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Taiwan?™s National Health Insurance (NHI) scheme, despite having been widely celebrated since its conception just over ten years ago, faced financial bankruptcy last year and had to be subsidized by $11bn NT of public money in order to remain operational. Some light investigation soon revealed that one of the lead architects of the system, William Hsiao (?­æ…¶??, a professor of economics at Harvard University, believed that, ?œTaiwan NHI?™s financial problems stem from two factors: people?™s mindset and politicians??intervention.?? The political problems were the result of consistent refusals by politicians to consider even modest rate hikes in a bid to win favour at the polls. As Taiwan?™s population ages and health care becomes more expensive, the relative cost of health care must sensibly rise with it. This is, of course, no different from any other nation in the world with a fairly comprehensive health care system. Taiwan?™s problem is precisely the same as other countries??in this regard. It was the mindset that was by far the most intriguing aspect of this problem. Who is creating problems for Taiwan?™s NHI, and why?

It didn?™t take long to find out that there are marked differences in the patterns of medicinal use here. In discussions it was invariably reported that it was only those in their 40?™s, 50?™s or above (and especially above) who were often to be seen trundling off to the docs for a quick checkup. I was told that the older generation went to the doctors so frequently because they had so much free time in which to do it. However, it?™s highly doubtful that pensioners in Taiwan have any more time on their hands than those of the same age in the West. And yet Department of Health Director-General Chen Chien-jen (?³å»ºä»? has said that each person in the country makes an average of 14.5 hospital outpatient visits per year, whereas the average in the US and major European countries is only seven or eight. Furthermore, the consumption of medicine, especially in oral form, is far more frequent and widespread here than in the West. Why in the world are pensioners so particular about popping pills?

The first aspect is that Taiwan?™s health care system is actually very good. Nearly every citizen throughout the country is covered and everyone contributes automatically as insurance payments are taken directly from wages. There are single payments to be made for each doctor?™s consultation or hospital visit but these are a relatively low one or two hundred at a smaller practice, rising to perhaps a few hundred at a more expensive hospital. Overall, however, the system is highly affordable, excluding virtually none who want to use it. If you feel like seeing a doc, you can.

The second factor affecting the system is that, ?œThe profitability of performing routine visits motivates the medical centers to continuously expand their outpatient clinics for primary care ??Taiwan?™s fee-for-service payment method encourages more visits and rehabilitation services and overuse of drugs.?? Judging from personal experience that many agree to be quite common, doctor?™s examinations are very quick, resulting in the prescribing of a standard concoction of drugs that will include various non-specific medicines, with an extra dose of pills to protect your stomach from the rest you?™ve just forced upon it. My own visit less than a year ago left me feeling suspect of the diagnosis I?™d been given and I opted not to take the surprisingly heavy packets of medicine the doctor had dumped on me. It meant that it probably took me slightly longer to recover from my ailment but the fact that I was supposed to take an extra something to protect my stomach from the very medicine that was supposed to help me seemed somehow wrong. And it appears that my instincts may have served me well. In a report published several years after the NHI?™s inception, it was found that, ?œThe top 5 most commonly dispensed drug categories were antacids and anti-ulcer drugs, anti-cough and anti-cold preparations, vitamins, simple analgesics and non-steroidal anti-inflammatory drugs, accounting for 48.8% of total prescriptions. In view of the frequency of relevant diagnoses, the overuse of antacids, vitamins, intravenous nutrient and electrolyte solutions, anti-cold preparations and antibiotics was apparent, as was that of drugs of questionable pharmacological value.?? There are financial pressures placed upon doctors with private practices, meaning that they need to see a relatively large number of patients in relative short spaces of time and, perhaps more tellingly, also need to keep their ?œcustomers??happy.

And like customers they are. One very great difference between Taiwan?™s system and that of, say, Britain?™s is that there is a near complete lack of family doctors in this country. This results in several difficulties. The first is that doctors must compete to survive, having a client base that can very rapidly disband if word gets around that you aren?™t giving the treatment that is wanted. There is no ?œfirst line??of consultation here and referrals are very few and far between. When a complication arises, the patient will go directly to whichever practitioner they feel best fits their troubles. The doctor will try their best but, if they are unable to help, will simply be unable to help, leaving the patient to decide for themselves who to try next. This results in a kind of ?œdoctor shopping??whereby people will immediately present themselves at specialists??waiting rooms and will not rest until they feel they have been satisfactorily seen to. Finding the right doctor is a mixture of luck and contacts. If a specific problem occurs, people will more often ask friends and relatives who they should consult rather a professional who would quickly and efficiently send them off to the right place or simply tell them to go home and rest, perhaps even leaving them empty-handed.

The final and most important factor, however, lies in that old culprit, ?œculture?? The main problem is that Taiwanese, especially of the older generation, feel that they simply must get something for their money. They are paying money into a pot from which one must actively reach into in order to receive anything at all. Traditional Chinese culture demands that paying into a system which gives nothing back is a waste of money. It just won?™t do. When pensioners visit the doctor it is not enough to be seen. They must have something concrete to show for the money they must pay. This is a major difference from in the UK, for example, where the system was founded during the post-war consensus of payment according to means and care in accordance with need. Such a view of insurance isn?™t prevalent here, as can also been seen in many families opting out of house insurance - as an unnecessary waste - and choosing to have their cars repainted on their auto insurance once they?™ve been making payments for a few years and feel they are ?œdue??something. Paying money only to have security in case of disaster appears to be quite a new idea. Thankfully, it does seem that things are beginning to change and the problems are being recognised. However, I have to say that I?™d rather not be the one to convince grandma that going to see doc just for reassurance or a handful of pills is actually not a very fraternal thing to do. Entire generations have been doing this for longer than I can remember and naturally form the most stubborn demograph. I wish the best of luck to the campaign leaders.

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