In 2020, the number of deaths in Taiwan exceeded that of births, with the crude death rate for that year of 7.34 per 1,000 exceeding the crude birth rate of 7.01 per 1,000, causing Taiwan’s population to shrink by 31,885 people.
This trend has continued to develop over the past three years, with 139,000 births and 207,000 deaths last year causing the population to fall by a further 68,000. If this trend does not change, Taiwan’s population will fall by 1 percent in 2070 — a reduction of 233,000 people, which is close to the population of Yonghe District (永和) or Tucheng District (土城) in New Taipei City.
Taiwan’s falling birthrate is causing the preponderance of people over the age of 65 to increase, which in turn is causing healthcare and social welfare resources to continuously be shifted toward long-term care of the elderly.
Limited social resources would put a squeeze on the resources available for the medical and social care of children.
The annual healthcare expenditure account of the Ministry of Health and Welfare’s National Health Insurance Administration (NHIA) for 2017 reveals the amount and proportion of National Health Insurance (NHI) spending by age group. The zero to 19 age group accounted for 18 percent of Taiwan’s population, but only used 8 percent of NHI resources — less than half this group’s proportion of the population.
In terms of the average NHI cost per person, the average amount spent on those aged 80 or over was approximately NT$140,000 (US$4,597), which was seven times the NT$20,000 average healthcare cost for infants up to four years old, and 14 times the NT$20,000 average healthcare cost for school-age children.
I am reluctant to use the more sensationalist argument that the money spent on caring for one 80-year-old person in Taiwan could be used to care for seven infants up to four years old, or for 14 school-age children, but that is the actual situation.
The NHIA is also planning to launch the National Ten-year Long-term Care Plan 3.0, which would provide NHI coverage for home care. It would also pay for major hospitals to build geriatric hospitals and re-equip the relevant departments. These NHI expenditures can only be paid for by increasing everyone’s NHI premiums or taking resources away from Taiwan’s infants and schoolchildren.
It is indisputable that NHI coverage for children is chronically low and inadequate. The NHI does pay an extra 100 percent coverage for infants under the age of six months, which is twice the standard amount, and an extra 50 percent for children under the age of six.
However, children’s medical care is labor-intensive. The patients, being children, are often unable to explain their ailments, thus requiring longer consultations and physical examinations on uncooperative children.
The children cared for in hospitals range from premature babies weighing just 1kg to obese children weighing as much as 80kg. The field also involves rare disorders and so on. All of these factors challenge the ability of children’s hospitals and pediatric departments to care for their young patients, who need the appropriate medical and sanitary materials.
Due to the small number of some kinds of cases and the difficulty of obtaining and operating the relevant medical equipment, four out of Taiwan’s five children’s hospitals’ financial reports show heavy losses. The only exception is China Medical University Children’s Hospital, which can just about break even because it has access to the main hospital’s personnel and equipment.
According to the Taiwan Foundation for Rare Disorders and National Taiwan University Children’s Hospital superintendent Lee Wang-tso (李旺祚), the unspent portion of the special fund for rare disorders over the years has been between NT$200 million and NT$1 billion. If these unspent NHI funds could be used to subsidize children’s medical care and children’s hospitals, it would be a major boost regarding the care of children with critical and rare diseases.
This would be a drop in the ocean compared with the ministry’s NT$25 billion annual spending on the National Ten-year Long-term Care Plan 2.0 and its estimated annual spending of at least NT$50 billion on the National Ten-year Long-term Care Plan 3.0.
Taiwan’s falling birthrate coincides with a growing number of women giving birth at a relatively late age, the technical term for which is “advanced maternal age,” and this has led to increasing rates of high-risk pregnancies and premature births.
The percentage of babies born before 37 weeks of pregnancy rose from 10.7 percent in 2016 to 11.6 percent in 2020, while the percentage of newborns weighing less than 1.5kg rose from 1.8 percent to 2.07 percent over the same period.
High-risk pregnancies require a pediatrician to stand by in the labor room during delivery, but the cost of this is not covered by the NHI. Babies with a low birth weight and premature babies often experience complications, so a special ambulance is needed to transfer them to a medical center or children’s hospital, but the NHI does not cover the cost of the transfer.
The average life expectancy of Taiwanese is in the top bracket of Organisation for Economic Co-operation and Development countries, but Taiwan has the second-highest mortality rate for children aged one to four. Taiwan’s neonatal mortality rate is 2.5 per 1,000 births, which is much higher than South Korea’s 1.5 per 1,000 and Japan’s 0.9 per 1,000. This figure remained high throughout the nine years from 2012 to 2021.
Taiwan’s pediatric resources and care are much less adequate than those of advanced countries.
During my 40 years as a pediatric practitioner, I have watched Taiwan’s falling birthrate turn into a national security crisis that the authorities can see, but are unwilling to confront. Medical students these days see pediatrics as a scary path to take and a sunset field of specialization that the NHI does not care about. They think it involves a lot of work and trouble for little money, and it is hard to disagree with them.
Children’s healthcare means caring for Taiwan’s future by trying to ensure that every newborn child can grow into a healthy adult. Those of us who work in this field sincerely call on the government to stop taking medical resources away from children and to set a lower limit for the NHI’s provision of pediatric resources instead of allowing them to shrink along with the falling number of children.
The government should raise the level of coverage for children’s healthcare and provide reasonable pay and conditions for pediatric staff, who spend much more time and effort on caring for children as they would need to do with adults.
The NHI should cover the cost of health checkups for children before they go to elementary school, as well as their vaccinations, which cost over NT$20,000 and are self-paid. Every Taiwanese child should be supported by the state.
The average age of inpatients in all of Taiwan’s major hospitals is now over 65, so the main purpose of all of these hospitals is to care for the elderly. What Taiwan most needs is more national-grade children’s hospitals and pediatricians to care for the ever-declining number of newborns, infants, schoolchildren and teenagers, because without those children, Taiwan has no future.
Wang Jiu-yao is superintendent of China Medical University Children’s Hospital.
Translated by Julian Clegg
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