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Unpublished Paper
A Costly Illusion? An Empirical Study of Taiwan’s Use of Isolation to Control Tuberculosis Transmission and its Implications for Public Health Law and Policymaking
ExpressO (2012)
  • Shinrou Lin
Abstract
The resurgence of tuberculosis (TB) and the emergence of multidrug-resistant TB have resulted in the detention of patients in a number of international jurisdictions since the 1990s, including in Taiwan. The Taiwanese government adopted isolation as an official policy to control TB’s spread in its 2006 Ten-Year Mobilization Plan, whose goal is to halve TB incidence from 66.7 per 100,000 persons to 34 per 100,000 persons. The isolation program allows treating physicians to nominate patients for isolation while public health officials may also isolate patients if necessary. Hospitals providing care to isolated patients would be reimbursed from the budget of the Centers for Disease Control (CDC) based on payment standards set by the National Health Insurance program (NHI) rather than from the NHI’s pool based on floated point-values under the NHI’s global budget scheme. An empirical study was designed to specify how Taiwan’s stated isolation regulatory scheme was implemented during its first three years (2006-2008). Results were then examined for relevant implications for public health law and policy in Taiwan using Lawrence Gostin’s evaluation framework for public health regulation. Qualitative semi-structured interviews were conducted between March and July 2009 with two groups: local health officials (fifteen individuals from ten local health administrations) and health care workers at hospitals designated for isolation (fourteen individuals from eight sites). Interview results revealed that treating physicians played a critical role in initiating the isolation processes. Treating physicians identified TB patients who had sputum smear positive test results and consented to hospitalization to the local health administration as candidates for isolation. A strong correlation was found to exist between treating physicians’ referrals for isolation and the full reimbursement incentives provided by the government’s isolation program. Local health officials were found to be deferential to physicians’ referrals in the review process but were more conservative in initiating isolation themselves. Only a few isolation processes were initiated by public health workers to ensure treatment of allegedly uncooperative or non-compliant patients, but these patients were typically from socially vulnerable groups. Interestingly, some allegedly uncooperative patients were not pursued for isolation, and those isolated did not always complete a full course of treatment. The actual application of TB isolation regulatory scheme raises concerns about the legitimacy of isolation as a public health policy in view of Gostin’s five-criteria public health regulation framework: significant risk, the effectiveness, the reasonable cost, the least restrictive measure and the fairness. The interview results suggested that to implement successful tuberculosis control while giving consideration to personal burdens, policy-makers need to pay more attention to the regulatory design to ensure that the exercise of isolation power is necessary, unbiased, and procedurally guarded. Specialized hospitals with proper security, personnel and facilities are also crucial in assuring the effectiveness of isolation by providing a suitable environment and essential medical services for isolated patients.
Keywords
  • tuberculosis,
  • detention,
  • regulation,
  • public health
Disciplines
Publication Date
April 22, 2012
Citation Information
Shinrou Lin. "A Costly Illusion? An Empirical Study of Taiwan’s Use of Isolation to Control Tuberculosis Transmission and its Implications for Public Health Law and Policymaking" ExpressO (2012)
Available at: http://works.bepress.com/shinrou_lin/1/