Taiwan's Public Health Miracle
From Infested Island to Health Heavyweight
Once seen as a disease-ridden tropical island, Taiwan won international kudos for eradicating malaria and other parasitic infections. And its national health insurance system has ushered in a new age of "fair, universal" public health.
From Infested Island to Health HeavyweightBy Ming-Ling Hsieh
From CommonWealth Magazine (vol. 427 )
This year the H1N1 "swine flu" virus appears to be sweeping across the globe.
In the third week of July, Taiwan recorded more than 1,000 cases of H1N1 in the span of a week, and the first local case with serious complications: a 34-year-old man suffering from multiple major organ deterioration who remains to date in intensive care.
Immunization authorities sprang into action, and Dr. Allen Lien, an epidemiologist with the Department of Health's Center for Disease Control, began tracking the source of the outbreak, poring over airline passenger manifests and manning the frontline of viral control by helping out on the newly established 1922 flu prevention hotline. Every day he reports for a shift at the Central Epidemic Control and Information Center.
During 32 months of service in the small town of Koudougou in the impoverished West African nation of Burkina Faso, Lien provided medical services to the needy, drilled freshwater wells, and helped establish an orphanage.
Along the way he became more acutely aware that public health and the allocation of medical resources are critical to the well-being of a nation. Upon his return to Taiwan from Africa, Lien resigned his post with the Veteran's General Hospital system and gained certification as an epidemiologist with the Center for Disease Control, believing he could learn much more, do more to help achieve social justice, and assist even more patients in need.
The pursuit and attainment of fairness has been a hallmark of Taiwan's public health system for 60 years now.
"Taiwan is a capitalist nation with a socialist health care system," notes Academia Sinica research fellow C.J. Chen. "It seeks equitable prosperity and fairness. And it has always taken the path of health care for all the people, not just for the elite."
Taiwan's pursuit of "fairness" in its health care system has also been widely recognized internationally.
In a 2000 survey of health care demand and allocation of resources conducted by the British publication Economist Intelligence Unit, Taiwan's well-equipped and reasonably priced health care system ranked No. 2 among 27 countries – second only to Sweden.
Taiwan's pursuit of equitable health care treatment for all has its roots.
In an apartment off a quiet lane in Taipei's Datong District, Dr. J.C. Lien, also known as "Dr. Mosquito," opens a wooden case containing samples of more than 100 species of mosquitoes he has collected, all arranged into neat rows and clearly labeled by their scientific names.
In his youth, he was one of the frontline medical soldiers in Taiwan's war to eradicate malaria. Within 10 years, cases of local malaria infection dropped from a million or more islandwide to zero. In 1965, the World Health Organization awarded its first "certificate of malaria eradication" to Taiwan.
Taiwan also waged a battle to the death against tapeworms and other parasites that endanger the health of children in developing countries.
In 1972, Taiwan began treating school children for intestinal parasites (including roundworms, hookworms and whipworms). Within 15 years the country had reduced the rate of parasitic infections in juveniles from 3 in 4 to less than 1 in 100.
Despite losing ground in the diplomatic arena, Taiwan still garnered kudos for its experience in wiping out malaria on the island. Nine years ago, the 73 year-old Lien was approached about assisting Taiwan's African diplomatic allies in their battle against malaria. After seven years of effort, local malaria infection rates in those nations fell from 60-70 percent to just 3 percent.
On a visit to Taiwan to meet with Department of Health officials, the public health minister for the African island nation of Sao Tome and Principe jokingly complained that the hospitals in his country were all empty, and they had no customers for their anti-malarial drugs.
From those earlier references to Taiwan as a "disease-ridden island" to the export of its experience in eradicating previously endemic infectious diseases, what Taiwan has shown the world these past 60 years has been a relentless effort at eradicating and preventing infectious diseases, as well as an outlook of "fair, universal" health care: the notion that the people have a right to be free of the threat of epidemic diseases and have equal access to health care resources.
Behind this outlook lies the notion of "government effort, providing the impetus from the top down."
"After living under both the Japanese and KMT governments, the public has gradually come to feel that prevention and treatment of infectious diseases is a government obligation," says Dr. Chen Yong-shing, a professor at Taipei Medical University's Graduate Institute of Humanity in Medicine.
Greatest Post-War Social Movement
Historically, "big government" has been advantageous to the implementation of public health policy: First there is the regulatory power of the state along with a high degree of public cooperation. Second, with top-to-bottom policymaking, plans are easily carried to completion with immediately discernable results.
During the Japanese colonial era, the introduction of public physicians and an exhaustively comprehensive household registration system provided an effective foundation for the implementation of public health policy measures.
Further, "following World War II, Taiwan established a very good grassroots public health system," says Academia Sinica's C.J. Chen. The KMT government continued the public health and sanitation policy initiatives of the Japanese, starting with basic medical care.
One indicator of this is the number of local health departments, which rose from 15 at the end of World War II to 360 by 1950.
The success of the malaria eradication program in 1965 is testimony to the effectiveness of promoting public health policy starting at the town and village level.
During the initial "assault phase" of the malaria eradication program, public health officials sprayed DDT in homes, allowing the chemical residue to remain on walls to kill the anopheles minimus species of mosquito that carried the disease. The task was actually fraught with difficulty.
Later, during the "mop-up phase," remaining cases of malaria were sought out and comprehensively treated to eradicate the malaria parasite from their bodies.
During this period, public health personnel were required to not only seek out carriers in their districts, but also personally visit their homes and see to it that they took their anti-malarial medication, even examining the insides of their mouths to ensure the medications had actually been swallowed. This task was carried out every day for two weeks to ensure complete eradication.
In J.C. Lien's estimation, both Taiwan and Sri Lanka approached near total eradication through the spraying of DDT. Taiwan's total mobilization of public health personnel for the follow up and thorough treatment of existing cases resulted in success. The Sri Lankan effort, however, unfortunately ended up right back where it started due to a lack of follow-up.
Tsai Duujian, another professor with Taipei Medical University's Graduate Institute of Humanity in Medicine, goes even further with the malaria eradication program, defining it as Taiwan's "greatest post-war social movement," given the personnel mobilization from the grassroots all the way to the central government.
Later implementation of programs to eradicate trachoma and intestinal parasites as well as vaccination and family planning programs all gained traction due to the establishment of this sort of grassroots medical care.
A system designed to improve public health starting from the grassroots also requires a large cadre of trained professionals willing to dedicate themselves to public health.
In post-war Taiwan, the willingness of the medical establishment elite to descend upon rural towns and villages around the island in the spirit of Albert Schweitzer was instrumental in crafting Taiwan's public health miracle.
Entrepreneurial Spirit Succeeds with National Health
Dr. Tsungming Tu, the first Taiwanese person to earn a Doctor of Medicine degree, who went on to become the first dean of Kaohsiung Medical University, was a paragon of the values inhabiting the hearts and minds of Taiwanese medical professionals of the time.
As Chen Yong-shing notes, Tu was the first to recognize the lack of medical care in mountain areas, and established the first classes dedicated to training aboriginal doctors. Taipei Medical University soon followed suit. Yangming University later established a system for publicly funded medical students to provide services at the grassroots level.
The impact of these traditional values runs deep.
Dr. Lin Young-tso, professor emeritus at Kaohsiung Medical University and a member of that institution's first graduating class, continued actively practicing medicine in remote areas after stepping down as Kaohsiung Medical University dean at age 65. He has been seen practicing medicine in such places as Taidong on Taiwan's southeast coast and the offshore islands of Penghu.
"Wherever people need support, I'll go," he says. "When people need me, I can make adjustments to my schedule, and I'll go."
With such powerful guiding values, Taiwan's National Health Insurance system naturally has similar attributes.
The system, begun in 1995, incorporates a single-payer plan while retaining the compulsory, universal characteristics of Taiwan's health care system.
But the speed and efficiency with which the system unfolded was founded on the "entrepreneurial spirit" of Taiwan's medical establishment elite.
As Taiwan Hospital Association chairman Chang Chin-un notes, there were several elements that factored into the smooth implementation of Taiwan's national health insurance program: first, private enterprise investment in health care beginning in the 1970s, which bolstered the supply of health care providers; and second, Taiwan's advanced capabilities in health care management.
The ability to handle large numbers of patients over long periods of time has made it possible for Taiwan to provide health care services that are superior in quality but low in price.
"How can Taiwanese hospitals survive?" asks Chang Chin-un. "Because we've got excellent hospital management."
The Ills of Fairness and Universality
The paradox is that the ubiquity and proximity created by national health insurance have also spawned a host of other problems.
Many worry that too many people do not appropriately value such medical care on demand.
According to National Health Insurance Bureau statistics, the average Taiwanese visited a doctor 15 times last year, a new record. The annual per capita volume of medicine consumption among Taiwanese is 7.2 times higher than that of Americans. Considering the constant state of financial crisis the national health insurance is in, the conflict between waste and access to care will always be present.
Others worry that while fair and accessible, the current health care system lacks incentives to encourage improvements in the quality of care, and in particular fear the volume-based reimbursement system will adversely impact the quality of care.
Koo Foundation Sun Yat-sen Cancer Center lab director Dr. Cheng Hung-chun warns that the current design of the national health insurance system fails to reflect the costs of examinations and could lead to a vicious cycle of "slipshod treatment" and "undervaluing of examination fees." Taking cancer treatment as an example, Cheng says mortality from cancer in the U.S. is around 40 percent of cases, while in Taiwan it stands at 60 percent.
How can Taiwan's world-famous "fair and universal" national health insurance system maintain its traditional values?
And how can the spirit of service embodied by Albert Schweitzer be imparted to Taiwanese medical students? Today, Taiwan's health care system has arrived at yet another crossroads.
Translated from the Chinese by Brian Kennedy