【Opinion Column】United Daily News — Global Budget Imbalance in National Health Insurance Is Driving Healthcare Workers Into Overwork

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2026-01-27 00:00, United Daily News
Lee Po-Chang / Chair Professor, College of Public Health, Taipei Medical University (Taipei City)

President Lai Ching-te has publicly called on hospitals and clinics to raise salaries for healthcare workers, saying, “Otherwise, how will we find people?” This statement, however, does not address the core issue. The loss of healthcare personnel is not a moral failing of hospital administrators, but a structural consequence of long-term distortions in the National Health Insurance (NHI) payment system. If we fail to confront the misaligned incentives embedded in the system itself and rely only on calls for pay raises, the healthcare system will continue “robbing Peter to pay Paul,” pushing medical professionals deeper into crisis.

Low salaries in hospitals are not accidental—they are the inevitable result of the payment system.

In most Taiwanese hospitals, personnel costs depend heavily on NHI reimbursement points. Under global budget caps and shrinking point values, hospital revenue growth remains limited, even as they face increasing workforce burdens and rising quality requirements. Although healthcare institutions are nonprofit entities, no employer can operate at a loss. As a result, hospitals resort to contract models such as revenue-sharing and performance-based pay to sustain operations.

This system design forces medical practice toward a “volume-for-points” approach, leaving no one with compensation that truly reflects professional expertise and risk. Over time, it is unsurprising that talented professionals cannot be retained. The recent debate over legislating nurse-to-patient ratios has likewise placed nurses and hospital administrators at odds. Yet the public and society at large pay limited attention to these interlocking issues of healthcare quality—an issue that poses a serious political challenge for the ruling party.

The structural imbalance within the NHI global budget is the root cause of the overwork crisis in hospitals.

More concerning is the internal allocation structure of the NHI global budget. For years, outpatient services have accounted for roughly 70% of expenditures, while inpatient care receives only about 30%. This distribution effectively incentivizes low-risk, high-volume outpatient services while systematically undervaluing inpatient care, emergency and critical care, and specialties such as internal medicine, surgery, obstetrics-gynecology, and pediatrics—fields that require high levels of expertise and intensive manpower.

Salary increases for healthcare workers should not begin as moral persuasion; they should be the natural outcome of meaningful payment system reform. Only through dialogue within the medical community can consensus be reached to examine two key questions:

  1. Do NHI reimbursement points truly reflect medical professionalism, risk, and workforce input?

  2. Does the internal allocation of the NHI global budget still overemphasize outpatient services while neglecting inpatient and critical care?

Without addressing these questions, repeated calls for higher pay amount to nothing more than short-term painkillers.

In the past, when faced with healthcare workforce shortages, the government has often relied on project-based subsidies, temporary bonuses, or special budgets as stopgap measures. While such approaches may temporarily support certain specialties, they fail to change the overall salary structure and may even exacerbate imbalances between specialties and institutions, ultimately triggering new waves of workforce migration and dissatisfaction. In some hospitals, entire teams have left en masse after failing to reach salary agreements. Genuine reform cannot rely on piecemeal subsidies; it must restore the NHI payment system to the fundamental principles of being profession-oriented, risk-oriented, and workforce-oriented.

The loss of healthcare personnel is not due to a lack of dedication among medical professionals, but rather the long-term systemic undervaluation of professional expertise. If we want to retain talent, raise salaries, and ensure the sustainability of the healthcare system, the key lies not in moral appeals but in fundamental reform of the payment system. Taiwan’s healthcare system must be built on an institutional foundation that truly respects professional value and can retain its talent.