Public Health in Taiwan after World War II

By , 2021-09-17 5:40 下午

Life expectancy at birth in Taiwan has increased from 54 years in 1950 to 80 years in 2013. One of major factors contributing to the remarkable increase of life expectancy is public health. The World Health Organization defines public health as all organized measures to prevent disease, promote health, and prolong life among the population as a whole. This paper reviews the development of public health in Taiwan after World War II, which consists of three periods: communicable diseases control (1945-1970), health care for all (1970-2000), and population health promotion (since 2000).

The Period of Communicable Disease Control

Taiwan was retroceded to the Republic of China at the end of the World War II after 50 years of Japanese rule. The new Government created the Taiwan Provincial Department of Health to take over public health administration, replacing the police system during Japanese occupation.

The War seriously damaged health care facilities and contributed to the spread of Infectious diseases. Based on experiences from the Ding Xian experiment in mainland China, the Provincial Department of Health initiated a comprehensive public health network project. By 1954, with financial support from the Join Commission of Rural Reconstruction (JCRR), there was a health bureau for every city/county, a health station for every township/district, and a health room for every selected rural villages.

In the beginning, this new public health network was facing the shortage of budge and health workforces. Yet, when the Cold War began in 1947 and the USA played as the world cop, the situation changed. In order to counteract communism the USA used foreign aid to help the socioeconomic development of friend countries. Taiwan was chosen as one of beneficiary countries due to its strategic value, particularly after the outbreak of Korea War in 1950.

With the generous support from USA, as well as from international health organizations such as World Health Organization and UNICEF, many public health programs in Taiwan became possible, including malaria eradication, tuberculosis control, maternal and child health services, and the supply of safe water and basic sanitation, in addition to the reconstruction and renovation of public hospitals.

Accompanying the development of public health in Taiwan, the health of people improved remarkably. For example, mortality declined rapidly among all age groups, particularly for under 5 child mortality which decreased by 80%, from 134 per 1000 in 1950 to 27 per 1000 in 1970. Accordingly, life expectancy increased for from 54 years in 1950 to 69 years in 1970.

With the substantial decline in death rate, Taiwan moved into the third age of epidemiological transition. In 1950, most of the leading causes of death were still communicable diseases including gastroenteritis, pneumonia, tuberculosis, nephritis, bronchitis, and malaria. However, they began giving way to noncommunicable diseases such as stroke, cancer, heart disease, hypertensive diseases, and accidents, when the WHO declared Taiwan as a malaria free area in 1965.

The Period of Health Care for All

By the 1970s, with the combination of an epidemiological shift to noncommunicable diseases and a rapid economic growth, people’s demand for health care drastically escalated in Taiwan. However, there was only 0.4 physicians and 2.4 hospital beds per 1000 population. The period of health care for all commenced immediately following the establishment of the Ministry of Health, Executive Yuan, in 1971.

To meet the challenge of the rising demand, the government firstly decided to expand medical education with an objective of one physician serving 1000 people. By launching more medical schools, augmenting class sizes of existing medical schools and initiating new postgraduate programs, the number of first-year medical enrollment per year increased from 600 to 1200.

At the same time, hospital capacity was targeted to increase to up to four hospital beds per 1,000 population. In addition to governmental endeavors, however, this was partly mobilized by the private sector, which benefited from the growing economy and was capable of investing in hospitals and construction of large-scale medical facilities.

Along with the growth of health care resources, the government took further actions to tackle the issue of geographic maldistribution. In 1983, the group practice centers (GPC) program was initiated to improve the access to physicians for people who live in under-served areas. In 1985, the Ministry of Health took a great leap to implement the Medical Care Network program dividing Taiwan into 17 health care regions. Under the program, a development fund was set up to encourage the private sector to build small hospitals in under-served areas. Meanwhile, the Department was authorized to prohibit the construction of new hospitals with more than 100 beds or prohibit hospital expansion in the saturated regions.

By 1990, Taiwan achieved the objectives of one physician and hour hospital beds per 1,000 population. Yet, without removing financial barriers, the growth of health care resources simply does not guarantee universal access to health care. In 1986, the Taiwan Government declared the goal of health insurance for all by the year of 2000 to protect against its legitimacy crisis. Prior to the policy announcement, there were three social health insurance schemes, covering 25% of the total population in Taiwan.

Then opportunity came knocking when Taiwan undertook drastic political reforms after 1986. In order to consolidate political power, the ruling party was no longer passive in developing the universal health insurance. Foreseeing an election of Legislative Yuan representatives in December 1995, and a presidential election in March 1996, the ruling party mobilized its legislators to pass the National Health Insurance (NHI) Law on 19 July 1994. The Executive Yuan further ordered the Ministry of Health to fully implement the NHI by 1 March 1995.

Almost 100% of total population in Taiwan are currently enrolled in the NHI, which is financed mainly by payroll tax and provides comprehensive health care benefits with moderate cost sharing. Not long after its inauguration, the NHI brought the hitherto uninsured up to a par with those who previously had social health insurance. In addition, nowadays the NHI reduces the national family poverty rate by about 1.5% through its social transfer effect, and more than 80% of the public are satisfied with this universal health insurance.

The Period of Population Health Promotion

From the perspective of public health, the NHI may improve the quality of life for patients, but it has limited contribution to the decline of mortality in Taiwan. Life expectancy at birth gained 4.4 years in two decades after the implementation of the NHI, compared to 3.9 years in two decades before its inauguration. What is worse is that large health inequalities remain in Taiwan. The gap between regions with the longest and shortest life expectancy, for instance, decreased by only 1.5 years from 9.7 years in 1998 to 8.2 years in 2013.

What will be our future? The answer rests on health promotion. The global health promotion movement began in Canada in 1974 when the Lalonde Report was published. Yet, Taiwan government was devoted to health care for all and took no major actions on health promotion until the 1990s. In 2001, the Ministry of Health created the Health Promotion Bureau, Taiwan’s public health moved into the period of population health promotion.

There are two approaches to health promotion. One focuses on empowerment and behavioral change with an assumption of individual responsibility; the other is to create supportive environments as social responsibility.

At first, Taiwan mainly concerned unhealthy individual lifestyle such as smoking, drinking, betel nut chewing, not wearing safe belts and hamlets, eating poor diets, and other risk behaviors. Ironically, in 1989 the Minister of Health even announced that “Health is your right; and health promotion is your responsibility”.

By the early 21st century, however, Taiwan already adopted the strategy of setting approach. In the early stage, most of setting approaches were initiated by either central or local government. In 1999, the Ministry of Health implemented the first healthy community program; in 2001, the Ministry of Education and the Ministry of Health started the first health promoting school program together; and in 2002, the Taipei City Government administrated the first health promoting hospital program. In addition, traditional worksite health promotion programs have gradually shifted into health promoting worksite programs.

Importantly, Taiwan has further applied the perspective of social determinants to population health promotion in recent years, following in the World Health Organization’s footsteps. In 2008, the Ministry of Health published a white paper entitled “Healthy Taiwan 2020”. This white paper used a triangle framework of health determinants: social environment, lifestyle, and health care, and for the first time, set health equity as one of two overarching goals. Another important event is to host a global health forum on health in all policies in 2013, with an ambition of health promotion going beyond the health sector.

Conclusions

The mission of public health is to pursue health for all. However, along with the socioeconomic development of the society, the health needs of people change and public health strategies evolve. Therefore, the focus of public health in Taiwan has shifted from communicable disease control to universal health care coverage, and to population health promotion since the end of World War II.

The case of Taiwan described above also demonstrates that the development of public health has been affected by both domestic and international situations. Nowadays, with the dominance of noncommunicable diseases and the re-emergence of infectious diseases, public health has to take actions on social determinants of health to reduce health inequalities, and not merely to decrease risks through individual behavior change.

 

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