As Taiwan confronts challenges related to promoting the health of the elderly and adapting society to their needs, locally attuned strategies are taking on increased importance.
Taiwan is less than four years from becoming a super-aged society, meaning 20% of its citizens will be over 65 years old. As the birth rate continues to decline, more than half of Taiwan’s population is expected to be aged 50 or above by 2034.
This demographic development has widespread ramifications for Taiwan’s workforce and the National Health Insurance (NHI) system. A super-aged society puts severe strains on its healthcare system, making disease prevention and proactive healthcare imperative for the economy.
The Ministry of Health and Welfare’s Health Promotion Administration (HPA) has responded to this issue by promoting local approaches that enable Taiwan’s counties to meet their unique challenges. As part of the strategy, HPA initiated the Age-friendly City Awards to encourage government agencies to draft public policies that include elderly health and build a supportive environment for senior citizens.
“We wanted our top-down policy to be promoted by local governments from the bottom up,” HPA told TOPICS in a written statement. “Since the inception of the awards, the number of contestants has continuously increased, promoting policies that cover not only health but also diverse aspects such as transportation, environmental protection, civil affairs, and taxation.”
Among examples of successful programs, HPA cited the Hualien County Health Bureau’s technological innovations within elderly care and a project by the Tainan City Education Bureau’s Sports Department to develop senior sports centers in rural areas.
By offering subsidies, HPA further encourages local health bureaus to manage age-friendly communities projects and serve as a local and cross-departmental integration platform consistent with World Health Organization (WHO) goals for age-friendliness. In 2020, 22 counties and cities and 137 communities in Taiwan had joined the subsidy program.
Lessons from Chiayi
Pioneering the model of age-friendly cities in Taiwan was Chiayi City, located in the middle of Taiwan’s most aged county, where those aged 65 or above represent over 20% of residents.
The Chiayi City government has followed the WHO guidelines for age-friendly cities, which address eight key aspects: housing, communication and information, transportation, public spaces for the disabled, opportunities for employment or volunteerism, opportunities for social activities, and community health support.
As a result, the HPA in 2018 named Chiayi City as Taiwan’s most age-friendly city due to its excellent scores regarding medical care, public health, social welfare, and affordable housing.
Meanwhile, Chiayi County has implemented policies to improve care services, with special attention to elderly communities, and enforce local care strategies. It also adjusted its infrastructure to the needs of the elderly through measures such as replacing traditional streetlights with high-performing LED lights and implementing a “happy bus policy” to increase access to rural areas.
Chiayi County Health Bureau Director Zhao Wen-hua notes that Chiayi County’s most pressing challenge concerning elderly care is the size of the county and its rugged terrain, which complicate access to medical treatment for many senior citizens. In response, the county launched four mobile hospital vans that drive to villages and cities around the county to provide greater access to healthcare.
“We have one mobile medical vehicle that specializes in X-rays and one for heart irradiation and electrocardiograms,” says Zhao. “The third is for mammography and pap smears, and the fourth is a medical education vehicle.”
The medical education vehicle travels to various locations for outreach through traditional media and public campaigns. Chiayi County also offers healthcare education in the form of professional support for migrant caretakers regarding more complicated medical conditions and care techniques that they may be unfamiliar with.
“When we bring a professional to teach the caretakers how to use, for example, a nasogastric tube, we also bring an interpreter,” says Zhao. “That way, we ensure that the medical professional can effectively convey their message to the caregiver.”
Community activities are also encouraged in Chiayi to improve mental health and social participation through community centers that provide such recreational programs as karaoke and croquet, as well as “peace-of-mind plans” and other specialized services.
Future development of the age-friendly project will include prioritization of oral health, notes Zhao, since that has been proven to affect general health, and many older people are reluctant to seek dental care.
“We hope to help them by promoting dentistry and health education, so we plan to have a car that can provide education on oral health and offer dental care,” she says.
The Changhua experience
Preventive care is an effective strategy to improve public health and cut costs long-term. By screening for chronic diseases, promoting “active aging,” offering vaccinations, and creating an age-friendly social environment, more elderly people can remain active and enjoy more years of good health.
In Taiwan, the average number of unhealthy years (average life expectancy minus average healthy years) is on par with most developed countries at around 9-10 years. But the average healthy years in Taiwan (71) is lower than in Japan (75) and Korea (73), and more can be done to increase the number of healthy years in a Taiwanese person’s life.
One example of such measures can be found in Changhua County, which initiated a bone mass density (BMD) screening program for early detection of osteoporosis in 2019. According to the findings from the program, more than half of the county’s elderly population has osteoporosis.
Yo Yu-Chin, chief of the Changhua County Public Health Bureau’s Health Promotion Section, stresses the importance of comprehensive preventive care related to low bone mass density. “Our healthcare system is not designed to care for elderly people, who face different kinds of health issues from the rest of the population,” he says. “We need to focus on disease-oriented healthcare as well as status-oriented healthcare.”
The bureau has divided its elderly population into three main groups and adjusts care strategies according to each group’s needs. The first group is those with robust health, representing around 45% of Changhua’s elderly. The second is elderly people with disabilities, who depend on care from others and represent approximately 15%.
The third group, representing around 40%, consists of elderly people who are frail. Preventing fractures due to falls and promoting a healthy lifestyle can enhance this group’s quality of life and increase their healthy years, Yo notes.
In addition to BMD screenings, Changhua County provides comprehensive care in the form of nutrition counseling and exercise programs. “People with very mild osteoporosis may not need medical treatment, so we use these measures to improve the status of their frailty and prevent complications from osteoporosis,” says Yo.
An essential contributor to the success of Changhua County’s program is its community care centers. These centers provide lunches, conduct various health promotion programs, offer opportunities for social participation, and help promote the BMD screening program.
When asked how other counties could implement similar programs successfully, Yo stresses the importance of coordination and outreach. Changhua County has extensive experience with volunteer work and with running health programs that rely on effective channels of communication.
“You can’t just get the machines and expect people to come,” says Yo. “You need to overcome the barriers of coordination and staffing arrangements and reach the public to convince them to participate. The care delivery is complex, but our example demonstrates that these hurdles can be overcome.”
Despite the risks of undetected osteoporosis leading to dependency and disability, preventive care and screening for osteoporosis are not covered by the National Health Insurance (NHI) system. Instead, a patient can receive reimbursement for osteoporosis treatment only if they have a history of fractures. This, notes Yo, is one of the biggest obstacles to preventing fractures among the elderly.
Although the budgetary impact of offering subsidized BMD screenings and using osteoporosis medications for the primary prevention of fractures would be significant, a study by scholars in Tainan concluded that these costs could be compensated through savings in fracture treatment costs. The current estimated direct and indirect cost of osteoporosis in Taiwan is NT$7 billion annually.
Another preventive measure that the NHI does not cover is vaccinations for pneumococcal diseases. In 2019, over 15,000 people died from pneumonia in Taiwan, making it the third most common cause of death on the island. Many deaths and hospitalizations due to pneumonia could have been prevented by administering pneumococcal vaccines to the elderly.
The Advisory Committee on Immunization has recommended that Taiwan vaccinate patients over the age of 65 for pneumococcal diseases, in addition to giving rotavirus vaccines to children. To fulfill these recommendations, Taiwan’s health authorities would need to secure at least an additional NT$1.03 billion for its National Vaccine Fund (NVF).
Funding long-term care
Taiwan’s NVF funding primarily comes from the national treasury and the health and welfare surcharge on tobacco consumption. But funds from tobacco consumption fluctuate, and treasury funds are insufficient to cover the promised amount. According to the Strategic Plan prepared by the Center for Disease Control, treasury funds should account for 60% of the NVF total coverage, but the actual average has been around 30-40% over the past five years.
Due to these funding constraints, the National Immunization Program has delayed covering pneumococcal vaccines for the elderly population over the last two years. And with an already strained healthcare budget and steadily increasing long-term care costs, prospects for funding are bleak.
Taiwan is widely known for its effective healthcare system based on compulsory, universal coverage. Yet the level of national health expenditure represented just 6.5% of GDP in 2019, lower than the OECD average of 8.8% before the COVID-19 pandemic.
To tackle some funding-related challenges, the Taiwan government amended its Long-Term Care Service Act in 2019 to encourage private-sector investment in long-term care. Taiwan’s Income Tax Act was also amended in the same year to provide an annual tax deduction of NT$120,000 for each person in need of long-term care services. The law increased the flexibility of existing work regulations that set Taiwan’s mandatory retirement age at 65.
In 2017, Taiwan’s Long-term Care 2.0 program added community-based services, including preventive care, dementia care, and family caregiver services, to its two-decade comprehensive long-term care program. Coverage was extended to about 738,000 care recipients, compared with the previous 511,000.
Although these are strides in the right direction, further policy changes are needed to fully cover the cost of care for a super-aged society. And while many local governments are making substantial efforts to improve the health of older residents in their areas, the lack of NHI coverage for many forms of preventive care has resulted in considerable inconsistency in the quality of care for the elderly among the various cities and counties.
The NHI accounted for 53.5% of total healthcare spending in 2019, while 40.2% came from the private sector – of which patients’ out-of-pocket payments accounted for 33%.
According to National Health Insurance Administration (NHIA) data, people aged 65 and over represent 15% of the insured but consume 39% of NHIA expenditures. And as Taiwan becomes a super-aged society, the number of people heavily dependent on the healthcare system will continuously increase.
Additionally, the cost of hospitalization for those aged between 50 and 64 is about twice that of 35-49-year-olds, and the cost for those 65 years and older is three times that of the 35-49 age group. Unless the government substantially increases its level of health expenditure or adjusts the content of NHI coverage, much of the increased costs will have to be covered by patients through out-of-pocket payments.