The Republic of China Yearbook 2009

CHAPTER 15 Public Health

Health Indices

As the living environment has improved and health and medical sciences have advanced, health levels in Taiwan have risen considerably in the past several decades. Indicators point to good health and nutrition as well as the well-being of Taiwan’s society. Between 1998 and 2008, the neonatal (0-4 weeks) mortality rate declined from 3.4 per 1,000 live births to 2.7 per 1,000, as did the infant (0-1 year) mortality rate from 6.6 per 1,000 live births to 4.5 per 1,000. During the same time period, average life expectancy rose from 73.1 years to 75.5 years for males, and from 78.9 years to 82.0 years for females. This increase has led to a corresponding growth of the population aged 65 and above from 8.26 percent to 10.43 percent.

National Health Insurance

Taiwan’s compulsory national health care system, called the National Health Insurance (NHI) program, has been touted worldwide for its success in lifting the health levels of the nation’s population. The NHI program was launched in 1995 to provide universal health care, streamline the previous system—which included 13 different public health insurance plans— and rein in costs. All citizens and foreign residents who have lived in Taiwan for at least four months are required to be insured under the program. The premium rate is currently 4.55 percent of taxable income.

About 24,000 medical facilities have signed with the NHI program to offer services to the public. NHI-covered services include inpatient care, ambulatory care, laboratory tests, X-ray examinations, prescription services, dental services, traditional medicine, day care for the mentally ill and limited home care. In addition, six preventive services are available for specific age or gender groups: adult health examinations, prenatal examinations, checkups for babies, children’s dental examinations, Pap tests and mammography. A number of more expensive treatments are also included under the program, such as organ transplants, kidney dialysis as well as therapy for human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS).

Medical Care System

On April 30, 2009, the Executive Yuan passed the Health Care Value-added Platinum Program to enhance public health and stimulate the development of the health care industry. The program calls for an investment of NT$86.4 billion (US$2.74 billion) over the next four years to boost the industry output value by NT$346.4 billion (US$10.99 billion) and add 310,000 jobs by 2012.

According to the Department of Health (DOH), the development plan will focus on three core industries—medical and long-term care services; value-added services, covering health maintenance, intelligent services, health care globalization and national health safety; and manufacturing, with emphasis on the biopharmaceutical sector.

Noteworthy in this package is the health care globalization initiative, which aims to encourage health tourism and other cross-industry alliances to bring in medical tourists. Over the past few years, the government has been promoting health tourism by highlighting the island’s excellent medical facilities coupled with low treatment costs. The Taiwan Nongovernmental Hospitals and Clinics Association established the Taiwan Task Force for Medical Travel in October 2007 to integrate medical, government and tourism resources for overseas patients seeking quality health services. (See Chapter 19, “Tourism,” for more details.)

Personnel

As of 2008, a total of 231,571 medical professionals were working in Taiwan. There were 18.27 doctors (including doctors of Chinese medicine) and 4.86 dentists per 10,000 people. Most received their education or training at one of Taiwan’s 11 medical schools and 35 paramedical colleges and junior colleges. Doctors, after qualifying, are licensed as specialists in one of 26 categories; further periodic training is required to renew licenses.

Higher salaries and transportation subsidies are offered to attract doctors and nurses to rural or remote areas and ensure that a high standard of medical service is available to all citizens. The government also runs a sponsorship program for medical students who agree to serve in designated areas for six years after graduation. Over 1,000 doctors who participated in this program are currently serving on outlying islands and in rural and mountainous areas.

Medical Facilities

In 2008, there were 515 hospitals and 19,659 clinics operating in Taiwan. These included 80 public hospitals and 461 clinics. The medical institutions had a total of 152,901 beds, at 66.37 beds per 10,000 people.

Hospitals may receive accreditation from the DOH for three or four years, based on the quality of medical services, personnel, facilities, management and community services. Clinics are not subject to accreditation but must apply to local health bureaus for an operating license.

Health Concerns and Health Promotion

Rising living standards and changes in lifestyle have led to new and different health problems. Chronic cardiovascular diseases have replaced infectious diseases as the major serious illnesses in adults. Pollution and smoking have led to higher rates of lung cancer, especially in urban areas.

In order to encourage a healthier lifestyle, the DOH has promoted the “ten thousand steps a day” concept since 2002. In 2006, it designated November 11 as National Walking Day. The date was so chosen because the numerals 11 for the day and the month resemble two pairs of legs. Since 2008, National Walking Day programs have been held in all cities and counties throughout Taiwan and people have been encouraged to engage in various physical activities. Information on walking and biking trails has been compiled and made available to the public (see also Chapter 20, “Sports”).

The Bureau of Health Promotion also launched the 2008 Health Promotion Community Certification Trial and Community Integration Project, urging people to eat five types of vegetables and fruits a day and to exercise for a healthier life. The project provides guidance to communities for developing smoke-free and betel-nut-free environments, preventing accidents or injuries and strengthening health among senior citizens.

Aiming to control chronic diseases, Taiwan has committed efforts to general health education, health promotion for high-risk groups, early detection and treatment as well as establishment of a comprehensive care network. In 2008, the 10 leading causes of death in Taiwan remained unchanged from the previous year, accounting for 75.6 percent of all deaths. Malignant tumors were again the No. 1 killer, causing 27.3 percent of all deaths. Of the top 10 causes, only accidents, cerebrovascular disease, and chronic liver disease and cirrhosis caused lesser numbers of deaths than in the previous year.

Cancer Control

In 2008, nearly 39,000 people died of cancer, which has been the leading cause of death in Taiwan since 1982. The five most common forms of cancer in men were liver, lung, colorectal, oral and stomach cancer. Among women, they were lung, liver, colorectal, breast and stomach cancer.

Under the National Cancer Control Five-year Plan covering the 2005-2009 period, efforts have been made to control tobacco and betel-nut hazards, reduce obesity and encourage immunization against hepatitis B to lower the occurrence of liver cancer. The DOH also promotes early detection and early treatment by providing screening services for cervical, breast, colorectal and oral cancers. During the past three years, 70 percent of women aged 30 to 69 had taken at least one Pap test and 12 percent of women aged 50 to 69 had had a mammography. Eleven percent of people aged 50 to 69 had received a fecal occult blood test—a check for colorectal cancer. Additionally, 25 percent of betel-nut chewers or smokers had received an oral mucosa inspection. In order to enhance quality of care, the NHI covers hospice and home-care services for cancer patients, while a hospital accreditation program for cancer-care quality was established in 2008.

Tobacco Hazards Control

Two decades of concerted effort to control tobacco hazards by the government and the private sector has shown a slight overall decrease of the smoking population. Telephone surveys conducted by the DOH annually between 2004 and 2008 revealed that the smoking rate of adult men dropped steadily from 42.93 percent to 38.57 percent, while that of adult women fluctuated between 4.55 percent and 4.75 percent. In a milestone move to ban indoor smoking, Taiwan implemented a newly amended Tobacco Hazards Prevention Act in January 2009. Aimed at lowering the smoking rate and minimizing exposure to secondhand smoke in public places, the act is in compliance with the Framework Convention on Tobacco Control adopted by the World Health Organization (WHO).

The revised law prohibits smoking in workplaces jointly used by three or more employees, public indoor venues such as karaoke lounges, restaurants and Internet cafes, as well as public outdoor areas including railway platforms and swimming pools. Primary and secondary schools are also off limits, but outdoor smoking areas may be designated in universities and colleges. Smokers are allowed to light up in indoor areas of hotels, restaurants and shopping malls that have separate smoking partitions with independent negative-pressure air-conditioning systems.

“No smoking” signs are legally required to be posted at the entrance of every smoke-free area. Violators may be fined between NT$2,000 (US$63) and NT$10,000 (US$317). People hoping to overcome their smoking addiction can seek assistance through drug therapy at outpatient clinics, toll-free counseling lines and community behavioral therapy programs.

In a further move to discourage smoking, the DOH doubled the surcharge on cigarettes to NT$20 (US$0.60) on June 1, 2009. The resultant revenue would be used for medical treatment for low-income families.

Rare Diseases

Special efforts have been made to address rare diseases that may be life-threatening or chronically debilitating. In addition to providing comprehensive health care through the NHI, the government subsidizes medical costs and special nutritious food for patients of rare diseases under the Rare Disease Prevention and Orphan Drug Act in cases where these expenses are not covered by the national insurance program. Taiwan is one of only five countries in the world to have passed a legislation related to rare diseases. It also has a supply center for special nutrient foods and drugs for rare diseases and subsidizes laboratory testing under an international collaboration scheme.

Long-term Care

Taiwan’s aging population, longer life expectancy and changes in disease patterns have increased the need for long-term care. In 2008, over 10 percent of the population was aged above 65, which represented an increase of 22 percent over a decade.

The government’s concern for senior citizens is apparent in a 10-year long-term care plan launched in 2007 with an investment of US$2.6 billion, making it the nation’s biggest social welfare plan after the national pension program. Under this plan, subsidized services are available for four groups of people who need assistance in their daily lives because of functional decline: people over 65; indigenous people in mountainous areas aged over 55; handicapped people aged over 50; and elderly people who live alone and need help with the “instrumental activities of daily living.” Services provided include home nursing and rehabilitation, acquisition and renting of auxiliary appliances, improvement of handicap access at home, meals as well as respite care, transportation, long-term care and institutional services. Subsidies, based on levels of disability and family income, range from 60 percent to full coverage of cost of care.

Communicable Diseases

The control of infectious diseases has improved greatly in Taiwan in recent decades. Considerable efforts have been made to coordinate with the International Health Regulations (IHR) adopted by the WHO. The Communicable Disease Control Act has been amended to strengthen Taiwan’s emergency response capacity. Several systems, including the National Communicable Disease Surveillance Systems, the School-based Surveillance System, the Symptom Surveillance System and the International Epidemic Intelligence Collection System, were set up to collect timely, complete and precise information on infectious disease. In addition to this integrated network that is instrumental for the control of communicable diseases, the Centers for Disease Control (CDC) under the DOH has been working in collaboration with medical care and academic research institutes to better understand epidemic conditions and formulate control measures.

Novel Influenza A(H1N1)

Soon after novel influenza A(H1N1) outbreaks were reported in Mexico and the United States, Taiwan set up the Central Epidemic Command Center in April 2009. The CDC proceeded with the preparations outlined in the Strategic Pandemic Influenza Preparedness Plan in order to coordinate cross-sectoral efforts and allocate resources. Border control measures were reinforced for inbound passengers, hospital-based surveillance was enhanced and hospitals were asked to be prepared for a possible outbreak. Plans were made in May to develop and produce H1N1 vaccines in Taiwan.

Although the global epidemiological data have shown that the severity of the pandemic appeared to be moderate and similar to that of seasonal influenza, the CDC will continue to monitor the epidemic and adjust its disease control strategies accordingly.

Tuberculosis

For years, tuberculosis had the highest incidence of all communicable diseases in Taiwan. In 2008, there were 14,234 new cases of the disease—an incidence rate of 61.8 per 100,000 persons. In the same year, this disease claimed 762 lives in Taiwan, or 0.5 percent of the total number of deaths, which represented a decline from 13th in 2007 to 15th highest cause of death.

In a bid to halve tuberculosis incidence by 2015, the CDC has launched a 10-year program that will expand use of the DOTS (directly observed treatment, short-course) method and improve epidemic reporting and surveillance.

Dengue Fever

The CDC has devised a three-stage prevention strategy to control the dengue fever epidemic. Primary prevention measures include vector-breeding sources reduction and control of the vector population. Secondary prevention measures cover disease surveillance and an emergency/ contingency mechanism. Tertiary prevention involves controlling the number of deaths from critical illness.

In 2008, there were 488 indigenous cases of dengue fever, concentrated mainly in the southern part of Taiwan, but no deaths resulted.

Enterovirus

To combat this disease, cases of infection and their distribution are announced periodically to help local governments take preventive measures. Programs are in place to teach high-risk groups (including children under 5) the importance of personal hygiene. Guidelines and consultations are provided for the treatment of complex cases. Timely and adequate medical care for severe cases is available at designated referral hospitals. In 2008, there were 373 confirmed cases of enterovirus infection with severe complications; 14 deaths resulted.

HIV/AIDS

There were 17,428 HIV cases in Taiwan as of 2008. Nearly 57 percent of these were infected through sexual contact, while 21.5 percent resulted from unsafe injecting drug use (IDUs), a category that accounts for a growing proportion of cases.

In order to curb HIV infection among IDUs, a harm reduction plan was implemented in 2006, covering needle-syringe programs, drug substitution treatment, as well as information, education and communication strategies. Furthermore, free HIV screening is available for pregnant women to counter the increase in the number of female HIV patients and address the problem of mother-to-child infection.

Hepatitis

About 2.5 million Taiwanese people are carriers of the hepatitis B virus, which is a major factor in chronic hepatitis, cirrhosis and hepatoma—all leading causes of death. It is estimated that 15 percent to 20 percent of the population over 40 are infected. Approximately 700,000 people are infected with hepatitis C.

Under a program launched in 1986, prenatal examination for hepatitis B and immunization for newborn babies have led to a significant decline in the percentage of hepatitis B carriers among 6-year-olds, from a high of 10.5 percent in 1989 to 0.8 percent in 2007. Makeup immunization is provided for preschool and elementary school children upon enrollment. In order to reduce the incidence rate of liver cirrhosis and hepatoma, the Bureau of National Health Insurance promoted a hepatitis B and C trial treatment program in October 2003.

Free immunization against hepatitis A in remote mountainous regions has eradicated the disease among indigenous communities from an incidence rate of 90.74 per 100,000 people in 1995.

Pharmaceutical Regulation

Taiwan promotes the current pharmaceutical good manufacturing practice (cGMP) and facilities are subject to regular and unscheduled inspection. As of 2008, Taiwan had 7,150 pharmacies as well as 33,983 dealers and 939 manufacturers of pharmaceuticals and medical products (including 160 cGMP certified companies).

The DOH is committed to safeguarding the interests of patients and pharmaceutical manufacturers. It has an updated database of authorized vendors to help medical care institutions in procurement. Also, an online medication information database containing photos and descriptions of 6,000 medications is available to help the public identify counterfeit and prohibited drugs. Victims of drug hazards may seek compensation from a relief fund set up by the DOH from annual mandatory contributions by pharmaceutical companies based on their fiscal turnover.

Traditional Chinese Medicine

Besides Western medicine, Chinese medicine is another popular health care practice in Taiwan. The Committee on Chinese Medicine and Pharmacy (CCMP) under the DOH oversees its practice. As of 2008, Taiwan had 10,377 licensed doctors and 5,184 institutions of Chinese medicine.

Taiwan is involved in research on Chinese medicine, acupuncture and other traditional medical practices. The CCMP has provided much support, increasing its research funding at an annual rate of 5 percent to 10 percent over the past decade. Its latest project was a four-year Chinese medicine nanotechnology plan launched in January 2009. Clinical trials of herbal medicine are conducted at about a dozen medical facilities throughout Taiwan, while an accreditation system for hospitals of Chinese medicine has been established.

Taiwan agrees with a call by the World Health Assembly (WHA) for nations to promote the use of traditional medicine and has encouraged academia-industry cooperation in related research. The China Medical University in Taichung offers English courses in traditional Chinese medicine to cater to international demand for studies in this area.

Food Safety and Regulation

Health officials regularly inspect the standards of food vendors and food-processing factories and release timely information to notify the public of potential risk. Items marketed as “health foods” must be examined, approved and properly labeled before entering the market. Imported foods are subject to random inspections. A food-safety alert mechanism as well as a traceability system have been introduced, giving consumers access to information on foods on the market such as test results on raw materials and finished products.

Taiwan has adopted the Hazard Analysis and Critical Control Points system to ensure food safety, aiming to prevent hazards from raw materials through end product, rather than inspecting finished products only. The system covers fishery, meat and dairy products as well as restaurants. For fruit and vegetables, a non-mandatory Certified Agricultural Standards system is in place to ensure safe use of chemicals for pest control. In response to public concern, the government also implements a pre-market approval monitoring program for genetically modified foods.

International Cooperation

Taiwan and the WHO

For the first time since its withdrawal from the United Nations and its specialized agencies in 1971, the ROC was formally invited to attend the WHA as an observer in May 2009. A 15-member delegation led by then Minister of Health Yeh Ching-chuan participated in the event in Geneva. In his address to the WHA, the minister emphasized that international health and disease prevention need broad multilateral cooperation to combat epidemics that have the potential to spread rapidly, and Taiwan’s WHO participation would be crucial in light of the new H1N1 outbreak.

Taiwan had already taken a significant step forward in the management and control of communicable diseases by joining the WHO’s IHR network in January 2009. Its inclusion in the IHR framework gives it direct contact with the world health body and access to firsthand information on health security issues from food security to the spread and control of pandemic diseases.

Having made great strides in improving the health of its people, Taiwan is ready to contribute to the work and activities of the WHO. While its participation in the world body will close a dangerous gap in the global disease prevention and control network, it will also join in international efforts to deal with public health emergencies. (For more on Taiwan’s participation in the WHA, please see Chapter 6, “Foreign Relations.”)

Health Work in the World Community

As a member of the global community, Taiwan upholds the spirit of the WHO Constitution in seeking the attainment of the highest possible level of health for its people and in aiding other nations to do the same.

Several cities and counties in Taiwan have joined the Alliance for Healthy Cities, which was initiated by the WHO. Through international cooperation and exchanges between people on the front lines of health issues, cities hope to improve the environment and expand community health resources for local residents. As of 2008, Tainan City, Hualien County, Miaoli County, Danshui Township in Taipei County, as well as the Da-an, Shilin and Beitou districts in Taipei City were members of the alliance.

In its commitment to improving health care services for its foreign residents, Taiwan co-sponsored a health seminar on “Migration: Challenges and Opportunities for Health Systems in Europe and Beyond” in Brussels in January 2008. This event held in Europe, where cross-border mobility is on the increase, offered an opportunity for Taiwan to learn from the European experience and to strengthen cooperation between Taiwanese and European referral hospitals.

Over the years, Taiwan has been sending medical missions to friendly countries around the world and, in more recent years, has established health centers in two of its Pacific allies. Medical experts from the Taiwan Health Centers in the Marshall Islands and the Solomon Islands have been working with local medical personnel on health education and public health plans, especially on diabetes and tuberculosis. They offer medical treatment and health checkups to the people of the two countries and, in cooperation with local hospitals, organize workshops for students and adults.

In addition to its regular health care assistance, Taiwan has been active in providing emergency medical relief to countries in need. Representatives of the Taiwan International Health Action (TaiwanIHA) and several Taiwanese nongovernmental organizations, including the Ling Jiou Mountain Buddhist Society and the International Cooperation and Development Fund (TaiwanICDF), participated in the Dubai International Humanitarian Aid and Development Conference and Exhibition in April 2009. At this largest international aid event in the world, which was sponsored by the United Nations and the United Arab Emirates, Taiwan’s delegation shared experiences in public-private sector partnership in rendering humanitarian assistance.