In late November, experts convened to address Taiwan’s critical healthcare issues and the challenge of making strategic investments for maximum effectiveness.

In less than two years, Taiwan will become a super-aged society, with at least 20% of the population aged 65 and older. With this development, the already rising rates of chronic diseases and cancers will escalate, and sufficient healthcare funding will become an increasingly imperative issue for national resilience.  

At 6.6% of GDP in 2022, Taiwan’s investment in healthcare falls far below the OECD average of 9.2%. Its low healthcare expenditure, coupled with lagging healthcare outcomes, raises concerns about Taiwan’s ability to handle the rising number of citizens with long-term healthcare needs.  

“Among the areas of cooperation between Taiwan and the United States, health is one of the most discussed topics,” Taiwan Premier Chen Chien-jen said in recorded opening remarks during the Investing in Health Forum, held by AmCham Taiwan and the American Institute in Taiwan (AIT) on November 28. As an example, Chen highlighted the first memorandum of understanding (MOU) on health cooperation signed between the Ministry of Health and Welfare (MOHW) and the U.S. Department of Health and Human Services in 2020.  

Under the MOU, the two sides agreed to various cooperation activities, including programs, personnel exchanges, training and bilateral visits, workshops, and conferences. These efforts have helped strengthen bilateral cooperation in the fields of global health security, chronic disease prevention, health promotion, digital health, and general capabilities of health, the Premier noted. 

“We strive to advance from treating disease in the mid-stages to accelerate active early-stage treatment and disease prevention to effectively improve the physical and mental health of the people and increase the average life expectancy of the Taiwanese people,” said Chen, who started his career with researching hepatitis B and has helped raise awareness about hepatitis vaccination in Taiwan.  

Taiwan should set a goal of at least reaching the healthcare expenditure of the OECD average, argued Vice Premier Cheng Wen-tsan during his remarks at the forum. “Therefore, we are also reviewing non-health insurance items in addition to health insurance expenditures,” including public health and social welfare investments, he added.  

In another concerning statistical observation, Rachel Lu, a professor at Chang Gung University College of Management who specializes in healthcare policy, noted the discrepancy between Taiwan’s GDP and the life expectancy of its people. Although Taiwan’s healthcare expenditure has remained stable in the last two decades, at times matching those of Japan and South Korea, “when we look at actual health outcomes, we are lagging behind these benchmark countries,” she said.  

A longstanding pain point in Taiwanese healthcare has been the slow introduction of new and innovative drugs. Constraints on the National Health Insurance (NHI) budget have led to continuous underfunding of new drugs and new indications. According to a report from PricewaterhouseCoopers (PwC), the average waiting time of 729 days for new drugs in Taiwan is significantly longer than in neighboring Japan. The long wait has also been exacerbated by the lengthy process for licensing by the Taiwan Food and Drug Administration and the subsequent assignment of reimbursement prices under the NHI program.  

Recognizing the need to expedite the introduction of innovative drugs, Vice Premier Cheng emphasized the government’s commitment to streamlining the process and promoting “preventive medicine, whether through screening or public vaccination programs.” 

Underprepared, understaffed, and underinvested – these are the three characteristics of Taiwan’s healthcare system posing major barriers to improved health outcomes, according to Professor Lu. “With limited resources and endless needs, we need to decide what investments are most worthwhile,” she said. Lu further emphasized the benefits of investing in preventive care to keep healthcare costs down while also noting that beyond healthcare investments, individual responsibility is an important piece of the puzzle.  

“The concept of health promotion within the healthcare system has been discussed, including the idea of doctors prescribing exercise to patients as part of their treatment plan,” Lu said. “However, the responsibility for health ultimately lies with the individual.”  

Managing chronic diseases 

“The number of people in Taiwan suffering from chronic diseases is increasing rapidly,” noted Wayne Sheu, vice president of the National Health Research Institutes during the forum. Alarmingly, the quality of care in Taiwan for chronic diseases, particularly diabetes and hypertension, lags behind benchmark countries. “The proportion of comorbidity is also increasing, especially due to conditions like the ‘three highs’ (hypertension, hyperlipidemia, and hyperglycemia) causing problems with blood vessels or even heart failure,” he added.  

Approximately 12% of Taiwan’s population grapples with heart abnormalities. Among cardiovascular health issues, heart valve disease (HVD) stands as one of the lesser-known conditions among the general population. Despite a high two-year mortality rate of around 50%, it frequently remains undetected – a concerning 41% of those with HVD delay seeking treatment until their condition becomes critical. Thankfully, advances in treatment could improve outcomes for these patients.  

“With the advancement of technology, many elderly patients who originally required extensive surgery are now gradually accepting minimally invasive procedures,” said Hung-Yen Ke, director of cardiovascular surgery at Tri-Service General Hospital. “In clinical practice, we only intervene when the disease has already occurred. I hope that by treating patients or intervening in severe disease progression, we can sometimes feel that if we can prevent or intervene earlier, we can achieve improved quality of life.”   

For example, recent years have seen significant progress in the treatment of severe aortic stenosis. Effective technologies have been implemented, although they are not always fully covered by health insurance. But in addition to investing in new technology, raising awareness and increasing the understanding of HVD and its early warning signs, such as the appearance of heart murmurs, could save lives.  

“We want patients to know that early intervention by specialists can reduce or even avoid the occurrence of heart failure,” said Ko. “This may be the direction we should work toward in the future. We hope that doctors at all levels, especially emergency room doctors, can refer patients to cardiologists for basic diagnosis and treatment when they hear some murmurs during examinations.” 

Although mortality rates for some cancers have decreased, the mortality rate among breast cancer patients in Taiwan is still on the rise, noted Director-General of the Health Promotion Administration (HPA) Wu Chao-chun at the forum. Overall, cancer remains the leading cause of death in Taiwan. Experts agree that if the government is to achieve its policy objective of scientifically lowering Taiwan’s cancer mortality rate, it needs to increase funding for new cancer drugs, research, and clinical trials.  

Wu stressed the need for an integrated care system to tackle cancer and other chronic diseases. Such a new framework will require “intergovernmental agency work and helping medical professionals pitch in with medical intervention,” he said. The MOHW has proposed a new cancer drug fund with the goal of reaching a total of NT$10 billion for innovative treatments, set to be launched next year. However, consensus has not yet been reached on the allocation of funds within the NHI. 

Another widespread public health issue is diabetes, which consistently ranks in the top 10 causes of death in Taiwan. Over 2.5 million individuals in Taiwan have diabetes, around 30% of whom are below the age of 60. Most cases are preventable type 2 diabetes. Diabetes leads to various health issues, causing over 12,000 deaths in 2022, and is now Taiwan’s third-costliest disease, with treatment expenses of around NT$40 billion in 2022. 

Taiwan has implemented a pay-for-performance (P4P) program for diabetes care, providing financial incentives to facilitate comprehensive and continuous care. Under the P4P program, healthcare providers receive financial incentives based on predefined quality benchmarks, such as evidence-based practices. Certified diabetes physicians voluntarily enroll patients in the program. 

But more efforts are still required to reduce the incidence rate of diabetes. “Currently, diabetes management goals in Taiwan mainly focus on care quality metrics, but we need to adopt a more holistic approach,” said Huang Jian-ning, president of the Diabetes Association of the Republic of China (DAROC). 

Huang highlighted experts’ recommendations to implement action plans that address diabetes comprehensively, from prevention to treatment, with cross-ministry resource integration and a robust tracking mechanism.  

By establishing a national diabetes office, the government could more effectively tackle diabetes by establishing treatment guidelines following international research, a national screening and intervention plan, and programs focusing on the quality of life and psychological needs of diabetic patients and caregivers, he argued.  

Regarding mental healthcare, MOHW’s Mental Health Department Director Chen Liang-yu stressed the importance of early intervention. His department cooperates with the community to provide early intervention care services for high-risk patients with mental illness. The NHIA has also increased its mental health resources since last year, providing dedicated funding for long-acting injection treatment for mental disease patients. NHI data shows the program can significantly reduce re-hospitalization and disease recurrence rates. 

Prevention efforts 

With an aging population, osteoporosis is a condition demanding increased attention. Known as the “silent killer of the elderly,” osteoporosis weakens bones, leading to minor accidents resulting in fractures. Studies reveal that one in three women and one in five men over 50 suffer from osteoporosis. Early detection and prevention through screening and health education are crucial to managing this condition, along with expanding osteoporosis treatment coverage under the NHI system.  

“The scary aspect of osteoporosis is that many people don’t know they have it,” said Chen Chung-huan, chairman of the Taiwan Osteoporosis Association. He noted that those with osteoporosis who suffer a hip fracture have a 50% risk of dying within five years of the incidence. Since many people are unaware that they have osteoporosis, bone density scans are imperative to diagnose the condition. Early intervention will not only save healthcare costs in caring for patients with fractures but also increase the number of healthy years for those with osteoporosis.  

“The government should fund scanning also for people without symptoms,” said Chen. Noting that “elderly women and people with family history and associated risk factors are at highest risk,” Chen stressed that funding for bone density scanning programs should initially, at minimum, cover these groups.  

NHIA Deputy General Tsai Shu-ling agreed that providing bone scanning is a vital measure to prevent lethal fractures and that treatments should be widely accessible. Estimating that there are about 111,000 affected patients in Taiwan, he asked the industry to “please provide us with better prices so more people can enjoy new drugs.”  

An encouraging development is that Taiwan has made massive strides in the eradication of hepatitis B and C. People aged 45-79 and indigenous people 40 and older are eligible for screening in Taiwan, and the government has introduced reimbursement programs for oral hepatitis drugs. Taiwan is also accelerating efforts to screen high-risk groups, including incarcerated people, men who have sex with men, and drug users, said HPA Director-General Wu Chao-chun. 

But there is still much to do in the eradication of hepatitis B and C. Experts on stage discussed the importance of matching domestic treatment guidelines with international guidelines for hepatitis B and the possibility of implementing a P4P program for hepatitis C.  

While there is a vaccine for hepatitis B, hepatitis C can only be treated and cured with drugs. But with new developments in medical research, “there is finally a cure and eradication in sight” for hepatitis C, said NHIA Deputy General Tsai Shu-ling. “We are excited about the new hepatitis C drugs. A few years ago, it cost one million dollars per person, and it’s great that the industry was willing to provide the government with better prices.” 

Another area in which vaccination has a significant impact is the prevention of Human Papillomavirus (HPV). In most cases HPV doesn’t cause health problems, but some genotypes can cause genital warts or cervical, anal, penile, vulval, vaginal, head, and neck cancer. Over 95% of cervical cancers are caused by HPV, and vaccination can greatly reduce the risk of cancer. 

As part of its efforts to eradicate HPV, Taiwan launched a national, public-funded HPV vaccination program for girls entering junior high and high school. (It’s important to note that both men and women under the age of 45 can take the HPV vaccine, as previous vaccines were only recommended for children and teenagers). When asked about the possibility of vaccinating both men and women, HPA Director General Wu noted that the incidence rate of HPV among men is lower in Taiwan than in the West, and with limited resources the government is focusing on inoculating girls first. 

Beyond vaccination, early detection of cervical cancer through pap smears is the most effective way of decreasing mortality rates. “But for pap smears, Taiwan has a problem,” said Chou Hong-shiue, professor and chief physician of the Department of Gynecologic Oncology at Linkou Chang Gung Memorial Hospital. “Only 30% of women above 30 get their annual pap smears, despite NHI coverage. It’s clear more needs to be done to promote and provide screening.” 

While no definitive conclusions were drawn during the forum, the importance of deep discussions around healthcare investments cannot be understated, noted Miyuki Ogushi, AmCham supervisor and Pharmaceutical Committee co-chair, during her closing remarks. “This kind of debate is imperative to setting the right direction for the future of health in Taiwan,” she said.