Taiwan’s path to universal health coverage—an essay by William C HsiaoBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5979 (Published 24 October 2019) Cite this as: BMJ 2019;367:l5979
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I have previously stated my views about universal health coverage (UHC); various misconceptions and ideological conflicts from different perspectives and assumptions (ref 1)
I would like to point out, despite the need to cap healthcare costs and equity in access to services, neither the author nor the other stakeholders concluded UHC must be free-at-point-of-delivery when given the opportunity to redesign (or create) a healthcare system.
Similarly the article reiterated the fact the health expenditure does not necessarily correlate with patient satisfaction, considering that Taiwan did not spend as much as OECD countries.
This challenged the flawed assumption that UHR can only be achieved with "free" service delivery, that equity in a national health scheme can only be attained by excluding user-pay co-payment. Taiwan demonstrated that affordable healthcare can occur in a mixed payment model, with capped costs, means-tested state-funded subsidised enrolment while improving outcomes in almost all areas.
Of course no healthcare system is perfect and what works for one country is not necessarily so for another. Certainly the reasons for the latter are many, but this is not surprisingly related to expectations and demands of the society so concerned, together with the fiscal discipline of individuals within that society.
It therefore should be of no surprise to readers that for countries who expect high quality services free-at-point-of-delivery without consideration of overall budgetary limitation, the average household debt is disproportionately high, household savings significantly lower compared to those living in countries with healthcare system with user pays co-payment arrangement.
Whether such expectation is intrinsically tied-in with fiscal responsibility is in contention, but there is no doubt patient expectation and satisfaction differs dramatically between neighbouring nations within one geographical region. When expectations of high quality care are not met due to budgetary and practical constraints, the country faces a dilemma whether to address the resulting dissatisfaction either by adjusting expectations to more realistic level, or increasing spending with no regard for economic sustainability. Perhaps like Taiwan, it may be more practical to establish a new funding system for the healthcare service rather than maintain the façade that a free-at-point-of-delivery healthcare system is sustainable in the long term.
You can't have your cake and eat it.
Competing interests: No competing interests