and vests were used but the client continued to misbehave and their last resort was to chain him. Finally, it was ruled that 'chaining was a misjudged (unsuitable) method of restraint but the force used was not an unlawful'

(South China Morning Post, 2.7.89).

202 Case 1.2

In 1996, a 70-year-old woman suffering from dementia spent four days semiconscious

in a ditch near her aged home. The operators say they plan to build a higher fence to

stop residents from 'escaping' but social workers have called for more health workers to

care for the elderly patients. Social workers fear a similar incident could happen unless

the government speeds up staff training and provides better care for those suffering

dementia (South China Morning Post, 11.4.1996). The home had failed to get a licence

because of lack of health care workers. A 12-month certificate of exemption had been

granted to the home to upgrade its provisions.

Case 1.3

In 1997, a 67 senile dementia wine-drinking resident thought he was Buddha and

wanted to die after being accused of battering an 80-year-old man to death with a toilet

seat. He was acquitted of the charge of murder and it was ruled that he was not mentally fit to stand trial (South China Morning Post, 18.12 1997). The accused has three children and a grandson living on the Mainland, but has no relatives to look after him in

Hong Kong. The defendant’s barrister said the case was 'sad and tragic'.

Case 1.4

In 1998, an 80-year-old demented woman was sexually assaulted by fellow residents in a home for the elderly (South China Morning Post, 11.5.1998). The woman moved into a four-person room at the home two years ago and had been molested on several occasions. It said that the woman has a 'strange' habit of taking off her clothes. The molesters were warned when discovered by staff but no disciplinary action was taken against them. A staff shortage led to them deciding to tie the woman to a chair to

203 prevent her wandering into areas where other residents could assault her. The incident

was described as 'the tip of the iceberg'. The Hong Kong Council of Social service task

force on the demented elderly to call for a special unit within care homes to be set up.

An editorial column titled 'Society’s Shame' was also published about the incident

(South China Morning Post, 11.5.1998).

All these cases call for a special unit for demented residents within care homes and for

an improved staffing ratio and training for carers. The use of restraint is common among

homes and is reported that nearly 20,000 elderly residents (about one-third of the total

aged home population in 2004) are restrained (Ming Pao Daily, 2.8.2004).

2. Homes closed due to business failure

Case 2.1

In February 1993, the owner of a private home who was unable to pay his rent for a

period of six months — he was HK$30,000 in arrears — applied to the court to be

declared insolvent. The operator explained that the home was set up in 1990 with a monthly rental payment of HK$52,000 and could accommodate up to 60 residents. The rate of occupancy had been low and he only managed to find 30 residents. In the winding up of the home, the operator requested assistance in finding placements for the residents. The SWD made it clear that this was a commercial dispute and therefore the department would not get involved. However, after an investigation of the matter it tried to help the residents find places. Of the 30 residents, 8 were on public assistance (Ming

Pao Daily, 16.2.1993).

204 Case 2.2

In 1 February 1999, a 52-year-old private home owner hanged himself inside his family

apartment. He was survived by his wife and three sons. In a note he left his family, he

stated that he had borrowed HK$3 million from his in-laws and godfather and had spent

it all on the renovation of his three-storey home, yet the government could only provide

him with HK$400,000 (Apple Daily, 1.2.1999).

Private home finance is volatile and also closely related to the macro-economic

environment. Rent is their major expense and if they cannot recover the cost from the

users they could be vulnerable. Homes run by individual operators are far more

vulnerable than homes run by companies with sound financial backing.

3. Arson and outbreak of fire due to accident

Case 3.1

In 24 Junel993, a gang of three threw Molotov cocktails into a private home with 30 residents, killing 2 elderly women and injuring 6 others. After hurling the firebombs into the home, they pushed blazing sticks through the grille door to ensure the rapid spread of the fire. The fatal attack happened just three weeks after a change of ownership. In police statements, Ho, 20, and Liu, 18, said they were asked to start the fire because the home’s proprietor had allegedly offended their boss and neither youth had realised that there were people in the home. Police hunted for the other man whom they believed was responsible for planning the attack. In 1994, when the missing defendant was found, they all stood trial. The person who masterminded the arson was convicted of murder and jailed for life and the other two were convicted of two counts

205 of manslaughter each and were sentenced to 12 years imprisonment (Ming Pao Daily,

20.7.1994).

Case 3.2

In August 1999, two fires occurred due to accidents. An electric fan in an expensive

home overheated and caused a fire. No casualties were reported (Ming Pao Daily

20.8.1999). Another fire occurred inside a cake shop, which was located on the ground

floor of a multi-storey building. Altogether there were four private homes above the

shop and residents had to be evacuated (Ming Pao Daily .25.8.1999).

Just after the arson case, in a survey conducted by the Fire Service Department in 1993,

nearly all private homes were found to be substandard and a few were even considered

death traps (Ming Pao Daily, 25.8.93). Except in some areas of the New Territories and

some up-market neighbourhoods of Hong Kong Island and the Kowloon peninsular,

where homes are in low-rise buildings, most are located in multi-storey buildings in

congested and densely populated older urbanised areas.

The outbreak of fires in aged homes resulted in tightening up the requirement of having smoke detection systems in homes, which added to the operation cost of homes. Private aged homes had been regarded as a 'social nuisance' since their emergence and people tended to look at them with the 'not in my backyard’ attitude. Following a court case in

2004, buildings had to have specifications on whether they could operate as private aged homes.

206 4. Standards of care: food, fights and the ‘seven deadly sins’

Case 4.1

The shortage of staff in homes could make close supervision difficult. This was

especially true among those clients without natural teeth who had difficulty swallowing

and could choke on food easily. Between November 1987 and May 1988, seven cases

of elderly residents were found at the coroner’s post mortem to have died from

asphyxiation due to choking on food (Woo, 1988: 37). This suggests that there was of a

shortage of adequately trained staff. Woo raised doubts about the possibilities of

avoiding such problems in the health care framework (ibid.). In other words, Hong

Kong’s health care system is ineffective. In 1998, 49 out of 56 asphyxiation cases

involved elderly victims. A year later, in 1999, a coroner maintained that training for

health care workers should be improved in order to tackle problems relating to

swallowing difficulties (Ming Pao Daily, 31.8.1999).

Case 4.2

Food poisoning was also found in old people’s homes. Between March 1998 and June

1999, four cases of food poisoning were reported to the SWD (Ming Pao Daily,

22.6.1999). It is suggested that there should be close working relationship between the

Health and Social Welfare Department. Among the official cases, three were from government subvented homes and one case was from a private home of the commercial sector. These were official cases and there may also have been unreported cases.

Case 4.3

207 Assaults of residents by staff, and staff and residents’ family members were not

uncommon. In one case, a health care worker was so angry about a resident’s foul

language that she beat him with a plastic club. The resident told his wife and she

complained to the home operator. When the health care worker found out about the

complaint, she beat the resident again till his mouth bled. The case was eventually

brought to court and the health care worker had to pay HKS2000 bail and was placed

under a 12-month supervision order (Netvigator Daily News, 22.1.1997).

Case 4.4

Graduates from the employment retraining scheme of the Confederation of the Hong

Kong Trade Unions organised a press conference because they were so angry about the

poor level of care they had seen and experienced during their fieldwork placements in

the commercial sector. They accused some of the private homes of the 'seven deadly

sins' as described by the media. These seven kinds of malpractice include the gross

neglect of the privacy of the residents such as group bathing, to clean resident’s body with the brushes which also clean the toilet, over-use of restraint, lack of safety, workers not having knowledge of first aid, the standard of the food and feeding and finally, lack of human resources (Oriental Daily News, 30.8.1999).

The four cases reveal the dark side of the private home welfare market. It is caused by a shortage of trained staff, a poor employment policy and attitude towards aged home care.

It was, therefore, not surprising when Dale Stevenson, a former Australian government official who now works as a consultant in Hong Kong and elsewhere on health and care for the aged commented that '... [Hong Kong] is economically in the First World, the

208 Standard of care given to the majority of old citizens is poor by First World standards'

(South China Morning Post, 18.4.1999).

Conclusion

In this period we note of the simultaneous development of both the community care and

commercial care policy. The limited supply of aged home places, the decline of a

traditional social support network together with an increase in the of ageing population,

and the availability of labour and building that under such favourable conditions that the

private home sector begins to take shape.

The long waiting list for NGO homes, the call for self-discipline by the government to

the private home operators, the issue of the code of practice for the residential care

service, the assessment for NGO home admission, and subsidies for the aged home providers and the users are different kinds of measures in the management of the residential care population. Most of these measures are meant to control the number of aged home admission with the key purpose of cost saving because of the need of abiding to the prudent fiscal policy. It is too early or difficult to mention perfect implementation about the private care sector. However, from the consumer’s viewpoint the chaotic situation of the private aged care industry is discouraging.

During this period, the 1991 White paper continues to promote the Chinese cultural values of family care, self-improvement and self-reliance. For the first time the White paper talked about 'dependency culture', a term which is new to Hong Kong but not with the ethos of the Hong Kong Chinese. It is because people do not usually consider depending upon the government for benefit. As a consequence, there is a strong cultural

209 economy of ageing within the general population with support by the family. In similar

vein, the 1994 working group on the care of the older population explicitly expressed

the significance of family care and social networks.

Given the continuous support for the value of family care, it would be helpful at this

stage to look closely the meaning of filial piety and its relationship with aged care

policy. The continuous support of the policy of the 'care in the community' over the

years has the effect of contributing to the centrality of tradition as noted earlier. The

value of xiao or filial piety is a complex web of ideas and relationship. Some

background information about xiao is useful. In agrarian society, xiao became the basis

of a socio-economic institution of reciprocity between generations. There is a traditional

Chinese saying ' to raise a son so as to have protection during one’s old age'.

Confucians also promotes filial piety to the summit of all virtues and it’s an act that

associates with descendants with ancestors and parents (Yao, 2000: 202-203). Xiao is

not only family-based but is also an act of expression reaching out to other members of

the society who are needy and less fortunate. Xiao has a close relationship with other

values such as ren (benevolence or humanity) and yi (righteousness). Buildings and monuments have been recreated to remember those who performed the great story of xiao. In brief, the practice of xiao is considered as act of a model citizen.

In Hong Kong filial piety is subtly expressed in its ageing policy. The ageing policy at one level aims for the 'conduct of conduct' (Foucault, 1991; Gordon, 1991: 48).

Through its policy the government promotes the value xiao so that people can act according to the virtues of the policy goals. At another level, the government through other policy measures such as to have children to make declaration for not supporting their parents before the parents can apply for public assistance, means-testing or

210 screening, makes sure that xiao can be practiced and that people will care for their

ageing parents rather than let them be neglected.

The practice of ethopolitics as proposed by Rose (2001) is another way to explain how

xiao is carried out. Instead of focusing on the Foucauldian disciplinary power,

ethopolitics 'work through the values, beliefs, and sentiments thought to underpin the

techniques of responsible self-government and the management of one’s obligations to

others' (Rose, 2001: 5). With ethopolitics and the goal of filial piety, the values of

self-perfection, 'shame, guilt, responsibility, obligations, trust, honour and duty' are

'forces that bind individuals into such groups and relations' (Rose, 2001: 5). Ageing

policy or social welfare policy with values of 'community care' or 'good tradition of

self-reliance' are examples of ethopolitics. The debate about who should support older people, families or the state is an example. The debate between action groups for old people and the government is another.

Filial piety or familial care is an expressive action. The implication of the expressive dimension is the affective elements of sentimental education and sentimental citizenship.

In a different direction in societal development, filial piety is encouraged throughout the social body of Hong Kong. It is the docile body (Foucault, 1978: 135) and the willful self (Maasen & Sutter, 2007: 6) which constitute filial piety as acts of docility. Familial care is able to cultivate the sentimental aspects of cultural citizenship. When referring to the distinction between formal and real citizenship (Chatterjee, 2004: 4), cultural citizenship in Hong Kong is not formal but real, and is the lived experience with one’s own family members.

211 Chapter 8 Community Care and Commercial Care: Phase Two The Hong Kong Special Administrative Region (1997-2007)

Introduction

In Phase Two of the Community Care and Commercial Care Phase of the Hong Kong

Special Administrative Region (1997-2007), the discussion revolved around the

introduction of the different schemes and programmes and their evaluation by different

stakeholders. Phase Two is divided into two parts. Part One is between 1997 and 2005

and covers the Tung Chee-hwa Administration, and Part Two covers the period between

2005 and 2007 when the Hong Kong government was presided over by Donald Tsang.

Before examining the ageing policy under the administrations of Tung Chee-hwa and

Donald Tsang, I will first briefly introduce some aspects of the society of the Hong

Kong Special Administrative Region and its welfare provision. Secondly, for Tung’s

administration (1997-2005) I will examine the key features of ageing policy provisions such as the Elderly Commission of 1997, the mandatory provident fund scheme of 2000, the Lump Sum Grant subvention system and an Audit Report on residential care from

2002. Thirdly, for Donald Tsang’s administration, I will examine the visit to a clinic by the Chief Executive Donald Tsang and the debate on long-term care (LTC) in the

Legislative Council Welfare Panel in 2005. At the end of the chapter is an analysis of elderly news according to Ming Pao Daily from 1999 to 2006. The discussion aims to present the nature of elderly people’s stories as reported in the newspapers. In the conclusion, I will examine the welfare model of the government of this period. The following analysis is also based on a three- stage analysis including the position of the government as expressed through policy and statutory bodies, debates, and evaluation of

212 the policy in different panel meetings and newspaper reports. Before turning to Part One

I will examine some aspects of the Hong Kong Special Administrative Region society

and the ageing policy.

Some aspects of the Hong Kong Special Administrative Region society and the

welfare provision

This phase (1997-2007) witnessed the return of Hong Kong from the UK to China. This

was a significant moment in Hong Kong’s history and China was eager to prove it had

the ability to manage Hong Kong as well as its predecessor. It soon became apparent

that Hong Kong faced both internal and external risks. Despite the smooth transition,

the newly established HKSAR government encountered serious internal problems such

as the logistics of the opening of the new airport in July 1997 right after the handover, and bird flu from late 1997 to early 1998 and then again in 2003. Hong Kong’s economy was hard hit by the Asian financial crisis from October 1997 to February 1998.

It was not only aged home places that became a commodity, but some community support services such as house cleaning usually financed by the government, were available to those who were willing to pay. For older people on social security, the charge was HK$5 an hour for household work, or for an escort service to attend a medical consultation. The NGOs also charged HK$11 and HK$18 per hour depending on the income level of the applicant. The commercial agency would charge HK$50 to

HK$60 an hour for a similar service. By 1997, Hong Kong had entered a market-oriented phase of welfare development, echoing the emergence of an aging enterprise as noted by Estes (1979) in the US. In this regard, the Hong Kong government, apart from being an enabler, played a minor role as a provider, and was

213 also a regulator targeting the social care industry. However, the private aged residential

home sector is not consistently a reliable partner, and malpractice and aged home

incidents reflected the failure of the welfare market, the lack of choice for the aged

home consumer and the ineffectiveness of the administration of aged homes.

In the field of social welfare, Hong Kong faced the problems of an ageing population, a

widening wealth gap and a rising demand for better and more service provision (Chau

& Wong, 2002: 202). However, it was argued by the ruling party that the government

had to tighten its budget to maintain financial sustainability and economic

competitiveness in view of the global economic downturn (ibid.). With these

contradictory demands, the HKSAR government introduced an increase in public housing units, a new social welfare subvention system, the Mandatory Provident Fund

(MPF) in 2000 and changes to the Social Security Assistance Scheme. These changes appeared to be politically motivated to meet the high public expectations of the post-colonial state, as well as to enhance the state’s legitimacy and capacity.

I will firstly outline some of the new features of welfare provision of the first part of this period. They include the Elderly Commission, the Lump Sum Grant Subvention System

(LSGSS), the service user assessment mechanism, training services, the personal emergency alarm link, the influence of Chinese ideas and the revamping of community and aged home services.

214 Part One Tung Chee-hwa Administration (1997-2005)

Introduction

In this section, I first examine the Deloitte’s report on the needs of elderly people, then

different kinds of initiatives, such as the establishment of the elderly commission, the

mandatory provident fund, the lump sum grant subvention system, the standardized

needs assessment mechanism, grant applications and training and the 24 hour personal

emergency alarm scheme. Lastly, I will examine the revamping of community support

and aged home services and its evaluation, and the 2002 Audit Commissioner Report on

residential care for the older people. At the end of this section is an evaluative summary

of Tung’s administration’s performance on ageing provision.

Study on the needs of elderly people in Hong Kong 1997

During Patten’s governorship, which was the last under British colonial administration before the return of Hong Kong to China, a consulting company, Deloitte and Touche

Tohmatsu International was invited to conduct a needs study of the elderly living in the community and in residential care (Deloitte & Touche, 1997).

The report concludes that due to an expanding aged population, the government needed a policy and planning framework to ensure that the care needs of the elderly are met. It also says that the reason for this study was due to a recommendation from the Working

Group on Care for the Elderly in 1994. This exercise was to assess both community and residential care needs, and to review and formulate the planning ratios for such services.

It aimed to propose whether and, if so, how current services should be modified or replaced by new services. In line with the financial mentality of the government, the

215 study would examine cost-effectiveness and options like fee-charging and self-financing

services (ibid. 1).

There were several important findings in the study. Hong Kong had a relatively healthy

and self-sufficient community of elderly people. In regards to care the report found that

four per cent of the elderly in the community needed assistance with more than one

activity of daily living (ADL) (ibid. 22). There were relatively more people with higher

grades of impairment in privately run homes than in subvented care and attention homes.

A proportion of residents in residential care had no or few physical and mental

disabilities. Of people in homes for old people (mostly of whom are healthy with

self-care abilities), 82 per cent required no assistance with ADLs and had no cognitive

impairment. Only 24 per cent of people in care and attention homes required no

assistance with ADLs nor had any cognitive impairment. There was scope for

're-profiling' the residents. The community survey identified strong family support for

the elderly in the community. The study found that most care for elderly persons in

Hong Kong is provided by informal carers, mainly family and 88 per cent of the elderly

in the community were living with a spouse. There was a lack of awareness among the community of formal services (ibid. 26). Home help services in Hong Kong were provided to less than 1 per cent of the population aged 60 or above. Hong Kong appeared to be providing a significantly lower level of home care than other developed countries, especially given the expressed policy of ageing in place. The study urged the government to stop providing hostel provision and to have the residents stay in the community for as long as possible.

216 The establishment of the Elderly Commission in 1997

When the new government took centre stage it established the Elderly Commission (in

1997), which consisted of representatives from government departments, professional

bodies, academia, NGOs and business. According to Chan and Phillips (2002: 25) this

was important because prior to the Tung Chee-wha administration (1997-2005) there

was no ageing policy, if 'policy' is taken to mean a coherent conceptual framework

linking different practices to achieve a goal or mission. The establishment of the Elderly

Commission in Hong Kong facilitated coordination between the different service

departments and respective policy areas. It was clear that 'the needs of the ageing

population cannot be dealt with by a single department such as the Social Welfare

Department' (ibid.). The needs of older people are diverse and a dignified later life

includes at least the basic necessities in terms of housing, medicine and health care. In

many ways the Elderly Commission contributed to better coordination of government departments, according to Phillips and Chan. The latter was the vice chairman of the

Elderly Commission. It meant that policy change was mainly top-down. Participation in the policymaking process through the Elderly Commission was mainly professionally based, with little participation from the service users like grassroots older people.

In this phase, traditional Chinese ideas were used by the first Chief Executive, Tung

Chee-hwa, to describe service provision. According to Tung Chee-hwa 'the special administrative region government will develop a comprehensive policy to take care of the various needs of our senior citizens and provide them with a sense of security, a sense of belonging and a sense of worthiness' (Tung, 1997).

217 According to Tam Yiu-chung, the first Chairman of the Elderly Commission:

it enabled a more thorough exchange of views and co-ordination of elderly

policies amongst the government departments. The elderly policies are designed

to meet aged people’s needs in care, housing, financial support, health, psychiatry,

employment, and recreation' (Tam, 1998: 6).

Tam also said that he understood the concern of the aged care group and that those who work at ground level were not members of the Elderly Commission, thus hampering efforts to hear directly from elderly people themselves. He said he would set up specialised groups and involve organisations and social workers at various levels.

As for the ‘sense of security’, he said it was important to provide elderly people with financial security so that they could maintain relatively comfortable living conditions.

He said medical services, home care and food were factors contributing to a sense of security. As for the goal of ‘a sense of belonging’, he said high rents often forced young people to separate from their elderly family members. He quoted Chief Executive Tung

Chee-hwa’s remark that 'the government will through a public housing priority plan, encourage family members to live with their family members in order to provide them with “a sense of belonging”' (ibid.). In relation to this goal, support would be given to day care and respite services, to shorten the waiting time for residential home placement, to review the length of stay in China and the 'portable comprehensive social security assistance scheme' for those who wanted to live in China, and to study the feasibility of living in China. The final goal of the ageing policy is a ‘sense of worthiness’ — productive ageing. It aimed to provide activities that gave the elderly healthy bodies and

218 minds so that they could continue to make a valuable contribution to society. He cited

the example of volunteer work and the training and expense allowances provided, so

that older people could participate in the community, with benefit for those who helped

them. He also talked about the importance of Chinese tradition, that 'if we were not to

build this moral value of ours, all our efforts in providing elderly care will come to

nothing' (ibid. 10). The three objectives of the HKSAR government’s aged policy are

classical Chinese expressions from the days of Confucius. They are from the Book of

Rites in a passage called the Grand Unity, meaning ‘harmonious ’ (Yao,

2000: 282). The original is a single sentence and it says that 'the aged will have a good

ending'. It implies that an ideal harmonious society has a good ending for everyone.

There is an image of social harmony and cohesion, a Chinese way of expressing

community care for older people.

The Mandatory Provident Fund (MPF), 2000

Although the Hong Kong government started to discuss the feasibility of setting up

some form of central contributory scheme in 1967, it was not until

December 2000 that the MPF was set up. It was a compulsory private insurance scheme with a monthly contribution of 5 per cent of a worker’s salary by both the employer and employee. With such a low contribution rate, it could take at least 30 years’ contributions to mature into an adequate retirement income. Thus many of the old people in Hong Kong would not get much joy from the MPF (Ngan, 2005: 432).

The Lump Sum Grant Subvention System

In Hong Kong, the majority of welfare services were provided by NGOs. The government supported NGOs in providing a wide range of services through cash grants

219 and other forms of assistance such as tax exemption and the leasing of premises at

concessionary rentals. These funding arrangements between the government and the

NGOs constitute the subvention system.

Prior to the revamping in January 2001, the government, through the SWD, reimbursed

NGOs for the actual costs incurred in delivering welfare services. The subvention

budget was controlled by stipulating NGO staffing structures, levels of pay, staff

qualifications and individual items of expenditure for each type of service. The system

was considered inflexible, involving elaborate rules and procedures in vetting staff

qualifications and the reimbursement of expenses. There was little incentive in the

system to encourage more effective use of resources to achieve lower costs, better value

for money or improved services to users. The traditional system did not encourage innovation and service re-engineering to meet changing community needs (Review

Report of the Lump Sum Grant Subvention Scheme, 2008:1). The Lump Sum Grant

Subvention Scheme was designed to address these shortcomings and was implemented in January 2001.

The scheme was a major revamp of the public funding and management of NGOs in the social welfare sector. The amount of lump sum grant (LSG) varied for different NGOs.

It was calculated according to a formula that took into account the NGO’s salary costs, the salary-related allowances and MPF for its staff, other charges and recognised fee income. Notably, a 'benchmark' specific to each NGO was set for the parts of its LSG that corresponded to staff costs, in order to standardise the funding levels to NGOs operating the same type of service. A 'snapshot' was taken of the NGO recognised staff establishment as at 1 April 2000 (that is, the 'Snapshot Staff); and the sum of their

220 salaries at mid-point on the civil Master Pay Scales (MPS) as at 31 March 2000 was the

'benchmark' for that NGO. The MPF provision was calculated on an actual basis for the

Snapshot Staff and at 6.8 per cent of the mid-point salaries of the recognised notional

establishment of the subvented service unit for non-Snapshot Staff. As for rent and rates,

the NGOs continued to be reimbursed for their premises on an actual basis.

With the introduction of LSGSS, salary structures and pay scales of NGOs were no

longer linked to those of the civil service, and staff costs were henceforth funded

according to the benchmark. The benchmark represented the level of subvention that was sufficient for the continuous provision of service. The enhanced productivity programme and efficiency saving, the tide-over grant and one-off grant were also introduced. The government gave HK$1 billion to form the social welfare development fund, for contingency purposes. Small NGOs with only one or two aged care centres were given the chance to upgrade. At the end, there were about eight aged centres that did not qualify for an upgrade.

This was a major overhaul of the business principles and philosophy of financing welfare agencies. The revamp was good for the large NGOs but not for the small ones.

This was because funding was based on manpower and since large NGOs had more staff they could generate more income. This was good for management but not for staff, since the whole exercise supported management rather than the frontline worker.

De-linking the salary structure of the NGOs from the civil service had a negative impact on the morale of the staff. The exercise introduced new management techniques for controlling the NGOs. De-linking the salary structure of the NGOs from the civil service’s structure by replacing it with the LSG meant that the government could

221 control the NGOs through its administration and therefore could govern them at a

distance. It was more about reframing the thinking around the political and moral

responsibility of the NGOs than about the money given to them (Ho, 2009).

The standardised needs assessment mechanism

In 1998, the Elderly Commission suggested developing a gate-keeping mechanism,

which was expected to be in place by early 2000 (Report of the Ad Hoc Committee on

Home Care, 1998). The purpose was to pave the way for the provision of one-stop

services for the elderly (Elderly Commission, 1998: 16). The internationally accepted but locally validated Minimum Data Set and Resident Assessment Protocols were adopted as the gate-keeping assessment mechanism to ensure the frail elderly were receiving appropriate forms of community support or long-term residential care (Chi,

2001). The scope of services under this assessment mechanism included homes for the aged, care and attention homes, nursing homes, day care centres and home help services.

The care needs assessment was carried out at the time when the frail elderly applied for services rather than waiting until their admission, so as to ensure that ‘gate-keeping’ of suitable services were performed at an early stage. It should be noted that gate-keeping helped to tackle the problem of some elderly people regarding residential care homes as a housing option and applying for admission, even though they were in good health (Ho,

2004: 7). The screening helped to distinguish between housing needs and nursing needs.

This is in line with the recommendation by the 1997 Report on Community and

Residential Care Needs (Deloitte & Touche, 1997). Care assessment was successful in ensuring that only the frail elderly with LTC needs were admitted, and it was shown that some 20 to 30 per cent of applicants to homes did not have the care needs to qualify for services (Ho, 2004: 14). After the 1997 Deloitte report, the government decided to

222 help those who were least able to help themselves and therefore phase out hostels for

those who could live independently. This group of people who had good self-care

ability were referred to the Housing Department. This practice was consistent with the

principle of value for money and prudent financial management.

Grant applications and training

In this phase, in addition to the regular funding of services, grant applications could be

submitted. The application depended on the initiative of the NGO or the staff concerned.

The different grants included the block grant, limited time subvention, item funding, the

social enterprise fund and the community investment and inclusion fund. Approval of

the grant depended on the application process and the amount was fixed, so there was

always a ceiling to contain the expenses. For instance, the community investment and

inclusion fund was initially set at HK$300 million.

Two training services are worth mentioning here. In 2006 the Hong Kong Jockey Club

Charities Trust gave HK$380 million for CADENZA (the full name is Celebrate their

Accomplishment and Discover their Effervescence and Never-ending Zest as they A), a five-year project to improve the quality of aged services. The money was not directly given to service providers or users but was for social and health care workers or informal carers who wanted to improve their knowledge and skills in working with older persons. The project aimed to revolutionise the way society viewed its elderly, the mode of care for the elderly, and the excessive reliance on the medical model of care.

The program was designed to provide general and professional education in gerontology for the general public, informal and family caregivers of older people and professional health care and social workers.

223 The Jockey Club Charities Trust also supported the Hong Kong Gerontology

Association in improving the quality of care in homes for the aged. With HK$3 million

from the Hong Kong Jockey Club, the Hong Kong Gerontology Association

implemented an accreditation scheme for the aged home sector for a period of three

years (2003-2006). This was a peer accreditation project based on quality and aged

home standards. The aim of the scheme was to train assessors. After training, a qualified

assessor could participate in the home accreditation process. The accreditation scheme

was voluntary but homes had to pay HKS5000 to participate in the two-day training

exercise. However, the response from the private commercial homes was not

enthusiastic — many did not join the scheme.

Twenty-four hour personal emergency alarm link

As noted in the last phase, in 1996, 100 elderly people passed away during a cold spell

and, in response to that unfortunate incident, a group of concerned people founded a senior citizen’s home safety association. This service linked users to a 24-hour Personal

Emergency service centre. Users simply pressed the trigger button of the emergency alarm system, and the staff of the centre identified their needs and provided an appropriate service, such as notifying their family members or the hospital emergency service. It charged HK$100 a month, and if the applicant was on social security payments or had financial difficulties, he or she could apply for the fees to be waived.

The association established a charitable fund to help those with economic difficulties to enjoy life-long free Personal Emergency link services. In 2001, about 11.4 per cent of older people were living alone (Census and Statistics Department, 2002) and it proved to be a popular service.

224 Revamping and evaluation of community support and aged home services

From 1998 there were attempts to revamp community support services and residential

institutions to cater for the LTC needs of the older population. This was based on the

Deloitte report ‘s (1997) recommendation, as previously mentioned. The division of

community care services between community health programmes and community

support services was paralleled by a division of providers. Community health

programmes were provided by hospitals and the Department of Health, and included

community geriatric assessment teams, community nursing services, home-based

rehabilitation, elderly health centres, and aged health outreach teams (Chi, 2001: 144).

Community support services, on the other hand, were mainly provided by NGOs, which received subsidies from government to operate their services.

The Hong Kong government re-engineered home service in 1999 by separating the meals on wheels and home-care services through competitive bidding. The home help service was reformulated to become integrated home care teams for the frail elderly with multidisciplinary input from social work and paramedical professional support

(physiotherapists, occupational therapists and nurses).

Despite the revamping of services, there were still ongoing problems. Family caregivers were finding it increasingly difficult to handle the disturbing and repetitive behavioural problems of elderly people with dementia — particularly people going missing (Ngan,

2004). Also, older people who were waitlisted for infirmaries displayed a significantly higher prevalence of stroke (43.1 per cent), dementia (24.8 per cent) and Parkinson’s

(7.5 per cent) compared with other samples (Ngan et al., 1997). As a reference, in 2004, there were 4458 applicants on the waiting list and finding a place would take 32 months.

225 It should be noted that, while acknowledging that community support services were the

cornerstone of a successful policy for ageing-in-place, the government stipulated that

care for the elderly should remain the responsibility of the family. As a result, the

development of community care services lagged behind, and such services were a very

small component of care services.

According to the philosophy of 'continuum of care' as proposed by the 1994 Working

Group Report, homes for the aged were overhauled to become LTC facilities so that the

frail elderly could receive the appropriate level of care in their existing aged home

without relocating to another nursing home (Leung, 2001). Therefore, under the Long

Term Care Policy, the emphasis was not to expand or build many more large residential

aged homes. As the then Director of the SWD said in 2003, 'Residential care which

inevitably creates isolation and adaptation problems for the elderly should be the last,

not the first, option to look after frail elders' (Lam, 2002: 3). For policymakers, residential care as the last resort makes great sense. However, the logic was not always as clear for those caregivers, the immediate family, who were increasingly left to cope with the behavioural problems of family members with dementia. Community geriatric assessment teams were set up after 1997 and they served as ‘gatekeepers’ to residential services, with the possibly of providing some short- term services in the community.

Residential provisions for this group of elderly people was quite limited; the charge for day care was about HK$200 and for overnight care, about $HK500. The Integrated Care

Home Teams (Ngan & Wong, 2004) reported cases of missing persons wandering the streets who were found by the police. Compared with care for the very frail, there was insufficient dementia care among NGOs. The only available option was the private old age home. With rising unemployment after the Asian financial crisis in 2003 and an

226 economic downturn, service workers in home care teams found an increase in requests

to place elders in LTC homes to allow family carers to move to mainland China to find

work.

If argued from the mixed economy approach (drawing upon the work of the formal,

informal, quasi-formal and commercial sectors), with a clear complementary notion of

shared care between each sectors (ibid.), and especially with the carer at the centre, the

revamping of community and aged home services should have improved the care of

Hong Kong elderly population. However, the findings are too limited to allow for this to

have a significant impact.

The 2002 Audit Commission on Residential Services for the Elderly

The main job of the 2002 Audit Commission on Residential Services for the Elderly was to find out whether the financial support for the residential care sector was really value for money. The report notes that under the existing arrangements, elderly persons applying for subsidised residential places were not required to undergo an assessment of their assets and income. It says that elderly persons in advanced countries are normally required to make contributions to cover part or all of the costs of residential places according to their income and assets, which is commonly known as means testing. It estimated that if some form of means-testing was introduced for subsidised residential services for the elderly, the government could achieve a potential saving of HKS269 million each year. This sum could then be used to subsidise another 175 nursing-home places and 3711 care and attention home places (Audit Commission on Residential

Services for the Elderly, 2002: vi). The aim was to pool 'resources' to meet the needs of care and attention homes. The Audit Commission Report notes that the service levels at subvented homes, in terms of minimum care per resident and staff requirements, were 227 higher than those at bought-place homes. As a result, many elderly persons chose to

wait for 35 months for a subsidised place instead of 11 months for a bought place (ibid,

v). The report concludes that in terms of cost-effectiveness the system was still far from

satisfactory.

An evaluative summary of Tung’s administration on its ageing provision

As we have seen during Tung’s Administration (1997-2005), there were major social

welfare and ageing provision reforms such as the new financial subvention system for

the NGOs sector. All of these reforms are basically steps in the right direction, such as

the combination of heath and social care in the revamping of community and aged home

services, but their success was hamstrung by the government refusing to allocate

adequate funding. The gate keeping measures of needs assessment for community or

residential care help to choose people who are least able to help themselves, and

indirectly channels those not qualified to the private commercial sector. The Elderly

Commission was far more explicit than the British Administration in extolling Chinese cultural values. Some of the new provisions such as the Cadenza project are not direct provision to the older people but an educational gerontology programme for people working with older people. This is another kind of family life education programme as mentioned in Chapter 6. The 24- hour personal emergency link is a useful service but it has turned the need for actual provision for the older people into a matter of personal and family risk management. Almost all these new provisions are in line with the administrative ethos of the government of trying to spend less and to have the family take care of their own members.

228 Part Two Donald Tsang’s administration (2005-2007)

Introduction

In this section I will first present how the Chief Executive, Donald Tsang, when he first

came to office in 2005, handled the issue of older people queuing up for medical

services early in the morning. Secondly, I will examine the debates of the Legislative

Council welfare Panel on residential care services for older people. Thirdly, I will

examine newspaper reports about older people from 1999 to 2006. Lastly, I evaluate the performance of the provision for the elderly during this period.

Donald Tsang’s early morning clinic visit

In a Legislative Council Monday Question Time, shortly after Donald Tsang became

Chief Executive in 2005, he commented that older people who queue from 4 am for a medical consultation were not actually seeking medical advice but rather were gathering to go for tea afterwards. His downplaying of the need to queue for a medical consultation was immediately criticised by the press. Queuing at out-patient clinics was a result of the quota system produced by the ‘first come first served’ principle. Those who did not show up early, did not get a chance to see a doctor. Two days later, in order to help dismiss his remark that the elderly did not have genuine medical needs, the

Chief Executive showed up at 7 am with two bodyguards and queued at a government out-patient clinic to express his concern for the weary elderly people in the queue (Ming

Pao Daily, 30.6.2005). It is interesting that the older people in the queue only complained about the poor manners of the security guard at the clinic and showed no dissatisfaction with the Chief Executive’s remark about going together for tea rather than seeking medical help (ibid.). The Chief Executive was also accompanied by the

Development Director of the , and pro-China and establishment camp

229 Legislative Councillors, with whom he discussed improvements to the medical appointment system.

In a letter to the editor of Apple Daily titled ‘Acting Real in An Unreal Show’ (2.7.2005) in response to this event, Shui calls this a display of the ‘public transcript’ (Scott, 1990) where there is interaction between the ruler and the ruled and one cannot know the reality just by reading the public transcript. The public transcript does not show the real attitudes and opinions of the subordinate people. Their complimentary and ingratiating attitudes and docile behaviour towards the powerful could disguise their real feelings.

The letter described a visit of this kind by a high-ranking official as well coordinated according to strict protocol with the atmosphere as quite formal, exhibiting the power and ability of the official to an extent that one would feel subordinate. However, there was no response from the groups concerned about the aged, such as the Association for the Rights of the Elderly, in regard to this issue. It should be noted that Tsang, like his predecessors Chief Executive Tung (1997-2005) and Governor Patten (1992-1997), also emphasised the importance and virtues of the family in Hong Kong.

In the next section I will use the different kinds of papers presented in the 2005

Legislative Council Welfare Panel meeting as a conclusion to this chapter.

The Legislative Council Welfare Panel on Residential Care Services for the Elderly

I noted that in 1986, the Social Welfare Advisory Committee (a high-level advisory body with government-appointed members) proposed adopting a positive approach to dealing with the development of the private home sector. In September 2005, in their examination of welfare provisions, the Welfare Panel of the Legislative Council

230 (composed of both appointed and elected members who may not be keen government

policy supporters) looked into the monitoring mechanism, and other measures to

enhance the quality of residential care homes for the elderly. According to the

information provided by the SWD to the Welfare Panel, at 31 July 2005, there were 744

residential care homes for the elderly; 578 (77.6 per cent) of them were run by private

operators and 166 (22.3 per cent) were run by NGOs. They provided 72,259 residential

home places, equivalent to nine per cent of the 842,000 people aged 65 and over.

Of the 72,259 residential care places, 26,982 (37 per cent) were subsidised. There were three types of subsidised places, namely those in subvented residential care homes run by NGOs, those in purpose-built residential care homes run by NGOs or private operators, and those in private residential care homes participating in the EBPS. There were also 22,000 elderly people making use of the comprehensive social security assistant payment to live in non-EBPS places in private residential care homes. Physical assessment under the standardised care need assessment mechanism was only introduced in November 2003, so not all the elderly had undergone the required assessment.

The standard of care was monitored by the Licensing Office of Residential Care Homes for the Elderly. This was a multi-disciplinary office set up within the SWD and comprising four professional inspectorate teams, namely fire safety, building, health care and social work. Home inspections were unannounced. The average frequency of regular and unannounced inspections for each residential care home was six times a year. Licensing Office of Residential Care Homes for the Elderly received about 240 complaints against residential care homes per year since 2001. However, Inside Story

231 Report, a Hong Kong television programme, found that the homes had their own ways

of tackling unannounced visits. It said that within a few minutes the staff could quickly

tidy up and restore order.

From 1996 to 2005, the Licensing Office of the Residential Care Home for the Elderly

successfully prosecuted 38 cases of residential care homes breaching licensing

requirements and in 2004, it revoked the licence of a private home. In the Welfare Panel

of the Legislative Council (Legco) paper (2005) as mentioned above, it says that the

government took a two-pronged approach in providing LTC: 'ageing-in-place' and

'continuum of care' (Legco, 2005: 7-8). It also says that the approach of the government

towards the monitoring mechanism of the quality of residential care homes was

three-pronged, namely licensing control, capacity building, and monitoring and

enforcement. (Legco 2005: 2). It is worth mentioning here that under the section on new

initiatives, it suggests improving the awareness of complaint channels for residential

care home residents and their family members. In this regard, the SWD had stepped up publicity on the residential care home complaint hotlines, requiring all residential care homes to display the hotlines together with their in-house complaints channels in a prominent location in their premises (ibid. 7). It is surprising to see that what may be considered a standard practice of complaining through a hotline was considered a new initiative in this field. In an attempt to strengthen capacity building, the department also tabled a revised Code of Practice effective from October 2005, which included requirements and guidelines covering areas such as food quality, meal arrangements, bathing skills, nursing and personal care (ibid. 3). However, the SWD came under fire from law-makers, who complained that the government’s measures did not go far enough (South China Morning Post, 5.9.2005). In a newspaper article titled ‘New

232 elderly homes code lacks teeth, say critics’, the Chairwoman of the Legislative Council

Welfare Panel, Chan Yuen-han, says, 'I have sat here for 10 years and we discuss this

issue every year, but every time we can’t solve the problem.’ She continues, 'I can’t see

the possibility of solving the problem in this meeting' (ibid.).

Representatives from the Hong Kong Council of Social Services, the Hong Kong

Psycho geriatric Association and the Hong Kong Private Aged Home Association were

present at the Panel’s meeting. Their views are summarised below.

The Hong Kong Council of Social Services (HKCSS)

The HKCSS is a coordinating organisation for 170 NGOs working in social welfare. It serves as a bridge between the government and the NGOs in the exchange of professional information, social service planning and problem solving. The aim of the

HKCSS is to tighten cooperation between the government, service providers and families. It suggested that the government work out a suitable Code of Practice for providers to follow and the regular inspection of homes. It also emphasised the importance of planning according to population and the financing of LTC. For providers, the HKCSS suggested organising a forum to promote professional knowledge exchange, working closely to service standards and requirements, and arranging visits to aged home residents who seldom had visitors. It proposed having a standardised admission assessment for both the NGO and private homes, as both were receiving Bought Place

Scheme and social security money. The HKCSS proposed a public education programme so that family members would recognise the importance of caring for their elderly (HKCSS, 2005: 2), and the protection of the vulnerable through the work of the

233 Guardian Board. It also suggested setting up a case management system for cognitively

impaired older people. These were proposals and were at the discussion stage.

The Hong Kong Psychogeriatric Association

The Hong Kong Psychogeriatric Association is a professional body consisting of

various medical, nursing and social work professionals, working or interested in the

field of the mental health of the elderly. The association is concerned with issues

relating to dementia, depression, suicide and abuse. It wanted to draw the Welfare

Panel’s attention to the plight of those with dementia, who are the most vulnerable

members of the ageing population. With their poor memory and cognitive state they

cannot stand up for themselves and are often the subjects of abuse. I have mentioned

some of the cases above. It should also be noted that subvented NGO homes were

reluctant to take dementia patients. There were about four day care centres, each

offering 20 places for demented older persons. The insufficient supply of services for demented persons is similar to other mental health services in Hong Kong; 83.2 per cent of mental health consumers were left alone in the community without any services and they relied on their families as caregivers (Yip, 2006: 812).

In a survey conducted by the Association, it was found that 460 residents (33.5 per cent) out of 1375 in nine subvented residential care homes were suffering from mental health problems needing psychogeriatric input. In another survey of a private residential care home with 138 places, 59 residents (43 per cent) were suffering from mental illness and many were suffering from dementia, some in the later stages. The Association also interviewed the staff and superintendents and they said they had great difficulty dealing with dementia cases. This is understandable, because they do not have the training. In

234 view of the difficulties encountered by staff in the private sector, the Association

proposed extending the Dementia Supplement (a disability allowance), only available to

the NGO homes, to provide training to staff:

in the private sector regarding the necessary skills to deal with behavioural

problems, nocturnal confusion and wandering; to involve health care

professionals from the geriatric outreach and the psychogeriatric team in the

monitoring of quality of care in residential care homes and to cover areas

such as the practice of restraining residents; and lastly, to involve carers

(Hong Kong Psychogeriatric Association, 2005:4).

The Association also noted that in Hong Kong, the percentage of the ageing population in residential care was high. It thought that there may be cultural reasons for in this high population in residential care homes but also felt that other factors may be at play, for example insufficient intensive community support for the elderly and their carers, early admission before care is needed, or that their elderly were less strong (although they lived longer) than their overseas counterparts.

The Hong Kong Association of Private Homes for the Elderly

The Hong Kong Association of Private Homes for the Elderly expressed concerns about the public attention given to the quality of care in private aged homes. The Association presents about 100 private homes, which means it more or less represents the industry

(Cheng & Chan, 2003: 407). It said that individual incidents reflected poor care in some homes but they did not represent the whole sector. It also stated that the private home sector was a key component outside the public medical care system. The sector had a

235 key role to play, especially for those who were discharged from hospital with nursing

care needs and in need of immediate placement. These cases constituted about 30

percent of the total caseload (Cheng & Chan, 2003: 407).

The Association suggested making the social security system more flexible, especially

the payment arrangement, so that those who can afford to pay more do so. Homes could

only receive the exact amount of social security payment, and any financial contribution

from the family was to be deducted from the social security payment. The rate of social

security payment (HKS3535 to HKS5135 a month in 2005) was relatively low and

homes could not afford to employ better qualified staff. The association thought that a

contribution from the family was important and it supported the policy of user pays. The

association also expressed concern that the ageing policy regarding the private sector

was not clear. An explicit ageing policy with a defined role of joint cooperation between

the public and private sectors was essential, it argued. The Association pointed out that

town planning did not take into consideration land for the construction of aged homes

and the human resource shortage they faced.

A summary of the performance of the community care and private residential care during Donald Tsang’s era (2005-2007)

We should not under-estimate the action of the Chief Executive in paying a visit to the older people queuing up for medical service. The use of Scott’s idea of 'public transcript' by Shui is revealing and it highlights feelings about the 'cultural economy' of ruler and the ruled. In trying to prove to the citizens of Hong Kong that he is not ignorant of the issue of queuing for medical services, and more importantly in showing his willingness to take care of the issue on his own no matter how difficult. Donald

236 Tsang is performing the role of a father and mother official (fumu guan) (Hayes, 2001:

70), 'treating] the people like his own children is inherent in the idea of what a good

official should be like in the Chinese political tradition' (Tsang, 2007: 27).

In the Legislative Council welfare panel debate, all the Associations’ suggestions and

comments were well-founded and constructive. However, the relationship between the

private sector and the government was not an easy one. They both needed each other

and neither liked the way things were carried out. The majority of malpractice cases

were in the private sector and yet forcing substandard homes out of business would not

be good for the government, because it would leave many elderly people without care

(Cheng & Chan, 2003: 404). In addition, using social security payments (about

four-fifths of those in private care were recipients of social security in 1998 (ibid. 411)

to stabilise home charges served the purpose of minimizing the market effect, but it

excluded some families who were happy to pay more. There were few community

services, and they were estimated to reach only 1 per cent of the elderly (Chi, 2001) as

note above. To summarise, after years of planning and coordination, both residential

aged home care and community support services had made little progress. Community support services include for example District Elderly Centres (originally known as a multi-service elderly centre) which provides home-help service, meal delivery, laundry services and house cleaning; and the Day Care Centre service, which includes personal care and limited nursing care during the day time for frail elderly persons living in the community.

237 Types of elderly news reported in Ming Pao Daily from 1999 to 2006

In the last chapter, I presented four types of cases about the poor quality of care in the residential sector. In this section, I present a table showing the types of stories on ageing that appeared in Ming Pao Daily between 1999 and 2006. I have categorised the news stories according to whether they are concerned with ageing policy, aged homes, societal concerns, social events/incidents (such as the demand for the increase of provisions and societal inclusion), accidents (such as suicide, hurt, traffic accidents and abuse), or health, giving a total of six types of news stories. The different kinds of cases and their respective years are presented in Table below.

Table 5 Types of elderly news in Ming Pao Daily from 1999 to 2006

1999 2000 2001 2002 2003 2004 2005 2006 #

# Total no. of cases 110 91 197 173 204 197 191 270 1433

1. Ageing policy 18 13 38 27 38 37 26 21 218

2. Aged homes 13 9 20 21 20 24 8 14 129

3. Concerns about 27 34 62 73 70 34 57 90 447 the elderly 4. Social events & 28 22 32 26 28 46 48 90 320 old people

5. Accidents 5 9 11 12 22 24 18 17 118

6. Health 19 4 34 14 26 32 34 38 201

1 8 Ming Pao Daily is a Chinese newspaper noted for its fairness and independence in reporting. These news clippings were downloaded from Hong Kong’s digital WiseNews website and found using the words 'older people'.

238 Stories expressing concerns about the elderly (item 3) were consistently among the most

reported. Such stories include NGOs’ activities for the old at different times of the year,

news about volunteers working with the old, alerts to the elderly or their family

members to beware of the changing weather, and crime prevention. This shows that

there is an overall concern about older people in Hong Kong. If we compare items 1 and

2 with 3, there are far more news stories about 3 than 1 and 2. This seems to show that it

is the social situation of the older people which is noteworthy rather than ageing policy

and aged homes. In sum, the shortage of services and the plight of old people sustain the

'charity' tradition of showing concern towards the elderly among different kinds of

NGOs. The traditional festivals also feature. These are occasions when people show

concern for and celebrate with the elderly, such as giving them rice dumplings during

the Dragon-Boat Festival in June, Taoist organisations distributing of 'peaceful rice' to

the elderly during the Yu-Lan (hungry ghost) Festival in July, giving 'moon-cake' during the Mid-Autumn Festival, having Hakka (people mostly living in the New

Territories) ethnic pot dinner parties in winter, hosting a banquet dinner for 1000 senior citizens, and Christmas and Chinese New Year banquets. These kinds of activities are sponsored by different people and organised by different NGOs in various districts and communities. Since sponsors for these activities desire recognition, they become stories in the newspapers. Therefore, there are far more of these news reports than those on ageing policy and aged home news. This reflects how newspaper reports frame the charity ethics as a feature of the Flong Kong welfare sphere. This kind of 'elderly assistance' is of limited use, because of its one-off nature and lack of direct financial assistance.

239 Older people’s homes, family relationships and the government’s administrative culture

The residential care population comprises a combination of both NGO and private

homes. Beginning from the 1990s, 70 to 80 per cent of home places were from the

private residential care sector while the remaining 30 to 20 per cent were from the

NGOs and non-profit making private organisations. If the aged home population was

just calculated according to the NGO sector, it was less than 2 per cent but if calculated

together with home places from the private commercial sector it was about 10 per cent

in 2006 (Chau & Woo, 2008: 50). Since the private sector performs a similar role to that

of the NGO sector, the number of home places they provide should be considered

together as a total unit of provision19.

The high residential care population is a result of several factors. Firstly, there is an

insufficient supply of community support services, especially in the areas of day care

and home help. Secondly, family size has fallen and there is an increase in employment

outside the home among female family members. Thirdly, there is limited space in

Hong Kong. Fourthly, older people tend not to enter care facilities unless they have lost

their self-care ability. With the increasing ageing population there is a higher chance

that those who are 80 and above would enter a home when they become frail.

In addition to the questions raised above, the development of residential aged care also faces difficulties as a result of the consistent emphasis on the importance of the 'family' factor and the ineffective legal regulation of private commercial homes. In an

19 In the Hong Kong Monthly Digest of Statistics the figures for residential provision are based on the NGO sector. The figures for the private aged home sector can be found in the Annual Reports of the Social Welfare Department. 240 examination of the social networks of nursing home residents in Hong Kong, Cheng

(2009: 165) notes that such residents can hardly develop social ties with their fellow

residents and some residents even try to relinquish social ties outside the homes. He

explained that this is the consequence of the cultural orientations of collectivism and

familism. The promotion of care in the community policy has had the effect of making

home residents feel less important than those staying in the community with their

families.

In the manner of 'investigative reporters who try to verify a story with key participants

before it is published', Cheng and Chan interviewed 41 home operators and the

Officer-in-Charge of the Licensing Office of the Residential Care Home for the Elderly between July 1996 and June 1997. They concluded that it was the lowering of the requirements of the licensing standards that allowed the homes to continue in business

(2003: 407). In other words, the carrot on the end of the stick, or the positive approach as mentioned above, was ineffective. It was the government’s pragmatic approach that tolerated the operation of poor quality homes, as they were afraid that closing homes down would leave the old with nowhere to go. Cheng and Chan also argue that the effect of 'saving face’ is central to Chinese culture (ibid. 412). They cite Reiss, who says that 'to actually carry out a punishment is a signal of its [Hong Kong government] failure to prevent the non-compliance’ (Reiss, 1984: 24 in Cheng & Chan, 2003: 412) and 'the effect of having to acknowledge failure is probably more pronounced in a culture that emphasizes face' (ibid.). It is not only the political economy of a limited budget which hinders the improvement of the quality of care of the residential care sector, but rather the administrative culture of 'face saving'.

241 In the whole period of community care and commercial care, phase one and two

(1987-2007) of this study both the British and HKSAR governments used different

kinds of 'cultural' descriptions in engaging with the people of Hong Kong. According

to Flowerdew (1998), Governor Patten liked to praise the people of Hong Kong

whenever possible. He liked to refer to Hong Kong as 'one of the world’s greatest

cities' (Flowerdew, 1998: 91), and said: 'you are the people of Hong Kong, who have

created here at the heart of Asia, a wonder of the world, one of the most spectacular

examples of the virtues of a free economy known to man' (ibid. 92). According to Chu,

a senior research officer of the One Country Two Systems Research Institute, Chief

Executive Tung was a Chinese chief par excellence (South China Morning Post,

26.3.05). His use of traditional classical sayings in reference to the provision of elderly

services (as mentioned above in the section about the Elderly Commission) is an

example.

Conclusion

On the whole, the care of older people is underpinned by the philosophy of the care in the community policy. It encourages old people to live with their families as long as possible in the community. In the residential care sector the regulations were not effective though there was heavy government involvement in both management and with financial subsidies. In the Politics of welfare developmentalism in Hong Kong, Lee

(2005) draws our attention to the fact that Hong Kong’s welfare regime is heavily reliant on NGOs for the provision of services, especially in the areas of education and social welfare (ibid. 118). However, Lee (ibid.) overlooks another feature noted above, which is that the family in Hong Kong has also been a major provider of care. There is a

242 paradox here that while the government through various means tried to discourage aged

home admissions through the use of the argument of community care, the aged home

population was by no means low, as noted above. In addition to the high aged care

residential population, there were also about 7000 older people on the waiting list for

aged home places. Older people in Hong Kong are not totally submissive and they have

different reactions to the ageing policy. However, they are by and large the 'interim

generation' (Phillips & Chan, 2002; Olson, 2006; Fu & Hughes, 2009) of only having

partial and transitional supply of formal support from the government. Looking back the

social reform of the ageing policy initiated by Governor MacLehose20 from the

mid-1970s can be summarized in the words of Little: 'while lip service is given to the

value of community living for the elderly, home delivered services to supplement

family care are seriously deficient' (1979 in Chow, 1992).

20 In Yep & Lui, (2010)'Revisiting the golden era of MacLehose and the dynamics of social reforms' China Information, 24: 3, pp. 249-272. The authors also note of the shortcomings of other social reforms at that period. 243 Chapter 9 Conclusion

During the four periods of the development of the ageing policy in Hong Kong

(1948-1972, 1973-1986, 1987-1997and 1997-2007) three primary forces were at work

in shaping it. These were budgetary constraints, the policies of 'care in the community'

(1973) and 'ageing in place' (1994) implemented by both the British colonial

administration and the HKSAR government, and, the growth of the private residential

aged care sector which was supported by subsidies from the government from 1989.

Nearly 70 per cent of the manpower of the industry comprised new immigrants from

China. In this chapter, firstly I will explain the three forces shaping the ageing policy in

Hong Kong, then discuss the four hypotheses as outlined in Chapter three. I conclude by

highlighting the key feature of Hong Kong social welfare planning and, based on this

observation, make recommendations.

The development of social welfare in Hong Kong was influenced by budgetary constraints. Between 1948 and 1997, during the British colonial administration, the principle of budgetary restraint was closely observed. The government was required to spend well within its proposed budget, with the understanding that the financial surplus would not be spent, and would be reserved in the Exchange Fund. After the handover of

Hong Kong to China on 1 July 1997, the HKSAR government continued this practice, and the requirement of a balanced financial budget was written as an article in the Basic

Law, the mini-constitution of Hong Kong. The political in the name of a balanced budget had an effect on the development of social welfare provision in general and ageing policy in particular. However, despite the claim of requiring a prudent budget, the government has used its non-current financial expenditure to

244 finance provisions such as the Gold-Coin flats in the mid-1980s and the private

residential aged care sector since 1987. On the whole, the two administrations were

financially pragmatic in the handling of provision for older people; however, they were

not entirely non-interventionist.

Another force of influence came from the idea of the policies of 'care in the

community' (Working Party on the Future Needs of the Elderly, 1973) and 'ageing in place' (Working Group on Care for the Elderly, 1994). The meaning of these two policy approaches resonated with the Confucian philosophy of filial piety, the familial ideal of care in the family and self-reliance. They provided an excuse for the British colonial government not directly providing home places for the old. The HKSAR government continued the policy with the explicit use of Confucian wording (1997) to describe the goals of provision. Both the governments converged on the emphasis on the centrality of family as a major care provider. The philosophy of the ageing policy helped to legitimatise not providing adequate age care. I explained that the practice of govemmentality and ethopolitics found favour in a liberal socio-economic and political environment such as Hong Kong, where ageing policy papers produced at different periods had a similar value orientation focusing on familial ideals and the tradition of self-reliance. The ageing policies produced over time (1973, 1977, 1994, 1997 and 2010) had the guiding effect on society of promoting 'acts of piety' or acts of virtuousness which contributed to the formation of the image of a cultural citizenship. Filial piety was still the major value guiding the behaviour of children towards their parents.

The implementation of the community care ageing policy was not without resistance.

Social action was organised by pressure groups and their coalition to petition for

245 improvement in provision and older people’s livelihood. But, all of these actions had

little effect on bringing about a change of policy. Older people were not passive and

submissive, and they played an important role especially during the second, third and

fourth periods of the development of the policy. They carried out different kinds of

action but their resistance had little impact. One example of resistance and the

self-reliant spirit of older people, particularly females, is the phenomenon of scavenging,

small-scale recycling of discarded household waste and newspapers. There were also judicial reviews initiated by two older women on the matter of the rent control of public

housing.

Thirdly, due to the shortage of NGO home places, the private residential aged care

sector mushroomed. As a practical measure, the government subsidised the private

sector through the BPS in 1989 and the EBPS in 1998. More than half of residents in private homes were also supported by social security payments. The regulation of the private residential aged care sector proved to be not an easy task at all. The subsidy for the aged home operators was meant to maintain charges at an affordable level for the general public and to bring about an improvement in the quality of care. The subsidy had some impact on the cost of aged care but the quality of care varied. Legislation was also introduced in the form of licensing, but was not effective in controlling the standard of care.

In sum, the Hong Kong government succeeded in removing itself from being a direct provider and the philosophy and discourse of the ageing policy and subsidy strategies helped to legitimate its role. I have explained that by the end of the fourth phase of ageing policy development there was a high proportion of the ageing population living

246 in residential care as compared with other Asian societies, as well as a long queue for

NGO aged homes .The argument on familial care was successful for the government

because it did not have to provide community and residential services as scheduled:

however, the legislation to control the quality of care in private aged homes was

inadequate and not successful.

In referring to the four hypotheses proposed at the end of Chapter 3, and with regard to

the different forces that shaped the ageing policy in Hong Kong, I argued that political

economy factors and cultural factors played an important role. The cultural factor

created a key inertia in the welfare . In the language of

Orientalism, represented by the traditionalism of familial care and self-reliance, and

Occidentalism, represented by the modernism of the care in the community policy, the shaping of the ageing policy was an interesting case of reverse Orientalism of the Third

Way emphasising family and self-responsibility. The synchronisation of the two different phases of welfare development in the UK and Hong Kong meant that the policy of 'care in the community' was an 'East in the West' approach which legitimated the acceptance of the policy. It was more of a cultural policy with its populist appeal than a policy which cared seriously about the provision of tangible services.

The planning of the ageing policy was based on numbers and output rather than the views of users and planning the services accordingly. During the early phase of the planning of the community care policy, the government was keen to test the effectiveness of community care and so suggested a moratorium on the construction of homes for a period of two years. The suggestion was not implemented as scheduled but the debate regarding the moratorium highlights the fact that the Social Welfare

247 Department focused on the development of homes, care and attention homes and

infirmaries but not hostels. It phased out hostel provision and let the Housing Authority

and Housing Society take up the task. It was not until 2002 that the process of phasing

out hostels began. It took three decades to achieve the goal. If the Hong Kong

government had had the political will to reform aged services like it did with hostel

provision, community support and residential provision may have had a fair chance of

developing.

Perhaps Hong Kong’s ageing policy has outgrown its usefulness in view of the rapid

socio-economic-political developments in the last three decades. Despite the reluctance

to provide more direct and universal provision, some sectors of the community are pushing in that direction. The ageing problem indicates a mismatch between the state’s philosophy (self-care, self-reliance and family support) and reality (abandonment, financial insecurity, poor quality of care). Either the policy or society, or both, have to change. The government has to find ways to re-balance the four sectors in order for provision to be sustainable.

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303 Appendix 1

List of Selected Events in Newspapers and Television Programmes

(Some of the following events can be found from Chapter 6 to 8)

Chapter 6

Protest against fee charging on 27.6.1980 reported by South China Morning Post

(SCMP), Standard and The Star

Charging fees could restore dignity to welfare receipient reported by SCMP on 8.7.1980

Priority for an expatriate home reported by SCMP on 27.2. 1980 and 18.1.1982; Wah

Kiu Yat Pao on 27.2.1980; Sing Tao on; 18.3.1980

Insufficient fund for community support services reported by Tin Tin Daily News on

8.6.1982; Ming Pao on 8.6.1982.

Report from Vienna Conference on Concern for the Aged reported by Wah Kiu Yat Pao

on 8.7.1983

Death found in private home reported by SCMP on 5.11.1985

Chapter 7, 8 & 9

Senile dementia cases reported on 2.7.1989 and 11.5.1998 by Ming Pao Daily

Throwing of Molotov cocktails into private aged home reported by Ming Pao Daily

304 on 25.8.1993. Most of the residents were bedridden, infirm, sick and very old.

'Elderly could not spend all the social security money because it’s sufficient' as told by

Mrs Fok, the Secretary for Health and Welfare reported by Ming Pao Daily on

14.10.1995.

'Assaults of elderly home resident by staff Netvigator Daily News, 22.1.1997

The 'seven deadly sins' of private aged home operation was reported by Oriental Daily

News on 30.8.1999. The 'seven deadly sins' are: group bathing and lack of personal privacy in the use of bathroom; to clean residents’ body with unhygienic brushes (for cleaning toilets); to tied up residents with strong restraints; unsafe environment slippery floor and with no walking hand rail; personal care worker lacks of first aid knowledge and worker who are new arrival cannot communicate with residents meaningfully; substandard meals and harsh manner in feeding residents who cannot eat on their own and serious shortage of manpower.

The Secretary for Health, Welfare and Food yesterday dismissed calls to help old people living in poverty who are too proud to accept welfare reported by SCMP on 28.1.2003

Son throws 80 year old father suffering from stoke into the sea on ground of mercy killing reported by Ming Pao Daily on 17.9.2004.

Inadequate services caused carer to divorce reported by Ming Pao Daily on 24.7.2004

305 'Donald Tsang acting like real' in a letter to the editor of Apple daily on 2.7.2005.

Son throws 82 year old blind and handicapped mother into the sea on ground of mercy

killing reported by Sing Tao Daily on 6.6.2006.

Guilty: ex-judge and his wife face jail for cheating social security assistance reported by SCMP on 13.1.2007

Elderly man robs 7-eleven convenience shop because of not having money to buy food reported by Oriental daily News on 30.8.2007

Television Programme (TVB is the Hong Kong Television Broadcasting Company Ltd.)

'Bought place scheme for private residential aged care operator' by TVB on 12.6.1987

'Older people in Hong Kong' by TVB on 11.5.1989

'Older people in China and Hong Kong' by TVB on 20.10.2003

'Home Horrid Home', by TVB on 20.7.2008

306 Appendix 2

Social services expenditure (exp) as a percentage of GDP, Hong Kong 1967 - 2009

Social Social Social Social services exp services services Public services Growth Public exp / / Total Growth exp / Year exp / Year exp / exp / in GDP GDP % public in GDP Total Total GDP % Total expenditure public exp GDP % GDP % % %

1967/68 1.70 12.00 39.20 4.70 1988/89 8.00 14.20 47.20 6.70

1968/69 3.30 11.70 39.20 4.59 1989/90 2.60 15.60 45.00 7.02

1969/70 11.30 10.90 40.30 4.39 1990/91 3.40 16.30 45.80 7.47

1970/71 9.20 10.90 40.30 4.39 1991/92 5.10 16.20 45.70 7.40

1971/72 7.10 11.20 40.00 4.48 1992/93 6.30 15.80 45.40 7.17

1972/73 10.30 13.70 32.60 4.47 1993/94 6.10 17.30 44.90 7.77

1973/74 12.40 13.10 36.40 4.77 1994/95 5.40 16.40 47.50 7.79

1974/75 2.30 14.30 39.50 5.65 1995/96 3.60 17.60 47.60 8.38

1975/76 0.30 13.40 43.40 5.82 1996/97 4.50 18.20 49.90 9.08

1976/77 16.20 11.70 41.30 4.83 1997/98 5.00 18.40 53.10 9.77

1977/78 11.70 12.60 41.50 5.23 1998/99 -5.10 18.50 53.60 9.92

1978/79 8.50 14.20 42.50 6.04 1999/00 2.90 21.70 54.50 11.83

1979/80 11.50 14.00 43.30 6.06 2000/01 10.20 21.90 56.50 12.37

1980/81 10.10 15.60 43.70 6.82 2001/02 0.50 21.10 54.60 11.52

1981/82 9.20 17.20 39.00 6.71 2002/03 2.30 21.50 55.10 11.85

1982/83 2.70 18.50 40.30 7.46 2003/04 3.00 22.60 57.00 12.88

1983/84 5.70 18.20 42.10 7.66 2004/05 8.50 22.50 57.70 12.98

1984/85 10.00 15.60 44.60 6.96 2005/06 7.10 21.50 58.10 12.49

1985/86 0.40 16.00 44.50 7.12 2006/07 7.00 19.50 57.40 11.19

1986/87 10.80 15.30 43.90 6.72 2007/08 6.40 16.00 57.80 9.25

1987/88 13.00 14.00 44.80 6.27 2008/09 2.50 16.90 57.70 9.75

Source: Annual Reports 1967 - 2009, Hong Kong Government.

307 Appendix 3

Demand and planned provision for various services

Types of Projection during the year

Provision 79/80 80/81 81/82 82/83 83/84 84/85 86/87 87/88

Home Help Demand 220 249 1220 125 220 233 239

Provision 95 144 184 306 33 35 40 50

Shortfall 125 105 914 92 185 193 189

Multi-service Demand 17 18 24 24 24 24 24 24

Centres Provision 4 5 7 10 11 12 13 13

Shortfall 13 13 17 14 13 12 11 11

Day care Demand 24 24 24 24

Centres Provision 2 6 4 4 6

Shortfall 18 20 20 18

Social Centres Demand 234 257 177 181 178 183 183 187

Provision 43 54 68 89 101 106 111 132

Shortfall 191 203 109 92 77 77 72 55

Hostels (places) Demand 4430

Provision 1470 1685 1140 1355 1565 1441 1509 1739

Shortfall 2960

Home for the Demand 3545 3985 5230 5480 5565 6075 6228 6641

Aged (places) Provision 2885 2700 3760 4230 4650 4334 4791 5752

Shortfall 660 1285 1470 1250 915 1741 1437 889

Care and Demand 1775 1990 2090 2190 2226 2430 2491 3321

Attention Provision 490 335 375 690 1090 1214 1434 1610

Homes (places) Shortfall 1285 1655 1715 1500 1136 1216 1057 1711 Sources: The Five-Year Plan for social welfare development in HK-Review, 1979/80- 1987/88

308 Appendix 4

Demand and planned provision for various services

Types of Projection during the year

Provision 88/89* 89/90 90/91* 91/92 92/93* 93/94 94/95* 95/96*

Home Help Demand 113 116 119 122 125 125

Provision 54 64 76 84 96 106 114

Shortfall 49 40 35 26 19 11

Multi-service Demand 24 24 24 30 31 32 33 34

Centres Provision 15 17 18 17 19 21 25 29

Shortfall 9 7 6 13 12 11 8 5

Day care Centres Demand 24 24 24 30 31 32 33 34

Provision 8 10 13 11 17 18 24 27

Shortfall 16 14 11 19 14 14 9 7

Social Centres Demand 190 144 147 256 265 264 271 279

Provision 146 118 126 165 185 194 216 245

Shortfall 44 26 21 91 80 70 55 34

Hostels (places) Demand

Provision 2162 2106 2106 2172 1917 1288 1258 1258

Shortfall

Home for the Demand 6641 7216 7487 7693 7961 7906 8140 8365

Aged (places) Provision 5752 7029 7449 7490 7852 8064 8153 8153

Shortfall 889 187 38 203 109 -158 -13 212

Sources: The Five-Year Plan for social welfare development in HK-Review, 1988/89-1995-96

309 Appendix 310

Source: Hong Kong Monthly Digest of Statistics, 1998/99 - 2007/* Appendix 6

Elderly Commission Study on Residential Care Services for the Elderly 2009

Although my research period is from 1948 to 2007, I include the Elderly Commission

Study on Residential Care Services for the Elderly in 2009 because I want to show the

continuation of the government’s persistent argument that community-based care is

family-based care. The study showed that Hong Kong seniors appeared to have less

health problems than was anticipated. The policy direction of ageing in place (a different way to describe community care) was consistent with the wishes of the majority of the elderly who would prefer to age at home rather than be institutionalised.

The report says that 'recognizing that the Hong Kong government and the Elderly

Commission share a similar vision in promoting ageing in place, the research team also notes with caution that the institutionalization rate in Hong Kong is relatively high as compared with other developed countries' (Elderly Commission, 2009: 2). The report recommended means-testing and a voucher system for users.

311