The COVID-19 pandemic has proven that investing in public health is a critical policy issue for governments worldwide. While Taiwan has led the world in pandemic management, it is now time for Taiwan’s leaders to make public health a priority as a way to accelerate its economic development and improve its international competitiveness. The Committee recommends that the authorities adopt a preventive approach and take bold steps to center public health as a top national policy area with continued impact well beyond the pandemic.
Suggestion 1: Improve HCV screening efforts and relax HBV reimbursement guidelines to reach the WHO’s goal of viral hepatitis elimination by 2030.
The latest Taiwan Cancer Registry report indicates that liver cancer remains the second-leading cancer in Taiwan in terms of mortality, taking more than 7,800 lives annually. The key risk factors for liver cancer are the Hepatitis B virus (HBV) and Hepatitis C virus (HCV).
The Taiwan government has taken many important actions to achieve its ambitious goal of eliminating HCV incidence in Taiwan by 2025 – five years earlier than the World Health Organization (WHO) target date of 2030. The measures include approval in 2017 for direct-acting antiviral (DAA) treatments. Since then, more than 100,000 HCV patients have been treated with DAAs. To enhance HBV-infected patients’ access to treatment, the National Health Insurance Administration (NHIA) in March 2021 expanded the HBV reimbursement criteria for certain special populations. In addition, the central government not only relaxed HBV and HCV screening criteria, but has also worked with local governments to enhance patient education programs regarding the importance of screening.
While these steps are admirable, several issues must still be addressed. Screening is a critical component of the effort to eliminate HCV in Taiwan. We appreciate the government’s relaxation of screening criteria in October 2020, which has led to a seven- to eight-fold increase in the number of people screened. However, some hurdles remain. For example, no national database tracking the progress of the elimination effort yet exists. The Health Promotion Administration (HPA) under the Ministry of Health and Welfare (MOHW) does maintain a database of HCV screening results, but physicians complain that the process for submitting data to apply for reimbursement is too complicated. If these doctors become frustrated with the difficulty of using the database, they might be less willing to encourage screening, which could result in less access to screening and treatment for eligible patients.
Since no definitive cure for HBV yet exists, oral antivirus drugs are the most appropriate treatment option for managing the disease. However, strict reimbursement guidelines deter some patients from completing treatment with these drugs. Such policies put patients at risk of reactivation and progression of the disease.
Recommendations:
- Develop a national HCV roadmap to track the progress of screening and treatment, with timely updates on the current status. In addition, MOHW should provide sufficient resources, simplify the screening reimbursement process, and integrate the HPA and NHIA databases for HCV screening and treatment by Q2 2021 in order to support the central and local governments in achieving their annual screening and treatment goals.
- Develop an HBV reimbursement policy roadmap by Q3 2021. The roadmap should be based on science and real-world data and should set a clear policy direction of continual relaxation of reimbursement criteria for HBV treatment. It should also seek to make reimbursement available for all HBV patients who require it and provide them with more comprehensive and stable care. Doing so would help the government achieve the WHO’s goal of eliminating HBV by 2030.
- Continue private-public partnerships to meet the WHO’s firm target of reducing new hepatitis infections by 90%, HBV patients treated by 80%, and deaths by 65% before 2030. Seek support from liver-health experts and initiate actions to reach these targets ahead of the deadline and improve Taiwan’s overall public health.
- Consider expanding the current HPV vaccination program to cover a broader cohort. Given HPV’s association with both cervical and other cancers, the government should also proactively develop a comprehensive HPV prevention strategy. This step would help sustain Taiwan’s role as a leader in the global health community and contribute to meeting the WHO’s goal of eliminating cervical cancer by 2030.
Suggestion 2: Develop a life-course immunization plan to strengthen Taiwan’s vaccine resilience.
The pandemic has highlighted the need to strengthen Taiwan’s vaccine policy, as well as to substantially increase funding for – and boost public confidence in – vaccines. Such measures have become an international prerequisite for national and economic security. The Committee recommends the following steps to ensure Taiwan’s vaccine preparedness during this era of great public health challenges.
Recommendations:
1. Increase vaccine funding to cover life-course immunization and explore multiple payment mechanisms to ensure sustainable financing. Viewing it as a national priority, the government should expand the protection afforded by its comprehensive pediatric National Immunization Program (NIP) to also cover life-course vaccinations. Such an investment would take into consideration both the benefit to the population it protects and the efficient deployment of the NHI’s health resources with a preventive approach.
Ensuring sufficient funding is a fundamental step in developing a successful life-course vaccination program. Currently, funding for Taiwan’s National Vaccine Fund (NVF) comes primarily from the national treasury and the health and welfare surcharge on tobacco consumption.
However, the NVF is facing a financial challenge. According to the Strategic Plan prepared by the Centers for Disease Control (CDC), treasury funds should account for 60% of the NVF total, but the actual average over the past five years was only 30-40%. In addition, large fluctuations in revenue from the tobacco surcharge over the past several years have made it an unstable source of funding for the NVF. To fulfill the recommendations proposed by the Advisory Committee on Immunization Practices (ACIP), Taiwan’s health authorities would need to secure at least an additional NT$1.03 billion for the NVF. This amount would cover the remaining NIP of pneumococcal vaccines for patients over the age of 65 and rotavirus vaccines for children.
The Committee recommends that the government immediately increase the amount of treasury funds for the NVF and begin amending legislation to ensure sufficient financing from the tobacco surcharge. Moreover, the government should explore and allow multiple payment mechanisms for vaccines. A subsidy program proposed by the National Health Research Institutes in 2020 could be a short-term solution. In addition, the authorities should consolidate resources and accelerate vaccination programs, which would have a positive effect on savings for the NHI.
2. Relax restrictions on vaccine advertising to raise public awareness.
Vaccination is one of the most effective ways to prevent diseases and reduce medical expenses resulting from infectious ailments. Yet the Pharmaceutical Affairs Act (PAA) currently prohibits the advertisement of prescription drugs and vaccines, resulting in insufficient public education regarding vaccine characteristics and the diseases they help prevent. Such restrictions undermine the effectiveness of and public confidence in vaccines as a disease prevention method.
We commend the Taiwan Food and Drug Administration (TFDA) for its immediate action in reviewing patient education materials on vaccines, following its discussion with the Committee at meetings convened by the National Development Council (NDC) last year. This effort has helped industry partners avoid violating the relevant provisions of the PAP.
Moving forward, industry partners are willing to share responsibility with the government on increasing citizen’s awareness of and confidence in vaccines. The Committee recommends that the government establish a national platform through which industry can provide educational materials on vaccines. Materials posted on the platform could also serve as a standard for local health bureaus to follow.
Further, the Committee continues to urge the government to loosen restrictions on the advertisement of vaccine products so as to enable citizens to acquire accurate vaccine information effectively and in a timely manner. If more citizens are willing to pay out-of-pocket to get vaccinated, the corresponding decrease in preventable diseases would relieve some financial pressure on the government.
3. Introduce a digital vaccine passport system and integrate vaccine records into the NIIS. Digital vaccine passports powered by blockchain or cloud computing would allow health authorities to gain more insights about the vaccination rate and demographics of targeted populations. Such passports would help control infectious diseases and boost confidence in vaccines. They would also provide Taiwanese citizens with easy access to their vaccination history and help them comply with government recommendations regarding vaccines.
To achieve this goal, the Committee recommends that the CDC begin by integrating self-paid vaccination records into the National Immunization Information System (NIIS) and then include publicly funded records once such funding is available. Doing so would allow the government to better monitor and contain infectious diseases that can be prevented with vaccines.
Suggestion 3: Increase osteoporosis screening and primary prevention of osteoporotic fractures.
In 2020, Taiwan for the first time experienced negative population growth. Taiwan is projected to become a super-aged society by 2025. The rapid aging of the population will have wide-ranging effects, including declining labor productivity and international competitiveness. Taiwan should strive to ensure the health of its aging population so as not to overwhelm its healthcare and long-term care systems.
A recent study indicated that one-third of women and one-fifth of men over the age of 50 in Taiwan have developed osteoporosis. In addition, during the first-ever community-based bone mineral density (BMD) screening program jointly initiated in 2019 by the Taiwan Osteoporosis Association, Changhua County Public Health Bureau, and industry stakeholders, 54% of participants were diagnosed with osteoporosis. To date, this public-private partnership has screened nearly 4,000 people over the age of 65.
Early diagnosis and treatment of osteoporosis can reduce the risk of fragility fractures by 50%, yet only 3% of medical institutions in Taiwan are equipped with BMD testing equipment. According to available statistical data, only 25% of patients have had their BMD tested, and only 33% have received treatment for osteoporosis. Consequently, Taiwan has the highest incidence of hip fractures in Asia, with nearly 20,000 cases reported annually. Among these, up to 80% of patients become disabled and 20% pass away within a year. The estimated long-term care cost per disabled patient is NT$6 million. If not properly addressed, the negative economic impact to society will be immense.
Recommendations:
1. Include osteoporosis screening and primary prevention of osteoporotic fractures in Taiwan’s national health promotion policy for the elderly.
- Conduct inter-ministerial research on how to reform the healthcare system to better promote healthy aging. The focus of this research should be on how to move the current healthcare approach of “break and fix” (receiving treatment only after becoming ill or injured) toward a “predict and prevent” model.
- Comprehensively evaluate the benefits of early diagnosis and preventive intervention to the national healthcare system and labor economy. Facilitate inter-ministerial budget planning for the NHI and long-term care systems to ensure operational sustainability through prevention and reduction in treatment of diseases.
2. Spearhead public-private partnerships to expand osteoporosis screening efforts.
The Committee recommends that government and local health authorities replicate the aforementioned Changhua County public-private partnership and coordinate with industry to promote disease education related to osteoporosis and fracture prevention, and develop a plan to increase the available supply of BMD screening equipment.
3. Consider providing NHI reimbursement for osteoporosis screening and primary prevention of osteoporotic fractures.
- BMD screening for patients without fractures is not currently covered by NHI reimbursement, creating diagnostic and treatment barriers for such patients. It has also made medical institutions less willing to invest in installing osteoporosis screening equipment. The committee recommends that HPA prioritize the inclusion of osteoporosis screening in its preventive healthcare services for citizens over the age of 65. That would in turn stimulate demand for and broaden the availability of BMD testing equipment in medical institutions.
- The Committee recommends that the government refer to the example set by other advanced countries, including Australia, Canada, Japan, the United Kingdom, and South Korea, in devising a reimbursement scheme for the primary prevention of osteoporotic fractures. Effectively covering such needs would put Taiwan in a much better position to manage its transition to a super-aged society. It would also help sustain Taiwan’s long-term socioeconomic development by making for a healthier and more productive workforce.
全球 COVID-19 疫情嚴峻,印證了投資公共衛生政策對各國政府而言,是非常關鍵的議題。台灣的超前部署及高度警戒的疫情管控措施,更突顯台灣的防疫成就居於世界領先地位;當下台灣政策制定者理應將公衛政策置於首要之務,以加速其協助經濟發展和提高國際競爭力的效益。公共衛生委員會建議台灣政府採取果斷的防治策略,將公共衛生作為最關鍵的國家政策方針,並在後疫情時代繼續發揮影響力。
建議一:提升 C 肝篩檢成果、放寬 B 肝治療給付規範,達成世界衛生組織(WHO)2030 消滅肝炎目標
根據台灣癌症登記中心最新資料,肝癌依然是台灣死亡率第二高的癌症,每年奪走超過 7,800 位國人的生命;導致肝癌的主要原因為 B 型肝炎(HBV)及 C 型肝炎(HCV)。
世界衛生組織訂定了 2030 年消滅肝炎的目標,台灣政府已展現積極作為並超前佈署,透過引進新型口服 C 肝藥物、持續放寬健保給付規範等策略,希望達到 2025 消滅 C 肝的目標。自 2017 年開始給付口服 C 肝藥物(DAA),至今治療人數已突破十萬人;針對 B 肝,中央健康保險署(NHIA)也在 2021 年 3 月進一步放寬健保給付規範,讓部分特殊族群的患者也有機會使用口服抗病毒藥物、降低 B 肝對健康的傷害。此外,政府也放寬 B 肝及 C 肝成人篩檢資格、並結合地方政府投入宣導篩檢,持續找出潛在病患予以治療。
台灣的肝炎防治成績有目共睹,然而為了達到滅除肝炎的目標,仍有需要進一步解決的問題。C 肝目前面臨篩檢人數趨緩,針對醫院內病患進行篩檢已被證實為有效找出潛在病患的方式。感謝 C 肝辦公室與國民健康署(HPA)在 2020 年 10 月已放寬篩檢條件,篩檢人數為放寬前之七至八倍。但因無法串聯分別建檔於國健署及健保署的篩檢與治療資料,讓醫師申請篩檢補助的程序變得複雜,連帶影響醫師篩檢的意願,並讓需要治療的病患無法獲得應有的照護。
由於 B 肝目前還無法完全治癒,只能透過口服抗病毒藥物長期穩定控制。但因為健保給付規範嚴格,僅有部分病患在篩檢確診後能獲得給付治療;也有部分病患因健保政策需中斷健保的給付,讓他們暴露在不知何時肝炎復發及惡化的風險中。
我們的建議
- 建立全國性的「C 肝滅除動態地圖」,及時追蹤、更新篩檢與治療成效。除此之外,衛生福利部應提供足夠資源、簡化篩檢補助程序,並在 2021 年第三季底之前整合國健署及健保署雲端病患資料,以協助中央及地方政府達成其篩檢與治療目標。
- 於 2021 年第三季之前訂定逐步放寬 B 肝健保給付規範的計畫。此計畫應以科學實證與國際現況資料為基礎,明確設定持續放寬 B 肝健保給付之條件。此計畫應該以提供所有需要治療的 B 肝患者完整及穩定的照護為目標,如此一來,政府才能達到 WHO 2030 消滅 B 肝的目標。
- 持續透過公私協力(public-private partnership)邁向WHO 2030 消滅肝炎的具體目標:降低 90% 新感染病例;讓 80% 的 B 肝病患獲得治療、降低 65% B 肝病患死亡病例。另外亦邀請肝病領域專家一同透過民眾衛教及其他相關方案,協助台灣早日達成目標、提升公衛品質。
- 建議考慮將當前的 HPV 疫苗接種政策擴大施打對象。有鑑於 HPV 除導致子宮頸癌外,還有與其他癌症別的關聯性,台灣衛生主管機關應積極制定更全面性的 HPV 防治政策,以維持台灣在全球健康社會中的領導地位,並實現 WHO 所設定之 2030 年消除子宮頸癌的目標。
建議二:制定終身疫苗接種計劃,以增強台灣預防接種政策的靈活度
COVID-19 的疫情嚴峻已突顯台灣有必要強化其疫苗政策,並相當程度地增加疫苗基金預算以增強社會大眾對疫苗的信心;這樣的策略已成為國際間國家安全及經濟發展的先決條件。在重大公衛體系面臨挑戰的時代下,委員會建議採取以下措施,以確保台灣的疫苗政策先行到位。
我們的建議
- 增加疫苗基金以實現終身接種疫苗計畫的策略,並研擬多種支付機制以確保基金政策能合理持續
政府應擴大國家預防接種計畫(NIP)的全面性,從僅施行於幼兒的疫苗接種保護到涵蓋終身接種疫苗的保護,且將其視為國家優先政策。這項國家投資不只嘉惠於全民,亦透過預防措施有效調配健保資源。確保資金足夠是制定成功的終身疫苗接種計劃最根本的方法。目前台灣疫苗基金(NVF)的資金主要來自政府的公務預算和菸品健康福利捐。
但是,國家疫苗基金正面臨財務挑戰。根據疾病管制署(CDC)制定的「充實國家疫苗基金及促進國民免疫力計畫」,公務預算補助應占國家疫苗基金總額的60%,但實際上,過去五年平均僅占了30-40%。此外,菸捐的收入在過去幾年歷經大幅波動,帶來國家疫苗基金來源的不穩定性。為實現衛福部傳染病諮詢會(ACIP)預防接種組所提出的專業建議,台灣的衛生主管機關至少需要為疫苗基金額外籌措新台幣 10.3 億元的資金。
委員會建議政府立即為國家疫苗基金增加公務預算比例,並啟動修法,以確保從菸捐中獲得足夠的財源。此外,政府應為預防接種政策研擬並啟動多種疫苗支付機制。再者,衛生研究院在 2020 年提出政府與民眾共同分攤的疫苗預防接種計畫將可以是一個短期解決方案。衛生主管機關應整合資源,並加快疫苗接種計劃,這將對台灣現行健保政策的節流措施產生正面影響。
- 鬆綁疫苗廣告限制以提升民眾接種意識
COVID-19 疫情讓民眾意識到疫苗接種為預防傳染疾病及減少醫療支出最有效方法之一,然而受限於現行《藥事法》(PAA)處方藥及疫苗不可廣告之規範,使現行疫苗資訊無法深入民眾衛教,讓第一手疫苗科學實證、疫苗特性等資訊無法及時有效傳遞,影響疫苗接種作為疾病預防之效益及民眾疫苗接種信心,一旦傳染病來襲,將無法及時提供保護力。委員會十分感謝食品藥物管理署(TFDA)於去年(2020)國家發展委員會(NDC)會議後,採納委員會建議,願意協助事先審查廠商疫苗衛教宣導資料,以避免產業夥伴在提供民眾衛教訊息時不慎觸法。
產業夥伴相當樂意與政府一起擔負提升民眾疫苗接種觀念及信心之責。委員會盼政府能進一步設置中央「疫苗衛教宣導專區」,提供廠商置放審核通過之疫苗衛教宣導素材,除有助地方衛生局對疫苗衛教宣導訊息內容一致,亦讓產業夥伴有機會一同分擔強化民眾對疫苗價值認知之責,提升民眾對疫苗價值認知。
為提升整體社會疫苗接種觀念,委員會冀盼主管機關給予疫苗衛教廣告更多彈性,鬆綁疫苗產品之廣告限制,讓民眾能及時接收正確疫苗訊息,以提升民眾對疫苗接種之正確認識及意願,若民眾有更高意願自費施打疫苗,相信亦能減輕政府編列公費疫苗預算之財務壓力,並減輕後續疾病衍生之醫療支出。
- 建立數位疫苗護照系統,整合公費及自費疫苗記錄至「全國性預防接種資訊管理系統」(NIIS)中
透過區塊鏈或雲端運算推動數位疫苗護照政策,讓衛生主管機關能夠深入瞭解有關目標族群的疫苗接種率和人口統計資訊。這類護照將有助於控制傳染病並增強人們對疫苗的信心;且台灣民眾亦能方便取得其疫苗接種的歷史記錄,協助他們遵照政府的相關預防接種建議。為實現此一目標,委員會建議疾病管制署首先將自費疫苗接種紀錄整合到「全國性預防接種資訊管理系統」中,接著當公費預防接種的資金到位,即可將公費施打紀錄納入系統;如此一來,政府就能精準監控那些能用疫苗預防的傳染性疾病。
建議三:政府主管機關帶動跨界合作,強化高齡社會的樂活健康,推動脆弱性骨鬆骨折之篩檢及初級預防
台灣在 2020 年首度面臨人口負成長,預計到 2025 年台灣將邁入超高齡社會。人口快速老化的影響層面甚廣,包括國家勞動生產力與國際競爭力下降。台灣應努力確保其高齡人口的健康,以避免其醫療照護與長期照護系統過度負荷。
最近的一項研究顯示,台灣 50 歲以上的人口中,有三分之一的女性以及五分之一的男性患有骨質疏鬆症;此外,中華民國骨質疏鬆症學會、彰化縣衛生局以及產業界自 2019 年共同發起全國首創以社區為單位的骨質密度(BMD)篩檢巡迴計畫;計畫初步顯示,有高達 54% 的參與長者被確診出患有骨質疏鬆症,迄今為止,這項公私協力計畫已經篩檢近 4,000 名 65 歲以上長者。
骨質疏鬆症的早期診斷與治療可降低 50% 脆弱性骨折的風險;然而台灣僅有 3% 的醫療院所設置骨密度檢測儀器。根據統計,髖部骨折患者中僅有 25% 接受過骨質密度檢測,即便已發生骨折,也僅 33% 接受骨鬆藥物治療。因此,台灣地區的髖骨骨折發生率為亞洲最高,每年有將近 2 萬件病例;在這些病例當中,一年內高達 80% 的患者失能,高達 20% 的患者會死亡。每位失能患者的長期照護成本估計為新台幣 600 萬,如果沒有適當的因應對策,將對整體社會經濟影響甚巨。
我們的建議
- 將骨質疏鬆篩檢和初級骨鬆骨折預防納入國家高齡健康促進政策
- 透過跨部會的研究,推動醫療照護改革,以促進健康樂齡。這項研究應聚焦於轉化現今「Break and Fix生病後接受治療」的思維 ,至更為永續的「Predict and Prevent預測與預防」模式。
- 全面評估及早診斷與預防對國家醫療體系和勞動經濟的效益,促進全民健保和長照體系的跨部會預算規劃,透過疾病的預防來降低治療的需求,確保醫療體系永續運作。
- 由政府帶動公私協力(Public-Private Partnership)以擴大骨質疏鬆篩查工作
- 建議政府與各地方衛生主管機關仿照彰化縣衛生局模式,透過公私協力攜手民間產業界力量,持續推動骨質疏鬆與骨折防治等衛教推廣,並研擬增設骨質密度篩檢儀器普及規劃,改善骨鬆篩檢可近性。
- 將骨質疏鬆篩檢和高風險之骨鬆骨折初級預防納入健保給付
- 現行健保給付之骨質密度測定仍排除非骨折病患的檢查,造成臨床診斷與治療障礙,亦影響醫療機構建置骨鬆篩檢儀器意願。建議國健署優先將骨質密度檢測納入65 歲以上國民健檢項目,從需求面刺激醫療機構設置骨鬆篩檢儀器並擴展其可近性。
- 建議政府應參考其他先進國家如澳洲、加拿大、日本、英國和韓國等,制定骨鬆骨折初級預防的健保給付,讓台灣在超高齡社會來臨前,做更好的準備,幫助台灣在更健康且更具勞動生產力的條件下,確保社會經濟永續發展。
AmCham Taiwan
Phone: +886-2-2718-8226