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1、Rethinking the Healthcare System,Ken N.Kuo MD FACS,Acting Deputy Director,Institute of Population Health Sciences&Director,Center for Health Policy Research and Development,National Health Research Institutes,大綱,Healthcare status in TaiwanCall for reform from WHO Tallinn Charter viewpointHealthy Peo
2、ple 2020 for Taiwan,-3-All Rights Reserved,-3-All Rights Reserved,2050 Global Population Change,Ave.growth rate-0.31,Ave.Growth rate1.13,Average growth rate-0.7,Ave.growth rate1.14,Ave.Growth rate-0.09,Average growth rate-0.54,Source：日本總務省，United Nations，內政部戶政司，行政院經建會，MIC整理,2008年5月,-4-All Rights Res
3、erved,-4-All Rights Reserved,Rapid Global Aging by 2050,Source：日本總務省，United Nations，內政部戶政司，行政院經建會，MIC整理,2008年5月,More than half of Asian countries have aged population exceed 21%(21%),Aging Time Schedule in Asian Countries,Resource:Health Statistic in Taiwan 2006,Department of Health,Aug,2008,Taiwans
4、 Declining Birth Rate,2000:320,000 life birth2007:210,000 life birthAverage 1.1 baby per couple,Reference:Jennifer Chun-Li Wu&Tung-Liang Chiang,JFMA,2007,106(2):177-80,IMR:number of deaths occurring under 1 year of age per 1000 live births,Reference:Jennifer Chun-Li Wu&Tung-Liang Chiang,JFMA,2007,10
5、6(2):177-80,U5MR:the probability of a child dying before reaching 5 years of age,expressed as rate per 1000 live births,Resource:Health Statistic in Taiwan 2006,Department of Health,Aug,2008,Resource:Health Statistic in Taiwan 2006,Department of Health,Aug,2008,NHE_ by financial resource,Resource:He
6、alth Statistic in Taiwan 2006,Department of Health,Aug,2008,TOWARDS HIGH-PERFORMING HEALTH SYSTEMS:THE OECD HEALTH PROJECT ISBN-92-64-01555-8 OECD 2004,NHE_ by financial allocation,90.77%,Resource:Health Statistic in Taiwan 2006,Department of Health,Aug,2008,Features of the Healthcare System,Public/
7、Private Mix of Providers Closed-staff system for hospitalsDominated by the private sectorNo gate-keeper system for outpatient visitsPatients are free to choose care providersHigh service volumes in outpatient department in most hospitals,Resource:Health Statistic in Taiwan 2006,Department of Health,
8、Aug,2008,Resource:Health Statistic in Taiwan 2006,Department of Health,Aug,2008,Resource:Health Statistic in Taiwan 2006,Department of Health,Aug,2008,The importance of primary care,Definition of primary care,First-contact care,accessible by all(free at the point of use),comprehensiveness,coordinate
9、d for its population(registered list),activated by patient choice.,Resource:Improving primary care in Europe and the US:Towards patient-centered,proactive and coordinated systems of care,synopsis of country case studies from Bellagio Primary Care Conference,April 2008,Four sets of PHC reforms,Refere
10、nce:The World Health Report 2008:Primary Health Care-Now More Than Ever,WHO,A 10-Year Experience with Universal Health Insurance in Taiwan:Measuring Changes in Health and Health DisparityChi Pang Wen,MD,DrPH;Shan Pou Tsai,PhD;and Wen-Shen Isabella Chung,MScAnnals of Internal Medicine 2008 Feb 19;148
11、(4):258-67,8.37,10.65,10.03,6.28,7.78,6.89,Results in life expectancy and health disparity,Overall life expectancy did not change.Life expectancy increased faster in lower health class groups than in higher health class groups.The gap in life expectancy in health class group 1(the healthiest)and hea
12、lth class group 10(the least healthy)decreased 6%after NHI.(0.62-year/10.03-year),Changes in providers and patients behavior,Substantial increase in utilization and expenditure,Changes in providers and patients behavior,Physician payment incentives have effect on how medical trainees choose their sp
13、ecialties.Lay referral instead of professional referral.Higher utilities may be encouraged by the ease of access.,Remaining issues,Although improve the health outcomes for those who were worse off before NHI period,the effect is not much in reducing health disparities.Its not practical to solely dep
14、end on universal healthcare coverage to reduce inequality.A broader,systemic strategy will be required to reduce many of the risk factors that contribute to disparities,including higher rates of smoking and betel nut chewing,and obesity.,Reference:Karen Davis and Andrew T.Huang,Ann Intern Med.2008;1
15、48:313-314,Other considerations,Implication from NHI expenditure controlPhysicians visiting Consultation timeAffecting specialty choices of medical trainees long-run sustainability,Another viewpoint,The increase of life expectancy can be explained by a number of factors,such as,rapid reduction in ag
16、e-specific mortality(eg.infant mortality and maternal deaths),socio-economic factors(eg.income and education),health-related behaviors(eg.smoking and physical activity),etc.,Marie DesMeules,Douglas Manuel and Robert Cho,BMC Womens Health 2004,4(Suppl 1):S9,Another viewpoint,Nolte and McKees study su
17、ggested that amenable mortality(referring to deaths from certain causes that should not occur in the presence of timely and effective health care)account for an average of 23%and 32%of total mortality in males and females under age seventy-five respectively based on OECD countries profiles.,Ellen No
18、lte and C.Martin McKee,2008,Health Affairs,27(1):58-71,Another viewpoint,Mortality from causes also fell in most of OECD countries over the period 1997-98 through 2000-01.However,the decline was generally much less steep than the decline in amenable mortality.,Ellen Nolte and C.Martin McKee,2008,Hea
19、lth Affairs,27(1):58-71,Taiwans evidence,Preliminary study results from NHRI,Yang-Ming Institute of Health and Welfare Policy also evidenced the similar trend that the amenable mortality had a significant decline during 1981 to 2005,in particular before and more after the launch of National Health I
20、nsurance in Taiwan.By YC Lee,YT Huang,YW Tsai,SM Huang and KN Kuo,Rethinking Resource Allocation,Resource:Health Statistic in Taiwan 2006,Department of Health,Aug,2008,A New Paradigm,emerging evidence is recasting health systems not as a drain on those resources but as an opportunity to invest in th
21、e health of the population and in economic growth.Recent studies showed that,no matter developing,middle-or high-income countries,poor health dragged down economic growth.,Reference:Josep Figueras,Martin McKee,Suszy Lessof,Antonio Duran,Nata Menabde(Eds),2008,Research evidence tell us.,People in poo
22、r health are less likely to work and,when in work,are less productive.They are less likely to invest in their own education or to save for retirement,and so to support the wider economy.The evidence is clear;a healthy population including healthy older people can contribute very substantially to the
23、 economy.,Health systems time to go beyond healthcare,Defining a health system:three elementsthe delivery of health services(both personal and population based);activities to enable the delivery of health services(specifically finance,resource generation and stewardship);andthose stewardship activit
24、ies that aim to influence what other sectors do when it is relevant to health,even where the primary purpose is not health.,Reference:The World Health Report 2000-Health systems:improving performance,Health and health system reconsideration,Health is central to well-being and wealthHealth and health
25、 systems work across sectorsHealth systems investment brings real benefitsPolicy makers can make health systems and health system investment work better,Commitment to Act,The Tallinn Charter:Health Systems for Health and Wealth,2008,WHO Regional Office for Europe,Social Determinants of Health,Pictur
26、e:G Dahlgren and M Whitehead Policies and Strategies to Promote Social Equity in Health(Institute of Futures Studies Stockholm 1991),Goals for Healthy People 2020,Increasinghealthy life expectancy,Decreasing health inequalities,Increasing healthy life expectancyTo promote quality of healthy lifeTo p
27、revent diseaseTo decrease co-morbidity and premature death,Decreasing health inequalitiesTo narrow health disparities due to life cycleTo narrow health disparities due to socioeconomic backgroundTo narrow health disparities due to physical&mental status,Conceptual Frame work,Determinants of Health,P
28、reventive careDisease managementHealth System Performance,FamilyCommunitySchoolWork Place,Physical ActivityDietInjury Prevention&Safety PromotionSafer SexStress&CopingSubstance Use,Focused Groups,Child&Youth,Elderly Population,Gender,Indigenous groups,Socially or Economically Disadvantaged Populatio
29、n,People with Disabilities,To wrap up,Turn our attention from healthcare only to the whole health systemEcho to Healthy People 2020 focusing on increasing healthy life expectancy&decreasing health inequalitiesAccountable performance and responding to peoples needPut evidence-based decision-making into the fundamental of policy forming,Thanks for your attention!,
