SIU-YAU LEE
Profit Seeking and Intergroup Conflict in Hong Kong
A Case Study of the Private Health Care Sector
ABSTRACT
Following a court ruling that babies born to mainlanders in Hong Kong are permanent residents, private hospitals cashed in by expanding services and raising fees,
leading to an outburst of anti–mainland Chinese sentiment. This study challenges
conventional accounts of intergroup conflicts highlighting economic contradictions
between in-group and out-group or faulting the state for blaming local problems on
the out-group.
K E Y W O R D S : intergroup conflict, profit seeking, health care, Hong Kong
INTRODUCTION
A giant locust appeared over the Hong Kong skyline in a full-page advertisement in a popular local newspaper, Apple Daily, on February 1, 2012. In Hong
Kong, ‘‘locust’’ (huangchong) is a derogatory label used by some for generalized Others, namely immigrants and tourists from mainland China (hereafter
‘‘mainlanders’’). Beside the locust was a list of data that purported to calculate
the value of public benefits that ‘‘shuangfei children’’ (babies whose parents
are not Hong Kong citizens) will consume in their lifetimes. The advertisement called for an end to the ‘‘unlimited infiltration of mainland Chinese
couples into Hong Kong.’’ It was paid for by a spontaneous online fundraising campaign on Facebook and a local online group called Golden Forum,
which received more than HK$ 100,000 (US$ 12,900) from 800 donors in
a single week.
S IU -Y AU L EE is Assistant Professor in the Department of Asian and Policy Studies, Hong Kong
Institute of Education. His research interests include language management, ethnic conflict, comparative political institutions, and Chinese politics. For invaluable comments and support, the
author thanks Kee-lee Chou, Nik Krause, Christine Lee, Patricia Thornton, Yim-fong Yu, and
Samson Yuen. This research was supported by research grants from the T. D. Allman Fund and
the Swire Educational Trust. Email: <[email protected]>.
Asian Survey, Vol. 56, Number 2, pp. 348–368. ISSN 0004-4687, electronic ISSN 1533-838X. © 2016 by
The Regents of the University of California. All rights reserved. Please direct all requests for permission
to photocopy or reproduce article content through the University of California Press’s Reprints and
Permissions webpage, http://www.ucpress.edu/journals.php?p¼reprints. DOI: 10.1525/AS.2016.56.2.348.
348
LEE / INTERGROUP CONFLICT IN HONG KONG 349
The publication of this advertisement represented the climax of a building
anti–mainland Chinese sentiment in 2012 that drew in a far wider array of
social groups than just the ‘‘extreme right.’’ According to a telephone poll
conducted by the University of Hong Kong in February, 50.6% of Hong
Kong locals (hereafter Hong Kongers) expressed negative impressions of
mainlanders.1 In another poll, conducted by the university in December
2011, only 16.6% of Hong Kongers identified themselves as Chinese, the
lowest such figure since 2000.2
The trigger for many, as suggested by the advertisement, was the steady
influx of mainland Chinese couples seeking to give birth in Hong Kong. In
2001, the city’s Court of Final Appeal ruled that babies born in Hong Kong,
regardless of their parents’ nationality, have the right of abode there. Since
then, the number of live births to mainland couples in Hong Kong has risen
exponentially, from 620 in 2001 to 32,653 in 2010 (Figure 1). Despite official
quotas on maternity care for nonresidents, in 2011 nearly 4 in 10 of the births
in Hong Kong were to mainland parents.3 Not surprisingly, the health care
sector has become an arena of intense conflict. Furious Hong Kongers argued
that such mainland couples not only occupied the scarce maternity beds in
hospitals, but also looted the city’s welfare benefits (e.g. free education). The
advertisement sparked a series of heated disputes between Hong Kongers and
mainlanders. Some mainlanders responded with a mock online advertisement urging China to cut off water and power supplies to the city.
Intergroup conflicts are widespread in Asia. Yet, while episodic large-scale
ethnic violence in ethnic-minority-concentrated regions like China’s Xinjiang
region attracts considerable scholarly interest,4 the more mundane and persistent tensions in cities—such as online hate speech against immigrants in
Shanghai, Singapore, and Hong Kong—have received less systematic attention. However, cities can represent key nodal points for intergroup conflicts
1. Chou Kee-Lee, ‘‘Gangren dui xinyimin de fumian taidu yanzhong ma?’’ [Is Hong Kongers’
negative attitude toward immigrants serious?], Ming Pao [Ming Pao Daily, Hong Kong], July 6,
2012. This poll will be discussed in more detail later.
2. ‘‘People’s Ethnic Identity’’, Public Opinion Programme, University of Hong Kong, <http://
hkupop.hku.hk/chinese/popexpress/ethnic/eidentity/poll/datatables.html>, accessed May 4, 2015.
3. Sharon LaFraniere, ‘‘Mainland Chinese Flock to Hong Kong to Give Birth,’’ New York Times,
February 23, 2012.
4. A recent example is Yuchao Zhu and Dongyan Blachford, ‘‘Economic Expansion, Marketization, and their Social Impact on China’s Ethnic Minorities in Xinjiang and Tibet,’’ Asian Survey
52, no. 4 (July/August 2012), pp. 714–733.
350 ASIAN SURVEY 56:2
figure 1. Number of Shuangfei Babies and Total Live Births from 2001 to 2010
100,000
Total live births
90,000
Number of births
80,000
Shuangfei babies
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year
Hong Kong Census and Statistics Department, Hong Kong Monthly Digest of Statistics: The
Fertility Trend in Hong Kong, 1981 to 2009 (Hong Kong: Census and Statistics Department, 2010) for
data prior to 2010; ‘‘Xianggang chushenglu bili’’ [‘‘Percentage of local babies and birth rate in Hong Kong’’],
Wenwei Po [Wenwei Post], May 3, 2011.
NOTE : Shuangfei babies are those born in Hong Kong to parents who are not citizens of Hong Kong.
SOURCES :
because they are where antagonistic groups encounter one another spatially and
functionally.5 A typical urban intergroup conflict is usually ignited by a salient
appeal to localism, in which existing urban dwellers identify themselves as
a community with distinctive cultural and economic characteristics, whereas
out-group members are depicted as parasitic, invasive, or both.
Why do urban intergroup conflicts arise? Traditionally, they are treated as
problems caused by exogenous forces such as immigration, tourism, and
foreign investment. Typical approaches cast strife as the result of economic
and cultural contradictions between in-group and out-group members.6
5. Scott A. Bollens, On Narrow Ground: Urban Policy and Ethnic Conflict in Jerusalem and Belfast
(Albany: State University of New York Press, 2000), p. 6.
6. Lawrence Bobo and Vincent L. Hutchings, ‘‘Perceptions of Racial Group Competition:
Extending Blumer’s Theory of Group Position to a Multiracial Social Context,’’ American Sociological Review 61, no. 6 (December 1996), pp. 951–972; Thomas J. Espenshade and Katherine
Hempstead, ‘‘Contemporary American Attitudes toward US Immigration,’’ International Migration
Review 30, no. 2 (Summer 1996), pp. 535–570; Joel S. Fetzer, Public Attitudes toward Immigration in
the United States (Cambridge: Cambridge University Press, 2000); John Sides and Jack Citrin,
‘‘European Opinion about Immigration: The Role of Identities, Interests and Information,’’ British
Journal of Political Science 37, no. 3 (July 2007), pp. 477–504.
LEE / INTERGROUP CONFLICT IN HONG KONG 351
Drawing upon data from established cross-national surveys, these studies
argue that natives are likely to develop a negative attitude toward outgroup members when the latter threaten their economic self-interest (e.g.
by increasing job competition) or cultural heritage. In this sense, intergroup
conflicts are generally considered inevitable with rising mobility, which
makes contact between different groups more likely. For example, increased
Han Chinese immigration into Tibet and Xinjiang is frequently highlighted
as a cause of the conflicts in those regions.7
Although the in-group/out-group dichotomy yields valuable insights, its
problematic assumptions detract from its usefulness. First, it cannot explain
variations in the frequency and intensity of intergroup conflicts.8 Intergroup
contact is common, but numerous studies demonstrate significant variation
in the level of violence and frequency of intergroup conflict among cities. In
many ethnically diverse societies, for example, civil conflicts are actually less
frequent than in their ethnically homogeneous counterparts.9 The focus on
exogenous differences between groups may therefore conceal the more
important endogenous triggers.
Second, group identity is neither static nor homogeneous; divisions within
groups are common. In fact, in most intergroup conflicts, not every member
of the in-group becomes the enemy of every member in another community.
Some subgroups are more aggressive than others in attacking the out-groups,
as is evident in the Hong Kong case. Although the campaigners framed
themselves as representatives of all Hong Kongers, the business and political
elites of the city remained silent. Relying merely upon exogenous differences
between groups to explain intergroup conflicts can therefore be a rather
unproductive approach.
Correcting the limitations of the previous accounts, some scholars propose
that institutions endogenous to the in-group are more useful in explaining
intense intergroup relations. The deliberation of the state, in particular, has
been a key area of examination. Scholars of the ‘‘deliberation theory’’ school
argue that states may deliberately promote intergroup conflicts so as to achieve
7. Zhu and Blachford, ‘‘Economic Expansion,’’ pp. 719–720.
8. Michael E. Brown, ‘‘The Causes of Internal Conflict: An Overview,’’ in Nationalism and
Ethnic Conflict (rev. ed.), ed. Michael E. Brown, Owen R. Cote, Sean M. Lynn-Jones, and Steven E.
Miller (Cambridge, MA: MIT Press, 2001), p. 3.
9. James D. Fearon and David D. Laitin, ‘‘Ethnicity, Insurgency, and Civil War,’’ American
Political Science Review 97, no. 1 (February 2003), p. 75.
352 ASIAN SURVEY 56:2
a range of political goals, such as elimination of opponents, or diverting public
attention from local problems.10 The deliberation theory has seemed to be
confirmed by some statistical analyses. Frederick Solt, for instance, analyzed
data on economic inequality and nationalist sentiments in countries around the
world and found that economic inequality has a powerful positive effect on
national sentiment.11 Solt uses this finding to confirm what he calls ‘‘diversionary nationalism,’’ according to which states externalize serious local problems
through strengthening a sense of commonality among their citizens.12
However, state deliberation approaches are prone to overestimating the
power of the state. Deliberation theory implicitly assumes that leaders of the
state can effectively invoke conflicts to achieve their political goals; in reality,
they are constrained by limitations of both resources and information, and
therefore often fail to get their way. Conflict creation is particularly difficult
because conflicts are costly in terms of risk of injury and loss of time and
money for their participants.13 In this regard, deliberation theory lacks the
capacity to account for intergroup conflicts that arise as an unintended outcome of state actions—such as the conflict in Hong Kong. There, the city’s
government receives no apparent benefit from the conflict and has struggled to
damp down, rather than inflame, the contentious sentiments of its citizens
toward mainlanders.
The account proposed in this article differs from the previous views in its
emphasis on the fragmentation of interests within the in-group as a cause of
tension between groups. More specifically, this article argues that intergroup
conflicts can be triggered by local market actors through their profitmaximizing behavior, instead of by state manipulations or merely intergroup
socioeconomic contradictions. Globalization increases the flow of people and
capital between places, which allows local market actors to pursue their
particularistic economic interests by offering goods and services that can
10. See e.g. Ross A. Miller, ‘‘Domestic Structures and the Diversionary Use of Force,’’ American
Journal of Political Science 39, no. 3, (August 1995), pp. 760–785; John R. Oneal and Jaroslav Tir,
‘‘Does the Diversionary Use of Force Threaten the Democratic Peace? Assessing the Effect of
Economic Growth on Interstate Conflict, 1921–2001,’’ International Studies Quarterly 50, no. 4,
(December 2006), pp. 755–779.
11. Frederick Solt, ‘‘Diversionary Nationalism: Economic Inequality and the Formation of
National Pride,’’ Journal of Politics 73, no. 3, (July 2011), pp. 821–830.
12. Ibid., p. 828.
13. David A. Lake and Donald Rothchild, ‘‘Containing Fear: the Origins and Management of
Ethnic Conflict,’’ in Nationalism and Ethnic Conflict, p. 130.
LEE / INTERGROUP CONFLICT IN HONG KONG 353
attract foreign resources. While this pursuit of profit is particularistic in
nature, when conducted collectively, this behavior can significantly undermine or improve the well-being of other members of the same community.
For example, sales of properties to foreign investors can push up local property prices and make housing less affordable to local buyers. Yet, concern for
private profit among local market actors is rarely advocated publicly despite
its social impact, especially when it implies significant social costs to the local
community. When tension between groups escalates, market actors who have
been capitalizing on the influx of foreign resources at the cost of local welfare
often remain silent, acting as if they are also victims of the consumption or
investment of the outsiders. Consequently, their role in intergroup conflicts
is often masked by media reports and popular commentaries that emphasize
or exaggerate the contradictions between insiders and outsiders.
The relationship between profit-seeking activities performed by local market
actors and intergroup conflicts is illuminated here by an in-depth case study of
Hong Kong’s private health care sector. The study traces how the ruling of the
Final Court of Appeal provided a unique opportunity for local private hospitals
to maximize their profit, and how the strategies undertaken by the private
hospitals contributed to the increased tension between Hong Kongers and the
mainland Chinese. The case is selected primarily because of its topical importance. Hong Kong’s health care system has been praised by some leading Asian
policy specialists as one of the most successful models in the region.14 Consequently, the case, which, to my knowledge, has not been previously described in
English-language scholarship, is highly relevant to countries that are experiencing rapid transformation in their health care systems. Moreover, in relation to
theory development, an in-depth analysis of a single case is particularly useful in
this context because single case studies can generate robust information to reveal
‘‘any unexpected aspects of the operation of a particular causal mechanism.’’15
CASHING IN ON RESIDENCY
Since the early 20th century, Hong Kong’s health care system has been largely
publicly funded. Today, coverage of the system is universal, and access is free
14. M. Ramesh, Social Policy in East and Southeast Asia: Education, Health, Housing, and Income
Maintenance (London: RoutledgeCurzon, 2004), p. 86.
15. Alexander L. George and Andrew Bennett, Case Studies and Theory Development in the Social
Sciences (Cambridge, MA: MIT Press, 2005), p. 21.
354 ASIAN SURVEY 56:2
or carries only a minimal charge. A private sector exists alongside the public
sector, but the services provided privately are far less comprehensive and
affordable. The Food and Health Bureau of the Hong Kong government is
responsible for forming policies and allocating resources for the running of
Hong Kong’s health services, while much of the day-to-day business of the
44 public hospitals is carried out by the Hospital Authority. This is an entity
whose quasi-autonomous statutory authority enjoys considerable financial
freedom but is subject to the directions of the secretary for food and health.16
The 12 private hospitals, in contrast, are independent as long as they comply
with the regulations set forth by the Department of Health.
This dual hospital system is designed to ensure efficient distribution of
scarce medical resources among patients with different medical needs and
incomes. Whereas those on lower incomes or with serious illness are guaranteed to receive medical treatment offered by the public hospitals, the wellto-do often opt for the private hospitals to receive much more efficient and
personalized health services. Although there have been concerns about the
long-term financial sustainability of the city’s health care system, various
health indicators such as life expectancy and mortality rate suggest that the
system has outperformed many of its Asian counterparts.
The city’s private health care system began to evolve into a crucial opening
for intergroup conflicts when it was designated as a gateway for attracting
foreign resources. In his 2008–09 Policy Address, then-Chief Executive
Donald Tsang announced his plan to establish a task force to assess the
impacts of the global financial crisis on the Hong Kong economy and to
identify business opportunities for consideration by the government and the
industries concerned. Subsequently, an 11-member task force was formed,
which was later known as the Task Force on Economic Challenges (TFEC).
Composed mostly of leaders of major Hong Kong financial and property
businesses, the task force concluded that health care, along with five other
‘‘emerging’’ industries such as education and environment, should be rapidly
developed. This strategic plan was hammered out with mainland China’s
market in mind. The policymakers believed that those industries enjoyed
a competitive advantage over their mainland counterparts. This is evident
in a speech given by the Chief Executive: ‘‘The government’s strategy for
16. ‘‘Overview of the Health Care System in Hong Kong,’’ GovHK, <http://www.gov.hk/en/
residents/health/hosp/overview.htm>, accessed March 31, 2013.
LEE / INTERGROUP CONFLICT IN HONG KONG 355
promoting the six industries is to seize the opportunities arising from our cooperation with Guangdong [Province] and align our efforts with measures
already introduced to get immediate results.’’17
According to the TFEC, the competitive edge of the health care industry
of Hong Kong was the quality of its service.18 In light of TFEC’s recommendations, the Hong Kong government began to encourage expansion of the
private hospital sector. Four sites were designated for the construction of new
private hospitals, and more training facilities for health care services were
proposed to support the foreseeable expansion of the industry.
The proposal was well received among the city’s private hospitals, as well as
local elites who were interested in the business. Many of them responded by
expanding their facilities or applying for the sites to construct new hospitals.
However, the opportunities they identified were clearly different from that of
the TFEC. Instead of competing with public hospitals, which have at their
disposal a budget and a mandate to improve and modernize specialist equipment and facilities,19 many private hospitals turned to providing less-capitalintensive obstetrics and gynecology services. These services had steadily
become more popular since 2003 as a result of two critical events. First, in
2001, the Court of Final Appeal ruled that babies born to nonlocal citizens
were automatically considered Hong Kong citizens. The ruling implied that
what Hong Kong hospitals offered nonlocal pregnant women was no longer
just obstetrics and gynecology care, but also Hong Kong permanent residency. Believing that Hong Kong residency would give their child access to
better education and social benefits, many mainlanders, particularly those
living in southern China, were attracted to give birth in Hong Kong.20
Second, in 2003, after the outbreak of the SARS epidemic, the mainland
and Hong Kong governments agreed to launch the Individual Visit Scheme,
which allowed mainlanders who obtained an endorsement from the relevant
17. Hong Kong Government, ‘‘Press Release: CE Unveils Plans to Promote Growth of Six
Industries,’’ GovHK, October 14, 2009, <http://www.info.gov.hk/gia/general/200910/14/
P200910140162.htm>, accessed May 4, 2015.
18. Task Force on Economic Challenges, ‘‘Summary of the Focus Group Discussions on the Six
Economic Areas,’’ Financial Secretary Office, June 22, 2009, <http://www.fso.gov.hk/tfec/eng/doc/
Summary%20focus%20groups%20_TFEC-INFO-12_%20_Eng_.pdf>, accessed May 4, 2015.
19. Robin Gauld and Derek Gould, The Hong Kong Health Sector: Development and Change
(Hong Kong: Chinese University Press, 2002), p. 29.
20. Annie Hung Tsz Bun, ‘‘Reasons Why Mainland Mothers Give Birth in Hong Kong,’’ Hong
Kong Heritage Stories, May 8, 2007, <http://jmsc.hku.hk/hkstories/content/view/129/1048/>.
356 ASIAN SURVEY 56:2
authorities in certain mainland cities to travel to Hong Kong on an individual
basis. The scheme prompted a huge influx of mainlanders who would otherwise be required to apply for business visas or join group tours. The number
of mainland tourists visiting Hong Kong through this scheme in 2011 was
18 million, a 26-fold increase compared to the 2003 figure. Taking advantage
of the scheme, pregnant women, often with the help of profit-making
‘‘maternity agents’’ based in Hong Kong or mainland China, entered Hong
Kong as tourists and gave birth in the city.
At first, the public hospitals were the preferred destination of the ‘‘birth
tours’’ because of their low fees. However, as the number of birth tours soared
and exceeded the capacity of the public hospitals, the Hospital Authority
took steps to increase the fees for obstetric services and required all nonlocal
women who intended to give birth in public hospitals to make prior booking
for the treatment and have antenatal examinations. Similar practices were
adopted by the private hospitals two months later. Consequently, mainland
pregnant women without a booking certificate from Hong Kong hospitals
were denied entry to Hong Kong. In addition, the public hospitals
announced that they would stop accepting bookings once the service capacity
was full or when more capacity had to be reserved to meet the demand from
local citizens. These policies together slowed the growth of birth tours.21
However, the demand for obstetric services provided by Hong Kong’s
hospitals remained high among mainlanders. Since the service was bundled
with Hong Kong residency, mainlanders were willing to pay a much higher
price for obstetrics than ordinary Hong Kongers would otherwise pay. This
‘‘excessive’’ cost gave rise to an economic rent in favor of the hospitals. While
public hospitals had little financial incentive to expand, the profit-seeking
private hospitals competed for the rent and expanded their obstetric services
to mainlanders, with much higher fees. In 2011, the tipping point before the
major outbreak of the anti-mainlanders campaign, there was a significant rise
(19% on average) in fees for obstetrics in private hospitals (Figure 2). The high
fees effectively deterred most Hong Kong pregnant women from giving birth
in private hospitals. Consequently, although maternity beds were, according
to the private hospitals, reserved for Hong Kong citizens, in practice many of
them were not taken and were subsequently allocated to the mainlanders.
21. Hong Kong Government, ‘‘LCQ2: Non-local Pregnant Women Giving Birth in Hong Kong,’’
GovHK, May 16, 2012, <http://www.info.gov.hk/gia/general/201205/16/P201205160279.htm>.
LEE / INTERGROUP CONFLICT IN HONG KONG 357
figure 2. Minimum Charges for Obstetrics in Private Hospitals in 2010 and 2011
Hong Kong Sanatorium & Hospital
2010
St. Paul's Hospital*
2011
Union Hospital*
Canossa Hospital
St. Teresa's Hospital*
Tsuen Wan Advenst Hospital
Precious Blood Hospital
Malda Internaonal Hospital
Hong Kong Advenst Hospital
Hong Kong Bapst Hospital
0
5,000
10,000
15,000
20,000
25,000
Minimum Charges for Giving Birth (in Hong Kong Dollars)
SOURCES :
Hong Kong Consumer Council, ‘‘Sijia yiyuan sheng BB tacan zuidi xiaofei xiangcha guowan’’
[‘‘The minimum fees for obstetrics in private hospitals differ by ten thousand dollars’’], Xuanze [Choice] no.
404, (2010), p. 34; Hong Kong Consumer Council, ‘‘Siyuan fenmian taocan jiajia zuigao yu sicheng’’
[‘‘Obstetrics package prices increase by as much as 40%’’], Xuanze no. 422, (2011), p. 30.
NOTES : Minimum charges refer to the least expensive obstetrics package available to Hong Kong residents.
Hospitals that charged more for nonlocal patients are asterisked. The charges quoted exclude administrative
fees and other additional surcharges. Data for two hospitals are not available.
The most astonishing case was revealed in 2012, in which a private hospital
reported that 90% of its obstetrics patients were pregnant mainlanders.22
FROM PROFIT SEEKING TO INTERGROUP CONFLICTS
The rising fees and expansion of private hospitals not only limited the choices
of local pregnant women but also had wider impacts on the general populace,
the majority of whom can only afford the public hospitals. Although Hong
Kong’s health care system has long enjoyed a good reputation for quality and
comprehensiveness, its capacity has been diminishing since the late 1990s. As
is the case in many developed economies, Hong Kong’s population is aging
and increasingly suffers from chronic illnesses. In 1966, the proportion of the
population above 65 years old was just 3.3%, but the figure had risen to 13.3%
22. Wei Lo, ‘‘Medical Sector Fears Impact of a Ban,’’ South China Morning Post, April 18, 2012.
358 ASIAN SURVEY 56:2
by 2011.23 Because Hong Kong has no social insurance taxes, all public
finances for health services come from the government. This imposes a heavy
burden upon the public health system, rendering it increasingly financially
unsustainable.24 By 2011, excessive workloads, rising staff shortages, and long
wait times became so significant that additional investment from the government was necessary.
Some observers argue that expanding the size of private hospitals is a means
to tackle the problems of the public health care system because it will help
divert patients from the public hospitals. This is not a new suggestion. Since
2001, two working groups set up at the behest of the Chief Executive have tried
to promote further cooperation between Hong Kong’s private and public
health care sectors.25 The government hoped to outsource part of its services
(e.g. primary care and specialist services) to private hospitals so that it could
concentrate its resources in four key areas: accident and emergency care; lowincome groups; treatment involving high financial risk; and training. However,
this was not to be. Fees charged by private hospitals are unaffordable for most
of the population. Also, there is no fee schedule, and fees can differ markedly
among providers.26 This makes standardized government subsidies impractical.
Indeed, problems in the public health care system deepened as private
hospitals expanded. As working conditions in public hospitals continued to
worsen, more doctors and nurses were drawn into the more lucrative private
practices. Of the 12,424 doctors registered in Hong Kong at the end of 2009
(1.77 doctors per 1,000 people), only around 40% worked in the public
sector.27 This shortage of doctors was particularly serious in maternity units,
which saw an 11% turnover rate in obstetricians in 2009/10.28 Moreover, on
average, 2 out of every 100 new births require neonatal intensive care: those
23. Hong Kong Census and Statistics Department, Hong Kong 2011 Population Census Thematic
Report: Older Persons, <http://www.statistics.gov.hk/pub/B11200642013XXXXB0100.pdf>, accessed
March 18, 2016.
24. Winnie Yip and William Hsiao, ‘‘A Systematic Approach to Reforming Hong Kong’s Health
Financing: The Harvard Proposal,’’ in Hong Kong’s Health System: Reflections, Perspectives and Visions,
ed. Gabriel M. Leung and John Bacon-Shone (Hong Kong: Hong Kong University Press, 2006), pp.
462–448.
25. David Fang, ‘‘The Private-Public Interface,’’ in Hong Kong’s Health System, pp. 199–208.
26. Yip and Hsiao, ‘‘A Systematic Approach,’’ p. 449.
27. Food and Health Bureau, ‘‘Hong Kong’s Current Private Healthcare Sector,’’ My Health My
Choice, <http://www.myhealthmychoice.gov.hk/pdf/appendixC_eng.pdf>, accessed May 4, 2015.
28. Hong Kong Government, ‘‘LCQ11: Obstetric Services,’’ GovHK, May 4, 2011, <http://www.
info.gov.hk/gia/general/201105/04/P201105040187.htm>, accessed May 4, 2015.
LEE / INTERGROUP CONFLICT IN HONG KONG 359
babies are sent to public hospitals because private hospitals lack the necessary
facilities. The number of referrals from private hospitals to neonatal intensive
care units of public hospitals increased from 281 in 2008 to 312 in 2009.29 It
was reported in 2011 that the public hospitals’ neonatal intensive care units
were 20% over capacity.30
On March 9, 2011, front-line staff working in public hospitals criticized the
government for expanding the city’s health care industry at the expense of their
working conditions.31 On April 5, as the pressure faced by the front-line staff in
public hospitals became increasingly unbearable, the Hong Kong government
proposed capping the number of newborn babies delivered in the city at
88,000. The proposal was rejected by the Private Hospital Association, a powerful interest group. They argued that there was little room to reduce the
number of admissions since investments had been made to cope with the
demand for obstetric services. As a result, no immediate measure was taken.
On April 28 the government announced that a working group would be set
up instead to determine the number of nonlocal pregnant women to be
admitted to give birth in Hong Kong in 2012.32 On May 11, 2011, the College
of Paediatricians and the College of Obstetricians and Gynaecologists, the
major training bodies for specialists in the respective fields, proposed to create
a database to chart the treatment of every expectant mother, which they
claimed would help medical auditors track the quality of care and detect
people trying to cheat the system.33 The problem persisted: the private hospitals continued to admit excessive numbers of pregnant mainlanders, and
the less wealthy local parents remained in panic.
Health care groups are powerful in Hong Kong because of the highly
specialized nature of their discipline and the government’s reliance on them
in the provision of health care services.34 As William Hsiao and Winnie Yip
observe, the health care sector in Hong Kong is dominated by a handful of
professional elites who are mostly graduates of the University of Hong Kong’s
29. Ibid.
30. Lo, ‘‘Mainlanders Threaten Maternity Care.’’
31. Ella Lee, ‘‘Delay New Hospitals, Services, Medics Say,’’ South China Morning Post, March 9, 2011.
32. Hong Kong Government, ‘‘LCQ4: Obstetric Services,’’ GovHK, May 11, 2011, <http://www.
info.gov.hk/gia/general/201105/11/P201105110171.htm>, accessed May 4, 2015.
33. Ella Lee, ‘‘Medical Groups Back Audit of Pregnant Mums,’’ South China Morning Post, May
11, 2011.
34. Yiu-Ming Chu, ‘‘Quality of Care and Patient Redress: A Patient Perspective,’’ in Hong Kong’s
Health System, p. 272.
360 ASIAN SURVEY 56:2
table 1. Number of Complaints and Regulatory Actions Taken by the Government
Complaints received
Investigations conducted
Warning letters issued
Prosecution initiated
2009
83
5
3
0
2010
89
24
2
0
2011
74
18
6
0
Total
246
47
11
0
Audit Commission, ‘‘Regulatory Control of Private Hospitals,’’ Audit’s Report no. 59 (October
2012), Tables 1, 2, 7.
NOTES : a. Only complaints made to the Department of Health are included. Patients can resolve their
issues directly with the private hospital concerned. From 2009 to June 2011, private hospitals received a total
of 2,063 complaints—not all of them were reported to the government as required. b. Under the Hospitals,
Nursing Homes and Maternity Homes Registration Ordinance, the Department of Health may cancel the
registration or refuse the re-registration of a private hospital if any condition relating to accommodation,
staffing or equipment is unfit.
SOURCE :
medical school. Their similar professional education and beliefs create close
professional loyalties and collective defenses against external influence.35 This
is particularly so among the private hospitals because of their independent
financial status. Although they are required to comply with the rules set forth
by the Department of Health (in the Code of Practice for Private Hospitals),
in reality those rules are rarely enforced. From 2009 to 2011, the Department
of Health received 246 complaints from patients concerning private hospitals’
services, but in the end issued only 11 advisory or warning letters (Table 1).
Even then, private hospitals concerned can significantly delay rectifying the
problems without being prosecuted.
Available records from the Department of Health illustrate this clearly. For
example, in June 2011, the department issued a warning letter to a private
hospital for admitting an excessive number of pregnant women. However,
instead of restricting its admission immediately, the hospital—as reflected in
subsequent warning letters it received—continued its practice and applied for
expansion of its maternity services in December.36 Although during an assessment in January 2012 the Department of Health observed that staffing was
35. William Hsiao and Winnie Yip, Improving Hong Kong’s Health Care System: Why and For
Whom? Food and Health Bureau, 1999, <http://www.fhb.gov.hk/en/press_and_publications/
consultation/HCS.HTM>, accessed May 4, 2015.
36. Follow-up investigations conducted by the Department of Health in June, October, and
November discovered that the hospital still failed to meet the requirements specified in the first
warning letter. Yet, no prosecution was initiated.
LEE / INTERGROUP CONFLICT IN HONG KONG 361
insufficient for expanded maternity services, a new Certificate of Registration
was still issued to the hospital after it had submitted further information to
demonstrate that it had taken steps to address address the problems.37 The
lengthy rectification process demonstrated how ineffective the regulatory
system was. Some observers even condemned the Department of Health for
adopting a ‘‘partnership approach’’ in monitoring the private hospitals.38
Of course, the private hospitals are not an isolated interest group: other
local industrial and political elites are connected to the hospitals either
through direct ownership, investment (e.g. shareholding), or family and
other personal ties. Consider the case of the Union Hospital. In 1982, a plot
of government land was sold under preferential terms to a company owned
by a group of merchants and bankers for construction of a private hospital.
However, instead of building a hospital, the company—which was eventually
controlled by property tycoon Lee Shau-kee in 1989—applied to convert the
land to residential use.39 After its applications were rejected by the government in 1986 and 1988, the company began to construct the Union Hospital
in 1990. Yet, only 54% of the land was used. For the undeveloped portion,
after years of applications, Lee obtained the government’s approval and
turned it into a luxury housing estate, generating at least three billion Hong
Kong dollars (approximately US$ 380 million) for his company. Although
there was no evidence that any government officials benefited in this transaction, the incident clearly exhibited the strong ties between private hospitals
and local elites, which were further substantiated as the influx of birth tours
since 2001 has made the private hospital business increasingly profitable. In
addition to Lee Shau-kee, property tycoons such as Lo Ka-shui and political
elites such as Bernard Chan (a former Executive Councilor) also publicly
expressed their interest in capitalizing on the influx of birth tours by applying
for land to open new private hospitals.40 This created a strong incentive for
the government to keep the health care industry profitable.
37. Audit Commission, ‘‘Regulatory Control of Private Hospitals,’’ Audit’s Report no. 59 (October
2012), pp. 20–21.
38. Ibid., p. 31.
39. Before Lee Shau-kee took over the company it was controlled by another tycoon, Li Ka-shing,
and his affiliates. Dennis Chong, ‘‘Developer That Bought Union Hospital Site Wanted to Build
Flats,’’ South China Morning Post, November 17, 2012.
40. The Executive Council is a core organ for assisting the Chief Executive in policymaking.
Bernard Chan was reappointed to the council in July 2012. Yuk-hang Ng and Ella Lee, ‘‘Government
Gets 30 Applicants for Private Hospitals,’’ South China Morning Post, April 1, 2010.
362 ASIAN SURVEY 56:2
More important, the overall policy orientation of the administration
strongly favored closer integration with the mainland, socially and economically. On July 15, 2011, the Chief Executive was on the record as saying that
allowing more mainland mothers to give birth in Hong Kong could help
tackle the problem of population aging, and would thus increase and sustain
the competitiveness of the city. He urged the public to view the influx of
mainland mothers ‘‘positively.’’41
Fueled by rumors and misinformation, the fears of under-represented local
groups soon turned into anger. By mid-2011, reports of the unlawful behavior
of some mainlanders garnered public attention. There were reports of large
numbers of mainland mothers who had not made a reservation with a Hong
Kong hospital but had concealed their pregnancies from customs officers
when entering Hong Kong, relying instead on emergency room care at public
hospitals to deliver their babies.42 However, such reports were biased and
exaggerated. The number of births in this fashion was actually minimal
(around 1,100 in 2011) compared to those given through the lawful channel
(around 35,000).43
Such exaggeration, however, plays a critical role in demonizing mainland
parents and is a contributing cause of some locals’ open discrimination as well
as hate speech. Of related videos uploaded to YouTube in 2011, a total of 80
contained the word ‘‘locusts’’ (in Chinese) in the title, among which 54 were
hostile to the mainlanders.44 Popular videos got nearly one million hits.45
Meanwhile, angry citizens created a Facebook group to try to end the influx
of mainlanders giving birth in Hong Kong. On August 29 around 100 locals
brought their anger to the streets, followed by another protest on October 23
with more than 600 participants.46 Clearly, the call for a termination of
medical tourism had developed into an anti-mainlander sentiment.
41. ‘‘Xingzheng zhangguan dawenhui dawen quanwen (3)’’ [Transcript of the Chief Executive’s
question and answer session (3)], GovHK, July 15, 2011, <http://www.info.gov.hk/gia/general/201107/
15/P201107150409.htm>, accessed May 4, 2015.
42. Isabella Steger, ‘‘Hong Kong Moves to Curb Births by Mainland Mothers,’’ Wall Street
Journal, June 25, 2011.
43. Edwin Chau, ‘‘Fanmai jugangquan?’’ [Selling the right of abode?], Ming Pao Life, February 15,
2012.
44. Data collected by the author through a Google search on September 3, 2012. Videos that were
hostile to mainlanders but did not have the word ‘‘locusts’’ in the title were excluded.
45. Andrew Higgins, ‘‘China Denounces ‘Hong Konger’ Trend,’’ Washington Post, January 11,
2012.
46. ‘‘City Digest,’’ South China Morning Post, October 24, 2011.
LEE / INTERGROUP CONFLICT IN HONG KONG 363
Of course, the impression among Hong Kongers that mainlanders are
displacing them is not limited to the health care sector but applies to a broad
range of aspects of social life. Similar sentiment has also evolved, for example,
in higher education, in which local universities compete with one another for
international students—most of them from mainland China. Again, the
profit-seeking behavior of local actors played an important role in the escalation of intergroup tension. Although universities in Hong Kong are owned
by the government, they have to compete among themselves for financial
resources and international recognition, which in turn prompts many of them
to expand their recruitment of nonlocal students and open self-funded programs.47 This trend has become particularly apparent since the education sector
was identified by the Task Force on Economic Challenges as an ‘‘emerging
industry’’ in 2009.
Mainlanders became the overwhelming majority of the nonlocal student
body not only because of their geographical proximity to Hong Kong but also
because of the strategic choices of many local universities. The great demand
for high-quality education in China provided an easy way for Hong Kong
universities to recruit ‘‘nonlocal’’ students and thus boost their income and
level of ‘‘internationalization.’’ The recruitment of mainland students was
particularly astonishing at the post-college level, constituting more than half
of its student body (Table 2). At the undergraduate level, while less than 20%
of local school-age students are admitted by local universities, the proportion
of mainlanders has also increased considerably since 1997 (Figure 3). The
influx has a significant implications for resource distribution because foreign
students (including those from the mainland) often receive generous scholarships and guaranteed accommodation from universities.
Collective fears over jobs, health care, housing, public order, and educational opportunities began to blossom among Hong Kongers. The aforementioned telephone poll conducted by Kee-lee Chou in February 2012 estimated
that nearly 40% of Hong Kongers believed that immigrants have threatened
their job prospects. When asked whether the number of new immigrants
should be increased, held steady, or decreased, 50.6% of polled residents
chose the last option, highlighting their negative impression of immigrants
(Table 3). More important, Chou found that this negative impression was
47. University Grants Committee, Higher Education in Hong Kong: Report of the University
Grants Committee (Hong Kong: Government Printer, 2002).
364 ASIAN SURVEY 56:2
table 2. Mainland Chinese Student Enrolment in Research Postgraduate Programs, 2007–2013
2006/07
2008/09
2009/10
2010/11
2011/12
No. of
2693
3018
3313
Students (92, 53) (94, 58) (94, 62)
3821
(94, 65)
4033
(92, 65)
4290
(90, 67)
Year
2007/08
2012/13
2013/14
4580
4767
(89, 68) (87, 69)
SOURCE :
Hong Kong University Grants Committee, ‘‘Statistics’’ (2014), <http://cdcf.ugc.edu.hk/cdcf/
statIndex.do?language¼EN>, accessed December 8, 2014.
NOTE : The first number in parentheses is the percentage of mainland Chinese students in the total number
of international students; the second is the percentage of mainland Chinese students in the total enrolment.
figure 3. Percentage of Mainland Full-Time Undergraduates in Hong Kong’s Public
Universities
9
8
7
Percentage
6
5
4
3
2
1
0
97/98 98/99 99/00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12
Academic Year
SOURCE : Hong Kong University Grants Committee, ‘‘Statistics,’’ 2012, <http://cdcf.ugc.edu.hk/cdcf/
statIndex.do?language¼EN>, accessed 15 January 2013.
NOTE :
% of mainland full time undergraduates ¼
No: of mainland full time undergraduates 100
.
No: of total full time undergraduates
concentrated mostly among under-represented groups: the poor, the less
educated, women, and the elderly.48
A series of events from August 2011 to February 2012, delineated in Table 4,
further intensified the tension between the two groups. In general, mainlanders
were accused of ‘‘uncivil’’ (buwenming) behavior in public, such as spitting and
48. ‘‘HKIEd Survey: Negative Perceptions Hinder New Immigrants’ Integration into Hong
Kong Society,’’ Hong Kong Institute of Education, November 22, 2012, <http://www.ied.edu.hk/
media/news.php?id¼20121122>, accessed May 4, 2015.
table 3. Results of a Survey Concerning Hong Kongers’ Attitudes toward New
Immigrants
Survey item
Result (%)
Do you agree that new immigrants lower local
salary levels?
Agree
Disagree
39.8 (+3)
Do you agree that new immigrants steal local jobs?
Agree
37.6 (+3)
Do you agree that new immigrants have an adverse
impact on Hong Kong’s economic outlook?
Agree
Disagree
44 (+3)
In your view, the number of new immigrants
allowed into Hong Kong should:
Decrease
50.6 (+3.1)
Remain the same
26.8 (+2.7)
Increase
16.8 (+2.3)
Disagree
46.7 (+3.1)
43 (+3)
39.5 (+3)
SOURCE :
‘‘HKIEd Survey: Negative Perceptions Hinder New Immigrants’ Integration into Hong Kong
Society,’’ Hong Kong Institute of Education, November 22, 2012, <http://www.ied.edu.hk/media/news.
php?id¼20121122>.
NOTES : 95% confidence intervals in parentheses. N ¼ 1024 (response rate ¼ 65.3%). Variables in the survey
are recoded into dichotomous or trichotomous variables. The survey was designed by Chou Kee-lee and
was carried out by the Public Opinion Program of the University of Hong Kong in February 2012.
table 4. Major Confrontations between Hong Kongers and Mainlanders from
August 2011 to February 2012
Date
Incident
August 2011
A YouTube video clip featuring a dispute between a Hong Konger
and a mainlander over a subway seat got more than 190,000 hits in
a week, and sparked furious discussions about the behavior of
mainlanders in Hong Kong.
October 2011
A Hong Kong student at the City University of Hong Kong publicly
denounced students from mainland China as ‘‘dogs.’’
January 9, 2012
Thousands of Hong Kongers protested outside a luxury shop that was
accused of giving preferential treatment to mainlanders.
January 15, 2012
A Hong Konger blamed a mainland mother for allowing her child to
eat on the Hong Kong subway. The dispute was captured on video,
which was then viewed extensively and caused heated discussions
amongst Hong Kong and mainland netizens.
January 20–21, 2012
A professor at Beijing University called Hong Kongers who do not
speak putonghua ‘‘British running dogs.’’ This caused around 200
Hong Kongers to take to the streets to protest.
SOURCES :
Dongfang ribao; Wenhui bao; The Economist; South China Morning Post.
366 ASIAN SURVEY 56:2
queue-jumping. They were also feared for the degree of their investment and
consumption in Hong Kong, which were believed to accelerate inflation. On
February 1, the online group Golden Forum funded the full-page advertisement against mainlanders in Apple Daily, referenced above.
It is important to note that this campaign strategy, which involved online
fundraising and newspaper advertisements, originated in a pro-democracy
movement in 2005. In that year, a user of Golden Forum, hoping to support
the pro-democracy protest with a newspaper ad, raised funds on the forum.49
In addition to giving money to support the cause, netizens also participated in
the event by proposing possible designs for the ad. As political representation
of different groups is unequal in established institutions, this strategy has
continued to be used by citizens whose voices could hardly be heard otherwise. In 2009, for example, users of the same forum organized a fundraising
campaign to launch an advertisement commemorating China’s June 4, 1989,
Tiananmen Incident. Through these activities, ordinary citizens accumulated
campaigning experience and organizational strength.
CONCLUSION
Through an in-depth examination of the recent development of the private
health care system in Hong Kong, this article argues that profit-seeking
activities of market actors within the local group can play a critical role in
triggering intergroup conflicts. As such, it makes two contributions to the
fields of Asian studies and intergroup relations. First, it affirms the importance of internal divisions among local persons in explaining urban intergroup conflicts. It is important to note that in most intergroup conflicts, not
all members in the same group participate actively. This article suggests that
scholars can identify the causes of conflicts productively by explaining the
variation in participation among different subgroups. Second, this article
provides concrete and robust information connecting profit-seeking behavior
and urban intergroup conflicts, which explains why the latter can be an
unwitting consequence of state action. It complicates the rather simplistic
explanations of intergroup conflicts and fills an important gap left by deliberation theory.
49. ‘‘Gaodeng hezi dengbao shengyuan shier yue si dayouxing’’ [Golden Forum fundraising
campaign to support the protest on November 4], Golden Forum (Hong Kong), November 21, 2005,
<http://golden124.blogspot.hk/>, accessed May 4, 2015.
LEE / INTERGROUP CONFLICT IN HONG KONG 367
The cause of intergroup conflict outlined in this article is clearly not
confined to Hong Kong. While the city, as a small and open economy, is
particularly dependent on foreign resources, many Asian economies have
similarly pursued reforms in the past two decades to attract foreign investment. Preferential policies are granted to sectors deemed to be enjoying
a comparative advantage. It is often assumed that these reforms are necessary
for making an economy more competitive internationally. As a result, their
negative impacts on the disadvantaged local population are rarely taken
seriously by the reformers. The policy implication of this article is that poorly
designed strategies for attracting foreign resources can generate considerable
problems for the disadvantaged local population, exposing them to direct
competition with outsiders for key resources, and subsequently paving the
way for intergroup conflicts.
In many ways, the Hong Kong case resembles intergroup conflicts in other
Asian cities. Singapore, for instance, has in recent years been beset by ethnic
cleavages in which policy disarticulations similar to the ones discussed in this
article played a critical role. In order to develop its high-value-added
manufacturing industry and to maintain a steady population growth, since
the late 1990s the authoritarian state has been keen on attracting skilled
foreign labor and students. As incentives, qualified foreigners receive a set
of preferential treatments from the state, such as amenities, generous scholarships, and subsidized housing. From 2000 to 2010, the foreign population in
Singapore increased by 73%, from 754,500 to 1,305,000.50 However, despite
years of rapid economic growth, the influx of foreigners has not really
benefited low-income Singaporeans, whose income has grown by only
0.3% in the same period.51 Suffering from rising costs of living, long working
hours, and stiffer competition for job vacancies, Singaporeans have directed
their anger toward outsiders, especially mainland Chinese, who accounted for
26% of purchases of residential properties by foreigners in the second quarter
of 2011.52 In the absence of effective institutional means for people to express
their discontent, xenophobic sentiments among the locals burst forth in
50. Singapore Department of Statistics, ‘‘Time Series on Population (Mid-year Estimates),’’
<http://www.singstat.gov.sg/stats/themes/people/hist/popn.html>, accessed July 30, 2012.
51. Singapore Statistics Department, ‘‘Singaporeans in the Workforce,’’ October 2011, <http://
www.singstat.gov.sg/pubn/papers/people/op-s17.pdf>.
52. ‘‘The Chinese are Top Foreign Buyers of Residential Properties in Singapore,’’ Singapore
Business Review, August 18, 2011.
368 ASIAN SURVEY 56:2
creative forms, such as launching a day of curry cooking following a complaint
lodged by a mainland Chinese family over the smell of the dish.53
Of course, not all profit-maximizing activities of local market actors are
detrimental to intergroup relations. It is likely that the link between them is
stronger when there is no effective system of regulation in the market concerned. Well-designed regulations can limit the ability and incentives of local
market actors to develop preferences which diverge significantly from those of
the insider community. These rules also serve as a corrective mechanism so
that conflict-inducing business strategies adopted by market actors can be
modified in a timely manner. The absence of effective regulation in one
market may be an associated feature of a dysfunctional bureaucracy, but it
can also be a result of disconnection of interests between the regulators and
the public. This problem is common in many nondemocratic regimes in
Asia, where serious internal inequalities in economic power and political
representation persist. Since the interests of the affluent are favored, regulators are likely to be disconnected from the concerns of multiple significant
segments of society, and thus fail to prevent local hostility toward outsiders
from escalating.
No city survives in isolation from the rest of the world. Yet, policies
attracting outsiders for resources can be harmful or threatening to the existing
population if they are not formulated in a democratic context. The intergroup conflicts in Asia are well documented. However, the scholarly community has yet to articulate a causal mechanism to account for conflicts that
arise as an unintended consequence of state actions. This article serves as an
initial effort to tackle this problem. Further research, by explaining subgroup
variations in reacting to intergroup conflict in other cities, may help generalize the finding presented in this article.
53. Andrew Jacobs, ‘‘In Singapore, Vitriol against Chinese Newcomers,’’ New York Times, July 26,
2012.