The COVID-19 pandemic has highlighted the importance of public health to governments globally. In addition to recognizing the Taiwan government’s outstanding performance in managing the pandemic, the Committee also greatly appreciates its efforts to implement a national policy and action plans for eliminating hepatitis C, as well as the significant progress it has achieved in this regard.
To help Taiwan continue to succeed in the post-pandemic era, the Committee recommends that the government take bold steps to resolve the following public health issues and continue to prioritize these areas when setting national policy.
Suggestion 1: Implement an approach of prevention, screening, and treatment to effectively reduce the rate of cancer-causing illnesses.
According to the Ministry of Health and Welfare (MOHW), cancer has been the number-one cause of death in Taiwan for 39 consecutive years. Reducing the cancer mortality rate is thus a public health priority of the Taiwan government. The World Health Organization (WHO) notes that 30-50% of cancers can be prevented. In addition to an unhealthy diet and poor lifestyle habits, viral infections such as hepatitis B (HBV), hepatitis C (HCV), and the human papillomavirus (HPV) are also key risk factors for cancers.
MOHW data indicates that around 10,000 patients are diagnosed with – and 7,700 die of – liver cancer (hepatocellular carcinoma, or HCC) in Taiwan each year, making it the island’s fifth most prevalent cancer and the one with the second-highest mortality rate. One of the key contributors to developing liver cancer is viral hepatitis. Although the NHIA has reimbursed HBV treatment since 2003, over 70% of liver cancer deaths are still related to HBV, indicating substantial room for improvement in managing this disease. Disease progression model projections show that the incidence of liver cancer and deaths caused by viral hepatitis would be significantly reduced through early treatment of HBV.
In addition, HPV infections can cause certain cancers of the cervix, vagina, and vulva in women, and of the oropharynx, anus, and penis in men, as well as genital warts with a high recurrence rate. To eliminate HPV-related cancers, a strategy of gender-neutral vaccination plus screening has been recommended by the Asia-Pacific Economic Cooperation forum and the EU, and has been adopted by 40 countries including the U.S., Canada, UK, and Australia. Although Taiwan began a program subsidizing school-based HPV vaccination for middle school-aged girls in 2018, there is still no clear strategy or timeline for implementing a gender- neutral HPV vaccine policy.
As liver cancer and HPV-related cancers are some of the few cancer types that can be prevented through treatment and vaccination, we recommend that the government implement a preventative healthcare policy by taking the following steps:
1. Refer to Taiwan’s successful approach to eliminating HCV in developing a national HBV management policy to include patient education, screening, and advanced HBV treatment. Such a policy would reduce the mortality rate of HBV and other relevant diseases and, more importantly, effectively manage hepatitis D, which only becomes contagious when combined with HBV. In addition, it would help Taiwanese people reduce their risk of developing liver cancer and enable Taiwan to achieve the WHO’s hepatitis management goals of reducing new infections by 95% and deaths by 65% between 2016 and 2030.
2. Align Taiwan’s public health policy with global trends by formulating a national policy to eliminate HPV-related cancers. In addition, establish a National Human Papillomavirus Program Office to integrate resources and work toward the goal of cancer elimination.
Suggestion 2: Implement preemptive national immunization and infection control policies for the post-COVID era.
The Committee applauds the government’s quick action in investing in vaccine procurement following the outbreak of COVID-19. This preemptive measure has not only made Taiwan a good model to follow in the global fight against the pandemic, but has also allowed Taiwan’s economy to continue to grow. However, we note the following issues that could hamper Taiwan’s efforts to safeguard public health in the post-COVID era:
2.1 Insufficient budget for immunization against notifiable infectious diseases. The MOHW was able to secure NT$12 billion to purchase COVID-19 vaccines, but an insufficient National Vaccine Fund (NVF) means that regular vaccines have been pushed to the side. For example, Taiwan’s Advisory Committee on Immunization Practices (ACIP) proposed expanding the cohort for the publicly funded pneumococcal vaccine for those above the age of 65 and rotavirus vaccines for children, but this expansion was delayed for many years due to budget constraints.
According to the Strategic Plan prepared by the Centers for Disease Control (CDC), treasury funds should account for 60% of the total NVF, but the average amount since 2018 has been only around 30% at most. Meanwhile, large fluctuations in revenue from the tobacco surcharge resulting from a decrease in the smoking population and competition with other government agencies for allocation have made funding for the NVF unstable.
2.2 Domestic infection control has not yet been implemented to respond to the threat of emerging infectious diseases. The WHO and the U.S. CDC have warned that the COVID-19 pandemic has exacerbated the threat posed by antimicrobial resistance (AMR) globally. According to the Taiwan CDC’s AMR Surveillance System, a steady increase of many drug-resistant bacteria has occurred in Taiwan over the past decade, and MOHW data indicates that if Taiwan fails to properly control AMR, 33,000 people may die every year after 2050. We call on the government to learn from countries such as the UK and the U.S. by actively formulating national-level antibiotic policy incentives and goals in response to the AMR crisis as early as possible.
2.3 Infection prevention measures are not clearly listed in hospital accreditation standards. Studies have revealed that patients diagnosed with COVID-19 have a higher incidence of ventilator-associated pneumonia (VAP), which has a mortality rate as high as 42.7%. Currently, medical accessories related to VAP are commonly reused in Taiwan’s hospitals, a practice that can raise the risk of exposure and infection for patients if the reused accessories are not well sterilized. This in turn can increase the amount of antibiotics prescribed, the length of hospitalizations, and patient medical expenses. Such issues are not unique to Taiwan; the U.S. Food and Drug Administration has indicated that the number of nosocomial (or hospital-acquired) infections caused by contaminated medical accessories is severely underestimated due to a lack of investigations of hospitals.
We call on the government to immediately deploy vaccine resources and invest in infection control policies to ensure the continued success of its pandemic control in the post- COVID era.
1. Designate the Executive Yuan to spearhead a national vaccine policy, actively allocate funds, and pilot a program of partial subsidies.
We suggest that the Executive Yuan convene a national immunization policy meeting to review the financial resources for the NVF (such as those listed in Article 27 of the Communicable Disease Control Act) and formulate vaccine strategies that deliver economic benefits, fulfill prevention needs, and reduce follow-up medical expenses in order to introduce innovative vaccines and implement a life- course vaccination program on a timely basis.
Increase the allocation of treasury funds for the NVF to at least 60% of the total, raise the proportion of the tobacco surcharge flowing to the NVF to at least 10%, and utilize multiple financial sources to enlarge the fund.
Adopt the vaccine subsidy scheme suggested by the National Health Research Institutes at the Financial Solutions for Immunization Forum as a solution to the insufficient NVF. Under this scheme, the cost of vaccines would be shared by the government and the public, reducing pressure on the NVF as the sole source of funding for vaccines. Subsidization of vaccines may also lend itself to an increased willingness among citizens to get inoculated as they do not have to shoulder the full cost. We urge government to run a small-scale pilot program of partial subsidies for vaccines as a gradual solution to the problem of vaccine financing.
2. Encourage AMS practices.
Incentivize medical institutions and antibiotics suppliers to practice antimicrobial stewardship (AMS) – efforts aimed at measuring and improving how antibiotics are prescribed by clinicians and used by patients – as a way to address AMR. For example, implement innovative payment models that delink the price paid for antibiotics from the volumes sold and encourage hospitals to execute AMS through its incorporation in National Health Insurance (NHI) reimbursement items or by providing rewards.
Reward the introduction of antibiotics under the NHI and provide price protection to encourage essential R&D, formulation optimization, and storage stability for antibiotics in order to ensure diversified treatment options to fight against superbugs.
3. Increase the usage of disposable medical accessories.
Require the use of disposable accessories during mechanical ventilation support (e.g., through anesthetic machines or ventilators) in hospital accreditation standards to reduce the incidence of – and medical expenses related to – VAP.
Suggestion 3: Expand osteoporotic fracture education and promote a healthy aging society.
Given Taiwan’s rapidly aging population, innovative disease prevention and health promotion concepts to prevent chronic disease-related disability among the elderly are urgently needed.
Osteoporosis is the fourth most common chronic disease among the elderly in Taiwan, behind the “three-high” conditions of high blood pressure, high blood sugar, and high lipid levels. A “silent disease” without significant symptoms, many patients with osteoporosis receive delayed diagnosis and treatment, which can result in severe disability or even death.
Consequently, Taiwan has the highest incidence of hip fractures in Asia and the ninth-highest worldwide. Among those affected, up to 24% pass away within a year and 80% become sufficiently disabled to require long-term care. Medical costs for osteoporotic fractures in men are much higher than those for women.
Strengthen disease education and increase awareness of osteoporosis and osteoporotic fractures.
Expand the traditional “three-high” approach to chronic disease prevention to include a “one-low” (low bone density) and promote education on osteoporosis and osteoporotic fractures on the Health Promotion Administration’s website. Enhancing fall prevention by adding osteoporosis risk assessments in relevant brochures and providing education on increasing muscle mass and maintaining bone density is also critical. By taking this step, Taiwan can expect to reduce the risk of disability caused by osteoporosis and fractures, as well as the burden of disease care.
Suggestion 4: Strengthen the detection of cardiovascular diseases and optimize use of the NCVDP.
Heart disease ranks as the number-two cause of death in Taiwan and accounts for 10% of NHI expenditures annually. Taking into account the indirect costs resulting from disability and loss of productivity, the burden of heart disease on society is estimated at NT$170 billion per year. If the government does not act aggressively to reduce the rate of this condition, it could significantly impact Taiwan’s public health and the economy.
1. Strengthen screening and risk assessment for cardiovascular diseases and promote precision preventive health.
• The WHO indicates that 80% of cardiovascular events are preventable, and early intervention is therefore critical. Currently, the diagnostic rate for heart disease in Taiwan is low. For example, only 52% of people with hyperlipidemia have been diagnosed, and among younger generations, the rate is even lower at less than 40%. Furthermore, the continuum of care between screening and medical intervention is not well established.
The Committee therefore suggests lowering the age for starting the annual health checkup provided under the NHI from 40 to 20, as is the case in Japan and South Korea. In addition, adopt international risk assessment tools to identify the level of risk for developing cardiovascular diseases and provide precise preventive measures to achieve disease control targets through lifestyle modification and medicine.
2. Allocate sufficient budget to optimize the NCVDP Program
• As cardiovascular diseases affect such a large number of people and Taiwan’s population is rapidly aging, the government should expand efforts to combat these conditions, including through its National Cardiovascular Disease Prevention Program (NCVDP). However, the annual budget for this program is currently only around NT$100 million and is only tentatively covered by the surcharge on tobacco products. Such funding is obviously inadequate and insufficiently stable to ensure the NCVDP’s execution. Therefore, the Committee urges the government to prioritize cardiovascular disease prevention by providing the NVCDP with a larger, more stable annual budget to ensure the implementation of disease control measures and safeguard the health of Taiwanese people.