The 2021 ECCT EU-Taiwan Healthcare Forum brought together experts from Europe and Taiwan to discuss solutions for today's most urgent healthcare challenges. The forum was organised by the ECCT, with the support of the European Economic and Trade Office (EETO) and the National Development Council (NDC) acting as an advisor. Under the theme "Sustainable Healthcare through Public Private Partnership", medical experts from the public and private sector in Europe and Taiwan shared ideas for sustainable and cost-effective healthcare, using AI and other technologies to reduce the disease burden and improve health outcomes, the future vaccination ecosystem, and how to tackle Taiwan's ageing population and low birth rate.

The event began with opening remarks by guests of honour Vice President Lai Ching-te, Guillermo Martinez, Deputy Head of the European Economic and Trade Office, and ECCT Chairman H Henry Chang. This was followed by presentations in four sessions and a lunch that featured a keynote speech by Dr Chen Shih-Chung, Minister of Ministry of Health and Welfare (MOHW) and a panel discussion between speakers from the morning session that was moderated by former Vice President Dr Chen Chien-jen, who is currently a Distinguished Professor at Academic Sinica. The event was concluded with remarks by Dr Yu Chien-hwa, Deputy Minister of the NDC. Presentations by speakers from Europe were pre-recorded and shown at the event while speakers from Taiwan participated in person. 

In his opening remarks Vice President Lai called upon Taiwan and European countries to deepen their partnerships and create more business opportunities, as they seek to gradually resume economic activities and reopen their borders. In particular, he highlighted supply chains and the production of vaccines as potential areas of cooperation.

In his remarks, ECCT Chairman Henry Chang said that the pandemic had provided some valuable lessons and produced some remarkable scientific developments. This included the development of extremely effective vaccines and treatments in record time. However, he noted that the pandemic has also exposed weaknesses in national healthcare systems, governments, and global institutions. In addition, there is a risk that preoccupation with the pandemic will divert focus from other urgent healthcare-related issues, particularly Taiwan's rapidly-ageing population, along with which comes the rise of non-communicable diseases.

Session 1
In the first presentation of the session, Dr Stefano Stuard, Senior Vice President and Chief Clinical Officer for Europe Middle East and Africa (EMEA) for Fresenius Medical Care spoke on the topic "Big data and Artificial Intelligence in Healthcare – Experience in kidney disease". He cited statistics from the National Kidney Foundation, which estimates that 10% of the global population is affected by chronic kidney diseases, out of which, more than a million die each year due to the lack of affordable treatments. An ageing global population together with continuing increases in the prevalence of key risk factors for the development of kidney disease, such as hypertension and diabetes, mean that the incidence, prevalence and costs of kidney failure will continue to rise in the future. The increased demand for kidney replacement therapy will lead to an increase in the uptake of haemodialysis, which will pose substantial economic challenges for healthcare systems worldwide.

Kidney replacement therapy absorbs up to 5-7% of total health-care budgets, despite the fact that kidney failure affects only 0.1-0.2% of the general population in most regions. The cost of dialysis (especially that of in-centre haemodialysis) is likely to continue to rise as the dialysis population increases.

While major technological advances in dialysis have been made over the past 20 years, they have not yet translated into longer patient survival or improved patient quality of life. Optimal predialysis care in preventing the cardiovascular damage that accumulates before the start of dialysis and timely creation of arteriovenous fistula (AVF) is a more effective and more economical strategy in the long-term outcome of dialysis patients, according to Stuard.

The use of smart monitoring devices (like smart watches), together with the application of digital analysis can help to preempt and prevent disease on a more personal level, rather than merely reacting to symptoms and accelerate diagnosis time.

In his presentation, Dr Hsu Chih-Cheng, Investigator and Deputy Director of the Institute of Population Health Sciences at the National Health Research Institutes (NHRI) gave a presentation on the subject "How to tackle the chronic disease by precision healthcare through public private partnership".

He began by noting that the disease burden will increase as a result of ageing. 16.8% of Taiwan's population is now over 65 and this percentage will rise to 20.7% by 2026 based on the current trajectory. Of the top 10 leading causes of death in Taiwan, malignant neoplasms (cancerous tumours) was No. 1, followed by heart disease, pneumonia, cerebrovascular disease (strokes) and diabetes mellitus. Meanwhile, Nephritis and other forms of kidney disease were also in the top 10. According to Hsu, the incidence of End Stage Renal Disease (ESRD) in Taiwan has increased by 34% over the past 18 years and Taiwan now has one of the highest ESRD prevalence rates in the world at 523 per million people and over 90,000 patients with chronic dialysis.

Individualised health promotion and precision healthcare using AI can provide early identification and risk prevention. According to Hsu, deep phenotyping provides an entire molecular profile of an individual's physiological status. When longitudinally tested, the pathways can be tracked to identify the progression of disease. Various omics technologies along with other physiological measurements will be used to molecularly characterise an individual's risk for disease. Further implementation of a systems approach to the big-data analysis and integration will provide a platform for machine learning and artificial intelligence (AI) in clinical decision-making for early disease risk identification and prevention.

AI precision models have been developed in the American VA system that may help to identify patients at risk of acute kidney injury (AKI) within a timeframe that enables early treatment while early detection of arteriovenous fistula aneurysms is now possible from uploading images taken on smart devices and accurately analysing them using AI. Meanwhile research continues to advance. Thousands of papers have been published in recent years on AI techniques and clinical applications of AI.

In Taiwan the government is assisting in the process to integrate precision health into the healthcare system. The BioTaiwan Committee (BTC) was established in 2019, endorsed by the Executive Yuan's Board of Science and Technology. The BTC has since made a number of recommendations to improve inter-ministerial coordination (especially between the Ministry of Science and Technology, the Ministry of Health and Welfare and the Ministry of Economic Affairs) to accelerate the development of the health industry, evaluate emerging medical technologies, build up a technological platform for genome diagnosis, construct a sustainable platform for big data in health where data can be accessed and shared, and cultivate talent.

The NHRI is working to develop collect and integrate big data in health, which includes collecting data from individual biobanks (25 out of 33 so far), establishing a common data model and standardised protocol to provide value added services and encourage innovative research. For example, the NHRI initiated a project for the Biobank Consortium of Taiwan in October 2019 to help establish standardised protocols for the best use/access of the medical database. The NBCT alliance aims to becomes an important biomedical research resource in Taiwan to provide value-added services for genetic analysis of biological samples, encourage innovative research and collaboration between Taiwan and international biomedical industries. The NHRI is now cooperating with firms such as Pfeizer, Merck and Novartis and hopes to promote more such public private partnership to act as a catalyst to facilitate precision healthcare.

Session 2
The first presentation in the second session was by Dr David Salisbury, Chair of the WHO Global Commission for Certification of Polio Eradication and Associate Fellow of the Global Health Programme at the Royal Institute of International Affairs, Chatham House, London. He gave a presentation on the topic "Adult vaccination: Factors that point to success". Taking data from immunisation programmes in the UK, particularly against influenza, herpes zoster, and invasive pneumococcal disease (IPD), he demonstrated how vaccination programmes have been successful in reducing mortality, particularly among older patients that are most at risk from these diseases, which is particularly relevant for the coronavirus.

He noted that seasonal influenza vaccine uptake was high in the UK among seniors but not so much for under 65s with risk factors. 80% of seniors in the UK took influenza vaccines even during the pandemic. The high uptake can be attributed to several factors but especially due to GP checklist and performance assurance process and targeted national advertising campaigns.

Under the GP checklist practice, the first step is to identify a named lead individual within the practice who is responsible for the flu vaccination programme who liaises regularly with all staff involved in the programme. The next step is to create a register that can identify all pregnant women and patients in the under 65 years at risk groups, those aged 65 years and over, and those aged two to three years, update the patient register throughout the flu season paying particular attention to the inclusion of women who become pregnant and patients who enter at risk groups during the flu season. Then, accurate data is submitted on the number of patients eligible to receive flu vaccine and flu vaccinations given to its patients, ideally using the automated function. The final item on the checklist is for GPs to order sufficient quantities of flu vaccines, taking into account past and planned improved uptake and expected demographic increase and to ensure that everyone eligible is offered the most effective flu vaccine for their age group consistent with national guidance.

Next comes the implementation phase. Here it is important to have robust scheduling, call and recall arrangements in place to ensure that everyone listed gets vaccinated. This includes sending a standard email to all patients to explain where they can get their seasonal flu vaccine, even during the pandemic, as well as a follow-up text message.

The speaker concluded that having a managed adult immunisation programmes is essential, data for management must be timely, complete and used and if coverage maxes out, then alternative strategies need to be used, such as the vaccination of children to interrupt transmission.

In his presentation, Dr Lee Ping-Ing, Associate Professor in the Department of Paediatrics at National Taiwan University Children's Hospital, spoke on the topic "Mobilizing diverse & sustainable financing to achieve immunization across the course of life". He noted that the government has a self-declared responsibility to improve the welfare of women children and promote preventive medicine. However, while Taiwan has largely succeeded in eradicating diseases like small pox and polio, immunisation does not get sufficient funding. According to Lee, only about half of the budget for vaccines is from government funding, while most of the rest comes from the tobacco tax.

He speculated that immunisation does not get enough attention because the results are not clearly visible. Disability-adjusted life year (DALY) assessments of the burden of disease analysis combines years of life lost due to premature mortality and years of life lost due to time lived in states of less than full health. However, the cost-effective analysis usually used for vaccines often underestimate the real value of vaccines.

He stressed that it is important to have sufficient independent funding for vaccines and to ensure that vaccines are provided to both the old and the young. He joked that a lot of funding goes to support things like cancer research but this mostly benefits the old when the national healthcare priority should really be to safeguard the health of the youth, since they represent the future.

Raising awareness of the importance of vaccines is essential to reverse the situation. This should include raising awareness to address vaccine hesitancy, increase vaccine acceptance, increase donations and the motivation of stakeholders to support vaccination programmes. Measures Lee recommended to increase awareness are public education, starting from primary schools, media education, continued education of medical professionals of preventable disease. This would help to increase funding, reduce vaccine hesitancy and increase acceptance.

He said that most parents are willing to pay in part for vaccinations as long as they are affordable so co-payment schemes are feasible and should be explored as part of the solution.

Session 3
The first presentation in the third session was given by Lo Yu-Mei, Senior Specialist for the National Development Council, on the topic of low fertility and population ageing in Taiwan.

The speaker began with an overview of Taiwan's demographic trends, showing a declining birth rate and rapidly ageing population. The fertility rate has fallen from 1.8 births per woman in 1990 to 1.0 births per woman in 2020. There are several reasons cited for Taiwan's low birth rate. First, given the social stigma attached to having children outside of marriage, the falling proportion of married women of reproductive age is a key factor. According to statistics cited by Lo, this proportion has fallen from 54.5% in 1999 to 41.7% in 2019. Moreover, in the 25-34 age group, the percentage has significantly dropped by nearly 30 percentage points, from 63.7% to 33.7%. A second reason is delayed marriage and childbearing. As women spend longer in education and starting careers, they are delaying marriage and their first birth to an average age of 30.4 and 31.0, respectively, while the proportion of mothers aged 34 and above at birth of first child has increased from 6.2% in 1999 to 29.4% in 2019. Given the fact that fertility decreases with age, this makes it more difficult for women to conceive and bear children. This situation is likely to worsen as the number of women of reproductive age (15-49), which peaked in 2020, is expected to drop by half by 2070.

One of the consequences of demographic trends is a rising burden on the working population. The working-age population peaked in 2015 and began to fall. The elderly population exceeded that of the youth in 2017. By 2070, the youth population is projected to have fallen by 1.6 million, the working-age population is projected to have fallen by 9.0 million, while the elderly population is projected to have increased by 2.8 million. In 2020, there were approximately 4.4 people of working age to support one elderly person. By 2070, the number will have fallen to 1.2 people of working age to support one elderly person. As a consequence, the number of people in Taiwan needing long-term care, including the elderly with disabilities, with cognitive impairment, and in frail health, will increase by an average of around 30,000 a year to between 920,000 and one million in 2026.

While there is no silver bullet to reverse the current trend, the government has adopted a number of policies, such as a national childcare policy aimed at boosting willingness to marry and have children, raising labour productivity, supplementing the labour supply and increasing capacity for caring for the elderly.

In his presentation, Alan Lovell, Senior Associate, Health Policy and Clinical Evidence for The Economist Intelligence Unit spoke about a report published earlier this year sponsored by Merck about how to address Taiwan's falling birth rate. The report looked at experience from four other countries: Japan, France, Singapore, and South Korea. Singapore and South Korea have put in policies such as prenatal and childcare subsidies, tax incentives, parental leave systems (90 days at 100% full salary in South Korea). South Korea also subsidises childcare. However, these have not yet made a dent in continuing decline in fertility rate.

Besides just focusing on the fertility rate, we should ask how can encourage people to marry given that there is a clear correlation between marriage and having children, how can we improve financial security for young people and the issue of IVF to address declining fertility rates.

There are three overarching themes: money, culture and Covid-19. On the subject of money, Taiwan spends relatively little on social support (11% compared to 30% in other developed countries). According to Lovell, there is a clear correlation between spending on family benefits and the fertility rate. As countries spend more, fertility tends to increase.

While money is important, cultural factors are also. He referred to study from the Netherlands, which has had a consistent fertility rate of 1.7 for the past five decades in spite of not having prenatal policies. However, the country provides strong cultural support for women, social welfare benefits and a flexible labour market. It also has more flexible parental leave policies and better childcare. Having good role models is also important. New Zealand's Prime Minister, for example set a good example by taking maternity leave after giving birth while in office. Housing is also important as is reducing long working hours of men.

Covid is making matters worse for fertility. A BBC report showed the lowest monthly birth rates in recent times.  

In conclusion, Covid-19 has sped up long term trends. Policies are important but also how they are implemented. There is no one size fits all. You also have to take into account specific situations on the ground. A solution in one country may not be suitable for another country.

In his presentation Dr Chen Ming-jer, Chairman of the Taiwanese Society for Reproductive Medicine, spoke about how to make Taiwan a better place to have a family.

He began by introducing the Taiwan Fertility Policy Think Tank, which aims to initiate public-private partnership to promote awareness on fertility-related issues. Stakeholders include the government (NDC and MOHW), the Fertility Society of the ROC, the Taiwan Fertility Policy Think Tank, research institutes (Academia Sinica and National Taiwan University) and industry partners.

Citing the report conducted by the Economist, there are several ways to increase fertility: encourage marriage, creating family friendly working environments, increasing awareness of the fertility age concept and accessibility and affordability of IVF treatment.

Recommended actions include encouraging people to get married earlier by providing things like affordable social housing, enabling a family friendly work environment by incentivising companies to have onsite childcare facilities, promoting better work-life integration (flexible work places and working hours) and increasing economic security. In this regard, the government could offer more grants, paid family leave, subsidised childcare costs and education. The government could also consider broadening eligibility for IVF subsidies to allow more patients to take advantage.

Session 4
In the fourth and final session, Dr CH Herbert Wu, President of the Development Center of Biotechnology, under the Ministry of Economic Affairs (MOEA) gave a presentation on the topic "The competitiveness of multi-sectors integration driving precision health development in Taiwan".

Transitioning from a "one-size-fits-all" approach to "precision medicine" will enable delivery of the right intervention to the right patient at the right time. By reducing or eliminating unnecessary treatment, it will also ultimately reduce medical expenses.

Precision health is about predicting and preventing disease, not just treating it. It takes a big-data approach to disease prevention and detection, focusing on the various factors that help maintain health throughout life and takes into account differences in people's genes, environments and lifestyles and formulates treatment and prevention strategies based on patients' unique backgrounds and conditions. Precision health combines data about an individual's genes, environment, and lifestyle with innovation and diverse partnerships to more precisely predict and diagnose disease, target therapies, and personalize health and wellness plans. Moving to a precision medicine will therefore require genomic information.

The Taiwan government has proposed various policies towards precision health and is part of President Tsai's six core strategies, which covers data science and biomedicine.

Several industry sectors are involved in precision health including nutrition, medical devices, pharmaceuticals, regenerative medicine and data systems.

Taiwan is ideally placed to develop smart health because of its advanced healthcare system, business environment, ICT capability and innovative biomedical industry. According to Wu, Taiwan has 626 applied biotech companies, 360 pharmaceutical companies, 1,157 medical device companies, 157 academic institutions, nine major research organisations, 145 PIC/s GMP facilities for western medicine, 29 GMP facilities for raw materials, 87 GMP facilities for Chinese medicine, 653 ISO13485/GMP facilities, as well as 20 clinical trial centres and 127 hospitals.

Taiwan also has interconnected biomedical clusters which make it easy to integrate drug, medical device, and smart agricultural value chains. The government is planning to rearrange its data systems to make healthcare data available for commercial use.

The speaker went on to cite some examples of case studies of smart health devices combined with data collection and analysis that can monitor patients' health, detect strokes, side effects from drugs, use AI and VR to a accelerate drug development.

In his presentation Szymon Bielecki, Programme officer in the European Commission's Directorate General for Communications, Networks, Content and Technology spoke about the ‘European 1+ Million Genomes' Initiative.

The initiative was launched in 2018 by EU member states with the objective to connect one million sequenced genomes in the EU by 2022, which would bring together data now distributed across many platforms and provide a sufficient volume of data for analysis. 24 countries have signed declaration and are cooperating to reach the goal. It is fully aligned with the EU's digital agenda and healthcare objectives.

The initiative aims to achieve better healthcare outcomes, better policy making, better research and innovation. Regulation will come out this year that will cover ethics for the use of AI in healthcare, data quality standards (format structure to be discoverable and analysed), infrastructure (IT to connect datasets without moving the data), and capacity building for users and citizens (such as what it means to consent to use data).

Why collaborate? Good experience from previous analysis of genomic projects showed that problem arise when there are consortiums and limited datasets in silos. To realise full benefits a larger scale is needed which can take advantage of data from multiple sources. Doing so would benefit people and industries by achieving quicker diagnosis, better and more personalised treatments. Eventually it would improve efficiency in healthcare systems through better diagnosis and more effective and efficient use of resources.

An organisation will be established next year to implement the initiative. The ministries of health and research from member states will participate in technical and use case working groups. Member state medical experts will consult with industry to ascertain their needs and listen to advice on equipment, services, skills and business models.

Keynote speech
In his keynote presentation during lunch MOHW Minister Chen shared some of Taiwan's efforts to contain the pandemic.

He noted how Taiwan's response had been informed by its experience with SARS in 2002-2003, which had led to adjustments in preparedness, training and response. Taiwan was ready to respond when the pandemic struck and has been successful thanks to proper resource allocation, open and transparent information, timely border control measures, smart community prevention and control measures, advanced medical technology and the good etiquette of citizens.

A valuable lesson from SARS was how a lack of cross-agency integration mechanism can cause chaos and panic. That is why, following SARS, Taiwan set up a Central Epidemic Command Center (CECC) to coordinate actions and communication. The CECC has been consistently open and transparent, publishing and broadcasting information about the pandemic on multiple channels and holding press conferences almost every day since the pandemic began in order to reassure the public.

Proper resource allocation started with the mask rationing policy while supplies were critical, which were gradually lifted as production was ramped up. Now Taiwan has a surplus of face masks, which can be sent to other countries.

Border control measures were introduced early and maintained but also adjusted when necessary. Chen joked that the CECC and MOHW often receive criticism, both that policies are overly restrictive or for not being restrictive enough. You will never be able to satisfy everyone but the CECC's approach is to err on the side of caution.

In terms of medical technology, Taiwan has established a technical support platform to accelerate the development of vaccines, drugs and rapid test kits. Meanwhile, the good etiquette of citizens has played an important role in containment.

Taiwan's few community outbreaks showed that people sometimes lie about their travel history. While they were pilloried in the media and society, it is understandable that they just wanted to come home. Another lesson from the pandemic is that tests are not always accurate. This means that it is possible that Taiwan has more cases than official figures suggest. However, as long as the quarantine policy is maintained, it is highly unlikely that there will be large community outbreaks in future.

As to vaccine procurement and priority, Chen said that, unlike other countries where the elderly are given vaccine priority, Taiwan has not done so because border restrictions mean that there is a much lower risk of community outbreaks which would put the elderly and those with pre-existing conditions at risk. This is why Taiwan has given vaccine priority to healthcare workers. Chen said that recent Covid-19 cases affecting airline pilots may necessitate moving airline staff higher up the priority list.

On the subject of border control measures, Taiwan has always made special arrangements for diplomatic visitors and there are ways to make special arrangements for business travellers (allowing them to apply for shortened quarantine periods). Looking ahead, the government will continue to adjust policies based on the situation. Since 1 March foreign residents have been able to enter Taiwan and short-term business travellers have been able to apply for shortened quarantine periods. Taiwan has also started to release a limited number of vaccines for self-pay. Authorities are also reviewing travel bubble options. Palau was chosen as a first test case because it had no Covid-19 cases. If experience from Palau is successful, the government may consider extending the implementation of travel bubbles.

Panel discussion
Following the keynote speech, speakers from the morning session participated in a panel discussion that was moderated by former Vice President Chen Chien-jen.

On the subject of vaccination policy, Dr Lee said that vaccination success depends first on having a sufficient budget. Taiwan's childhood vaccination programme has been successful to date. Instead of a physical vaccination card, an electronic database for children connected to the NHI system should be considered. Once again, this will require funds to create the software system. Taiwan could also learn from the UK's experience to ask doctors to urge patients who have not been vaccinated to do so. He added that the ban on vaccine promotion should be lifted. While it is reasonable to ban advertising of drugs, he said that banning promotion of vaccines is not reasonable. This is because there is no danger of abuse since no one can buy vaccines over the counter and not being able to promote vaccines is therefore counterproductive if Taiwan wants to increase uptake.

Raising awareness is very important. Just as awareness has been raised about the dangers of smoking, the benefits of vaccinations should also be promoted.

On a question as to how to promote digital health in Taiwan, public private partnership can help to develop precision healthcare. However, there are still challenges related to privacy protection, integration of health records, and disparate information silos in a lot of digital biobanks. Panellists said that the first step is for government to build sustainable platform to integrate the necessary resources for all parties and to create rules for access to data and how to balance privacy concerns. The industry and academia can also provide input based on international experience.

Chen noted that existing NHI data can give indications of which patients are at risk of developing renal disease, for example. This can help to monitor risks for all manner of diseases. Digitalisation will also make it easier to promote telemedicine and improve efficiency.

On the question of fertility, given the fact that women are choosing to give birth later in life, they will need more support in the form of longer recovery time, longer maternity leave and childcare subsidies.  

The NDC is taking a new look at what has been done and how to improve childcare support. In addition, social housing is high on the agenda of the president. Two years ago NDC pushed the NHIA to open data but it is not just the administration but also the general public that are concerned about data protection. Taiwan will follow the EU's GDPR but is working to strike a balance following opposition to new digital ID system, which has slowed down the process.

Closing remarks
In his closing remarks, Deputy NDC minister Yu said that NDC is encouraging more people to get vaccinated. In terms of fertility, one in ten women have fertility problems which is why the NDC is considering extending fertility subsidies. It will also continue to strengthen healthcare database and improve cooperation with Europe. He noted that Taiwan's demographic situation will become a national security issue given more healthcare needs and a shrinking labour force.