Written by Jillian Sprenger In 2016, the United Nations General Assembly committed to tackling the growing global threat of antimicrobial resistance (AMR). Around the same time, it was projected that if AMR were to continue to spread at the current rate, it could cause up to 10 million deaths around the world per year by 2050. As a major threat to the attainment of the Sustainable Development Goals, particularly in developing countries, it is clear that this is a pressing problem. In Taiwan, rampant overuse of antibiotics has been a major cause for concern over the years. Interestingly, the structure of the Taiwanese health system itself is a major factor contributing to overuse. Run under a national health insurance system, doctors claim reimbursement on a fee-for-service basis, including for the prescription of drugs. Doctors are encouraged to prescribe so they can retain their patients, who frequently insist on receiving medication. In fact, throughout the 1990s, approximately 30% of Taiwanese people diagnosed with a common cold were given antibiotics, even though the cold is a viral rather than bacterial infection. In addition, due to short wait times and poor gatekeeping to specialist services, patients often seek second or third opinions from several doctors, and can receive more than one prescription. Since the early 2000s the Centre for Disease Control of Taiwan has made significant efforts to curb antimicrobial resistance, demonstrating considerable political will. How did Taiwan accomplish this, what strategies did they take, and which were most beneficial? More importantly, could lessons be learned from Taiwan’s efforts that could then be applicable to other global contexts? These questions formed the basis of several weeks of field research in Taiwan, where I interviewed policymakers, medical doctors, and academic researchers to develop a better understanding of Taiwan’s efforts to address AMR. It was clear that we have much to learn from Taiwan and their demonstrated commitment to addressing the challenge. Policy reform In 2001, the Bureau of National Health Insurance introduced a policy reform on antibiotic prescription procedures. From that point forward, doctors have been required to present evidence (such as a bacterial culture or swab) to prove that a patient truly requires antibiotics. Without this evidence, doctors are not reimbursed for the antibiotics they prescribe. Policymakers used the national health insurance system to their advantage with this intervention, by withholding payment from those who do not abide by the rules. Though this reform has been successful, it has been challenged in recent years by a rise in the number of people paying privately for antibiotics. As antibiotics are relatively inexpensive, people are sometimes willing to bypass the insurance system. Restricting prescriptions Taiwan has also introduced a policy to restrict certain prescriptions. Doctors must now consult an infectious disease specialist if they would like to prescribe a 2nd or 3rd line antibiotic. It is widely agreed that this is one of the most successful policies implemented. Most doctors now think twice about prescribing, and only do so if really necessary, as they are aware that an AMR expert will subsequently determine if the prescribed drug is truly needed. Of course, some controversy does exist around restricting physician autonomy. Most doctors now think twice about prescribing, and only do so if really necessary, as they are aware that an AMR expert will subsequently determine if the prescribed drug is truly needed. Besides these policies, other smaller-scale programs were also implemented. In 2013, seeing the need for renewed efforts to address AMR, the Centre for Disease Control introduced the Antimicrobial Management project. There were two arms to the project: antibiotic control and infection control. The antibiotic control portion involved audits, effective health information systems, and education for patients and doctors. The infection control portion involved hand hygiene and resistance data analysis. The program has just wrapped up recently, but researchers expect to see a reduction in the consumption of antibiotics, in resistance and in healthcare-associated infections. Innovative tech as a tool Taiwan has also piloted innovative technology-based interventions to help address AMR. A team of researchers used a social media platform to reach a wide audience with educational messages on reducing healthcare-associated infections. These campaigns can often be dry and academic, but in this case a series of simple and engaging YouTube videos were uploaded to Facebook to reach people more effectively. This targeted the families of hospital patients, who in Taiwanese culture are often directly involved in patient care. Several hospitals also implemented the use of an antibiogram to evaluate treatment risks and opportunities. This is a computer matrix which determines the most common infections in each ward at individual hospitals, and helps to identify the most effective drug for each pathogen. This highly specific and localised data helps to avoid the resistance that can emerge when an infection is first treated with an ineffective drug. The challenges of global health diplomacy Though Taiwan has demonstrated commitment to addressing AMR, it faces significant challenges for its global health diplomacy. Taiwan is not currently allowed to be a part of the World Health Organization and other such governing bodies and as a result, cooperation and discussion on international health issues can be a challenge. This is problematic as microbes do not respect national borders. In our increasingly interconnected world, resistant microorganisms are easily spread across regions and between states. The infrastructures and health systems of countries may be different, but sharing experiences and strategies to avoid the spread of AMR is crucial. Taiwan should continue to be a leader in addressing antimicrobial resistance. If we are to effectively address this seemingly intractable problem, we will certainly need strong and effective policy making, as well as creativity and innovation in the years to come. Jillian Sprenger is a Global Health student at the University of Toronto. She is currently interning at the AMR Secretariat at the World Health Organization in Geneva. Her previous research has focused on innovations to address child malnutrition in Myanmar, sustainable environmental governance models in Ecuador, and interventions for food security in Ethiopia. Find her on Twitter at @jilliansprenger
