TOWARDS Better Health'' is a consultation paper. My experience with such documents tells me that often the satisfaction which comes from publication is out of proportion to its agonies. The road to reform is anything but smooth. So, why do we have this document? The reason is that we must do what is right; and we are well positioned to do it now. Towards Better Health, written with the help of health economists, scientists, lawyers, the public and engineers, is truly a Hongkong publication. Written by the people, for the people, it is a frank document and we expect an equally frank response to it. Reform does not mean a reduction in the Government's responsibility to providing quality health care. To ensure the Government's commitment to public health services remains the top priority, the Governor pledged last October ''to increase recurrent spending on health care by 22 per cent in real terms by 1997''. Access to affordable health care is a public right, protected in Section 4(d) of the Hospital Authority Ordinance. This right remains the cornerstone of the Government's policy. Our health care system has often been described as a ''dual monopoly'', in that the public system is perceived to be cheap but the consumer has to wait, while service in the private sector is available immediately but expensive. The public perception is that you either wait or pay. There are very few areas where the two systems converge. We need the systems to work more closely together and to offer greater choice. Hitherto our emphasis has been on curative treatment in hospitals. Our focus should now shift toward preventive care and the promotion of good health. With good health comes quality of life and productivity; stability and prosperity. The changing environment adds to the pressure for reform. For example, the population as a whole is ageing while the working population is decreasing proportionately; medical costs are rising at a rate faster than the growth rate of the economy; and public expectations about standards of medical care are rising. We need to improve accessibility and provide better service and choice for consumers at a price they can afford. We need to restructure the system so as to provide greater emphasis on preventive care and better links between primary and tertiary care. Whereas the consultation document does not propose specific fee levels, there is nothing that concentrates the public mind more than the level of fees. This is to be expected. But what is revealing, is that our existing system of charges is neither understood nor its inequities acknowledged. Fees charged by our public hospital system have their origins in the post-War years when they were based on the cost of catering, while the fees charged by public out-patient clinics were based on operating cost. Fees levied in all public hospitals - acute/general, infirmary and psychiatric - are the same irrespective of the different levels of service, operating cost and patient's ability to pay. All fees are updated every year, based on average operating cost and in line with the movement of the Government Consumption Expenditure Deflator. Some hospitals (ex-subvented) still impose ''itemised charges'' in addition to the all-inclusive basic rate. For example, as gazetted, some hospitals, in addition to the daily charge of $43 for a general ward bed, charge separately for admission, surgical operations and drugs. In some cases, consumables, related to special procedures, are also subject to separate levies. The current fee-charging system does not carry with it a clear-cut waiver system except for people on Public Assistance. Elderly people and long-stay patients cannot be sure of gaining a waiver. The historical inconsistencies and anomalies in our fee structure need to be rationalised. We have thus identified these possible options as a way forward which include: Different ways of charging and giving waivers; Greater choice of accommodation in hospital wards; A co-ordinated approach to promote voluntary insurance. As regards different ways of charging, it is suggested that fees be linked to the operating cost of the service. For example, under the scenario of, say, a 95-per cent subsidy and a 50-per cent waiver for selected groups, the fees charged could be $105 for acute/general hospitals, while the exempted fee level would be $52.50. For infirmaries, fees would be $45.50, while the exempted fee level would be $23. For psychiatric hospitals, the fee level would be $21.5 while the exempted fee level would be $11. In the case of infirmaries and psychiatric hospitals, if this formula was accepted, those in need would pay much less than at present. Initial response suggests there is resistance to change. This is based on the misconception that there would be large fee increases. Hence, we welcome views on the acceptability and modification of this option after people have studied the consultation document. The adoption of this option, in our view, would have the advantage that costs were understood by both the provider and consumer with transparency; that the increases/decreases in operating cost were identified and justified. As regards waivers, our health and welfare policy has always prided itself on the philosophy of helping the vulnerable and those with special needs. The consultation document offers an approach to exempt, fully or partially, those who have special needs, from paying fees. We suggest that the poor, the old, long-stay patients and disabled people should fall into this category. In other words, government subsidy is aimed with precision at those in need. Semi-private rooms in public hospitals constitute a standard of accommodation between unsubsidised private wards and heavily subsidised general wards. They aim to offer greater privacy, convenience and comfort. Semi-private rooms could each accommodate six to eight patients. They could be equipped with a television, telephone and en-suite bathroom. There could be a choice of meals and flexible visiting arrangements. Permission could also be given for employmentof private nurses and helpers. However, there would be no preferential treatment over general ward patients either in terms of choice of doctors or priority for elective surgery. Access to, and quality of, medical services would be the same for all patients. As we see it, for those interested in a co-ordinated, voluntary insurance scheme, the greatest advantage is the assurance that the coverage and corresponding premium of an approved plan have received independent endorsement. In addition, competition between the insurance companies would enhance choice and keep base premiums competitive. For those who could not, or would not, wish to take out insurance, heavily subsidised public services would still be available. More importantly, this approach is simple to administer and provides greater access and choice to subscribers. It may also facilitate links between the public and private sectors, particularly in the use of expensive equipment, and reduce the segregation inherent in the present dual system. Our objective is to ensure increased access, better choice and better consumer protection in the health care system. To do this, we should revamp our system to make it better managed, more transparent, cheaper for those who cannot pay and fairer for everyone. Consumers should all have a monitoring role to play and have more choice. Above all, there should be a strong safety net. It is only then that we can begin to talk about patients' right to know and right to choose. It is only then that we can begin to talk about nobody being turned away and to mean what we say. Adequate health care at an affordable price is every patient's right. Elizabeth Wong Chien Chi-lien is Secretary for Health and Welfare.