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Canadian Family Physician•Le Médecin de famille canadien Vol 54: july • juillet 2008Community of care
Chi-Hua Yen
MD MSChun-Chieh Chen
MD PhDShiuan-Chih Chen
MD PhDErnest Y.T. Yen
MD DrPHMing-Chih Chou
MD PhDMeng Chih Lee
MD PhD MPHS
haped like an elongated sweet potato, Taiwan mea- sures about 144 km wide and 394 km long (around 36 000 km2), slightly smaller than the Netherlands.Taiwan lies 160 km east of China1 and has a population of 23 million. Its rapidly growing economy includes a yearly per capita income of $15 000 (US).2
Taiwan has had a long history of community medi- cine, from the traditional Chinese medicine of antiq- uity to the modern medicine of the 20th century. In the 1950s and 1960s, community health centres were the main primary care facilities in most Taiwanese towns.
The successful eradication of infectious diseases, includ- ing malaria and smallpox, and the generally longer life expectancy were achieved through the work of general practitioners at community health centres.
In response to the World Health Organization’s 1977 call for “health for all,”3 the Department of Health (DOH) sup- ported the National Taiwan University in starting a fam- ily medicine residency training program that same year to improve access to primary care.4-5 The Taiwan Association of Family Medicine was established in 1986, with authori- zation from the DOH to accredit family medicine residency training, utilize community health centres for main ambu- latory teaching sites, and place primary care physicians in underserved areas. In 2003, the DOH required all first-year residents, regardless of their specialization, to complete 1-month community medicine rotations at one of the com- munity health centres. Beginning in 2006, the requirement increased to 2-month rotations for first-year residents; the curriculum is shown in Table 1.
Cumulative changes
The first community health centre was established in 1941 by the National Taiwan University to train medi- cal students in community-oriented medicine. This idea was drawn from Dr John B. Grant’s successful expe- riences with the Beijing Sunrise Community Health Center in 1923.6 In 1951, Dr Grant advocated training general practitioners at community health centres in Taiwan to help meet the health needs of those com- munities. By 1952 a total of 361 health centres had been established, and each township had a community health centre to provide both medical and preventive care to its residents. Taiwan experienced rapid socio- cultural change in the 1970s and was proud of its “eco- nomic miracle.” However, about one-third of townships were still considered to have primary care physician shortages, and around 25 townships (7%) were con- sidered underserved. Moreover, the offshore islands, the high mountains, and natural disaster areas, among others, were lacking physician services. When the first family medicine residency training program began in 1977, it used the community health centres in under- served areas as main ambulatory care training sites.4 Outreach community mobile clinics were organized to direct medical care services to the underserved and the underprivileged populations, including the elderly, the poor, the unemployed, the mentally ill, and the for- eign labourers. Several hospitals, medical centres, and community hospitals combined their resources to open family medicine residency programs.
Letter from Taiwan
Table 1. Community medicine training for first-year residents as of January 2006
MonTH CurriCuLuM DESCriPTion
First month:
basic training Holistic care • Biopsychosocial model
• Health promotion and disease prevention
Community-oriented primary care • Community diagnosing: planning, executing, and evaluating
• Role and function of primary care physicians Integrated delivery system • Community health care networking
• Community-based mental health care Second month:
advanced training
Practice of community health projects • Community health construction
• Health promotion for families, schools, and workplaces Integrated health care delivery system • Community medical care team
• Community health team
Long-term care • Home care
• Institutional care
Utilization of community resources • Resources for children, adolescents, disabled people, and the elderly
• Resource and community networking
Reflections
•Réflexions
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Starting in 1983 through to the late 1980s, many family physicians were trained, mostly in the tuition- free medical education programs. With the financial support of the DOH, they established primary care group practice models at the community heath cen- tres to serve the underprivileged populations of underserved areas. The DOH has also implemented medical care networks and, in 1995, instituted the National Health Insurance Program. Both programs depend on family physicians to provide cost-effective, high-quality health care.
In 2006, after the establishment of the Taiwan Association of Family Medicine, there were 73 family medicine residency programs in Taiwan, 5000 certified diplomats, and 180 first-year resident positions open per year, equaling 14% of medical school graduates in Taiwan. Since 2006, a total of 4 months of required and 4 months of elective community medicine rotations at community health centres have become part of all fam- ily medicine training program curricula.
new challenges
Although more than 75% of Taiwanese people approve of the National Health Insurance Program, the pro- gram is experiencing financial strain. The payment system has prompted a shift from the traditional fee-for-service model to a managed-care system with a global budget and patient capitation. With this shift toward managed care, even more primary care physi- cians are needed. In response to the growing demand for primary care physicians and owing to the severe acute respiratory syndrome crisis, the DOH is planning
an ambulatory-based teaching program for all resi- dents, regardless of specialization.
Community health centre rotations have success- fully exposed residents to community medicine educa- tion and have been useful in training family medicine residents to practise in the underserved areas. This venture has enabled Taiwan to produce more primary care–oriented physicians who are ready to meet the needs and demands of the general population under the National Health Insurance Program.
Dr C-H Yen, Dr C-C Chen, Dr S-C Chen, Dr Chou, and Dr Lee are physicians in the Department of Family and Community Medicine at the Chung Shan Medical University Hospital in Taichung, Taiwan. Dr E. Yen is a physician at the Family Health Center in Harbour City at the University of California in Los Angeles.
Competing interests None declared
References
1. GlobalSecurity.org. Taiwan geography [website]. Alexandria, VA:
GlobalSecurity.org; 2008. Available from: www.globalsecurity.org/military/
ops/taiwan-geo.htm. Accessed 2008 May 15.
2. Bureau of Health Promotion. Taiwan public health report 2005. Taipei, Taiwan:
Department of Health, Republic of China; 2006. Available from: www.bhp.
doh.gov.tw/english/category.php?table=publications&page=list&pid=17
&cate=90. Accessed 2008 May 15.
3. World Health Organization. Executive summary: achieving health for all. Geneva, Switz: World Health Organization; 1998. Available from: www.who.int/
whr/1998/media_centre/executive_summary6/en. Accessed 2008 May 15.
4. Yen EYT, Lee MC. Family practice residency training programs in Taiwan.
Taiwan J Fam Med 2001;11:107-16.
5. Gladfelter T, Brownlee HJ, Aucremann CE. Family practice in Taiwan. J Fam Pract 1986;22(1):87-8.
6. Chen CC, Yen YET, Yen CH, Chen SC, Lee MC. Community-oriented family practice. Taiwan J Fam Med 2004;14:113-20.
A typical community health centre. The first floor is a community clinic and the second floor is an office for community medicine teaching and community health administration.
