Taiwan set a good example by having efficient cancer care & control programmes to cope with the growing cancer burden in the country. We invited Dr. Chiou Shu-Ti, to share insights on how Taiwan government manages cancer care & control effectively.
“Sin tax reduces not only tobacco consumption in Taiwan, but also generates additional budget to improve cancer care for patients. Currently, we’ve allocated 11% of our budget on cancer control.”
Dr. Shu-Ti Chiou
Director-General, Health Promotion Administration,
Ministry of Health and Welfare, Taiwan
Shu-Ti Chiou, M.D., Ph.D., M.Sc., a board-certificated family physician and a Ph.D. in Epidemiology, is the Director-General of Health Promotion Administration, Ministry of Health and Welfare, Taiwan and Adjunct Associate Professor of School of Medicine, National Yang-Ming University. She specialized in preventive medicine and health service research, and has led and engaged in health promotion and policymaking at all levels-local, national, and international. She has received numerous awards for outstanding civil services in different government posts. Recognized for the many highly successful and innovative health promotion projects in Taiwan under her leadership, Dr. Chiou also holds major executive positions in international organizations. She assumed the President of the International Network of Health Promoting Hospitals and Health Services for 2012-2014. In 2013, she was elected as Global Vice President for Partnerships of the International Union for Health Promotion and Education (IUHPE).
1. What different methods and approaches do you have in your country that will promote cancer care & control and increase awareness?
We did almost everything that other countries did, including the PPP (Public-Private Partnership). We have a strong patient group and have researchers who are doing very good cancer researches as well. We have National Health Insurance which not only covers cancer treatment and is zero copay basis. We had so many things similar to other countries, but I think there is one thing very special which really pushed Taiwan’s cancer control programme to a more comprehensive and well-developed status - political communication. That is something very different.
As you can see everyone talked about HTA (Health Technology Assessment) evidence data, we have that too. Evidences and data are important, we should not do decision-making just based on sensational idea.
We have Taiwan Cancer Registry since 1979, the earliest cancer registry in Asia. However, actually after we launched national health insurance as I mentioned, that covers cancer diagnosis and treatment at the zero copay scheme, everyone in Taiwan thought that the war was over, but that is not true. The international comparison data showed that we still have higher cancer mortality rate than many developed countries, including Japan and Singapore. For the other diseases or other conditions, it is a 10% copay, you have to pay 10% out-of-pocket, the insurance pays 90%. However, cancer is on the list of major devastating diseases, the national health insurance offers copayment exemptions for treatment and care.
As we have relatively higher mortality rate for cancer, so it’s not only about medical care, we still have to emphasise on early detection and prevention. Hence we disclose the data and evidences which act as foundation, however, you have to take action and work upon those stepping stones. If you don’t work, those stones mean nothing.
Nine years ago during the current president’s first election campaign, I was in his team, so I said to him that “Cancer is the no. 1 killer and this is the most impatient killer. It won’t wait for you, so we have to take action now.” It's Action, and It's Now! He promised to fight against No. 1 killer to reduce the mortality rate about 10% in the near future. After he won the campaign, his ministers took action to allocate budget for early detection and prevention, and also for quality improvement of healthcare. As money can be wasted upon unnecessary interventions, so we also get the budget. He raised the sin tax and he earmarked 5.5% for Cancer Prevention and Control (CPC). And last year we did another fighting again… (Laughing) We doubled it to 11% and we have another tobacco control raised from 3% to 5%, so in total we have 16% from the sin tax to do prevention and control for cancer problems.
Therefore, political engagement is very important to get budget for healthcare system. If people say we should invite Minister of Finance to sit in, but the Minister of Finance could not really decide where to spend the budget. It is his boss, the president elected by the people who will make the decision. Thus either the president or the prime minister is very important.
HTA is for the allocation inside the health budget. But you really need to expand the pocket for health, so you have to do the external lobbying.
We are trying to make every payment counts, whether the money spent in the right way to get right result.
2. Any challenges or hindrances in implementing these strategies like what are the current obstacles you’re facing? What steps are being taken to overcome them?
Actually getting the budget is the first and foremost thing because it will really bring changes to the system. While the implementation is another thing. You get the budget but how do we do to really achieve the targets is also very important.
The second step is to reorient to transform our healthcare system with the special budget for cancer. Within the budget we got, we have some budgets for each hospital to do quality improvement upon their cancer care, cancer prevention, and the screening. We do accreditation and we also grant their project. Every year, they send their proposals on how they plan to improve their implementation, the provision of screening, prevention and the improvement in their care quality to get the special budget.
We also link the accreditation with the special budget. We link the cancer care accreditation with the overall hospital accreditation and that is so important. In Taiwan, hospitals try to get higher ranking in accreditation to get better payment, funding and insurance. In this way, we bring the members work with us but still we spend a lot of time on communication and training to help them to do a better job to provide prevention and screening to the patients.
We have the proactive, digitalised IT system for everyone who comes to the hospital. The computer system will automatically check the eligibility for cancer screening and check the records of small kids’ status. And for those who are eligible for cancer screening, they check the records of screening, and if there is no record of screening, the hospital will invite the patient to do the screening.
Thus, if you go to the hospital for your joint problem, you will also be check for everything you need. It is an automated check, person-centred holistic care system now. It is difficult and will take much more time. In this way, our hospitals nowadays are the virtual family physicians for all the patients.
I visited many superintendents. Every time before my visit, he or she realised that must be something wrong about the hospital. So he or she will hold the meeting, and will review their performance data. So actually before I went there, they already proposed their improvement plan. It is difficult but it is very important.
The other obstacle is from our people - because we have the wonderful national health insurance, they don’t have to worry about diseases, so there are no incentives for them to take action.
We have rapid and remarkable increase in cancer screening rate, for instance, the current colorectal cancer screening is 42% in Taiwan. Although we have very good progresses and rapid increase in cancer screening rate, still we are not satisfied. We hope to provide free check-up, 80% or higher in the future.
We worked with NGOs in communities and also in hospitals, they told people their stories and demonstrated how much more suffering you will experience if you wait until late stage of cancer. It is a very powerful partnership to work with us to persuade more people to do screening for early detection and prevention. We have very strong patient groups, and actually from the sin tax, we also have special budget to support NGOs to some extent, and have grants for them. We support them and they also support us. They are the team members in our national committee for cancer control. We all including our boss will set aside some time to sit there and listen to them.
3. What are other future plans you would have to better implement cancer care policies?
We feel that to improve health literacy, our people are really the priority that we have to work upon. Secondly, we are trying to improve the partnership between Health Promotion Administration (HPA) and National Health Insurance Administration (NHIA). Among the top killers in various types of cancer, liver cancer is a very preventable one, and viral hepatitis is a very important cause for liver cancer in Taiwan. We have the evidence to show it is actually effective in treating patients with viral hepatitis. Therefore, we have to push the national health insurance because the current scheme is very conservative in spending more money. We want them to achieve better on treating viral hepatitis in patients.
This interview was conducted by APBN, Catherine D. Ong and Carmen Jia Wen Loh at Healthcare Forum: War on Cancer on 17th March 2016.