Integration

The requirements and the concepts of “integration” is to be able to reach the goal of comprehensiveness, aggregation, and consistency (Underdal, 1980). Also, an integrated system should be capable of recognizing a wider horizon of a policy’s consequences in the sense of not only space and time but also issues.

It is a rather interesting result that both Japan and Taiwan face the same problem of the integration in regard to governance structure. The problem of integration leads to the inefficiency of the administration process, which would negatively affect the financial affairs.

Respondents in Taiwan mentioned the lack of integration between social welfare, health system, the labor policy, and even with the actual business content.

“I think finally social welfare and health system are integrated, however there are still lots of integration problems left from the past.” (T1)

“Now there is a department of long-term care, which is an integration of social welfare and health system, however the local governments are still not integrated, so I think there are still some room for improvements when it comes to efficiency of administration.” (T2)

“My suggestion is that the actual business content needs to be integrated.” (T3)

“Social Welfare, health system and the labor policy are not integrated… the main labor forces for Taiwan’s long-term care are foreign workers, however, it’s Ministry of Labor in charge of most foreign labor policies, which is not affiliated with the long-term care system. Most families in Taiwan, having the need of long-term care, hire foreign workers;

however, there’s not a unified regulatory authority to separate long-term care system and the foreign worker system.” (T4)

Meanwhile, we gathered some public released data from the director of Social and Family Affairs Administration, Ministry of Health and Welfare, H. Jian (2017) about the integration scheme in Taiwan’s long term care 2.0.

“In order to integrate the long-term care management system of local governments, Long-term Care 2.0 integrated the social welfare and the health system by reforming the principle of setting up the care management center sub-station, promoting the care management centers to be included as formal organizations, cooperating with the promotion of the community-integrated care system, reviewing the long-term care service delivery process and adjusting the mode of care management.”

As for Japan, both the central government (J1) and the scholar (J6) stated that the integration between long-term care service and medical service is difficult and a problem to resolve.

“It is very hard to integrate the medical service and long-term care service due to the difficulties to combine and connect the different policies.” (J1)

“Integrated care system is indispensable, but it’s hard to carry out due to the separation of long-term care and medical care; however, it’s also very difficult to integrate them.”

(J6)

After observing the data from respondents in both countries, it came to a brief summary that when it comes to the governance structure, the idea of integration is difficult in general.

However, it would surely affect financial sustainability positively if the respective issues of integration from both countries are resolved.

4.2 Service Delivery

The second institutional aspect is the service delivery. “Aging in place” seems to be an important goal for both Japan and Taiwan. The concept is originated from the 1960s when the European countries took care of the elderly by using the sources in the area they lived. As a result, this way of care-taking became a goal where countries around the world pursue ever since 1990s; “aging in place” in the other word means care recipients don’t have to move to

a few reasons why countries are following the kind of service delivery: the main reason is that the elderly would be able to keep the privacy and be independent. In the other word, being able to live in their own house, their familiar surroundings and environments are the goal for the policy. Moreover, even if they don’t have their families around, the neighbors and friends could be their community resource provisions. Therefore, when the community is offering sources to the elderly, the elderly is sharing their experiences by telling their life stories as the feedbacks to the community at the same time. (Q. Li, O. Lin, R. Chen, R. Pan, 2010: CH.10)

The long-term care service delivery in Japan is called “The community-based integrated care system”, which is showed in graph 18 (The original layout could be found in appendix 3). According to the Ministry of Health, Labour and Welfare (2016):

“As ageing proceeds, premiums estimated to rise to 6,771 yen in 2020 and 8,165 yen in 2025. In order to maintain sustainability of the Long-Term Care Insurance System, it would be necessary to establish the Community-based Integrated Care System, and to make services more focused and efficient.”

The Community-based Integrated Care System could be traced back to 1974 when the care system is first developed in a town called “Mitsugi”, which is located in Hiroshima prefecture. The Mitsugi Hospital, the town, and prefecture governments collaborated and came up with the idea of “community-based integrated care system” and then started to carry it out.

After various evaluations and assessments, the system then was succeeded and was not only proposed but shared to the whole country. Eventually, it became the role model of Japan’s long-term care policy plan of the service delivery. (Hatano, Matsumoto, Okita, Inoue, Takeuchi, Tsutsui, Nishimura, Hayashi, 2017)

The system integrates the health-care resources not only through the hospital but also the welfare facilities, home-visit care services, and even clubs and association center for the elderly to join the activities among neighborhoods. The reasons why “housing” is set as its core are two. Firstly, the traditional facility-base care is expensive and there is a shortage of welfare facilities (Morikawa, 2014). Therefore, for those with severe diseases or disabilities are usually receiving their cares at home. Secondly, the community-based integrated care system is the system where people can reach out to the long-term care services such as medical care and senior citizens’ club in within 30 minutes from home. Therefore, the housing is in the middle but people can still attend other cares around them.

Graph 18. Long-term Care Service Delivery in Japan

Source: Ministry of Health, Labor and Welfare (2016)

By implementing this system of service, they combined the community medical services

Housing Healthcare

Senior Citizens' Club, Residents'

Association, Long-term Care

Prevention Long-term Care

Care Manager

central government, prefectures then design their operating plans, and then pass on to the municipalities. The long-term care insurers are people in “shikuchōson” (市区町村), which are four types of municipalities including cities, towns, villages and special ward (Kayama, 2010), the insurers are multiple. In this sense, according to The Control Yuan (2015: 28-29), the government in Japan could provide different services based on difference local conditions by combining community resources and offering various services such as medical and residential.

As a result, they reach the goal of letting the elderly in Japan not only stay their familiar community environments but also keep their own dignities.

The service delivery system in Taiwan is similar to Japan. It is called Comprehensive Community Care Service System (社區整體照顧服務體系), which is also known as Long-term Care ABC (長照 ABC). According to P. Lu (2017) from the Ministry of Health and Welfare,

“The goal of Long-term Care ABC is to create a comprehensive care system that integrates medical care, long-term care services, housing, prevention, and social assistance to allow people with disability to receive the care they need within a 30-minute drive” (p.13)

In graph 19 (the original layout is in Appendix 4), there are three different tiers: tier A helps individual cases of their care plans by providing right proper care resources, tier B combines service centers and provides a variety of long-term care services for the elderly, and tier C is the long-term care stations that are located around the blocks, which provides a place for neighborhoods to gather, to have meals together, and even to receive temporary nursery with primary prevention programs. They are like three layers of services from the main center to the smallest but more in numbers that are located in blocks. There is an example for the operation of the service delivery, if Ms. Wang needs a term care, she will call the

long-term care service line. Then, City Long-long-term Care Management Center will evaluate Ms.

Wang’s situation, the level of care, and the payment. After evaluating, tier A will make a suitable care plan for Ms. Wang and arrange tier B to provide the service such as offering housing service for Ms. Wang every Monday and Wednesday, and arrange her to go to the service center every Tuesday to Thursday. Furthermore, Ms. Wang can go to the tier C to touch base with her neighbor friends.

Same as Japan, the housing is in the center to show not only how easy for people to reach out to the long-term care from their houses, but also they can receive the cares at home.

Graph 19. Long-term care Service Delivery in Taiwan

Source: Ministry of Health and Welfare (2017)

Housing Tier A – Community integrated service center

Tier C – LTC stations around the

blocks Tier B– Combined

service center

Care Management Center

The amount of the Long-term Care ABC facilities in have been increasing dramatically in within two years. According to graph 20, it is shown that the number of three tiers respectively had increased over time since 2017 especially for tier B.

Graph 20. Numbers of the three tiers of service delivery in Taiwan

Source: DATA.GOV.TW (2019)

As we stated in the public released data above, Japan’s policy for service delivery is

“Community- based Integrated Care System” while Taiwan addressed the policy of

“comprehensive community care service system (Long-term Care ABC)”. In this section, we would focus on the functions of the two service delivery policies based on the in-depth interview from both countries. Here, four main elements of service delivery that would affect long-term care financial sustainability are pointed out and would be further analyzed respectively. These four elements include decentralization, human resources, resource allocation, and administrative process efficiency.

2017 2018 2019

Tier A 80 472 539

Tier B 199 2974 3280

Tier C 441 1604 1901

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