Q: National health insurance is one of the current projects of the DOH which receives the greatest public attention. When you were a legislator, you proposed a bill demanding that NHI, originally set to begin in 1995, begin in 1994. What are the current main points of DOH work in this area? Is there enough time to prepare for implementation three years?

A: NHI involves two major parts. One is the completion of the health care system and the other is putting the system of financing and payment on a sound basis. These two tasks alone are extremely complex, and many steps must be taken as quickly as possible. We are currently proceeding according to the anticipated plan.

Of these, regarding the health care system, spreading health resources evenly, which means the construction of a province-wide health care network including group care hospitals, regional hygiene medicine, medical centers, regional hospitals, district hospitals, and clinics, is the most important. You could say that its implementation is the foundation for NHI. Not long ago I invited the heads of the bureaus of public health for the 21 cities and counties across the province for discussion, which had never been done before. As a result, we discovered that of the province's 363 health and hygiene facilities, 53 have no doctors at all, and some, for example in Panchiao City, are responsible for 3-500,000 people, and cannot cope with demand. Therefore I asked them to report what they need to meet their needs, for the DOH to write additional subsidies into the budget.

In the past, the DOH only subsidized three to five counties or cities, focusing on key areas. This was not enough. Isn't it ridiculous that the health care network in Taiwan since 1950 still has so many gaps?

Q: Does the inadequacy of base level health care have anything to do with the outflow of medical personnel?

A: That remote areas cannot find doctors is a common global problem. The Japanese government offers high salaries to attract doctors to "doctorless villages," and I have even heard that some doctors from Taiwan have taken jobs there. Comparatively speaking, Taiwan's health network is generally OK, much better than Korea, Thailand, or the Philippines. It does not have such situations as a lack of places to get inoculations or an inability to find a hospital bed when one is sick.

But the distribution of health resources is still not equal. Major urban areas have continually built public and private large scale hospitals, not only saturating the area, but also creating vicious competition. Whereas local and base levels have been ignored. This is something the government has to accept responsibility for.

Q: Are there other problems with the national health insurance system?

A: There are quite a few problems. Because the planning work for the first stage was done by the Committee for Economic Planning and Development, the planning committee members were all public health and financial specialists, without any doctors participating. When the plan is given to the DOH to implement, there will definitely be problems. Already the DOH has formally received the second stage plan, and is under-taking a comprehensive review. The EY has already passed revisions for laws related to the new planning committee, and the areas of responsibility for each ministry, and all must begin as quickly as possible.

I often say, in the past the Ministry of Health was like a "false front." In name it was the highest unit for health care for the whole nation. But in fact, it is one level removed from the provincial health bureau and the health units of the counties and cities. Moreover, all kinds of medical insurance are not within the scope of the DOH--civil service insurance is under the Central Trust of China, labor insurance and farmers' insurance are under the Bureau of Labor Insurance, military insurance is under the military--so the health department really has had no place to go to work.

Also, these different kinds of insurance have different rates and methods of payment. Taken together, they will be difficult to handle. But no matter how difficult, if in the future we want to do national health insurance properly, it will definitely be necessary to establish some kind of "National Health Insurance Bureau" to take over comprehensive planning for overall health insurance affairs. We can't just have everybody doing something different.

Q: You have said that the finance and payment system is also a serious problem. The Democratic Progressive Party has listed "free health care" as one of its party platforms. What's your view?

A: If I only think of being a "good guy," then of course I would promote free health care, or I would say, if the national finances and resources were adequate, I would be very happy to approve, but in fact this is impossible. Currently, the financial losses are serious for every kind of insurance. Thus is because the amount paid by the insured is small and use is excessive. If in the future there is free health care, the people will value it even less, and it will become a situation of "take as much as you want, it's free!" As a result, the vast medical costs will still have to be assessed on each taxpayer.

Therefore, I believe that the most reasonable is the "partial burden sharing" system. The insurance payment rate should be, as Premier Hau Pei-tsun says, to achieve "no waste and no losses." After all, insurance is something to help in an emergency, and is not to allow people to use insurance payments for free medical care, which will create vast waste for the country.

Furthermore, under the existing payment system for labor insurance, there are many areas that need to be improved. The difference in treatment between private and public hospitals is an example. I served in the Kaohsiung Medical College (KMC) for more than ten years. I know that private hospitals must rely on their own funds to add equipment or construct new hospital rooms, whereas public hospitals have their hardware costs paid by the government, medical personnel receive public salaries, and if there is a loss it is subsidized by the government. The "foothold" of the two is fundamentally un equal. Since labor insurance still "lays it on thick" for public hospitals and "spreads it thin" for private hospitals, no wonder the private hospitals complain. Since it is necessary to draw on the strength of private hospitals to establish the health care network the government must seriously address their opinions.

Q: It seems like the distribution of health personnel is more and more serious. There are often reports in the newspapers that many people think it's no longer so great to be a doctor.

A. This is worth paying attention to; otherwise the problem of a doctor brain drain will be even more serious.

Another thing connected to doctors' salaries: When the "separation of the medical and pharmaceutical practices" is promoted, at the same time fees for doctors' examinations must be raised. Currently when most people go to a small clinic, if the doctor doesn't dispense medicine, then ordinarily it's not necessary to pay, or there is only a nominal fee. The examination fee listed on the labor insurance forms is NT$100. There are still many people who love taking medications, and when they go to see the doctor it's not to have their illness examined but to pick up medicine. That isn't right. When I went to France on this trip to participate in the EY technology conference, I asked about doctors' examination fees in France, which are about F120, or about NT$600; it's even higher in the US. Therefore, if you want to establish doctors' authority and avoid excessive use of medication, it should be necessary to raise the examination fee in the future. But currently this is a contract problem between the labor insurance bureau and each hospital, and the DOH can only make suggestions.

Besides this, the problem of doctors in Taiwan is an even bigger headache than in other countries because we have both Western medicine and Chinese medicine. Currently the special examination for Chinese medicine is not reasonable; people just cram for the exam and then forget everything. If one takes the exam once and passes, then one is qualified to practice Chinese medicine. It is hard to avoid inconsistencies in quality. In the future I hope that all Chinese doctors can be developed through a departmental system, such as the Department of Chinese Medicine at the China Medical College. This will require amending current laws.

Q: It sounds as if the DOH is confined in law and authority, and can't make progress in many areas. The image of most people of the DOH is of dealing with epidemic prevention, or investigating food and pharmaceutical products.

A: This is really hard to understand. However, the work of epidemic prevention has been carried on quite well on Taiwan. Rapid contagious illnesses, like last year's dengue fever and prevention of AIDS over the past few years, have seen quite good accomplishments. It's a pity that attention devoted to preventive medicine is still inadequate. For example, recently there has been the rise of Type C hepatitis. To buy a test dose on the market costs more than NT$200, but the DOH has only budgeted NT$50, which will naturally affect the success of preventive medicine.

Currently, those in charge of practical work and education and inoculation are the base level health centers. Thus they are often on the front line and have the broadest impact and do the most. This brings us back to what we said earlier about putting the medical system on a sound basis and the problem of the equal distribution of health care resources.

Q: About yourself, you have gone from being a professor and department chairman in Kaohsiung Medical College to mayor, a legislator, and now head of the DOH. You have changed roles many times.

A: My original profession is medicine and public health. So in the past being a professor and now being head of the DOH is putting my studies to good use. On the contrary, being a mayor and a legislator were like operating on unfamiliar terrain. But I've actually quite liked each role, and have felt very happy during the whole journey. Now in particular, since the department is directly responsible for public health for the whole nation, it's a place where I can get things done. On the other hand, it is also the ministry with the least politicization. Aside from smalltechnical problems, both government and opposition have quite similar views on the future direction of public health. Therefore, this does not conflict with my stand as an independent.

As for the future, I cannot foresee political events. I can only rely on my conscience and do what I need to do, so that I can face myself and society proudly.

[Picture Caption]

Department of Health Director Chang Po-ya, a doctor by profession, has served as mayor of Chiayi, a legislator, and is the first one to enter the cabinet as a "non-party woman legislator."

The elderly are the group in most urgent need of medical insurance. (photo by Vincent Chang)

The inadequacy of base-level health care resources will be a serious test for implementing national health insurance in the future.

Actively engaging in international health care exchange is one of the main points of Chang's policies. The photo is of her and Pretoria University Professor D.M. Joubert on his visit to Taiwan in June of last year. (photo courtesy of the Department of Health)

Will our next generation be the beneficiaries of national health insurance? Or merely inherit its debts? This all depends on establishing a good financial and payment system for NHI. (photo by Arthur Cheng)