The introduction of a universal health insurance system was a major achievement in the history of public health in Taiwan. It is immensely valuable and something that people in Taiwan should feel justified in having pride in. However, since it was first implemented in 1995, it has been mired in virtually continuous controversy.
It has been a tumultuous 15 years, a time in which Taiwan has tried to ignore the two elephants in the room. The first represents a weakening of preventative medicine in the public health system, making it harder for the public to keep healthy. As a result, there has been a sustained increase in the number of people needing medical treatment, placing a burden on the health insurance system.
The second is that the public health system has fallen prey to market forces, becoming a prostitute to profit, and the institutions in charge have become bloated and ungainly. These two factors have colluded to bring about a whole raft of problems and health insurance expenditure has now gone through the roof.
Something has to be done if we are to avoid the wholesale collapse of the health insurance system in this country. One fundamental solution is to promote greater overall health in the general populace, to reduce the amount of avoidable illnesses that otherwise have to be dealt with.
The problem is that the departments within the system that could promote and implement this change are the departments responsible for preventative medicine. It is a problem because there is a radical contrast in the way they have been resourced in terms of personnel, budget and other resources, compared with other medical departments, and this has been true for decades now. During this time, the medical treatment branches have been expanded to the extent that they have dwarfed their preventative medicine counterparts.
In 2008, NT$788 billion (US$26.7 billion) was invested in medical health insurance in Taiwan, with a full 90 percent of this being spent on the medical treatment branches. By contrast, a paltry 3.3 percent went to the public health preventative medicine sector.
The problem of inadequate staffing and resource allocation to public health preventative medicine branches has most seriously affected the ground level health institutions, the health clinics. Between the 1950s and 1970s, these clinics were on the front line in the fight against infectious diseases and other public health issues and they did a magnificent job at it, earning the respect of the community as “guardians of the public’s health.”
However, the 1980s saw a shift in which many of these health clinics established group practices that were run more like businesses, assuming responsibility over the finances of the practice. The result was that they were increasingly focused on treatment over prevention and in some cases this meant that they actually became commercialized. More recently, time spent on preventative work in the community has been given over to administrative work. This has led to a drop in morale as health workers feel impotent in the face of health problems in the community.
Back in 2003, when Taiwan was in the grip of the SARS epidemic, I wrote an article in which I pointed out, contentiously as it turned out, that the public health system was no longer equipped for the task of preventing a pernicious communicable disease such as SARS. Seven years later, the problems in the system have not improved and may have even gotten worse. Given the weakened state of preventative medicine in this country, we can in no way hope to demonstrate the veracity of the old adage “prevention is better than cure.” How, then, do we convince people that the preventative approach can effectively maintain the public’s health? We are bombarded with wave after wave of diseases and health problems, and the public becomes addicted to treatments for their ailments and become ever more reliant on the national health insurance system.
Statistics show that, in Taiwan, the rate of increase in expenditure on medical treatment per person is actually higher than both the rate of economic growth and the rate of increase in average income. It appears, then, that not only has the increase in expenditure on medical treatments not improved public health, it may even have had the opposite effect. This is the result of prioritizing treatment at the expense of prevention.
Then there is the “truth” of the influence of the market and profits on the medical treatment branches. The national health insurance system was built on the medical treatment industry in Taiwan, an industry highly driven by commercial interests, market forces and profits.
The industry is fiercely competitive and according to the dictates of capitalism, this means that it should do its utmost to maintain the flow of paying customers (the sick and diseased), to stimulate demand for its product and to maximize profits.
Add to this the relative impotence of the argument for preventative medicine, thus -misleading Joe Public into thinking the hallowed road to health is paved with downing tablets and frequent hospital trips. This is where the value and meaning of the national health insurance system lies, the public thinks.
This relationship between the public and the hospitals has produced a litany of unnecessary and excessive treatments, the excessive use of drugs and an increase in the number of visits to the doctor. This is why expenditure on national health insurance has gone up.
So back to the elephants in the room and the repercussions thereof, namely the sustained and prodigious expansion of the medical treatment industry in Taiwan. The reason Taiwanese don’t want to face these two inconvenient truths regarding health insurance is because of what it will take to reverse the problem. It involves interfering with the profits of medical treatment sectors in the public health system; it involves changing long-established ideas and conventions concerning health and treatment; and it involves addressing entrenched public health policy that favors treatment over prevention, a mistake that has come to be taken as gospel through the simple process of repetition.
It may take years to redress these misconceptions, but procrastination has led to a health insurance system on the brink or bankruptcy and a hue and cry over increased insurance premiums. The Department of Health needs to do more than evade the looming bankruptcy of the system: It needs to come up with a long-term plan for reform.
Chen Meei-shia is chair of the Taiwan Association for Promoting Public Health and a professor of public health at National Cheng Kung University.
TRANSLATED BY PAUL COOPER
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