2. TITLE AND SUBTITLE Health manpower in a developing economy: Taiwan,a case study in planning 3. AUTHOR(S) Baker, T.D.; Perlman,Mark 4. DOCUMENT DATE i5. NUMBER OF PAGES i 6. ARC NUMBER 1967J 215p.J ARC 7. REFERENCE ORGANIZATION NAME AND ADDRESS Johns Hopkins 8. SUPPL.EMEN TARY NOT ES (Sponaaotlng Otdanlzatlon. Pubtiahetag A vallablity) 9. ABSTRACT (HEALTH R & D) 10. CONTROL NUMBER PRICETI. OF DOCUMENT PN-AAD-277 12. DESCRIPTORS 13. PROJECT NUMBER 14. CONTRACT NUMBER CSD-832 Hes. Is. TYPE oF DOCUMENT AID Sgo0-i (4-741 II A A P - 27"7 HEALTH MANPOWER IN A DEVELOPING ECONOMY 0 TAIWAN, A CASE STUDY IN PLANNING lyr 0w t 0 BY TIMOTHY D. BAKER / AND MARK PERLMAN THE JOHNS HOPKINS MONOGRAPHS 0 " IN INTERNATIONAL HEALTH HEALTH MANPOWER IN A DEVELOPING ECONOMY: TAIWAN, A CASE STUDY IN PLANNING I2 HEALTH MANPOWER IN A DEVELOPING ECONOMY: TAIWAN, A CASE STUDY IN PLANNING BY TIMOTHY D. BAKER AND MARK PERLMAN THE JOHNS HOPKINS PRESS BALTIMORE, MARYLAND COPYRIGHT ( 1967 BY.THE JOHNS HOPKINS PRESS, BALTIMORE, MARYLAND 21218 LIBRARY OF CONGRESS CATALOG CARD NUMBER 67-22892 MANUFACTURED IN THE UNITED STATES OF AMERICA ALL RIGHTS RESERVED BY THIS BOOK WAS ORIGINALLY PREPARED UNDER A GRANT THE UNITED STATES AGENCY FOR INTERNATIONAL DEVEI.OPMENT. PREFACE IN 1704 a book called An Historicaland GeographicalDescriptionof Formosa, an Island Subject to the Emperor of .7apan, was written by George Psalmanaazaar, "a native of the said island, now in London." Although Psalmanaazaar was supported by the Church of England and respected by Samuel Johnson, who said of him, "I should as soon think of contradicting a Bishop," the book was pure humbug. Even the title was false, for at that time Formosa was subject to the Emperor of China. Not only was Psalmanaazaar not "a native of said island," he had never been there. This study of ours may likewise be subject to errors; but at least we have been there. This volume is the result of two and a half years of collaboration between the Division of International Health of The Johns Hopkins University, the Health Division of the Joint Commission for Rural Reconstruction of the Republic of China, and the Provincial Health Department of Taiwan. The major source of financing was a grant from the Agency for International Development to The Johns Hopkins University. The study is the first in a series of four Johns Hopkins' health manpower surveys; the others are being carried out in Turkey, Peru, and Nigeria. These studies developed from our conviction that planning for human resources in the health field is essential for adequate health services in newly dcveloping nations. This book was designed to serve a dual purpose-to assist the government of Taiwan in its planning for the next twenty years, and to develop methods of health manpower analysis. Lessons learned in this study may be applied to professional manpower planning in other developing nations. vi / PREFACE In the fall of 1961 we learned of the interest of the government of Taiwan in a joint research project. In March, 1962, after a series of conferences, an agreement was reached to carry out this research project in Taiwan. Preliminary plans were developed during the next three months. Field work was initiated in Taiwan in June of 1962. Our research consisted of five substudies: (1) a complete census of all health workers on the island; (2) a random sample survey of twelve thousand households to determine medical care demands; (3) an analysis of the results of the joint entrance examinations of the past five years; (4) a survey of the medical training institutions of the island; and (5) a student-attitude survey in the colleges of medicine, nursing, dentistry, and pharmacy. We would like to thank a number of persons and agencies who contributed significantly to the success of our study. The Joint Commission for Rural Reconstruction gave us office space, ad­ ministrative services and, above all, the assistance of Dr. S. C. Hsu, Dr. K. K. Chang, and Dr. L. P. Chow of their Rural Health Division. Dr. Chang was instrumental in the administration of the project during our absence; without his assistance, we would have very little solid data. Dr. Chow worked full-time with us on the design of several of the substudies. He is the author of Appendix II, The Sampling Frame. Dr. Hsu was always available for consulta­ tion and help in solving our problems. Commissioner C. H. Yen, and Commissioner T. C. Hsu of the Provincial Health Department not only gave us ideas and good advice but provided office space, transportation, and staff during the first months of the study. The deans and directors of the medical and nursing schools were most generous in giving us ideas and information. Dean Wei, Dean Tu, General Yang, General Loo, General Peng, Miss Hsu, and Miss Li were particularly helpful. The staff of the Agency for International Development (AID) Mission in China facilitated our work in many ways. Dr. Ronald Freedman of the Michigan Population Studies Center, who was working in Taiwan, was most generous in advice on the initiation of our project. His assistant, Dr. John Takeshita, was invaluable in the development of our Institute for Inter­ viewers. Dr. William Reinke, Biostatistician for the Division of International Health, deserves full credit for our inultivariable analysis, a basic component of our projection method. He is the author of Appendix I, dealing with multivariable analysis. PREFACE / Vii We thank Dr. Abel Wolman, Dr. Carl Taylor, Dr. S. C. Hsu, Dr. L. P. Chow, Dr. Harald Frederiksen, Dr. Oliver McCoy, Mr. J. G. Goellner, Mr. Ralph Berry, Miss A. C. Hsu, and the other readers of our manuscript who made many helpful suggestions. We were able to incorporate many of their suggestions into our revised draft. In conclusion, we would like to express our gratitude to the thirty-five public health nurses of Taiwan who served faithfully and well under extremely arduous working conditions. Without them there would have been no study. We hope that readcrs concerned with the development of health services in Taiwan will be able to use this document to good ad­ vantage. We hope that those interested in the fields of health planning and manpower planning will find the methods and ideas presented in this book both useful and interesting. NOTE Taiwan refers to Taiwan Province of the Republic of China. Taiwanese refers to all persons living in the province of Taiwan, regardless of province of birth. In a few instances mainland-born Chinese citizens are differentiated from Taiwan-born Chinese citizens. "Overseas Chinese" refers to persons of Chinese origin who come from Hong Kong, Malaya, etc. CONTENTS PREFACE . .......... ......................... v CHAPTER 1. WHY HEALTH MANPOWER? WHY TAIWAN? I Significance of health manpower studies. Reasons for choosing Taiwan as an experimental model. CHAPTER 2. ILHA FORMOSA-BEAUTIFUL ISLAND . 6 Introduction to history, geography, education, people, economy, and government for readers unfamiliar with Taiwan. CHAPTER 3. SIXTY-SIX THOUSAND INTERVIEWS AND OTHER SOURCES OF DATA ... ........ 29 Methods of data collection, and solutions to the problems en­ countered in conducting our: (1) islandwide household survey; (2) health workers' census; (3) joint medical school entrance examination substudy; (4) .student attitude survey; and (5) medical training institutions survey. CHAPTER 4. PHYSICIANS, HERBALISTS, AND QUACKS 46 Detailed information on Taiwanese medical schools; educa­ tion of practicing physicians; types of practice; the number, distribution, age, sex, income, prestige, and national origin of Taiwanese physicians. This chapter supplies data for the surprising conclusion that there will be a shortage of doctors by 1973, which could grow progressively worse. The herbalist and the unlicensed doctor are discussed less ex­ tensively than physicians, since they are of decreasing impor­ tance in Taiwan. CHAPTErt 5. NURSES AND MIDWIVES .... ......... 77 This chapter is critical. At the time of our survey there were ix CONTENTS fewer nurses than doctors in Taiwan. However, the nursing profession is changing rapidly. It now appears possible to increase the number of nurses fast enough to meet the rising demand for them. The section on midwives is relevant to health planners, mater­ nal and child Health Institute (MCH) workers, and family planners in developing nations. Over half of the 400,000 annual deliveries in Taiwan are attended by midwives. Many deliveries are unattended. CHAPTER 6. DENTISTS AND PHARMACISTS ... ...... 93 Of the 1,600 persons practicing dentistry in Taiwan, 1,200 have little or no formal training. Taiwan's licensed dentists are aging, without replacement. The island's four dental schools are suffering from tremendously high drop-out rates. This chapter describes the problems of dental practice and dental education. There is one pharmacist for 8,000 people; one drugstore for 800 people. Taiwan is not so much short of pharmacists as over­ run with drugstores. Most of these stores are not adequately licensed or staffed. The competition is all but economically ruinous. Because young pharmacists cannot make a living running drugstores, they seek work as drug salesmen. CHAPTER 7. ENVIRONMENTAL SANITATION WORKERS -FROM POLLUTED WELLS TO PURE WATER ...... ................... 104 Since sanitation workers are not subject to the same type of demand as other health workers, their supply and demand are treated together in this chapter. Although sanitation is more a responsibility of public works than of public health in Taiwan, this chapter has some relevance for the health manpower planner. CHAPTER 8. THE BIOLOGICAL BASIS OF DEMAND FOR MEDICAL CARE .... ........... 112 The basis of demand for medical care in terms of morbidity and mortality patterns on the island. Some data from Tai­ wanese health department sources, some from our sample survey of 66,000 Taiwanese residents.