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Taiwan’s path to universal health coverage—an essay by William C Hsiao

BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5979 (Published 24 October 2019) Cite this as: BMJ 2019;367:l5979
  1. William C Hsiao, K T Li professor of economics, emeritus
  1. Harvard T H Chan School of Public Health, Boston, USA
  1. hsiao{at}hsph.harvard.edu

Who could pass up a chance to redesign a society’s healthcare system, no matter how challenging it may be? William C Hsiao describes how he responded

I was teaching economics at the Harvard School of Public Health when, in 1988, I received a surprising telephone call from the deputy chairman of the Taiwanese government’s planning commission. Could I come to Taiwan and lead a taskforce that was developing plans to provide access to affordable healthcare for the whole population? The task was daunting. Success would require a major revamping of Taiwan’s healthcare system, and the high level taskforce had been suffering from a lack of leadership.

Taiwan was then an emerging economy with 20 million people. Only 40% of its citizens were covered by social health insurance—civil servants and their families and employed workers but not their families. Private health insurance was almost non-existent. The social health insurance plans were run inefficiently by bureaucrats; providers were filing costly fraudulent claims; paying for care was a real challenge for most of the uninsured; and health costs were rising much faster than Taiwan’s high economic growth rate. The government didn’t have much tax revenue available or the technical expertise to overhaul its health system.

Nevertheless, I could see that Taiwan had already created some favourable conditions for universal health coverage (UHC). It was moving from an authoritarian state to a democracy, and the emerging grassroots opposition party was pushing for UHC. The government had asked the taskforce to plan a healthcare system with three clear goals: universal coverage with equal access to quality care, efficient use of health resources, and controlling the rise in health expenditure.

Taiwan had a strong central government with a powerful political elite that could make difficult decisions, and a fast growing economy that created larger economic capacity. …

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