Taiwan claims to have one of the best healthcare systems in Asia in terms of affordability, quality and access. Around 99% of the island republic's 23.6 million people are covered by a universal healthcare programme that has been running since 1995. Over 90% of its clinics and hospitals are under the National Health Insurance (NHI) system.
NHI ensures that every resident has access to quality and affordable care, with a consultation and medicine at a neighbourhood clinic costing only US$5. Coverage includes inpatient and outpatient care, prescription drugs, traditional Chinese medicine, dental services and home nursing care. Enrolment is mandatory for all citizens, including foreign residents.
Patients in Taiwan can choose among many doctors and hospitals and waiting times are short. Copayment fees are modest at $2.50 to $11.50 per consultation. Each NHI holder has a smart card that contains their medical records, giving providers easy access to the information they need for diagnosis and treatment.
Other countries in Asia have universal health coverage (UHC) programmes, and Thailand's is frequently mentioned as a model for developing countries. But the fact remains that good public hospitals are overcrowded and patients with limited financial resources have few other options. As a result, more Southeast Asian patients are travelling to Taiwan for treatment, something the country is welcoming.
NEW SOUTHBOUND POLICY
Exporting the successful Taiwan healthcare model is one of the goals of the New Southbound Policy (NSP) announced in 2016 by President Tsai Ing-wen. The One Country, One Center (1C1C) programme now links at least seven Taiwanese hospitals with seven Asian countries, according to Dr Lee Roy Chun, deputy director of the Chung-Hua Institution for Economic Research, which advises the Ministry of Health and Welfare on NSP issues.
He sees Asean and India as priority areas for cooperation under the NSP.
"[The NSP] is not trade and investment alone. We want to share Taiwan's experience. We want to share Taiwan's resources in many senses, so it is actually more of a development-assistance oriented policy," Dr Chun said at the recent Taiwan Thailand Innovative Medical Cooperation 2019 exhibition in Bangkok.
"Taiwan's medical sector is of high quality, but affordable. The sector's level of technology and innovation is very high, patient-oriented, along with one of the most advanced universal healthcare coverage programmes in the world."
Taiwan ranked ninth in the 2018 Bloomberg Health Care Efficiency Index, which looks at medical costs and value for 56 global economies. Hong Kong and Singapore are ranked first and second. The United States was ranked 54th and is the most expensive country for treatment.
The strengths of Taiwan's healthcare sector are not well recognised by those in Asean and India, Dr Chun acknowledged. But the 2014 HSBC Expat Explorer survey of more than 9,000 expats in 100 countries gave the system high marks: nearly seven in 10 expats in Taiwan said they spent less on healthcare than they used to before moving there.
"I paid NT$150 ($5) for an obstetrician-gynaecologist consultation, an ultrasound and medicine at a neighbourhood clinic," Kiyomi Liu, a Hsinchu-based American who moved to Taiwan in 2013, told The News Lens International in Taipei last year. "Back home, my bill came to $1,000 for the same procedure. I had to pay everything out of my own pocket because my insurance deductible was $1,500."
The Expat Insider survey by Germany-based InterNations, with a sample size of 12,500 respondents representing 166 nationalities, ranked Taiwan first in its Health and Wellbeing category followed by Austria, Denmark, Sweden and Finland.
"As many as 68% of expats are completely satisfied with the quality of healthcare, the highest percentage worldwide," the report said. "Medical care seems to be affordable too: well over eight in ten respondents (87%) couldn't be happier with healthcare costs in Taiwan. Even in Denmark, which has the second-best rating, only 49% of respondents describe medical care as very easy to afford."
"This is not well understood," said Dr Chun. "Not many people understand that Taiwan should be the preferred destination for medical and healthcare cooperation so we want to elevate awareness, elevate the understanding of Taiwan's strength in this field as well as our willingness to cooperate with Asean and India in this aspect."
One of the four objectives under the NSP for healthcare and welfare is capacity building. Changhua Christian Hospital (CCH), with more than 3,500 beds and over 8,000 employees serving in 10 branches and affiliated hospitals across Taiwan, is now providing training for medical professionals in Taiwan to create and expand a medical supply chain in Asia.
In Thailand, CCH has signed memoranda of understanding with Overbrook Hospital in Chiang Rai, Bangkok Christian Hospital, Rangsit International Hospital and Siriraj Hospital.
The seven priority countries in the NSP healthcare and welfare programme are Thailand, Malaysia, Myanmar, India, Indonesia, the Philippines and Vietnam. CCH is the main Taiwanese hospital involved in Thailand. Other partners are Veterans General Hospitals in Vietnam, Shin Kong Wo Ho-Su Memorial Hospital in Myanmar, Chang Gung Memorial Hospital in Malaysia, National Taiwan University Hospital in Indonesia, National Cheng Kung University Hospital in India, and Hualien Tzu Chi Hospital in the Philippines.
China accounted for a market-leading 40% of all foreign patients in Taiwan in 2014. But last year inbound patients from Asean surpassed those from the mainland.
"As you can see, there is a great potential here and the New Southbound Policy's healthcare and welfare policy is actually delivering results already," Dr Chun said.
Vietnam is the top source of foreign patients from Asean in Taiwan, followed by Indonesia, the Philippines, Malaysia, Myanmar and Thailand respectively.
"The reason why Thailand is lower is because Thailand also has one of the best medical services sectors so we are looking at cooperation rather than competition for patients," he said. "We have different models for different forms of cooperation with different countries."
In terms of training, Thailand is actually the second recipient of the 1C1C capacity building programme. In May this year alone, Taiwan received 181 trainees from Asean, led by 50 from Malaysia, followed by Thailand, Vietnam, the Philippines and India. Eighty percent of the Thai trainees in Taiwan are doctors taking short courses lasting three weeks to three months. The remaining 20% are non-MDs with five medical students taking part in a full seven-year degree programme there.
"We want to see this number increase more rapidly in the next three to five years," Dr Chun said.
SECRETS OF AFFORDABILITY
Technology and innovation can improve the quality of healthcare by providing more timely and accurate diagnosis while lowering treatment and medicine costs along with waiting times. But policymakers believe the real secret to more affordable universal healthcare that serves everyone is education.
"We have a very robust and sound foundation for medical education and I think education is the starting point," Dr Chun told Asia Focus. "Medical education in Taiwan requires not only professionalism, but also moral education so that doctors and nurses understand that they are doing this not for profit making only."
It helps that Taiwan has strong information and communication technology (ICT) capability, along with firms that see good opportunities to improve efficiency in the healthcare field, said Beren Hsieh, business development manager at Imedtac, which provides Internet of Things (IoT) and cloud services to more than 30 hospitals.
"What we do is combine our ICT technology into our healthcare services," he said. "Before, Taiwan had the same problem as other Asian countries which was long waiting lines. Now, Taiwanese people can do doctor shopping because of ICT."
Because coverage is universal and affordable, Mr Hsieh said, it's not unusual for a patient to go to one medical centre in the morning, and then seek a second opinion in the afternoon from another physician.
"Seeing the top-of-the-line doctors in Taiwan would only cost you around 400-500 baht so you can go doctor shopping every day if you want to," he said. "Every patient only needs less than five minutes to be diagnosed because the doctor would already have the patient's medical records at the push of a button via technology."
Products offered by Imedtac include a portable, multi-function vital signs station that records height, weight and blood pressure before uploading it to the system along with patient medical records for doctors and nurses to access via a mobile app. It also offers robotic assistants for indoor navigation, interactive health education and video calls.
As well, Imedtac makes an automated dispensing cabinet. Patients can use radio-frequency identification and facial recognition or simply scan their prescription to obtain their medications from drawers fitted to the machine.
"There are many patients so how to queue them in the right places is very important," said Mr Hsieh. "The doctors will be able to see everything once you enter the hospital or clinic, including all of your vital signs and medical records, on their computers and mobile phones and they can start their diagnosis right away."
Managing patient queues, expediting diagnoses and getting the right medication faster can be achieved through technology, but it won't get you more doctors in rural areas where they are needed the most. So, education of medical professionals and government policy are crucial.
Dr Chun said there is a very strong mindset among medical professionals in Taiwan that healthcare cannot be managed on a purely business basis; they see it as a "moral obligation", a lifesaving practice.
"In the US, for example, it is increasingly becoming more about a profit-making mindset and we are starting to see this in Taiwan, but it is not the mainstream," he said. "Society in Taiwan has established a universal consensus that medical care should be affordable by everyone, where business considerations should not prevent the primary objective which is to increase welfare provision. This belief is our secret."
He says his family of three pays around $350 per month for insurance under Taiwan's universal healthcare programme, which is "quite a lot", but premiums are adjusted to personal or family income, so the more you earn, the more you pay.
"At the start, people complained, especially the rich people because they were contributing more," he said. "But over time, in the last five years, I think everybody is accepting the fact that this is just a kind of income tax.
"The key is that they pay more but they also receive better healthcare through this government policy. The other key is to make this universal healthcare and insurance regime financially sustainable."
The way the government funds medical schools is part of the solution. For example, in a class of 90 medical students, the government might fund 10 places by offering free tuition for the entire seven-year programme, but those 10 students must agree to serve in rural areas for five to 10 years.
"They have an obligation to serve in rural areas after they graduate and many of them stay after their contracts end because they know the patients and they are familiar with the places," said Dr Chun.
Wages for doctors in rural areas might be lower but the basic starting salary is the same across the board, and rural physicians qualify for a living allowance. Doctors in big cities also can earn a per-head bonus based on the number of patients treated, but with caps to prevent abuse and ensure quality.
Some doctors in Taipei even choose to serve around three months in a year in rural areas to support the local resident doctors, said Dr Chun.
"Education is the first step," he said. "Our medical students were trained to think this way when they were more idealistic about saving the world, so it is easier to instill this mindset of putting saving lives before business at that age, and the government funding programme is also helping."
