The decade did not begin auspiciously in terms of health. A few months after the handover, Hong Kong was grappling with an outbreak of H5N1 bird flu, the first time the virus had jumped the species barrier to humans. An unprecedented mass culling of poultry stopped the outbreak, but not until after six of 18 patients died. This led to an overhaul of the food safety regime and a slew of anti-bird-flu measures to keep the bug at bay. Hong Kong was to experience three more outbreaks, but fortunately they didn't infect any people. Since 2003, the world has been on watch, fearing that the continuing H5N1 bird flu outbreaks in several countries could trigger the next flu pandemic. But if there was a defining moment in the past decade, it was March 12, 2003, when the spectre of a new emerging disease was first announced at a public hospital. Sars - severe acute respiratory syndrome - proved to be a major new threat to international public health. The epidemic in Hong Kong lasted three months and infected 1,755 people, killing 299. Sars struck Hong Kong with a severity not seen in other affected countries. It almost broke the city's health-care system, swamping public hospitals with patients and causing the quarantining of residents in one whole block at Amoy Gardens. The epidemic highlighted the urgent need to review the capacity of the health-care system, and to better prepare for any future outbreak. Because of Sars, Hong Kong set up the Centre for Health Protection to prevent and control outbreaks of communicable and non-communicable diseases. Sars has not made a comeback, except for a few laboratory-acquired cases on the mainland, in Singapore and Taiwan. But the threat of H5N1 bird flu has lingered since 2003. There have been poultry outbreaks in 12 countries in Asia, Europe and Africa, and human cases as well. To date, 315 people have been infected and 191 have died. As the threat of a flu pandemic loomed, the government's preparedness plan was published in early 2005. It adopted a cross-sector and population-based approach, underpinned by an overall emergency response system involving the government. The plan, which includes keeping a stockpile of anti-flu drugs, is constantly being updated and tested in simulation exercises. To improve disease surveillance and control, the centre also is setting up a HK$100 million communicable-disease information system aimed at creating a comprehensive database for disease analysis. Hong Kong also tested the waters for health-care reform, but found them chilly. The 1999 government-commissioned Harvard report on health-care reform proposed compulsory enrolment in health insurance and a personal savings account for long-term care. It suggested a health security plan for serious diseases, which did not go down well, but a proposed medical savings scheme was favourably greeted by the public. Still, no action was taken. The following year, the health secretary released a consultation document that proposed individual health protection accounts to cover medical and dental bills after retirement. But they never saw the light of day. In 2005, Secretary for Health, Welfare and Food York Chow Yat-ngok released a new consultation document, 'Building a Healthy Tomorrow', which set out proposals for health-care service models. It envisaged a family medicine network in which family doctors would be the gatekeepers of the hospital system. Public hospitals would concentrate on acute and emergency care; low-income and underprivileged groups; illnesses that entail high costs; advanced technology and multidisciplinary professional teamwork; and the training of health-care professionals. It also proposed a review of fees and charges for accident and emergency services and outpatient clinics, and for medications at public hospitals. It was scrutinised during a three-month consultation in late 2005, which received 600 submissions. The community still awaits the consultation's second phase, which will detail health-care financing proposals, expected later this year. The Hospital Authority, meanwhile, went on an aggressive improvement programme at public hospitals. But high expectations and an ageing population brought with it financial problems. The Hospital Authority has recorded budgetary deficits since 2001. A HK$100 fee for accident and emergency services was introduced for the first time in 2002, followed by a general increase in hospital and clinic charges and other new fees, such as a HK$10-per-item charge on drugs. The past decade also saw organisational changes, sparked partly by the 1997 bird flu outbreak. A Food and Environmental Hygiene Department was created in 2000 to take over half the functions of the defunct municipal councils. The other half was taken over by the Leisure and Cultural Services Department. The Health and Welfare Bureau took on the added task of policymaking for food safety, and was renamed the Health, Welfare and Food Bureau. From this month, the bureau will consolidate its health and food functions, and welfare will be shuffled to a new bureau. The government also is banking on the Centre for Food Safety, set up last year, to set up better food safety mechanisms. Many hope Chief Executive Donald Tsang Yam-kuen's second term will achieve reforms to health-care financing that will help assure the sustainability of the public health system.