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Taiwan created a successful health-care system by learning from Canada. We should now be learning from them




This column is an opinion by Harmeet Nanner, a research analyst at the Centre for Addiction and Mental Health in Toronto. For more information about CBC’s Opinion section, please see the FAQ.

In the 1970s, Taiwan began an effort to radically transform its health-care system. Building up its supply of health-care resources to serve a rapidly industrializing country was the first priority, but the more complex problem was how health-care services should be funded while providing equitable access for all. 

In the late 80s, an expert task force was commissioned to address this issue, and William Hsiao, a Harvard economics professor renowned for his work on health-care financing, was selected as chief advisor. 

Prof. Hsiao began an economic study of insurance schemes in six countries: the U.S., the U.K., Germany, France, Canada and Japan. The results were in favour of a single-payer system based on Canada’s experience with medicare in the 80s, at which time the quality of services was very high. This helped influence Taiwan to also adopt a single-payer framework, a program they call the National Health Insurance (NHI).

The task force learned from both the successes and failures of Canada and over a dozen other countries to piece together a system that was ideal for Taiwan. Consequently, our systems can look quite different, even though they share the same basic framework. 

Taiwan very good at controlling costs

The research and data-driven process has allowed for a finely-tuned system, such that the NHI can provide comprehensive coverage for dental, prescription drugs, physical rehabilitation, and more, all while putting a tight lid on costs — and it is very good at controlling costs

In 2017, Taiwan’s national health expenditure (NHE) was 6.1 per cent of GDP; the OECD average that year was 8.8 per cent, and Canada’s NHE was 10.4 per cent. Most impressive is how much performance is squeezed out of every dollar; while Canadians have spent the last two decades increasingly haunted by wait times, the Taiwanese system is notable for having minimal wait times. 

Am I suggesting that Taiwan has the perfect system? Definitely not. There are some glaring issues and some aspects may be unacceptable to Canadians, but the system’s efficiency means that Taiwan has lots of room to increase its health-care budget to address shortcomings. 

On the other hand, Canada’s health-care system is simply tragic. We’re seeing it at its worst right now, but our system has been failing Canadians for a number of years, most obviously with wait times. 

As Prof. Hsiao notes, Canadian health care began its descent in the 1990s, when funding grew tight during a recession. However, the Canadian system has always been missing certain features that would maximize how efficiently we use the resources we’re paying for. 

Even now, Canada’s NHE is among the highest in the OECD. 

Paramedics push a patient on a stretcher towards the door of an emergency department as four other ambulances are shown parked by the entrance.
Ambulance paramedics unload patients at Toronto Western Hospital. With the tragic state of health-care services, we may finally have the motivation we need to fix our system, writes Harmeet Nanner. (Evan Mitsui/CBC)

What exactly do we get for such high costs? According to the Commonwealth Fund, which made a very comprehensive comparison of health care in 11 different countries (Taiwan is not one of them), Canada has the absolute worst system of universal care. 

Some may assume that the message of this article is for Canada to emulate the specific policies and procedures that Taiwan has built their system out of, but that’s actually not it. What I want us to emulate is the process that Taiwanese officials used to achieve their health care success, a process of mobilizing the world’s knowledge and relying on a diverse group of experts to create effective policy solutions. 

The task force which led to the creation of the NHI was notable for how it reached across borders in order to get the best information available. The Canadian federal government should similarly bring together an expert task force to make recommendations on comprehensive health care reform, not just on the issue of funding and health insurance, but for all components that make up the system, such as policies that can enable more effective health care delivery. 

Politics is the hardest part

The difficult part of this plan is the politicians and federalism. Our governments can be quite good about calling expert groups together to make recommendations, but they’re horrible at implementing them, at least as it pertains to health care. Several government-sanctioned reports have been produced in the past to advise on methods of improving, modernizing, and sustaining the health-care system, but those reports have largely been ignored. 

In 2002, following the publication of the Romanow Commission report, one poll found that a majority of Canadians approved of it, but 39 per cent were pessimistic that its advice would be followed. Unfortunately, those Canadians were right, but had they been wrong, we probably wouldn’t have so many shuttered ERs at the moment. 

Those who remember past advisory reports may scoff at my suggestion as another useless attempt to reform health care, a waste of money to make recommendations that will go nowhere. I disagree. 

The discussions I often hear about reforming the system, in the public, media, and from governments, are far removed from the solutions that are the most transformative and well-researched. In the worst case, an expert task force would help thrust alternatives into the public dialogue, and this would help the voters of today to understand just what sorts of policies their governments should be supporting. 

The best case is, of course, that those policies go through. With the tragic state of health-care services, droves of health-care workers pushed to the brink, the clear failure relative to other OECD countries, and a single-payer role model in Taiwan, we may finally have the motivation we need to fix our beloved health-care system.

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