Health, policy and medicalisation : a case study of Taiwan's health care reforms
This thesis charts the rising importance of the state in extending the influence of modern medicine, contexualised within the history and political-economic dynamics of the health care reforms in Taiwan, a leading Newly Industrialised Country (NIC) which has a distinguished record of health improvement. It highlights the processes by which health care reforms represented a shift towards medicalisation, particularly as consolidated by the creation of a universal National Health Insurance (NHI) system in 1995. The thesis seeks to analyse these processes by bridging the gap between medical sociology and health policy evaluation. It deploys a range of methods: historical analysis of secondary sources and multiple methods of data collection. These include qualitative in-depth interviews with key actors, a questionnaire survey and relevant policy documents. This thesis employs an overarching framework for analysis, which embraces both the 'political economy' and the 'cultural critique' approaches to health, in ways which seek to integrate discussion of policy issues and developments at the macro, meso, and micro-levels. It starts by locating the NHI reform against longer-term historical processes of modernisation, often as a result of outside influences, and the associated transformation of medical paradigms that occurred in different periods. It charts how particular structural factors have impinged on medicine to enable it to become dominant collegiate profession, with special reference to the role of the state promoting the legitimation of particular modes of medical intervention. The thesis highlights the fact that the NHI has extended the influence of doctors, paradoxically also provides the basis by which medical autonomy has been undermined. On the other hand, it charts the social impacts of modern medical care, and argues that the NHI has played an important role in stimulating the process medicalisation and consequently fostered a culture of dependency and passivity contained in medical technology and in the healing relationship. This thesis is a reminder that the contemporary Taiwanese health care state is arriving at a moment of crisis, and that deep reflection on the strengths and weaknesses of the NHI reform is necessary in order to deal with problems associated with growing medicalisation, public demands for greater social equity, and new threats to health, the latest being SARS.