The new government is drafting a roadmap for a healthier nation through the ambitious Healthy Taiwan initiative, aiming to transform the island’s healthcare landscape.

“Doctor Lai comes back to visit me quite often,” an elderly heart disease patient told Chen Jyh-hong in 1990. Back then, Chen was an attending physician at Tainan’s National Cheng Kung University (NCKU) hospital.

“That was how I became aware that we had a young doctor at our hospital who was interested in politics,” Chen says.

The elderly man, who was from a prominent family in local politics, spoke to the young doctor about Taiwan’s history – from the Japanese colonial era to the arrival of the nationalist Kuomintang (KMT) and the subsequent White Terror era. Curious about local political identities, the doctor frequently returned to engage with the old man, diligently taking notes during their discussions.

Fast forward to 2024: Chen is now hospital superintendent at NCKU, and the young doctor is president of Taiwan.

“I had a dream that if I’m elected president, I’ll use my professional knowledge and, with the help of the medical community, create a healthier, stronger Taiwan,” Lai Ching-te, who was then president-elect, said at the inaugural Healthy Taiwan forum organized in April by The Alliance for Promoting Healthy Taiwan.

When Lai first had the idea, he immediately sought advice from Chen, who had been Lai’s teacher for almost his entire medical career. Chen mobilized his network of Taiwan’s top medical professionals to help “put meat on the bones” of Lai’s policy aspirations.

The result was the “Healthy Taiwan” plan, a comprehensive roadmap aimed at upgrading Taiwan’s healthcare, with goals ranging from decreasing deaths from cancer to ensuring the financial sustainability of the National Health Insurance (NHI) program. Chen is now a co-convener of the Healthy Taiwan Promotion Committee, of which Lai himself presides.

“Our life expectancy here in Taiwan is around 80 years of age – that’s pretty good,” says Chen. “But on average, eight of those years are spent in a state of dependency due to ill health.” In some Nordic countries, meanwhile, the average length of dependency due to ill health at the end of life can be measured in weeks.

Health for all

Chen energetically rattles off the proposals included in the “Healthy Taiwan” plan, all designed to extend the health span of the Taiwanese people.

As a 30th “birthday present from the government,” a comprehensive health exam will be provided. Additionally, the government plans to deploy telemedicine and on-site visits to deliver medical care directly to long-term care patients. Schools can anticipate the introduction of a Social Emotional Learning (SEL) program, and there are commitments to heighten focus on both psychological and physiological prenatal conditions.

The “888 plan” has been launched to enhance early diagnosis of the “three highs” – hypertension, high blood sugar, and high cholesterol. This initiative aims to integrate 80% of patients suffering from these conditions into the caretaking network within eight years. The plan includes providing lifestyle advice and ultimately seeks to achieve an 80% control rate for these conditions.

But the most ambitious goal of all relates to the top cause of death among Taiwanese: cancer. Lai has set a target to reduce cancer deaths by one-third by 2030, using the 2022 baseline of 222.7 deaths per 100,000 population.

Decreasing cancer deaths requires a dual-pronged approach, explains Chen. The government needs to increase screening for early detection and unlock access to the latest cutting-edge drugs and treatment modalities currently not covered by the NHI.

I’m curious as to how the target was set and whether Chen is confident that it will be met. Chen replies that the proposal was inspired by U.S. President Joe Biden’s “Cancer Moonshot” program that seeks to reduce the cancer death rate by at least 50% over the next 25 years.

He adds that although Taiwan’s goal is ambitious, “I believe we have a chance to meet it. You need a goal to get everyone to extend themselves.”

Several proposals under the “Healthy Taiwan” initiative support President Lai’s ambitious cancer reduction goal. These include enhanced screening processes and the establishment of an NT$10 billion fund dedicated to new cancer drugs and treatments.

Cancer patient advocates have long called for better availability of the most advanced treatments. However, Chen notes that integrating these into the NHI system has been challenging.

For the Taiwanese public, access to healthcare is like an all-you-can-eat buffet. Each individual can be assured care for any ailment, provided the treatment is covered by the NHI. Quick access to specialists is astonishingly convenient. However, this apparent bounty does not mean healthcare spending is unconstrained – no matter how much healthcare is consumed under the NHI, it all has to add up to the annual global budget.

“There are different drugs for every different cancer, and the life cycle of those drugs is really short, and those drugs are really expensive,” says Chen. “Due to the limits of the global budget, it’s impossible to cover every new treatment.”

The “global budget” system was implemented by Taiwan’s National Health Insurance Administration (NHIA) in 2002. It sets an annual cap on total national healthcare insurance spending and restricts drug reimbursement prices. While this system helps control expenditures, it also significantly impacts the development of healthcare and the integration of new technologies.

Think of the global budget as a big pie to be shared by all providers within the NHI system each year. The pie can be divided up creatively, but no matter how you cut it, you won’t magically conjure more dough. The high cost of advanced cancer treatments simply cannot fit under the current system without blowing the budget that must cover everything else. This is where the separate NT$10-billion-dollar annual fund comes into play.

“With this fund, we can allow cancer patients access to the newest drugs and therapies while we assess their efficacy,” says Chen. “If we find clear evidence of their efficacy, then maybe they will be graduated to be covered by the NHI.”

As a reporter who first covered the NHI in 2007, I have repeatedly observed the contradiction between the ironclad constraint of the global budget and the NHI’s promise of unlimited coverage across various facets of Taiwan’s medical care.

This financial constraint is why Taiwanese hospitals typically don’t employ orderlies except in the emergency room, relying instead on patients’ families to provide non-medical care. It also contributes to the overwork and comparatively low pay of Taiwanese medical professionals by international standards, as well as the brevity of the typical doctor’s visit. Hospitals and clinics, paid per patient, require high patient turnover to make ends meet.

It’s also why while Japan achieves drug coverage for 95% of new drugs within an average of less than 60 days, Taiwan’s average waiting period for new drug coverage exceeds 700 days, with only around 55% of new drugs achieving coverage. Fortunately, the NHIA has since 2023 been making efforts to expedite the coverage of new drugs and has introduced a series of reform measures to address these delays.

The funding issue

“The government’s medical policy can’t come out of the NHI’s global budget,” says Chen. Fortunately, other Healthy Taiwan proposals similarly seek to alleviate problems in the health system without raising the global budget.

One example is the proposal to “reexamine the salary structure of medical staff in public hospitals.” Salaries for staff at public hospitals are not paid from the NHI’s global budget but from sources such as the municipality for city hospitals. These salaries can be increased without raising the NHI premiums that build the budget. But what about private hospitals and clinics?

“If we raise the salaries for public hospitals, then the private hospitals will have to keep up to compete,” says Chen.

Taiwan’s healthcare expenditure, at approximately 6.6% of its GDP, is notably lower than the OECD average of around 9%. This raises the question of whether it’s feasible to increase premiums to fund improved care, or if it’s more practical to identify alternative funding sources for the ambitious “Healthy Taiwan” programs. To answer this question, I turn to Democratic Progressive Party (DPP) legislator Jerry Wang.

“Just raise the premium – so simple, right?” Wang says with a chuckle. “I used to think that way.” The NHI premium primarily falls on workers and their employers. Increasing that burden is so politically unpopular that it has become an “absolute last resort.”

Before he became a party-list pick for the legislature, Wang was a professor of hematology-oncology at Chang Gung Memorial Hospital. He is also the founder of the Hope Foundation Cancer Care, an advocacy group for cancer patients. But since taking office in February, Wang has learned a lot about the practical aspects of governance and how to effectively navigate the complexities of government operations.

“Everything is more difficult and complicated than I could have ever imagined,” he says.

Finding funding for programs that don’t fall within the NHI system is also far from straightforward. According to the Budget Act, special funds like Lai’s proposed NT$10 billion Cancer Drugs Fund must have a designated funding source. For instance, cancer screening programs are paid for by a tax on tobacco and alcohol. Such a source has yet to be located for the Cancer Drugs Fund, although there are plans to kick-start the program temporarily using funds from the administrative budget.

“Through my work as a doctor I observed the urgent need for these life-saving drugs for patients – that’s why I advocated for them,” says Wang. “Now I hope to find consensus within the government so this need can be met.”

Taiwan’s legislature can be a rough-and-tumble environment. In addition to his legislative duties, Wang has been spotted in his medical role patching up legislators who sustained nicks and cuts after physical brawls on the floor.

Despite the harsh altercations that can sometimes be seen at the legislature, Wang is optimistic that the ruling DPP and the two opposition parties, which together hold legislative majority, can come together to improve healthcare.

“When it comes to changes that improve the lives of people, there is always room to cooperate,” he says, noting that the Regenerative Medicine Act was passed in early June with multi-partisan consensus.

To keep the momentum moving forward in “Healthy Taiwan,” Lai has said he will check in with his committee every quarter and hold an annual meeting to assess progress.

Chen says of his former pupil: “In his bones, he is still a doctor.”