Health System and Health Professionals in Taiwan

Hsiu-Hung Wang, PhD, RN

Deputy Minister of Health The Executive Yuan, Taiwan Sep. 15, 2005
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Organization of the Department of Health

Counselors
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

Minister

Deputy Ministers

Chief Secretary

Department of Health,Taiwan

Vision:
Healthy Taiwan
Promise people safe and healthy lives
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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

Profile of Taiwan (2004)

Population: 22.60 million Land area: 36,188 km2 (14,000 mile) 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%
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Department of Health,Taiwan

Health Professionals in Taiwan

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 Registered Nurses Pharmacists

673 4817 2259 294 723 1121

14.87 2.08 4.43 34.04 13.84 8.92

Assistant Pharmacists

3031

3.30
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Number of Medical Personnel (July, 2005)

Medical Personnel Number of Professionals Number of Professionals per 10,000

Medical Radiation Technologists

Nutritionists Physical Therapists Occupational Therapists

6192
12421 9579 18510

1.61
0.81 1.04 0.54

Clinical Psychologists
Counseling Psychologists Respiratory Therapists

52740
79478 23978

0.19
0.13 0.42

Comparison on the Manpower of Medical Personnel to Service Population

Singapore
Germany
Number of each physician serves Number of each nurse serves

Australia

New Zealand

Taiwan

France
297 132

Korea

Japan

Hong Kong

USA

UK

291

361

414

441

476

492

617

585

634

688

100

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 Taiwans 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.

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Medical Personnel Granted Licenses

in Process
dental technologists audiologists optometrists

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Legislation Year Regarding Medical Personnel

Profession Legislation Year

Physicians Act Pharmacists Act Midwifes Act Dietitians Act

Registered Nurses Act Psychologists Act Physical Therapists Act Medical Radiation Technologists Act Medical Technologists Act Respiratory Therapists Act Occupational Therapists Act

1943 1943 1943 1984

1991 2001 2002 2002 2002 2002 2003

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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

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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.
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Licenses Renewal
Medical personnel is subject to management guidelines to renew licenses. Currently, physicians, clinical psychologists, medical technologists, medical radiation technologists, dietitians, 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.
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Valid Term of Licenses for Medical

Personnel
Medical Personnel Valid Term of Licenses (years)

Physician Medical Technologist Medical Technician Medical Radiation Technologist

6 4 4 4

Medical Radiological Technician

Dietitian Psychologist

4
6 6

Respiratory Therapist
Midwife

6
6
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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 Taiwans ministry of education. With respect to medical departments, the proposal should be submitted with the examination and management by the ministry of education.
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Action Plans for Medical Manpower

Setting up guidelines for specialization and qualification of physicians according to physicians 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
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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
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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

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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

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Department of Health,Taiwan

Nurse Practitioner (NP) System

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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.
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Role of the Nurse Practitioner

Major role:

To provide continuous and integrated medical and nursing care collaboratively with physicians.

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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
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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)

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Regulations Governing Specialties and Examination of Nurse Practitioner

Promulgated on Oct. 27, 2004 by the Department of Health

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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

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Department of Health, Taiwan

National Health Insurance (NHI)

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Development of Social Insurance Programs in Taiwan

1950 1958 1985 1990 1995 Laborers Insurance Government Employees Insurance Farmers Insurance Low-income Household Insurance National Health Insurance
(Consolidating

the health care component of existing insurance programs into one)

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Major Achievements of NHI

Universal enrollment Comprehensive coverage Easy access Affordable cost Acceptable quality High satisfaction
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Universal Enrollment
Population Covered22 million (99%), 2004
1%
Staying abroad In transition of jobs Reluctant to join

99%

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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
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Easy Access
Medical care institution contract
rate : 93%

No. of physicians per 10,000: 16

No. of beds per 1,000: 60

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Total Health Expenditures as % of GDP, 1983-2003

% 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
1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
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2003

Worldwide Health Rankings

Taiwan

The Economist Intelligence Unit (2000)

Healthcare International, 2nd quarter 2000: 66-67, 72-75

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High Satisfaction
(19982004)
90.0% 80.0% 70.0% 60.0% 50.0% 40.0%
39.0% 47.0% 50.2% 36.5% 27.0% 22.5% 23.4% 25.9% 22.0% 24.5% 24.2% 20.1% 17.2% 13.60% 29.60% 20.60% 17.00% 11.60% 15.90% 13.30% 65.4% 61.0% 66.5% 68.3% 63.3% 63.8% 71.1% 67.2% 65.6% 78.50% 77.60% 70.90% 59.70% 78.60% 76.30% 76.60%

Satisfied (DOH) Satisfied (BNHI)

Dissatisfied (DOH) Dissatisfied (BNHI)

30.0% 20.0% 10.0% 0.0%

05/95 09/95

Satisfied

Dissatisfied

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

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Department of Health,Taiwan

Cancer Control

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Changes of Main Causes of Death

1952
Gastroenteritis Pneumonia

2004
1 2 3 4 5
Malignant tumor
Cardiac disease

Tuberculosis Cardiac disease

Vascular disease of central nervous system
crude death rate 950.80

Cerebrovascular diseases
Injury Diabetes

0.1 million (population)

crude death rate 590.28

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Five Leading Causes of Death

Rank Cause of Death Death % Adjusted MTR (Per 100,000)

1 2 3
4 5

Malignant tumor Cardiac disease Cerebrovascular diseases Diabetes mellitus Accidents and adverse effects

27.20 9.62 9.23

6.88 6.32

87.05 24.81 24.42

19.17 29.32
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Data resource: Ten Main Causes of Death Rate in 2004, Ministry of Health, the Executive Yuan, TAIWAN

Five Leading Sites of Cancer in Taiwan

Mortality (2004)
Liver M 44.92 Lung F 19.71 16.91 14.57 12.04 8.33 443.03 Liver 19.76 Colorectum 15.94 Breast 14.17 Cervix Lung Colorectum Oral Stomach

Incidence (2004)
Liver M 51.9 Breast F 39.6 27.9 23.73 20.0 18.3 39.4 Colorectum 35.8 Cervix 26.46 Liver 18.6 Lung Lung Colorectum Oral Stomach

Per 100,000
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Rationale for Screening Policy

WHOs 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
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Cancer Screening Programs

Sites Uterine cervix Breast Target Women > 30 Women > 35 High risk women 50-69 Women 50-69y Oral cavity Colonrectum Smoker, BN chewer > 18 Tool and Interval Pap smear; NHI: 1 y; BHP: 3 y CBE by dr./nurse Starting year 1990 (DOH) 1995.07 (NHI) 1999-2001 (BHP)

Mammography 2002.07 2004.06 (BHP) Family Hx: 1 y Other high risk: 3 y Mammography 2 y Exam of oral mucosa; 3 y 2004.07 (NHI) 1999 (BHP) July 2003 (BHP)
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General pubic 50-69 FOBT; 1 y

Infrastructure of Screening
Delivery system of screening services
Accreditation program for cytology and

mammography
Computerized information system for each

cancer screening program

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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

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Department of Health,Taiwan

Disease Prevention and Control

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Communicable Disease Control

Surveillance

Prevention

Quarantine

International Cooperation

Strengthen Control System

Avoid Disease Threats

Information Management
Research Infection Control
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Immunization Program
Small pox vaccination started in 1906
DPT vaccination in 1954

Polio vaccination in 1966

HB vaccination in 1984

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Eradication of Communicable Diseases

Plague Smallpox Rabies Malaria Poliomyelitis

1948 1955 1959 1965 2000

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National Health Command Center (NHCC)

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Communication System Framework

National Health Command Center

Radio Computer : communication Web-site & system e-mail

Videoconferencing

Telephoneconferencing

fax

Satellite Telephone communication

Each Branch

Mass Media

Public Health Bureaus

Emergency Medical Network

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

(2005/5/15-5/21)

score

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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.

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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
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Department of Health,Taiwan

Long-Term and Elderly Care Services in Taiwan

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Population Growth Rate (1947-2004)

60 50 40 30 20 10 0
1947 51 60 70 80 90 20.18 18.15

Crude Birth Rate

49.97 38.3138.40

Natural Increase Rate Crude Death Rate

38.87 32.03 27.16 22.26 23.38 18.63 6.83 16.55 11.35 4.90 4.76 5.21 9.56 5.97 3.59 2004
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11.57

Life Expectancy (1951-2004)

Years
90 80

Female Male

71.56

74.54

76.75

79.41

66.40
70 60

56.33 62.31 66.66 69.56

71.33

73.60

50 40

53.38
1951 60 70 80 90 2004
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Long-Term Care System in Taiwan

Acute Chronic medical care medical care

Long-term care

Rehabilitation care

Acute hospitals

Chronic care hospitals

Skilled care

Non-skilled care
Foster institutions

Nursing homes Nursing care institutions Home health care Home services Day care Day care centers

Medical care Department of Health

Commission for Retired Servicemen

Daily life care Ministry of the Interior

Commission for Retired Servicemen

Medical Care Act Nurses Act

Welfare of the Elderly Act

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Pluralistic Care Systems for the Elderly

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

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

medical centers
regional hospitals

district hospitals

home care

in home services

health stations

primary care institutions

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

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Department of Health,Taiwan

Thank you for Your Attention

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