The implementation of universal health coverage in Taiwan has not decreased the urban-rural gap in either short-term or long-term psychiatric service use, according to a new study by researchers at National Taiwan University. This study has been published on 3 March 2015 in BMJ Open. The researchers come to this conclusion by analyzing the medical claims records of approximately 70,000 patients with psychosis who had been admitted to the psychiatric wards in Taiwan for the first time between 1998 and 2007.
“The results came to our surprise,” says Dr. Chih-Lin Chiang, the first author of this study, who is a MPH graduate from Taiwan and a practicing psychiatrist at Shin Kong Wu Ho-Su Memorial Hospital. Since 1995, Taiwan’s National Health Insurance (NHI), a compulsory health insurance program, has been providing over 99 pecrent of Taiwanese people with essential health services, including a wide range of psychiatric services. In urban and rural areas alike, this comprehensive coverage of psychotropic medications and psychiatric services by NHI should have gradually decreased the rural-urban gap in service accessibility of people with serious mental disorders, as the researchers initially hypothesized. In addition, since Taiwan is densely-populated, the problem of rural-urban inequity should have been easier to resolve in Taiwan than in other countries.
To evaluate the urban–rural inequality in mental health utilization, the authors chose a variety of quality indicators after discharge from the first admission: all-cause psychiatric readmission at 2 and 4 years, dropout of psychiatric outpatient service at 30 days, and emergency department (ED) treat-and-release encounter at 30 days. Their main findings revealed, between 1998 and 2007, the 4-year readmission rate decreased from 65 percent to 58 percent, the 30-day dropout rate decreased from 18 percent to 15 percent, and the 30-day ED encounter rate increased from 8 percent to 10 percent. Risk of readmission has significantly decreased in rural and urban patients, but at a slower speed for the rural patients (p=0.026). The adjusted HR of readmission in rural versus urban patients has increased from 1.00 (95 percent CI 0.96 to 1.04) in 1998–2000 to 1.08 (95 percent CI 1.03 to 1.12) in 2005–2007, indicating a mild widening of the urban–rural gap. Urban–rural differences in 30-day dropout and ED encounter rates have been stationary over time.
The negative finding of this study has important policy implications, pointed out by Dr. Wei J. Chen, the corresponding author of this study and Dean of College of Public Health at Taiwan. In recent years, universal health coverage has been often heralded as an indispensable measure to resolve health inequity. However, policy makers should be aware that a trickle-down progress is usually seen during the expansion of health services. Beyond the expansion of health coverage, equity in quality of care and resource allocation should be simultaneously achieved during the pursuit of health equity. Many middle- and low-income countries have been transforming their health systems, and Taiwan’s experience may serve as a valuable lesson to them.