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Population aging and its impacts: Strategies of the health-care system in Taipei
Ageing Research Reviews 9S (2010) S23–S27
Contents lists available at ScienceDirect
Ageing Research Reviews journal homepage: www.elsevier.com/locate/arr
Review
Population aging and its impacts: Strategies of the health-care system in Taipei Ming-Hsien Lin a,c , Ming-Yueh Chou b,c , Chih-Kuang Liang b,c , Li-Ning Peng a,c , Liang-Kung Chen a,c,∗ a
Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec 2, Shih Pai Road, Taipei 11217, Taiwan Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung 1st Road, Kaohsiung 81346, Taiwan c National Yang Ming University School of Medicine, No. 155, Sec 2, Linong Street, Taipei 11217, Taiwan b
a r t i c l e
i n f o
Article history: Received 5 May 2010 Accepted 19 July 2010
Keywords: Elderly Geriatrics Long-term care Post-acute care
a b s t r a c t Taiwan is one of the fastest aging countries in the world. As such, the government has developed various strategies to promote an age-friendly health-care system. Health services are supported by National Health Insurance (NHI), which insures over 97% of citizens and over 99% of health-care institutes. The current health-care system has difficulties in caring for older patients with multiple comorbidities, complex care needs, functional impairments, and post-acute care needs. Taipei, an international metropolis with a well-preserved tradition of filial piety in Chinese societies, has developed various strategies to overcome the aforementioned barriers to an age-friendly health-care system. These include an emphasis on general medical care and a holistic approach in all specialties, development of a geriatrics specialty training program, development of post-acute services, and strengthening of linkages between health and social care services. Despite achievements thus far, challenges still include creating a more extensive integration between medical specialties, promotion of an interdisciplinary care model across specialties and health-care settings, and integration of health and social care services. The experiences of Taipei in developing an age-friendly health-care service system may be a culturally appropriate model for other Chinese and Asian communities. © 2010 Elsevier B.V. All rights reserved.
1. Introduction The demographic transition of birth and death rates in Asia from 1960 to the 21st century has brought about dramatic shifts in the age structure. Rapidly aging societies across Asia may have resulted from the combined forces of declining fertility, increased life expectancy, and the transitional dynamics of varying cohort sizes moving through the age distribution. Rapid population aging is also expected to become a challenge for other countries in Eastern Asia including China, Hong Kong, Singapore, and South Korea. This rapid demographic transition is associated with the aging of the segment of the population popularly dubbed the ‘baby boomers’ combined with a declining birth rate. Three common features have been identified in all countries of Eastern Asia: (1) the aging of the older population itself, with those aged 80 years and over increasing in proportion compared to older persons in general; (2) the disproportionate number of older persons who are women, especially among the oldest old; and (3) the higher levels of aging among rural, compared to urban, populations owing primarily to the out-migration of young rural adults to towns
∗ Corresponding author at: Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Shih-Pai Road Sec 2, Taipei, Taiwan 112. Tel.: +886 2 28757460; fax: +886 2 28737901. E-mail address: [email protected] (L.-K. Chen). 1568-1637/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.arr.2010.07.004
and cities. The implication of this rapid trend of population aging is that even countries with a low percentage of older persons cannot afford to be complacent about population aging. Taiwan is one of the fastest aging countries in the world. Faced with the various impacts of population aging, Taiwan has developed various culturally appropriate strategies and has gained certain positive outcomes. Taiwan became an aging country (considered to be when the elderly population exceeds 7% of the total population) in 1993, and is expected to become an aged country (considered to be when the elderly population exceeds 14% of the total population) in 2017 (Executive Yuan, 2008). Life expectancy has increased by 25 years in the past 50 years in Taiwan (Fig. 1), while fertility rates have dropped (Fig. 2). The rate of population aging in Taiwan is higher than that in any other countries, and by 2050 the elderly population is estimated to exceed 30%, surpassing the United States (Executive Yuan, 2008). In Taiwan, the rate of population aging has increased by an estimated 0.6% every year since 2006, and the growth rate of the elderly segment of the population is among the highest globally (Hwang, 2008). Population aging is associated with a variety of societal impacts that include social, economic and health issues. The 2005 Survey of Health and Living Status of the Middle Aged and Elderly in Taiwan showed that 33.4% of the elderly population reported having a fair to good health status and the prevalence of chronic illnesses among elderly population reached 65.2% (The Foundation of Chinese Labor-Management Affairs). Common health problems
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M.-H. Lin et al. / Ageing Research Reviews 9S (2010) S23–S27
Fig. 1. Trend of life expectancy of men and women in Taiwan (1950–2005).
of elderly Taiwanese include cardiovascular disease (55.2%), musculoskeletal disease (26.9%), and endocrine and metabolic diseases (22.5%); followed by diseases of the sensory organs (12.1%), digestive system (8.9%), urologic system (6.8%), and respiratory system (5.5%) (The Foundation of Chinese Labor-Management Affairs). In the past few years, several strategies have been developed in Taiwan to cope with population aging. These include postgraduate education and specialty training with an emphasis on general medical care and a holistic approach in all specialties; development of a geriatrics specialty training program; development of geriatric service models of outpatient, inpatient and post-acute services; and an integration of health and social services in an effort to strengthen ties between community-based long-term care services and the health-care system (Liu, 1998; Tseng, 2006; Tsai et al., 2008; Lotus Shyu et al., 2005; Lee, 2002; Chen et al., 2004a). Taipei, the capital of Taiwan, has been a pioneer in developing health and social care services in Taiwan and leads the country in this effort. This review will focus on the strategies that Taipei has developed to meet the challenges of population aging, with the aim of providing information for policy and service decisions appropriate for other Chinese societies in the future.
longer lived than their fellow citizens, which may be due to the city’s more robust economy and social welfare system. Taipei is an international metropolis with a relatively stable population, but there is a slight trend for residents to move to suburban satellite cities due to economic pressures. After the Chinese Civil War in 1949, Taipei experienced an influx of people from different provinces of the Chinese mainland. Their presence has enriched Taipei with a diversity of Chinese culture. Traditional filial piety and family ties in Chinese societies are important and nurtured; in this system, family plays the most important role in caring for older people. This model may encounter serious challenges in modern society with an escalating elderly population and its related financial burdens. However, the Chinese tradition of filial piety may remain important in Taiwan. The National Census Survey showed that approximately 30% of elderly Taipei citizens live alone or with their spouse only, which is lower than Western countries and even lower than some major cities in China (Directorate-General of Budget, Accounting and Statistics, Executive Yuan, R.O.C.; Helen and David, 1997). Among all elderly Taipei citizens with long-term care needs, 75% live at home with their children, which is an impressive phenomenon in an international metropolis (Wu and Ju, 1994). However, not all Chinese traditions remain unchanged in the cosmopolitan environment of Taipei. Traditionally, Chinese prefer to die at home when they are terminally ill so that the dead can find their way home in their afterlife. However, due to the space limitations of modern buildings, the vast majority of terminal cancer patients die in hospitals in Taipei (Chen et al., 2004b). In 1980, the Welfare Act for Older People was enacted in Taiwan. This legislation ensures the rights of older people in preventive services, health care, rehabilitation services, pension, housing arrangements, and labor market participation, to name a few examples. In Taipei, elderly citizens are provided with free annual physical checkups, National Health Insurance (NHI)-based health services and community-based health professional services. The latter includes physical therapy, occupational therapy, nutritional therapy and respiratory therapy, and is available to all elderly people in need. Compared with other cities or counties in Taiwan, Taipei provides more comprehensive community-based services, which are not included in the NHI program.
2. Population aging and its impacts in Taipei 3. The health-care system for older people in Taipei Taipei has a population of 2.6 million. People aged 65 years and over account for 12.6% of the total population in Taipei, which exceeds the national average of 10.6% for this population (Department of Statistics, Ministry of Interior). The life expectancy of Taipei citizens is also longer (79.9 years for men and 84.4 years for women) than the national averages (75.5 years for men and 81.7 years for women) (Department of Statistics, Ministry of Interior). Overall, the citizens of Taipei may be considered healthier and
Fig. 2. Crude fertility rate and mortality rate of Taiwan from 1982–2009.
3.1. General health-care system In Taiwan, health services are covered by the NHI with over 97% of all residents and over 99% of health-care institutes included in the coverage (Chiang, 1997). This creates a near-universal level of health-care services in Taiwan. In Taipei, there were 40 hospitals and 2,970 clinics by the end of 2008, which makes Taipei the country’s most abundant source of acute hospital bed resources (35.0 beds per 10,000 people) and physician services (30.0 physicians per 10,000 people) (Department of Health, 2008; The Statistics Analysis of Medical Care Institution’s Status & Hospital’s Utilization, 2008). Generally speaking, people aged over 65 spend over one-third of the annual NHI expenditures in Taiwan (Fig. 3). Therefore, the sharp increase in elderly population is expected to cause an even sharper increase in health-care expenditure. A national survey conducted in 2003 found that over 85% of all older persons had at least one chronic illness, and 64% had two (Survey of Health and Living Status of the Middle Aged and Elderly in Taiwan Survey Report, 2003). In 2007, the Taiwan Longitudinal Study on Aging indicated that 15.0% of older Taiwanese had various impairments in their activities of daily living, and 47.6% had impairment in their instrumental activities of daily living (Bureau of Health Promotion, Department of Health, R.O.C.).
M.-H. Lin et al. / Ageing Research Reviews 9S (2010) S23–S27
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diseases and end-stage renal disease. To avoid over-hospitalization of end-of-life care, a pilot program to step-up care homes to provide end-of-life care in communities is being launched in 2010. 3.4. Comparisons of health-care service delivery in Asian cities
Fig. 3. The relationship of population aging and health-care expenditure in Taiwan (2000–2008).
3.2. Geriatric health-care services Health-care services in Taiwan feature specialty-based practices, a self-referral system, and disease-oriented treatment which results in a fragmentation of health-care services. Nevertheless, older people usually need a holistic approach, integrated services and an emphasis on functional improvement; all great challenges to the current health-care system. In 2006, Taipei Veterans General Hospital (VGH), the country’s largest public hospital, started the first integrated geriatric outpatient service in Taiwan by affiliating internist/family practitioner, neuropsychiatric doctors and rehabilitation specialists to provide one-stop care and medication reviews for all patients to optimize medication use. Implementation of the service involved the affiliation of two community hospitals to commence community hospital-based intermediate care services. All patients received 4-weeks of comprehensive, geriatric assessment-based, multidisciplinary team care. In 2009, following positive results from the VGH program, the Bureau of NHI launched an integrated outpatient service to promote the quality of chronic disease management, especially for elderly patients with multiple comorbidities. The current NHI program provides acute care services and some long-term care services, but intermediate care services are lacking. Older people discharged from acute hospitals without proper intermediate care for functional recovery can experience significantly poorer clinical outcomes in the ensuing 12 months (Young et al., 2005). In Europe and the United States, where the same challenges exist, an intermediate care service was developed (mainly in Europe) and a post-acute care service was developed (U.S.) to actively promote functional independence after treatment of acute illnesses. The Taipei VGH program has significantly improved short-term functional independence for older patients after major acute illnesses (Lee et al., in press) and this short-term functional improvement has also significantly reduced the 12-month mortality risk by 64.4% (Chen et al., 2010). In 2010, the Bureau of NHI formally committed to a national pilot program of post-acute care services. 3.3. End-of-life care For end-of-life care, Taipei piloted the first hospice and palliative care service in 1985. Initially, hospice and palliative care focused on terminal cancer patients only, and both a home-care model and inhospital hospice unit care model have been well-developed (Lai and Su, 1997). In 2009, the hospice and palliative care services began to cover several other non-cancer end-stage diseases, including acquired immunodeficiency syndrome, dementia, severely disabling stroke, congestive heart failure, liver cirrhosis, chronic lung
The health-care service delivery systems for older people in the Asian cities of Taipei, Tokyo, and Hong Kong are essentially quite similar. “Ageing in place” is the most common scenario in these cities so the health care and long-term care services for older adults are also community-based. However, health-care services for older adults in Beijing are not well-developed due to a lack of improvement in geriatric services and long-term health-care. Moreover, the national birth control policy in China has caused a significant burden due to the rapidly increasing elderly population. Currently, older people with severe disabilities in Beijing are often cared for in hospitals because of the lack of long-term care services. In Tokyo, Hong Kong and Taipei, population aging and economic achievements are parallel, but economic development is somewhat behind population aging in Beijing. Therefore, although the aging rates of Tokyo, Hong Kong, Taipei and Beijing are similar, the development of geriatric and long-term care services is of particular importance to Beijing. To cope with the escalating growth of the elderly population in Taiwan, Taipei VGH initiated several pilot geriatric service models, beginning in 2006. These have been successful, and have produced significant improvements in the quality of health care for older people, including outpatient, inpatient, intermediate care and even long-term care services. The unique experiences of Taipei may spur other Asian countries to develop culturally appropriate health-care service systems in the future. With the advantage of a common Chinese cultural background and language, Taipei can provide practical recommendations for Chinese societies worldwide. 4. Long-term care services in Taipei Across all forms of long-term care services, home-care services may be the earliest model developed in Taiwan. The public health situation in the 1950s was a driving force for home-care. Similar to experiences of other countries, home-care services progressively became the most important model of long-term care services in Taiwan (Steel et al., 1998). In the 1990s, home-care nursing institutes providing home-based, long-term nursing care have become the most popular model of long-term care services and were reimbursed by the NHI. However, the current home-care model, which provides mainly nursing procedures such as nasogastric tube replacement, urinary catheter replacement, tracheostomy tube replacement and certain wound care services (e.g. pressure sore and stoma care), do not meet the many and complex needs of those receiving care, particularly the elderly. According to the NHI inclusion criteria, all home-care recipients must be severely disabled and need some form of long-term nursing care, which does not cover the many other home-care needs. Overall, 4000 Taipei citizens receive home-care services and home-care providers are almost exclusively hospital-affiliated home-care nursing institutes (Wu et al., 2007). Although the NHI only reimburses home-care nursing services, home-based physical therapy, occupational therapy, nutritional therapy and respiratory therapy are reimbursed by the Department of Health of Taipei City Government. Due to the success of the aforementioned home-based professional therapy in Taipei, the national Ten-Year Long-Term Care Program formally included all professional home-care services and extended the scope into social services like personal care, meal delivery services, day services, respite care services, transportation services, and many other social services (Department of Health, Taipei City
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Government). Additionally, to cope with the rapidly increasing elderly population and long-term care needs, a National Long-Term Care Insurance will be launched in 2012 to provide seamless care for older people, from health-care to social welfare. In addition to home-care services, there are 15 skilled nursing facilities (1038 beds) and 160 long-term care facilities (6379 beds) in Taipei to provide institutional long-term care services. Until recently, institutional long-term care has been self-funded. The pending National Long-Term Care Insurance plans to partially reimburse the institutional care of severely disabled older people. Characteristically, there is a national long-term care facility accreditation system to ensure the quality of care for residents. The license of institutes not passing the accreditation will be suspended. A major challenge for long-term care services in Taipei is the integration with health-care services. In this cost-containment era, the reduction of hospital beds and hospital lengths-of-stay further strengthen the need for communities to look after sub-acute and post-acute patients. A seamless integration between health-care and social care services should be bridged by an intermediate care service. However, in the spectrum of care, patient-centered care should be delivered by interdisciplinary teams across different settings of care. Traditionally in Taiwan, physician participation in long-term care services has been uncommon, except for physician visits in home-care services. However, nowadays, to successfully bridge health-care and long-term care services, physicians should play a more active role instead of merely referring patients for services to ensure the quality of health care. 5. Development of geriatric medicine The first academic organization for the study of elderly care, the Gerontological Society of Taiwan, was established in 1982. It was a purely academic platform for all researchers to share their expertise, but no clinical geriatric service was developed. Years later, National Taiwan University Hospital and Taipei VGH, the two leading national medical centers in Taiwan, began offering clinical geriatric services. However, both institutions closed these services in the 1990s due to the, then, limited proportion of elderly population in Taiwan. In 2004, the National Health Research Institute launched the first geriatrics fellowship training program with assistance from Mt. Sinai Medical School of New York. The pilot program ended in 2006 due to budget limitations. In 2006, Taipei VGH also started its own geriatrics fellowship training program through a collaboration with the British Geriatrics Society. This international collaboration continues. Geriatrics is deemed a subspecialty of internal medicine, family medicine, neurology, psychiatry and rehabilitation medicine, which is similar to the current U.S. model. To date, there are nine training centers in Taiwan, with three in Taipei. Due to the specialty-based practice pattern, the key goal of clinical geriatric services in Taiwan is to integrate clinical services into a holistic model. In addition to research and education, geriatricians in Taiwan play important roles in intermediate care and long-term care services. In the future, the development of geriatrics in Taiwan will focus on extending clinical services and integrating more care resources to promote seamless care across the health-care settings. The main challenge for geriatricians in Taipei is research development. Difficulties in obtaining research grants for geriatrics are almost universal worldwide; however, more research activities must be developed to ensure the future of geriatrics in Taiwan. 6. Conclusions Population aging is an epidemic in Asia, and the impact of population aging varies from country to country. Taipei, as an
international metropolis, has a modern, Western lifestyle in many dimensions, but also has retained the filial piety of Chinese culture. The development of geriatric services is an international program, which incorporates Japanese, American and British experiences. Although the current health-care service system for older people in Taipei is still fragmented and limited, barriers have been gradually overcome. The introduction of the NHI program in 1996 has been a tremendous success and is a model to the world. The National Long-Term Care Insurance, to commence in 2012, will actively provide a wide range of long-term care services. Strategies developed for older people in Taipei could have valuable applications in all Chinese societies. Conflict of interest statement All authors declare no conflict of interest. Role of the funding source None. References Bureau of Health Promotion, Department of Health, R.O.C. http://olap.bhp.doh. gov.tw/Search/ListHealth1.aspx?menu=1&vid=2&mode=5&year=96&sel=0 (accessed 10 May 2010). Chen, J.Y., Lu, B.H., Chen, C.Y., Tai, T.Y., 2004a. Geriatricians play a cooperative role in community care for the elderly. Taiwan Fam. Med. Res. 2, 1–9 (Chinese). Chen, L.K., Hwang, S.J., Chen, T.W., Tsai, S.T., Chen, T.J., 2004b. In-hospital death of cancer patients in a medical centre in Taiwan: comparison between hospice and acute wards. Palliat. Med. 18, 577–578. Chen, L.K., Hwang, S.J., Peng, L.N., Lin, M.H., Lai, H.Y., et al., 2010. Effectiveness of community hospital-based post-acute care on short-term functional recovery and long-term mortality in older patients: a prospective cohort study. Ann. Med. (unpublished results—in revision). Chiang, T.L., 1997. Taiwan’s 1995 health care reform. Health Policy 39, 225–239. Department of Health, Executive Yuan, R.O.C. (Taiwan), 2008. http://www.doh. gov.tw/CHT2006/DisplayStatisticFile.aspx?d=74403&s=1 (accessed April 27, 2010). Department of Health, Taipei City Government. http://subweb.health.gov. tw/longterm care web/home.asp (accessed 10 May 2010). Department of Statistics, Ministry of Interior. http://sowf.moi.gov.tw/ stat/week/week9904.doc (accessed 10 May 2010). Department of Statistics, Ministry of Interior. http://www.moi.gov.tw/stat/life.aspx (accessed 10 May 2010). Directorate-General of Budget, Accounting and Statistics, Executive Yuan, R.O.C. http://www.dgbas.gov.tw/public/Attachment/51191426871.doc (accessed 20 May 2010). Executive Yuan, 2008. Executive Yuan: Council for Economic Planning and Development. Population Projection of Taiwan. Taiwan. http://www.cepd.gov.tw/m1.aspx?sNo=0000455&key=&ex=2&ic=0000153 (accessed 10 May 2010). Helen, B., David, R.P., 1997. Ageing and aged care in the People’s Republic of China: national and local issues and perspectives. Health Place 3, 149–159. Hwang, M.N., 2008. Aging society: emerging issues and perspectives from the Republic of China. In: Chadha, N.K. (Ed.), Longevity and Productivity: Experiences from Aging Asia. Asia Productivity Organization, Taipei, pp. 34–45. Lai, Y.L., Su, W.H., 1997. Palliative medicine and the hospice movement in Taiwan. Support Care Cancer 5, 348–350. Lee, S.D., 2002. Exploring policy and financing options for long-term care in Taiwan. J. Aging Soc. Policy 13, 203–216. W.J. Lee, L.N. Peng, Y.Y. Cheng, C.Y. Liu, L.K. Chen, et al. Effectiveness of short-term interdisciplinary intervention in post-acute patients in Taiwan, J. Am. Med. Dir. Assoc., in press. Liu, C.T., 1998. Health care systems in transition II. Taiwan, Part I. A general overview of the health care system in Taiwan. J. Publ. Health Med. 20, 5–10. Lotus Shyu, Y.I., Liang, J., Wu, C.C., Su, J.Y., Cheng, H.S., Chou, S.W., Yang, C.T., 2005. A pilot investigation of the short-term effects of an interdisciplinary intervention program on elderly patients with hip fracture in Taiwan. J. Am. Geriatr. Soc. 53, 811–818. Steel, K., Leff, B., Vaitovas, B., 1998. A home care annotated bibliography. J. Am. Geriatr. Soc. 46, 898–909. Survey of Health and Living Status of the Middle Aged and Elderly in Taiwan Survey Report, 2003. Bureau of Health Promotion Department of Health, Taiwan. http://www.bhp.doh.gov.tw/bhpnet/portal/Them Show.aspx?Subject =200712270002&Class=2&No=200712270017 (accessed April 27, 2010). The Foundation of Chinese Labor-Management Affairs. http://fclma.org/ ShowPost/10916.aspx (accessed 28 June 2010).
M.-H. Lin et al. / Ageing Research Reviews 9S (2010) S23–S27 The Statistics Analysis of Medical Care Institution’s Status & Hospital’s Utilization, 2008. http://www.doh.gov.tw/CHT2006/DisplayStatisticFile. aspx?d=72356&s=1 (accessed April 27, 2010). Tsai, J.C., Liu, K.M., Lee, K.T., Yen, J.C., Yen, J.H., Liu, C.K., Lai, C.S., 2008. Evaluation of the effectiveness of postgraduate general medicine training by objective structured clinical examination-pilot study and reflection on the experiences of Kaohsiung medical university hospital. Kaohsiung J. Med. Sci. 24, 627–633. Tseng, C.M., 2006. Elder’s welfare generalization and policy outlook of Taiwan. Taiwan Geriatr. Gerontol. 1, 112–121 (Chinese).
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Wu, S.C., Ju, C.M., 1994. Public attitudes toward long-term care arrangements for the elderly: findings from 1994 social image survey. Taiwan J. Publ. Health 14, 369–382. Wu, M.P., Chen, L.K., Kao, W.C., Hwang, S.J., 2007. Home care services in Taipei City. Taiwan Geriatr. Gerontol. 2, 263–270. Young, J., Robinson, M., Chell, S., Sanderson, D., Chaplin, S., et al., 2005. A prospective baseline study of frail older people before the introduction of an intermediate care service. Health Soc. Care Commun. 13, 307–312.
Contents lists available at ScienceDirect
Ageing Research Reviews journal homepage: www.elsevier.com/locate/arr
Review
Population aging and its impacts: Strategies of the health-care system in Taipei Ming-Hsien Lin a,c , Ming-Yueh Chou b,c , Chih-Kuang Liang b,c , Li-Ning Peng a,c , Liang-Kung Chen a,c,∗ a
Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec 2, Shih Pai Road, Taipei 11217, Taiwan Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung 1st Road, Kaohsiung 81346, Taiwan c National Yang Ming University School of Medicine, No. 155, Sec 2, Linong Street, Taipei 11217, Taiwan b
a r t i c l e
i n f o
Article history: Received 5 May 2010 Accepted 19 July 2010
Keywords: Elderly Geriatrics Long-term care Post-acute care
a b s t r a c t Taiwan is one of the fastest aging countries in the world. As such, the government has developed various strategies to promote an age-friendly health-care system. Health services are supported by National Health Insurance (NHI), which insures over 97% of citizens and over 99% of health-care institutes. The current health-care system has difficulties in caring for older patients with multiple comorbidities, complex care needs, functional impairments, and post-acute care needs. Taipei, an international metropolis with a well-preserved tradition of filial piety in Chinese societies, has developed various strategies to overcome the aforementioned barriers to an age-friendly health-care system. These include an emphasis on general medical care and a holistic approach in all specialties, development of a geriatrics specialty training program, development of post-acute services, and strengthening of linkages between health and social care services. Despite achievements thus far, challenges still include creating a more extensive integration between medical specialties, promotion of an interdisciplinary care model across specialties and health-care settings, and integration of health and social care services. The experiences of Taipei in developing an age-friendly health-care service system may be a culturally appropriate model for other Chinese and Asian communities. © 2010 Elsevier B.V. All rights reserved.
1. Introduction The demographic transition of birth and death rates in Asia from 1960 to the 21st century has brought about dramatic shifts in the age structure. Rapidly aging societies across Asia may have resulted from the combined forces of declining fertility, increased life expectancy, and the transitional dynamics of varying cohort sizes moving through the age distribution. Rapid population aging is also expected to become a challenge for other countries in Eastern Asia including China, Hong Kong, Singapore, and South Korea. This rapid demographic transition is associated with the aging of the segment of the population popularly dubbed the ‘baby boomers’ combined with a declining birth rate. Three common features have been identified in all countries of Eastern Asia: (1) the aging of the older population itself, with those aged 80 years and over increasing in proportion compared to older persons in general; (2) the disproportionate number of older persons who are women, especially among the oldest old; and (3) the higher levels of aging among rural, compared to urban, populations owing primarily to the out-migration of young rural adults to towns
∗ Corresponding author at: Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Shih-Pai Road Sec 2, Taipei, Taiwan 112. Tel.: +886 2 28757460; fax: +886 2 28737901. E-mail address: [email protected] (L.-K. Chen). 1568-1637/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.arr.2010.07.004
and cities. The implication of this rapid trend of population aging is that even countries with a low percentage of older persons cannot afford to be complacent about population aging. Taiwan is one of the fastest aging countries in the world. Faced with the various impacts of population aging, Taiwan has developed various culturally appropriate strategies and has gained certain positive outcomes. Taiwan became an aging country (considered to be when the elderly population exceeds 7% of the total population) in 1993, and is expected to become an aged country (considered to be when the elderly population exceeds 14% of the total population) in 2017 (Executive Yuan, 2008). Life expectancy has increased by 25 years in the past 50 years in Taiwan (Fig. 1), while fertility rates have dropped (Fig. 2). The rate of population aging in Taiwan is higher than that in any other countries, and by 2050 the elderly population is estimated to exceed 30%, surpassing the United States (Executive Yuan, 2008). In Taiwan, the rate of population aging has increased by an estimated 0.6% every year since 2006, and the growth rate of the elderly segment of the population is among the highest globally (Hwang, 2008). Population aging is associated with a variety of societal impacts that include social, economic and health issues. The 2005 Survey of Health and Living Status of the Middle Aged and Elderly in Taiwan showed that 33.4% of the elderly population reported having a fair to good health status and the prevalence of chronic illnesses among elderly population reached 65.2% (The Foundation of Chinese Labor-Management Affairs). Common health problems
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M.-H. Lin et al. / Ageing Research Reviews 9S (2010) S23–S27
Fig. 1. Trend of life expectancy of men and women in Taiwan (1950–2005).
of elderly Taiwanese include cardiovascular disease (55.2%), musculoskeletal disease (26.9%), and endocrine and metabolic diseases (22.5%); followed by diseases of the sensory organs (12.1%), digestive system (8.9%), urologic system (6.8%), and respiratory system (5.5%) (The Foundation of Chinese Labor-Management Affairs). In the past few years, several strategies have been developed in Taiwan to cope with population aging. These include postgraduate education and specialty training with an emphasis on general medical care and a holistic approach in all specialties; development of a geriatrics specialty training program; development of geriatric service models of outpatient, inpatient and post-acute services; and an integration of health and social services in an effort to strengthen ties between community-based long-term care services and the health-care system (Liu, 1998; Tseng, 2006; Tsai et al., 2008; Lotus Shyu et al., 2005; Lee, 2002; Chen et al., 2004a). Taipei, the capital of Taiwan, has been a pioneer in developing health and social care services in Taiwan and leads the country in this effort. This review will focus on the strategies that Taipei has developed to meet the challenges of population aging, with the aim of providing information for policy and service decisions appropriate for other Chinese societies in the future.
longer lived than their fellow citizens, which may be due to the city’s more robust economy and social welfare system. Taipei is an international metropolis with a relatively stable population, but there is a slight trend for residents to move to suburban satellite cities due to economic pressures. After the Chinese Civil War in 1949, Taipei experienced an influx of people from different provinces of the Chinese mainland. Their presence has enriched Taipei with a diversity of Chinese culture. Traditional filial piety and family ties in Chinese societies are important and nurtured; in this system, family plays the most important role in caring for older people. This model may encounter serious challenges in modern society with an escalating elderly population and its related financial burdens. However, the Chinese tradition of filial piety may remain important in Taiwan. The National Census Survey showed that approximately 30% of elderly Taipei citizens live alone or with their spouse only, which is lower than Western countries and even lower than some major cities in China (Directorate-General of Budget, Accounting and Statistics, Executive Yuan, R.O.C.; Helen and David, 1997). Among all elderly Taipei citizens with long-term care needs, 75% live at home with their children, which is an impressive phenomenon in an international metropolis (Wu and Ju, 1994). However, not all Chinese traditions remain unchanged in the cosmopolitan environment of Taipei. Traditionally, Chinese prefer to die at home when they are terminally ill so that the dead can find their way home in their afterlife. However, due to the space limitations of modern buildings, the vast majority of terminal cancer patients die in hospitals in Taipei (Chen et al., 2004b). In 1980, the Welfare Act for Older People was enacted in Taiwan. This legislation ensures the rights of older people in preventive services, health care, rehabilitation services, pension, housing arrangements, and labor market participation, to name a few examples. In Taipei, elderly citizens are provided with free annual physical checkups, National Health Insurance (NHI)-based health services and community-based health professional services. The latter includes physical therapy, occupational therapy, nutritional therapy and respiratory therapy, and is available to all elderly people in need. Compared with other cities or counties in Taiwan, Taipei provides more comprehensive community-based services, which are not included in the NHI program.
2. Population aging and its impacts in Taipei 3. The health-care system for older people in Taipei Taipei has a population of 2.6 million. People aged 65 years and over account for 12.6% of the total population in Taipei, which exceeds the national average of 10.6% for this population (Department of Statistics, Ministry of Interior). The life expectancy of Taipei citizens is also longer (79.9 years for men and 84.4 years for women) than the national averages (75.5 years for men and 81.7 years for women) (Department of Statistics, Ministry of Interior). Overall, the citizens of Taipei may be considered healthier and
Fig. 2. Crude fertility rate and mortality rate of Taiwan from 1982–2009.
3.1. General health-care system In Taiwan, health services are covered by the NHI with over 97% of all residents and over 99% of health-care institutes included in the coverage (Chiang, 1997). This creates a near-universal level of health-care services in Taiwan. In Taipei, there were 40 hospitals and 2,970 clinics by the end of 2008, which makes Taipei the country’s most abundant source of acute hospital bed resources (35.0 beds per 10,000 people) and physician services (30.0 physicians per 10,000 people) (Department of Health, 2008; The Statistics Analysis of Medical Care Institution’s Status & Hospital’s Utilization, 2008). Generally speaking, people aged over 65 spend over one-third of the annual NHI expenditures in Taiwan (Fig. 3). Therefore, the sharp increase in elderly population is expected to cause an even sharper increase in health-care expenditure. A national survey conducted in 2003 found that over 85% of all older persons had at least one chronic illness, and 64% had two (Survey of Health and Living Status of the Middle Aged and Elderly in Taiwan Survey Report, 2003). In 2007, the Taiwan Longitudinal Study on Aging indicated that 15.0% of older Taiwanese had various impairments in their activities of daily living, and 47.6% had impairment in their instrumental activities of daily living (Bureau of Health Promotion, Department of Health, R.O.C.).
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diseases and end-stage renal disease. To avoid over-hospitalization of end-of-life care, a pilot program to step-up care homes to provide end-of-life care in communities is being launched in 2010. 3.4. Comparisons of health-care service delivery in Asian cities
Fig. 3. The relationship of population aging and health-care expenditure in Taiwan (2000–2008).
3.2. Geriatric health-care services Health-care services in Taiwan feature specialty-based practices, a self-referral system, and disease-oriented treatment which results in a fragmentation of health-care services. Nevertheless, older people usually need a holistic approach, integrated services and an emphasis on functional improvement; all great challenges to the current health-care system. In 2006, Taipei Veterans General Hospital (VGH), the country’s largest public hospital, started the first integrated geriatric outpatient service in Taiwan by affiliating internist/family practitioner, neuropsychiatric doctors and rehabilitation specialists to provide one-stop care and medication reviews for all patients to optimize medication use. Implementation of the service involved the affiliation of two community hospitals to commence community hospital-based intermediate care services. All patients received 4-weeks of comprehensive, geriatric assessment-based, multidisciplinary team care. In 2009, following positive results from the VGH program, the Bureau of NHI launched an integrated outpatient service to promote the quality of chronic disease management, especially for elderly patients with multiple comorbidities. The current NHI program provides acute care services and some long-term care services, but intermediate care services are lacking. Older people discharged from acute hospitals without proper intermediate care for functional recovery can experience significantly poorer clinical outcomes in the ensuing 12 months (Young et al., 2005). In Europe and the United States, where the same challenges exist, an intermediate care service was developed (mainly in Europe) and a post-acute care service was developed (U.S.) to actively promote functional independence after treatment of acute illnesses. The Taipei VGH program has significantly improved short-term functional independence for older patients after major acute illnesses (Lee et al., in press) and this short-term functional improvement has also significantly reduced the 12-month mortality risk by 64.4% (Chen et al., 2010). In 2010, the Bureau of NHI formally committed to a national pilot program of post-acute care services. 3.3. End-of-life care For end-of-life care, Taipei piloted the first hospice and palliative care service in 1985. Initially, hospice and palliative care focused on terminal cancer patients only, and both a home-care model and inhospital hospice unit care model have been well-developed (Lai and Su, 1997). In 2009, the hospice and palliative care services began to cover several other non-cancer end-stage diseases, including acquired immunodeficiency syndrome, dementia, severely disabling stroke, congestive heart failure, liver cirrhosis, chronic lung
The health-care service delivery systems for older people in the Asian cities of Taipei, Tokyo, and Hong Kong are essentially quite similar. “Ageing in place” is the most common scenario in these cities so the health care and long-term care services for older adults are also community-based. However, health-care services for older adults in Beijing are not well-developed due to a lack of improvement in geriatric services and long-term health-care. Moreover, the national birth control policy in China has caused a significant burden due to the rapidly increasing elderly population. Currently, older people with severe disabilities in Beijing are often cared for in hospitals because of the lack of long-term care services. In Tokyo, Hong Kong and Taipei, population aging and economic achievements are parallel, but economic development is somewhat behind population aging in Beijing. Therefore, although the aging rates of Tokyo, Hong Kong, Taipei and Beijing are similar, the development of geriatric and long-term care services is of particular importance to Beijing. To cope with the escalating growth of the elderly population in Taiwan, Taipei VGH initiated several pilot geriatric service models, beginning in 2006. These have been successful, and have produced significant improvements in the quality of health care for older people, including outpatient, inpatient, intermediate care and even long-term care services. The unique experiences of Taipei may spur other Asian countries to develop culturally appropriate health-care service systems in the future. With the advantage of a common Chinese cultural background and language, Taipei can provide practical recommendations for Chinese societies worldwide. 4. Long-term care services in Taipei Across all forms of long-term care services, home-care services may be the earliest model developed in Taiwan. The public health situation in the 1950s was a driving force for home-care. Similar to experiences of other countries, home-care services progressively became the most important model of long-term care services in Taiwan (Steel et al., 1998). In the 1990s, home-care nursing institutes providing home-based, long-term nursing care have become the most popular model of long-term care services and were reimbursed by the NHI. However, the current home-care model, which provides mainly nursing procedures such as nasogastric tube replacement, urinary catheter replacement, tracheostomy tube replacement and certain wound care services (e.g. pressure sore and stoma care), do not meet the many and complex needs of those receiving care, particularly the elderly. According to the NHI inclusion criteria, all home-care recipients must be severely disabled and need some form of long-term nursing care, which does not cover the many other home-care needs. Overall, 4000 Taipei citizens receive home-care services and home-care providers are almost exclusively hospital-affiliated home-care nursing institutes (Wu et al., 2007). Although the NHI only reimburses home-care nursing services, home-based physical therapy, occupational therapy, nutritional therapy and respiratory therapy are reimbursed by the Department of Health of Taipei City Government. Due to the success of the aforementioned home-based professional therapy in Taipei, the national Ten-Year Long-Term Care Program formally included all professional home-care services and extended the scope into social services like personal care, meal delivery services, day services, respite care services, transportation services, and many other social services (Department of Health, Taipei City
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Government). Additionally, to cope with the rapidly increasing elderly population and long-term care needs, a National Long-Term Care Insurance will be launched in 2012 to provide seamless care for older people, from health-care to social welfare. In addition to home-care services, there are 15 skilled nursing facilities (1038 beds) and 160 long-term care facilities (6379 beds) in Taipei to provide institutional long-term care services. Until recently, institutional long-term care has been self-funded. The pending National Long-Term Care Insurance plans to partially reimburse the institutional care of severely disabled older people. Characteristically, there is a national long-term care facility accreditation system to ensure the quality of care for residents. The license of institutes not passing the accreditation will be suspended. A major challenge for long-term care services in Taipei is the integration with health-care services. In this cost-containment era, the reduction of hospital beds and hospital lengths-of-stay further strengthen the need for communities to look after sub-acute and post-acute patients. A seamless integration between health-care and social care services should be bridged by an intermediate care service. However, in the spectrum of care, patient-centered care should be delivered by interdisciplinary teams across different settings of care. Traditionally in Taiwan, physician participation in long-term care services has been uncommon, except for physician visits in home-care services. However, nowadays, to successfully bridge health-care and long-term care services, physicians should play a more active role instead of merely referring patients for services to ensure the quality of health care. 5. Development of geriatric medicine The first academic organization for the study of elderly care, the Gerontological Society of Taiwan, was established in 1982. It was a purely academic platform for all researchers to share their expertise, but no clinical geriatric service was developed. Years later, National Taiwan University Hospital and Taipei VGH, the two leading national medical centers in Taiwan, began offering clinical geriatric services. However, both institutions closed these services in the 1990s due to the, then, limited proportion of elderly population in Taiwan. In 2004, the National Health Research Institute launched the first geriatrics fellowship training program with assistance from Mt. Sinai Medical School of New York. The pilot program ended in 2006 due to budget limitations. In 2006, Taipei VGH also started its own geriatrics fellowship training program through a collaboration with the British Geriatrics Society. This international collaboration continues. Geriatrics is deemed a subspecialty of internal medicine, family medicine, neurology, psychiatry and rehabilitation medicine, which is similar to the current U.S. model. To date, there are nine training centers in Taiwan, with three in Taipei. Due to the specialty-based practice pattern, the key goal of clinical geriatric services in Taiwan is to integrate clinical services into a holistic model. In addition to research and education, geriatricians in Taiwan play important roles in intermediate care and long-term care services. In the future, the development of geriatrics in Taiwan will focus on extending clinical services and integrating more care resources to promote seamless care across the health-care settings. The main challenge for geriatricians in Taipei is research development. Difficulties in obtaining research grants for geriatrics are almost universal worldwide; however, more research activities must be developed to ensure the future of geriatrics in Taiwan. 6. Conclusions Population aging is an epidemic in Asia, and the impact of population aging varies from country to country. Taipei, as an
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