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.