Taiwan's Universal Health Coverage

Universal Health Coverage
- from Quantity to Quality
Ying-Wei Wang, MD DrPH
Director General, Health Promotion
Administration,
Ministry of Health and Welfare Taiwan
1

Ministry of Health and Welfare
Where is Taiwan?

Ministry of Health and Welfare 3
2018 Taiwan Health Profiles
Total population (2018.4) 23.6 million
Population age 65 and above (%) (2018.4) 14.1
Crude birth rate (‰) (2017) 8.2
Crude death rate (‰) (2017) 7.3
Total fertility rate (per woman) (2017) 1.13
Maternal mortality rate ( per 100,000 ) (2016) 11.6
Neonatal mortality rate (‰) (2016) 2.4
Infant mortality rate (‰) (2016) 3.9
Under 5 mortality rate (‰) (2016) 4.8
Life Expectancy at birth (years) (2016) 80.0
Male (2016) 76.8
Female (2016) 83.4
Source： 1. Department of Statistics, MOI, R.O.C.
2. Department of Statistics, MOHW, R.O.C.

Universal Health Coverage (UHC)
UHC service coverage index 2015
6
Taiwan 85
NO. Tracer Indicator Taiwan Japan South Korea Singapore China Thailand Malaysia Philippines U.S.A. Canada Germany
UHC service
coverage index 85 ≧80 ≧80 ≧80 76.6 75.2 69.7 58.3 ≧80 ≧80 78.5

 Our average of UHC service coverage index is over 80, which is the same as Canada, South Korea,
the U.S.A., Singapore, and Japan. These are high health coverage countries.
 The index of service coverage in the major countries: Reproductive, Maternal, Newborn, and Child
Health (RMNCH) and Infection diseases.
NO Tracer indicator Taiwan Japan South Korea Singapore China Thailand Malaysia Philippines U.S.A. Canada Germany
UHC service coverage index 85.0 80 80 80 76.6 75.2 69.7 58.3 80 80 78.5
Ⅰ. RMNCH 89.9 85.7 89.4 88.6 86.1 91.3 77.7 64.6 91.6 92.2 91.1
1
Family planning demand satisfied
with modern methods (%)
75.2 65.0 83.0 77.0 95.0 91.0 53.0 54.0 86.0 89.0 82.0
2 Antenatal care, 4+ visits (%) 97.7 97.0 98.0 97.0 74.0 93.0 80.0 84.0 97.0 99.0 97.0
3 Child immunization (DTP3) (%) 97.8 96.0 98.0 96.0 99.0 99.0 99.0 60.0 95.0 91.0 95.0
4
Care- seeking behaviour for child
pneumonia (%)
91.0 89.0 80.0 86.0 79.0 83.0 87.0 64.0 89.0 90.0 91.0
Ⅱ. Infectious diseases 78.5 69.2 81.8 71.2 63.2 62.4 56.1 54.1 81.1 80.8 73.2
5
Tuberculosis effective treatment
(%)
70.0 46.0 76.0 68.0 82.0 42.0 68.0 78.0 74.0 74.0 55.0
6 HIV treatment (%) 69.0 72.0 72.0 53.0 41.0 61.0 26.0 27.0 72.0 72.0 72.0
8 At least basic sanitation (%) 100.0 100.0 100.0 100.0 75.0 95.0 100.0 75.0 100.0 99.0 99.0
Universal Health Coverage (UHC) index 2015

Antenatal care coverage – at least four visits (%)
2001-2015
9
Taiwan 97.7%
NO. Tracer Indicator Taiwan Japan
South
Korea
Singapore China Thailand Malaysia Philippines U.S.A. Canada Germany
2
Antenatal care coverage
– at least four visits 97.7 97.0 98.0 97.0 74.0 93.0 80.0 84.0 97.0 99.0 97.0

Newborn and Infant Mortality
Retrieved April 29, 2018, from
https://dep.mohw.gov.tw/DOS/cp-1720-7340-113.html
6.5 6.7
6.4 6.6
6.1 5.9 6.0
5.4
4.9
5.3
5.0
4.6 4.7 4.5
4.1 4.2 4.2
3.7 3.9
3.6
4.1 3.9
3.3 3.5 3.3 3.4 3.5 3.4 3.3
3.0
2.7 2.9 2.9
2.7 2.9 2.7
2.4
2.6 2.7
2.3 2.4 2.2
2.5 2.4
0.0
2.0
4.0
6.0
8.0
10.0
12.0
1995199619971998199920002001200220032004200520062007200820092010201120122013201420152016
Newbornandinfantmortality(per1,000)
Years
Infant
Newborn

The birth coverage in certified baby-friendly initiative increased
from 39.2 in 2004 to 78.1 in 2017.。
Proactive implementation of accrediting
Baby Friendly Initiative
38
58
74 77 81 82
94 94
113
144
158
163
176 177 182 187
180
39.2 40.8 41.3
47.4 46.3
53.9
67.2
71.4
75.1
79.2
76.6
80.7 79.9 78.1
0
10
20
30
40
50
60
70
80
90
100
0
20
40
60
80
100
120
140
160
180
200
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
coveragerateofbirthsbyBFHI(%)
numberofBFHIhospitals
Year
number of BFHI hospitals
coverage rate of births by BFHI
12

0 5,3002,650 Kil
Number of vaccines/antigens introduced in national
immunization schedules (July 2016)
13
5 antigens (DTP, Measles and Polio)
6 antigens
7 antigens
8 antigens
9 antigens
Not applicable
Not available
≥10 antigens
Taiwan
NO. Tracer Indicator Taiwan Japan
South
Korea
Singapore China Thailand Malaysia Philippines U.S.A. Canada Germany
3
Child immunization
(DTP3) (%)
97.8 96.0 98.0 96.0 99.0 99.0 99.0 60.0 95.0 91.0 95.0

Tuberculosis effective treatment coverage 2016
14
Taiwan 70
II. Infectious Diseases 78.5 69.2 81.8 71.2 63.2 62.4 56.1 54.1 81.1 80.8 73.2
5
Tuberculosis
effective treatment
coverage
70.0 46.0 76.0 68.0 82.0 42.0 68.0 78.0 74.0 74.0 55.0

TB incidence and
mortality in Taiwan
TB Prevention Policies
 1997 DOTS in Aboriginal Area
 2002 DOTS in sputum smear(+)
 2008 LTBI treated : before 1986 birth
 2016 LTBI treated : all groups
Death Mortality
http://daily.cdc.gov.tw/stoptb/CareMagChart.aspx?treeid=3f2310b85436188d&nowtreeid=D3A2CA330934BE69

 The index of service coverage in the major countries: NCDs and Service capacity
and access
NO. Tracer indicator Taiwan Japan
South
Korea
Singapore China Thailand Malaysia Philippines U.S.A. Canada
German
y
Ⅲ. NCDs 74.0 68.3 69.5 74.6 63.3 68.2 60.2 66.2 66.0 73.9 57.3
9 Normal blood pressure (%) 90.5 83.0 88.0 85.0 81.0 78.0 77.0 78.0 87.0 87.0 80.0
10 Mean fasting plasma glucose (mmol/L)f 5.5 5.3 5.4 5.3 5.5 5.2 5.7 5.0 5.7 5.5 5.5
12 Tobacco nonsmoking (%) 81.9 77.0 76.0 83.0 75.0 79.0 78.0 75.0 78.0 85.0 69.0
Ⅳ. Service capacity and access 99.9 100.0 100.0 99.7 99.7 82.1 89.9 50.0 99.0 100.0 99.7
13 Hospital beds per 10 000 populationc 56.8 134.0 115.3 24.0 42.0 21.0 18.6 5.0 29.0 27.0 82.8
14
14-1. Physicians per 1000 populationc 1.9 2.3 2.2 3.4 1.5 0.4 1.3 1.1 2.6 2.5 4.1
14-2. Psychiatrists per 100 000
population
6.7 8.4 7.0 13.7 1.7 0.9 0.8 0.5 12.4 13.4 7.5
14-3. Surgeons per 100 000 populationc 16.3 16.8 62.0 102.3 21.6 6.3 6.9 4.3 36.7 21.1 55.2
16
International Health Regulations core
capacity index (%)
99.6 100.0 100.0 99.0 99.0 98.0 99.0 84.0 97.0 100.0 99.0
Universal Health Coverage (UHC) index 2015

Prevalence of raised blood glucose ages 18+, 2000-2014
(age-standardized estimate) (>7.0 m,ol/L or medication for raised blood glucose)
17
Taiwan 5.5
10
Prevalence of raised
blood glucose 5.5 5.3 5.4 5.3 5.5 5.2 5.7 5.0 5.7 5.5 5.5

Diabetes Shared Care Program in Taiwan
18

Performance of Diabetes Share Care
20
Source： National Health Insurance Administration
1. Check rate is hospital grade and clinics grade.
2. Quality among P4P patients is hospital grade.
34.6% 36.3% 38.0% 38.0%
40.7% 42.7%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
2009 2010 2011 2012 2013 2014
HbA1c<7 %
LDL<100 mg/dl %
83.7 86.0 87.4 89.3 90.5 91.3 92.1 92.5
0.0
20.0
40.0
60.0
80.0
100.0
2009 2010 2011 2012 2013 2014 2015 2016
HbA1c Check Rate
59.6 62.9 64.3
75.7 77.5 78.6 79.7 80.4
0.0
20.0
40.0
60.0
80.0
100.0
2009 2010 2011 2012 2013 2014 2015 2016
Lipid Profile Check Rate
 In 2016, fundus examination rate is 38.5%, and micro-albuminuria
examination rate is 55.0%.

National CVDs Prevention Strategic Action Plan
2018-2022 (HEARTS framework)
Team-based /task-sharing care : Integrate cardiovascular prevention system and establish partnership
(community, NGOs, professional and medical service organizations)
Health literacy and Healthy lifestyle :Improve public health literacy and establish healthy lifestyles:
Accessibility : Increase service capacity for all levels of health institutions and create CVDs shared care network
Cross-lifecycleintervention
Risk-based management :Develop personalized prevention care services and implement early detection and early
treatment
Evidence-based guideline: Develop Evidence-based guideline for NCDs care : Evidence-Based Medicine
Early monitoring
and detection-
Risk factor
surveillance and
control
Early
diagnosis and
treatment-ER
treatment and
acute care
Chronic treatment
and management-
disease control
and rehabilitation
Hospice care
services in
long-term care
Reduce risk
factor-
Change in
behavior
Health living and community-1st
prevention
2nd/ 3rd prevention- Treatment management
and quality
Healthy
lifestyles-
Policy and
environment
Systems for monitoring and surveillance :Establish integrated database to enhance surveillance management
analysis and policy translation research
21
Vision：Reduce premature CVDs death and morbidity, diminish health inequality
Health system coordination, cooperation and NGOs participation

Primary and secondary prevention of cancer : Existence of
national screening program for cervical cancer
22
Taiwan Yes

23
Palliative care
 Whole person
 Whole family
 Full journey
 Whole team
 Whole community
WHO cancer control strategy in Taiwan
Prevention
 Common risk factors
of NCD
 Tobacco use
 Physical inactivity
 Unhealthy diet
 Harmful use of alcohol
 Betel nuts
 Hepatitis B/C
 HPV vaccination
Air pollution and other
chemical carcinogens
Radiation
Treatment
 Cancer Patient Navigation
 Timely treatment
 Participative decision-making
 Multi-disciplinary team
 Evidence-based medicine
and quality enhancement
 Sustainable development
and equality
 Survivorship
Early detection
 Cervical cancer
 Breast cancer
 Colorectal cancer
 Oral cancer
 Hepatocellular carcinoma
(National Health Insurance)
Screening

Secondary prevention : Early detection (Cancer
screening)
24
Cervical Cancer
F, 30-69 y/o, 3 yrs
Colorectal Cancer
50-69 y/o, 2 yrs
Oral Cancer
Smokers or betel-quid
chewers, ≧30 y/o, 2 yrs
Breast Cancer
F, 45-69 y/o, 2 yrs
Recommended by the WHO, 2007.

Cancer Care Quality Accreditation(CCQA)
59.5%
75.1%
76.9%
80.8% 82.0% 82.4%
85.1% 86.0% 86.8%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
2009 2010 2011 2012 2013 2014 2015 2016 2017
year
Cancer Care Coverage in accredited
hospitals
Nantou
Miaoli
Taitung
Penghu
Kinmen
Taipei
X 7
X 3
Medical center
non-medical center
Ilan
X 3
Pingtung
X 2
Changhua
X 1
X 1
Kaohsiung
X 3
X 4
Tainan X2
X3
Chiai X2
X2
Yunlin X 1
Taoyuan
X1
X2
Hsinchu X 2
New Taipei City
X 1
X 5
Hualien
X 1
Taichung
X 3
X 6
Keelung
X 1
Miaoli X 1
Taitung
X 1
58 hospitals have passed the accreditation
25

Asia’s report card: Room for improvement
Sources: EIU analysis; national cancer control plans, 2015

Age-standardized prevalence of tobacco smoking  15 y/o
27
Country: Taiwan
Age-standardized prevalence of tobacco smoking among persons 15 years and older: 18.1

Monitor Tobacco Use and Prevention Policies
 Adult Survey :Adult Smoking Behavior Survey (ASBS), Taiwan NHIS
 School based Survey: Global School Personnel Survey (GSPS), Global Health Professional
Student Survey (GHPSS) ,GSHS/Taiwan Youth Health Survey (TYHS), Global Youth
Tobacco Survey (GYTS)
Protect People from Tobacco Smoke
 Regulation Enforcement on Smoking ban area to assure smoke-free environments, public
awareness by mass media campaign
Offer Help to Quit Tobacco Use:
 Second-generation Payment Scheme for Cessation Services and Quit Line
Warn About Dangers of Tobacco
 graphic and text warnings on cigarette packs
Enforce Bans on Tobacco Advertising, Promotion and Sponsorship
Raise Taxes on Tobacco:
 Tobacco Tax
 Tobacco Health Welfare Surcharge
*In 2008, WHO packaged and promoted six proven measures to reduce tobacco use
worldwide. Known as MPOWER, the measures support scale up of specific
provisions of the WHO FCTC on the ground.
28
Tobacco Control in Taiwan
-Implement the WHO FCTC: MPOWER Strategies-

Tobacco-Free Hospital Initiative
 Members: 209 hospitals
 Since 2009, 18 Taiwanese hospitals among 50 globally
have won the Global Gold Awards for Tobacco-free
Hospitals
18 18
4
3
2 2
1 1 1
0
2
4
6
8
10
12
14
16
18
20
Taiwan Spain Germany Ireland Australia Austria Sweden South
Korea
Kansas-
USA
Gold members of each coumtry
29

Density of hospital beds (per 100000 population):
2004-2014
30
Taiwan 56.8

Health Care Quality Improvement
31

Health Promoting Hospital in Taiwan
2006-2017
5
29
41
61
67
79
93
131
151
160 163
0
20
40
60
80
100
120
140
160
180
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
2006
Start
2008
the awards of
HPH
2012
1.Inter-sectoral
collaboration
2.supplement the fund
2017
integrate
the largest network
within the International
HPH Network
/2017
32

33
Why do we promote Health
Promoting Hospital?
HPH
Better quality of care
Higher patient satisfaction
Higher staff satisfaction
More sustainable health system
Higher morale and cohesion

Health Promoting Hospital and Healthcare Organizations
• Reorient medical care
to health promotion
• 163 members as of Feb
2017
• Hospital coverage:
29.6%; service covered
70% of acute beds
Patient Staff
Community
• Patient
satisfaction 83%
• Staff awareness
88%
People
gains
International
Participation
As of end of February 2017, 25 National/Region Networks, 721 hospitals;
163 members in the Taiwan Network
The largest WHO-HPH Network in the world
Institution
wide
promotion
Healthcare
outcomes
+
Health gains
34

New Developing of Health Promoting Hospital
Accreditation in Taiwan
Healthy Hospital-Advance level
1. Cancer Care Quality Accreditation
2. Baby-Friendly Hospital
3.Quality Improvement Program for Tobacco-Free Hospital
1.HPH-46 items
2.Age-friendly institution-18 items
3.Smoke-free hospital-48 items
4.Environmental friendly hospital
38
items
Healthy Hospital-Basic level
Service Indicator
1.Accountability
2.Care quality
3.Health literacy
On site investigation
(PFM)
Written review or
on-the-spot investigation
(PFM)
apply
Performance
Quality Indicator
1.Care/screening rate
2.Employee health promotion
3.Health care outcome of cases
Regular reports and
national health insurance
data
Pay for performance
35
PFM: Patient Focus Method

Standard Contents No.
Standard 1 Policy and Leadership 7
Standard 2 Patient Assessment 5
Standard 3 Patient Information and Intervention 11
Standard 4
Promoting a Healthy Workplace and
ensuring capacity for Clinical Health
Promotion
4
Standard 5 Implementation and monitoring 8
Standard 6 Age-friendly Healthcare 2
Standard 7 Environment-friendly healthcare 1
New Taiwan Standards for Health Promoting Hospital
- Emphasize on Patient Empowerment and Health
Literate Organization-
• 3.1.7
Shared Decision
Making(SDM)
• 3.2.4
Health Literacy
36

Health
literate
individual
Health
literate
organization
Shared decision
making

Taiwan 5.47

Catastrophic out-of-pocket health spending
40

Milestones of Taiwan Health Insurance
1950
Labor
Insurance
(40.1%)
1958
Government
Employees
Insurance (8.5%)
1985
Farmers’
Insurance
(8.2%)
1990
Low-Income
Household
Insurance (0.6%)
1995
National Health
Insurance
(59->99%)
2013
2nd Generation
NHI (99.6%)
*( ) indicates % of people covered by the insurance.
41

High Public Satisfaction to
National Health Insurance (NHI)
(1995~2016)
42
61.0
65.4
63.3 63.8 65.6
78.5
59.7
70.9
78.6
72.3
64.3
77.5 79.3
82.9
85.2
80.4 79.4
73.9
67.6
78.6 80.0 79.8 81.0
83.1 85.8
27.0
22.5
25.9 24.5
20.1
13.6
29.6
20.6
11.6
22.1
34.1
22.1
15.9 15.8
13.4
17.3 15.7
22.0
28.1
19.4 18.2 16.9
14.1 12.5 11.3
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
Satisfied Dissatisfied
%
Premium &
Copayment Adjusted
Second Generation
NHI
year

We are part of the world.
We have our own color (data) in the UHC.

Taiwan
Health
Promotion
Administration
44
Protection Prevention Promotion
Participation Partnership

Taiwan's Universal Health Coverage

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