Health System and Health
Professionals in Taiwan
Hsiu-Hung Wang, PhD, RN
Deputy Minister of Health
The Executive Yuan, Taiwan
Sep. 15, 2005
1
Organization of the Department of Health
Counselors
Minister
Deputy
Ministers
Chief
Secretary
• Bureau of Medical Affairs
• Bureau of Pharmaceutical Affairs
• Bureau of Planning
• Bureau of International Cooperation
• Bureau of Food Safety
• Bureau of Nursing and Healthcare
• Committee of Hospital Management
• Secretariat
•Bureau of National Health Insurance (NHI)
•Center for Disease Control
•Bureau of Health Promotion
•National Laboratory of Food and Drug Analysis
•Committee of Chinese Medicine and Pharmacy
•NHI Supervisory Committee
•NHI Dispute Meditation Committee
•NHI Medical Expenditure Negotiation Committee
2
Department of Health,Taiwan
Vision:
Healthy Taiwan
Promise people safe and healthy
lives
3
Department of Health,Taiwan
Mission
1. To improve the health of people
2. To become the educator in health matters
for the people
3. To be the promoter of healthcare industries
4. To be the participant in international health
affairs
4
Profile of Taiwan (2004)










Population: 22.60 million
Land area: 36,188 km2 (14,000 mile²)
Population density: 625 per km2
Neonatal mortality rate: 2.88 ‰
Infant mortality rate: 5.35 ‰
Maternal mortality rate: 1.97 ‰
Population aged over 65: 9.5%
Life expectancy: 79.41 (female)
73.60 (male)
GNP per capita : US $13,529
NHE as % of GDP: 6.26%
5
Department of Health,Taiwan
Health Professionals in Taiwan
6
Number of Medical Personnel (July, 2005)
Medical Personnel
Number of
Professionals
Number of
Professionals per
10,000
Physicians
Chinese medicine
Doctors
Dentists
Registered
Professional Nurses
673
4817
14.87
2.08
2259
294
4.43
34.04
Registered Nurses
Pharmacists
723
1121
13.84
8.92
Assistant Pharmacists
3031
3.30
7
Number of Medical Personnel (July, 2005)
Medical Personnel
Number of
Professionals
Number of
Professionals per
10,000
Medical Radiation
Technologists
6192
1.61
Nutritionists
12421
0.81
Physical Therapists
9579
1.04
Occupational Therapists
18510
0.54
Clinical Psychologists
52740
0.19
Counseling Psychologists
79478
0.13
Respiratory Therapists
23978
0.42
8
Comparison on the Manpower of Medical
Personnel to Service Population
Germany
France
USA
Australia
New
Zealand
Japan
UK
Hong
Kong
Korea
Taiwan
Singapore
Number of
each
physician
serves
291
297
361
414
441
476
492
617
585
634
688
Number of
each nurse
serves
100
132
96
99
104
185
110
155
253
252
318
Notes: 1. Data resources: IMD World Competitiveness Yearbook 2004
2. The number of each physician and nurse serve at the above countries are based on the assessment of data
in 2003.
3.The number of patients of Taiwan’s physician serves are accounted as the number of both physicians
and Chinese medicine doctors divides the total number of population
9
Medical Personnel Granted Licenses
• Taiwan has 20 kinds of medical personnel:
• Physicians, dentists, Chinese medicine doctors,
pharmacists, assistant pharmacists, registered professional
nurses, registered nurses, registered professional midwives,
midwives, dietitians, medical technologists, medical
radiation technologists, physical therapists, occupational
therapists, physical therapy technicians, occupational
therapy technicians, medical technicians, clinical
psychologists, counseling psychologists, respiratory
therapists.
10
Medical Personnel Granted Licenses
in Process
dental technologists
audiologists
optometrists
11
Legislation Year Regarding Medical Personnel
Profession
Legislation Year
Physician’s Act
Pharmacist’s Act
Midwife’s Act
Dietitian’s Act
1943
1943
1943
1984
Registered Nurse’s Act
Psychologist’s Act
Physical Therapist’s Act
Medical Radiation
Technologist’s Act
Medical Technologist’s Act
Respiratory Therapist’s Act
Occupational Therapist’s Act
1991
2001
2002
2002
2002
2002
2003
12
Act of Medical Personnel Management
• General: Qualification rules
• Practice: regulation of practice registration,
continuing education, participation in local
association and rules to reissue certificates
• Obligation
• Sanction: requirements, methods, the
establishment of sanction committee, rules of
penalty and annulment of certificates
• Professional Society
13
Specialization of Physicians
• Physicians’ Specialities:
Family Medicine, Internal Medicine, Surgery,
Pediatrics, Gynecology, Orthopedics, Neurology
Surgery, Urology, Otolaryngology, Ophthalmology,
Dermatology, Neurology, Psychiatry, Rehabilitation,
Anesthesiology, Radiology, Pathology, Nuclear
Medicine.
• Physicians who join specialist qualification
examinations are confined to two fields.
14
License’s Renewal
• Medical personnel is subject to management
guidelines to renew licenses.
• Currently, physicians, clinical psychologists,
medical technologists, medical radiation
technologists, dietitian’s, respiratory therapists,
registered professional midwives and midwives
comply with the law to renew licenses.
• For the others, the relevant bill is accessed by the
Legislative Yuan.
15
Valid Term of Licenses for Medical
Personnel
Medical Personnel
Valid Term of Licenses (years)
Physician
6
Medical Technologist
4
Medical Technician
4
Medical Radiation Technologist
4
Medical Radiological
Technician
4
Dietitian
6
Psychologist
6
Respiratory Therapist
6
Midwife
6
16
Control of Medical Manpower
Medical students are under number control in
which the maximum of 1300 applicants are
admitted each year.
Regarding other medical manpower, relevant
departments and institutes are established with
the endorsement from Taiwan’s ministry of
education. With respect to medical departments,
the proposal should be submitted with the
examination and management by the ministry of
education.
17
Action Plans for Medical Manpower
• Setting up guidelines for specialization and
qualification of physicians according to
physician’s act in 1998
• Training physicians on government scholarships
at remote areas
• Promoting physicians to receive complete
professional clinical training
• Promoting training program on international
health
• Promoting on-job training program for nurses
18
Post-graduate year one
(PGY1) program for physicians
• This pilot program launched in August 2003 after
SARS outbreak for the first year resident
• Purposes:
– Providing hospital and community based training
– Accumulating experiences for taking care for
patients from cradle to grave
– Enhancing the first year residents’ acquisition of
detailed factual knowledge, the development of
clinical skills and professional competence in
general medicine
19
Post-graduate year one
(PGY1) program for physicians
• Curriculum:
• General medicine: 36 hrs
• Community medicine: 1 month
• General surgery: 1 month
• Internal medicine: 1 month
• Residents should finish above courses
within one year
20
Post-graduate year one
(PGY1) program for physicians
Outcome for the pilot program:
• $NT 70,000 ($US 2,190) per month per resident
paid by government budget
• 60 teaching hospitals participated in the program
by 2004
• 95 physicians have finished the preceptor training
for PGY1 by 2004
• 1,419 residents finished the PGY1 training by Aug
2005
21
Department of Health,Taiwan
Nurse Practitioner (NP) System
22
Purposes of Establishing NP System in Taiwan
 To upgrade the quality of medical services and




prevent and reduce medical errors.
To improve collaboration between physician-nurse
team work.
To readjust patient care tasks shared between
physician and nurse.
To improve physician-patient and nurse-patient
relation.
To establish a national standard for Training
Programs and Licensure System for NP to
ensure the high level of NP competencies.
23
Role of the Nurse Practitioner
 Major role:
To provide continuous and
integrated medical and nursing care
collaboratively with physicians.
24
The Development of NP System
Major Achievements of the Establishment since 2001:
1. Has completed a report on “recommendations
on the development of NP and related
regulations”
2. Has completed a pilot project on “ the training
program of NP and related regulations”
3. Has completed a project on the training of seed
clinical instructors for NP
25
A Policy Proposal on
Training Program
Designing and Practice
Model for Nurse
Practitioners in Taiwan
(published by NHRI
Forum/Center on Health
Policy R&D in July 2004)
26
Regulations Governing
Specialties and Examination of
Nurse Practitioner
Promulgated on Oct. 27, 2004 by the
Department of Health
27
Advisory Committee of the NP
•Chairman : Deputy Minister of DOH
•Nursing experts
•Medical experts
•Director, Bureau of Nursing and Healthcare, DOH
•Director, Bureau of Medical Affairs, DOH
28
Department of Health, Taiwan
National Health Insurance (NHI)
29
Development of Social Insurance
Programs in Taiwan
1950
1958
1985
1990
1995
Laborer’s Insurance
Government Employee’s Insurance
Farmer’s Insurance
Low-income Household Insurance
National Health Insurance
(Consolidating
the health care component
of existing insurance programs into one)
30
Major Achievements of NHI
Universal enrollment
Comprehensive coverage
Easy access
Affordable cost
Acceptable quality
High satisfaction
31
Universal Enrollment
Population Covered：22 million (99%), 2004
1%
•Staying abroad
•In transition of jobs
•Reluctant to join
99%
32
Comprehensive Coverage
 Inpatient care
 Ambulatory care
 Laboratory tests
 Prescription drugs and certain OTC drugs
 Dental services
 Traditional Chinese medicine
 Day care for the mentally ill
 Home care
 Some preventive services
33
Easy Access
Medical care institution contract
rate : 93%
No. of physicians per 10,000: 16
No. of beds per 1,000: 60
34
Total Health Expenditures as % of GDP, 1983-2003
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
% of GDP
NHI
7.0
6.5
5.99
6.0
6.26
Total Health Expenditures
5.5
5.91
5.44
5.46
5.0
5.275.29 5.27 5.33
4.5
4.77 4.81 4.93
4.67
3.80
4.0
3.39 3.44 3.59
4.20
4.10
4.00
4.00
4.00
3.5 3.70
3.90
2.94 3.06 3.14 3.02
2.93
3.0
2.76
Out-of-pocket
2.21 2.1
2.18 2.16
2.5
2.23
Health Insurance
2.0
2.00
1.96 2 2.1
1.5
1.85 1.89
1.82 1.77 1.82 1.8 1.85
1.65
Government Sector
1.0
0.81 0.82 0.81
0.5
0.77 0.69 0.59
0.51 0.47 0.47 0.46 0.51 0.45 0.44
0.0
35
Worldwide Health Rankings
Taiwan
The Economist Intelligence Unit (2000)
36
Healthcare International, 2nd quarter 2000: 66-67, 72-75
High Satisfaction
(1998～2004)
90.0%
78.50%
80.0%
70.0%
66.5%
65.4%
60.0%
50.0%
78.60%
77.60%
71.1%
68.3%
67.2%
63.3%
61.0%
Satisfied (DOH)
Satisfied (BNHI)
50.2%
76.60%
76.30%
65.6%
63.8%
47.0%
40.0%
70.90%
59.70%
Dissatisfied (DOH)
Dissatisfied (BNHI)
36.5%
39.0%
30.0%
27.0%
20.0%
23.4%
22.5%
10.0%
25.9%
24.5%
24.2%
22.0%
Satisfied
20.1%
Dissatisfied
29.60%
17.2%
20.60%
15.90%
13.30%
17.00%
13.60%
11.60%
0.0%
05/95 09/95
06/96
01/98 04/98 11/98
05/99
03/00
10/00
06/01
12/01
05/02
11 /02
07/03
12/03
04/04
09/04 12/04
37
Department of Health,Taiwan
Cancer Control
38
Changes of Main Causes of Death
2004
1952
Gastroenteritis
1
Malignant tumor
Pneumonia
2
Cardiac disease
Tuberculosis
Cardiac disease
3
4
5
Cerebrovascular diseases
Vascular disease of
central nervous system
crude death rate
950.80
0.1 million
(population)
Injury
Diabetes
crude death rate
590.28
39
Five Leading Causes of Death
Rank Cause of Death
1
2
3
4
5
Malignant tumor
Cardiac disease
Cerebrovascular
diseases
Diabetes mellitus
Accidents and
adverse effects
Death %
Adjusted MTR
(Per 100,000)
27.20
9.62
87.05
24.81
9.23
24.42
6.88
19.17
6.32
29.32
Data resource: Ten Main Causes of Death Rate in 2004, Ministry of Health, the
Executive Yuan, TAIWAN
40
Five Leading Sites of Cancer in Taiwan
Mortality (2004)
Liver
Lung
Colorectum
Oral
Stomach
44.92
443.03
19.76
15.94
14.17
Lung
Liver
Colorectum
Breast
Cervix
19.71
16.91
14.57
12.04
8.33
M
F
Incidence (2004)
Liver
Lung
Colorectum
Oral
Stomach
51.9
39.4
35.8
26.46
18.6
Breast
Colorectum
Cervix
Liver
Lung
39.6
27.9
23.73
20.0
18.3
M
F
Per 100,000
41
Rationale for Screening Policy
WHO’s suggestion on screening:
– Cervical ca. and breast ca. screening are
effective
– Colorectal ca. screening is partially effective
Incidence of oral and liver cancer is high in
Taiwan and domestic data proved screening is
effective
42
Cancer Screening Programs
Sites
Target
Tool and Interval
Starting year
Uterine
cervix
Women > 30
Pap smear;
NHI: 1 y; BHP: 3 y
1990 (DOH)
1995.07 (NHI)
Breast
Women > 35
CBE by dr./nurse
1999-2001
(BHP)
High risk women
50-69
Mammography
2002.07 –
2004.06 (BHP)
Family Hx: 1 y
Other high risk: 3 y
Women 50-69y
Mammography 2 y
2004.07 (NHI)
Oral
cavity
Smoker, BN chewer
> 18
Exam of oral
mucosa; 3 y
1999 (BHP)
Colonrectum
General pubic 50-69 FOBT; 1 y
July 2003
(BHP)
43
Infrastructure of Screening
• Delivery system of screening services
• Accreditation program for cytology and
mammography
• Computerized information system for each
cancer screening program
44
Strategies
•
•
•
•
•
Establish evidence-based screening models
Include screening in the National Health Insurance
Improve public awareness of early signs of cancers
Reduce screening obstacles and improve coverage
Establish an effective referral system for screening
positive cases
• Establish quality monitoring system for screening
• Establish screening databanks for monitoring and
evaluation
45
Department of Health,Taiwan
Disease Prevention and Control
46
Communicable Disease Control
Surveillance
Prevention
International
Cooperation
Quarantine
Strengthen Control System
Avoid Disease Threats
Information
Management
Research
Infection
Control
47
Immunization Program
• Small pox vaccination started in 1906
• DPT vaccination in 1954
• Polio vaccination in 1966
• HB vaccination in 1984
48
Eradication of Communicable Diseases
•
•
•
•
•
Plague
Smallpox
Rabies
Malaria
Poliomyelitis
1948
1955
1959
1965
2000
49
National Health Command Center (NHCC)
50
Communication System Framework
National Health
Command Center
Radio
Computer :
communication Web-site &
system
e-mail
Each
Branch
Mass
Media
Videoconferencing
Public Health
Bureaus
Telephoneconferencing
Emergency
Medical
Network
fax
Satellite
Telephone
communication
Infectious
Prevention
Hospitals
International
Organizations
• WHO
• US CDC
51
The Platform for Information Integration
Shigellosis Typhoid fever
Paratyphoid fever
Japanese Encephalitis
Dengue Fever
Enteroviruses infection
Complicated Severe Case
Meningococcal Meningitis
Diphtheria EHEC infection
Cholera
New Influenza
epidemiological index ：1. stable 2. controlled 3. severe 4. extremely severe
score
(2005/5/15-5/21)
52
Preparedness of
Influenza Pandemic
1. Possible effects of the next pandemic in
Taiwan
• >70,000 hospitalizations
• >10,000 deaths
2. National Preparedness Plan of Influenza
Pandemic has been implemented.
3. Influenza Vaccine Self-manufacturing Plan
has been completed.
53
Strategies against
New-typed Influenza and Avian-Flu
 Three strategies
1. to bar transmission
2. to reserve anti-virus drugs against influenza
3. to research and develop influenza vaccine
 Four preventive measures
1. to prohibit outside frontiers
2. to detect disease at borders
3. to prevent and control within community
4. to secure medical system
54
Department of Health,Taiwan
Long-Term and Elderly Care
Services in Taiwan
55
Population Growth Rate (1947-2004)
60
50
‰
Crude Birth Rate
Natural Increase Rate
49.97
Crude Death Rate
40
38.3138.40
30
38.87
32.03
27.16
20
10
20.18
18.15
22.26
23.38
18.63
11.57
16.55
11.35
6.83
4.90
4.76
5.21
‘80
‘90
0
1947 ‘51
‘60
‘70
9.56
5.97
3.59
2004
56
Life Expectancy (1951-2004)
Female
Male
Years
90
80
71.56
74.54
76.75
79.41
66.40
70
56.33
60
62.31
50
66.66
69.56
71.33
73.60
53.38
40
1951
‘60
‘70
‘80
‘90
2004
57
Long-Term Care System in Taiwan
Acute
Chronic
medical care medical care
Acute
hospitals
Chronic care
hospitals
Long-term care
Skilled care
Non-skilled care
•Nursing homes •Nursing care
institutions
•Home health
care
•Home services
•Day care
Rehabilitation
care
Foster institutions
•Day care centers
Department of Health
Daily life
care
Ministry of the Interior
Commission for Retired Servicemen
Commission for Retired Servicemen
Medical care
Medical Care Act
Nurse’s Act
Welfare of the Elderly Act
58
regional
hospitals
district hospitals
health
stations
or
ef
car ed
g
me
a
ho the
e
car
ng ons
rsi ti
nu nstitu
i
e
ar
ice
yc
erv
da
es
medical
centers
m
se
ho
ea eds
ng
di s d b
rs i
nic an
nu
ro ls
ch spita
ho
he
ma alth
i
he n ten p rom
a lt an o
h c ce ti o
are , pr n, h
em
ser eve eal
er g
vic nt iv th
en
es e
cy
car
es
erv
ice
s
Pluralistic Care Systems for the Elderly
primary care
institutions
home care
in home
services
other social welfare
and services
preventive healthcare services acute medical care services rehabilitation and after-care service
health promotion
medical care network plan long-term care development plan
59
Department of Health,Taiwan
Thank you
for Your Attention
60