Health System and Health Professionals in Taiwan Hsiu-Hung

Health System and Health Professionals in Taiwan Hsiu-Hung Wang, Ph. D, RN Deputy Minister of Health The Executive Yuan, Taiwan Sep. 15, 2005 1

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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) n n n n n Population: 22. 60 million Land area: 36, 188 km 2 (14, 000 mile²) Population density: 625 per km 2 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 Physicians Chinese medicine Doctors Dentists Registered Professional Nurses Registered Nurses Pharmacists Assistant Pharmacists Number of Professionals per 10, 000 673 4817 14. 87 2. 08 2259 294 4. 43 34. 04 723 1121 3031 13. 84 8. 92 3. 30 7

Number of Medical Personnel (July, 2005) Medical Personnel 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 Ne w Zealand Japan UK 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 professional 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 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 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 Valid Term of Licenses (years) Physician Medical Technologist 6 4 Medical Technician 4 Medical Radiation Technologist 4 Medical Radiological Technician Dietitian 4 Psychologist Respiratory Therapist Midwife 6 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 (PGY 1) 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 (PGY 1) 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 (PGY 1) 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 PGY 1 by 2004 • 1, 419 residents finished the PGY 1 training by Aug 2005 21

Department of Health, Taiwan Nurse Practitioner (NP) System 22

Purposes of Establishing NP System in Taiwan Ø To upgrade the quality of medical services and Ø Ø 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 Ø Universal enrollment Ø Comprehensive coverage Ø Easy access Ø Affordable cost Ø Acceptable quality Ø High satisfaction 31

Universal Enrollment Population Covered： 22 million (99%), 2004 • Staying abroad • In transition of jobs • Reluctant to join 32

Comprehensive Coverage Ø Inpatient care Ø Ambulatory care Ø Laboratory tests Ø Prescription drugs and certain OTC drugs Ø Dental services Ø Traditional Chinese medicine Ø Day care for the mentally ill Ø Home care Ø Some preventive services 33

Easy Access ØMedical care institution contract rate : 93% ØNo. of physicians per 10, 000: 16 ØNo. of beds per 1, 000: 60 34

Total Health Expenditures as % of GDP, 1983 -2003 NHI Total Health Expenditures Out-of-pocket Health Insurance Government Sector 35

Worldwide Health Rankings Taiwan The Economist Intelligence Unit (2000) 36 Healthcare International, 2 nd quarter 2000: 66 -67, 72 -75

High Satisfaction (1998～ 2004) Satisfied (DOH) Satisfied (BNHI) 05/95 09/95 06/96 01/98 04/98 11/98 05/99 03/00 10/00 06/01 12/01 Dissatisfied (DOH) Dissatisfied (BNHI) 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 0. 1 million 950. 80 (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 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 Mammography 2002. 07 – -69 2004. 06 (BHP) Family Hx: 1 y Other high risk: 3 y Women 50 -69 y 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 Prevention International Cooperation Surveillance 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) ‰ Crude Birth Rate Natural Increase Rate 49. 97 Crude Death Rate 38. 3138. 40 38. 87 32. 03 27. 16 20. 18 18. 15 22. 26 23. 38 18. 63 11. 57 11. 35 6. 83 1947 ‘ 51 16. 55 ‘ 60 4. 90 ‘ 70 4. 76 5. 21 ‘ 80 ‘ 90 9. 56 5. 97 3. 59 2004 56

Life Expectancy (1951 -2004) Female Male Years 66. 40 71. 56 56. 33 62. 31 66. 66 74. 54 76. 75 69. 56 71. 33 ‘ 80 ‘ 90 79. 41 73. 60 53. 38 1951 ‘ 60 ‘ 70 2004 57

Long-Term Care System in Taiwan Acute Chronic 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 Medical care Medical Care Act Nurse’s Act Welfare of the Elderly Act 58

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Department of Health, Taiwan Thank you for Your Attention 60