BY SYDNEY PENG AND REBECCA LIN

Taiwanese medical schools can enroll a maximum of 1,300 students per year, a government-set quota that has not changed in 24 years. In Taiwan’s aging society, this number is insufficient to satisfy rising demand for medical services.

Three national universities – National Tsing Hua University, National Chung Hsing University, and National Sun Yat-sen University – have just gained approval to launch fast track degrees in medicine for applicants who already hold a bachelor’s degree in a related science. Although the programs have not yet been launched, application information is already available online.

Announcement of the new programs was followed by expressions of concern from the medical community. The Federation of Medical Students in Taiwan issued a statement emphasizing that 40 years ago, five schools – National Taiwan University, National Yang Ming University, National Cheng Kung University, Chang Gung University, and Kaohsiung Medical University – all established similar “post-graduate departments of medicine.” The departments shut down one by one, mainly because the government’s quota for the number of medical students enrolled in universities per year limited acceptance rates.

Post-graduate medical degrees can be obtained in four years, as opposed to traditional medical degrees, which are obtained after six years of study. While the first two years of the six-year degrees are devoted to the fundamentals, the four-year degree programs delve directly into anatomy and other fields of medicine.

Currently, the 13 universities in Taiwan with medical departments together can enroll a maximum of 1,300 medical students per year. This cap has remained unchanged since 1998, although Taiwanese healthcare needs have changed dramatically over that time.

In 2016, the Ministry of Health and Welfare (MOHW) launched a special publicly funded five-year program to train medical specialists to be posted to more remote and underserved areas. The program aims to train 750 specialists in internal medicine, surgery, obstetrics and gynecology, pediatrics, and emergency medicine.

Given that Taiwan is an aging society with rising demand for the treatment of age-related diseases and conditions, and that new hospitals are under construction across the island, the 3,500 vacant physician positions expected by 2030 cannot be filled based on current medical school enrollment.

Taiwan averages 21.7 physicians per 10,000 people, lagging far behind the median of 33.6 physicians in OECD countries. Among these, only Turkey  has fewer doctors per capita than Taiwan, whereas Taiwan’s Asian neighbors Japan and South Korea boast much higher numbers.

Exacerbating the problem is the dramatic change in Taiwan’s population structure over the past 24 years. While those over 65 accounted for just 10.5% of the population in 1999, this will reach 20% by 2025.

“Older people have a lot of needs, the most obvious being medical care,” says Chang Hong-jen, adjunct professor at the Institute of Public Health of National Yang Ming Chiao Tung University and a former deputy health minister. Demand for geriatric care will markedly increase, she adds. At the same time, Taiwan’s baby boomers will reach retirement age by 2030. Given that about 30% of active physicians are older than 60,  a massive retirement wave will ensue. As Chang points out, “physicians require care, too.”

To meet the rising demand for geriatric care, particularly for cancer and other chronic diseases, cities and counties across the island are building large hospitals in addition to the already-expanded capacity in response to the pandemic. At least 11 new regional hospitals will start operating by 2030.

Taoyuan is at the forefront of this expansion. Twelve hospitals are currently being established or expanding, with at least three brand-new regional hospitals being built. A  910-bed hospital that National Tsing Hua University is planning  in the city is expected to be completed in five years.

The shortage of physicians is therefore the most pressing issue. A forecast of Western medicine physician staffing developments by the Institute of Population Health Sciences under the National Health Research Institutes (NHRI) in 2019 evaluated six scenarios. Factored in were future medical care demand, physicians’ workloads, and expected changes in the supply-demand relationship.

A key variable is the growing number of regional hospitals in the coming decade. If one regional hospital is added annually for the next 10 years, Taiwan will face a shortage of 3,500 physicians by 2030.  While hospitals of all sizes are expected to experience a shortage of doctors, the effect will be felt most severely at small clinics in rural areas rather than large medical centers and regional hosA two-decade limit

Why has the cap on medical students remained for 24 years? In an investigation, Control Yuan members Yeh Ta-hua and Lai Ting-ming found that the Ministry of Education and the Ministry of Health and Welfare both say that they cannot find the data on which the calculation of this cap was based. The Control Yuan has criticized the implementation of this policy, which is seemingly based on an unfounded recommendation, as “too arbitrary.” Over the past 24 years, most other countries have expanded the number of university places for medical students. In the Netherlands, the number of medical graduates has doubled. Even Japan, which used to have strict limits on the number of medical school students, has added 1,000 places to alleviate the shortage of physicians.

Yeh says that the NHRI’s staffing forecast failed to consider emerging medical needs such as epidemics,  mental health issues, and homecare. She also notes that the data used was outdated and does not reflect recent developments.

“If the recruitment and training of physicians are to be a national focus, then we should have a clear legal basis for it, including a mechanism for establishment and withdrawal [of hospitals],” she says. “All this should be public and transparent.”

The number of physicians is related to the amount of national health care expenditure, the growth of which is restricted since the National Health Insurance program is a single-payer system. NHI expenditure accounts for a rather low share of GDP at 6.1%, compared to South Korea’s 8.2%, Japan’s 11%, and the United States’ 16.8%.

As Cheng Shou-hsia, dean of the College of Public Health at National Taiwan University points out, the healthcare expenditure is low because salaries in Taiwan have hardly increased in recent years, leading to difficulty raising health insurance premiums which are salary-based. This starkly contrasts to South Korea, which has heavily invested in long-term care insurance and the biotech industry.

In terms of healthcare’s share of the national budget, which stands at 11%, Taiwan also falls short of the 15% OECD average. This number indicates that the government does not invest enough in healthcare, which in turn constrains the industry’s growth potential. Given that funding has stagnated, there is little room financially to attract and retain the greater number of doctors needed to meet future needs.

Chen Liang-fu, spokesperson for the Taipei Medical Association, notes that Taiwan does not have enough physicians to meet current workloads. He admits that “increasing the number of physicians with the current scope of investment in medical resources is difficult.”

Underinvestment in mental health epitomizes the health system’s ailments. The number of people struggling with mental problems – ranging from long-term insomnia to suicidal ideation – is on the rise. More psychiatrists will be needed to address the growing number of people in need of help.

Health insurance is an important pillar of the population’s health and safety, but the system’s efficiency is built on the hard work of its medical personnel. Over the past five years, the MOHW annual quota for psychiatric specialist training has remained at around 51-56 people. Since the NHI budget – the financial pie that everyone wants a piece of – isn’t expanding, and the number of physicians cannot be increased.

At the same time, demand for medical care is rising and becoming more complex, which means physicians are exhausted from constant overwork. In an NHRI survey of physicians, one out of four respondents said they were planning to quit or retire within three years. Among those who wanted to quit their current jobs, 23% were planning to switch to practicing cosmetic surgery at a private clinic, and 33% were looking to practice abroad.

Predicting Taiwan’s demand for physicians for the coming decade is challenging, since any small change in one variable – such as work-hour calculations or the population structure – profoundly changes the big picture. And setting the total number of physicians still fails to solve what have been called the three “imbalances” in the system.

The first imbalance can be found within medical specializations. Internal medicine specialists are urgently needed in an aging society like Taiwan’s, where chronic diseases are very common.  But for many years only around 80% of these positions have been filled

Next is the gap between cities and underserved rural communities, as physician density is markedly higher in metropolitan areas. Taiwan has 244 local communities, towns, and urban districts with less than 10 physicians per 10,000 inhabitants. This level does not meet even  the World Health Organization’s lowest standard.

The third is the workforce imbalance between hospitals and clinics. When the large hospitals currently under construction open, they will attract medical personnel like magnets. As a result, physicians and patients from smaller hospitals and local clinics will leave their current positions, further aggravating the lack of medical resources in remoter areas. Taiwan has perhaps just three years left before becoming a super-aged society. Do we want to risk patients not being able to find a doctor nearby? Are we aware that it could be us?

This article first appeared in CommonWealth Magazine Vol. 745 in April 2022. It has been reprinted, with editing and updating, with permission from the publisher. Translation from the original Chinese was done for CommonWealth by Susanne Ganz.