臺日長照政策之比較制度分析研究 - 政大學術集成

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(1)國立政治大學社會科學學院應用經濟與社會發展英語碩士學位學程 International Master’s Program of Applied Economics and Social Development College of Social Science National Chengchi University. 碩士論文 Master Degree Thesis. 臺日長照政策之比較制度分析研究 A Comparative Institutional Analysis of Long-term Care Policies in Japan and Taiwan. Student：山下仁心 Hitomi Yamashita Advisor：陳敦源博士 Dr. Don-Yun Chen. 中華民國 108 年 10 月 October 2019. DOI:10.6814/NCCU201901221.

(2) Abstract. Taiwan has entered the aged society in 2018. The demand for long-term care has been increasing rapidly. In this way, it became more urgent for the government to implement robust policies especially in terms of financial issues. Since Japan initiated long-term care plans decades ago, also the situation in Japan is said as a reflection of Taiwan's future, this thesis compared the policies in both countries on the basis of Comparative Institutional Analysis. In order to come up with constructive suggestions, the research not only analyzed the publicly released data but also conducted the in-depth interviews with the governments, NPOs, and the scholars in Japan and Taiwan. The research came up with suggestions with regard to the aspects of governance structure, service delivery, finance scheme, and sustainability scheme that might be able to solve the issue of financial shortage when it comes to long-term care plans and pursue the goal of financial sustainability.. Key Words: Long-term Care, Financial Sustainability, Comparative Institutional Analysis. DOI:10.6814/NCCU201901221.

(3) A Table of Contents – Simplified Edition. Chapter One- Introduction………………………………………………………………..1 1.1 Research Background……………………………………………………..…………1 1.2 Research Motivation……………………………………………………...……………2 1.3 Research Questions…………………………………………….………………………9 Chapter Two- Theory and Literature Review…………………………..………………11 2.1 History of The Welfare State Theory and Practice……………………………………11 2.2 Past and Present of Long-term Care Policies…………………………………………22 Chapter Three- Methodology………………………………………………..…………..39 3.1 Document Analysis……………………..……...……………………………………..39 3.2 In-Depth Interview………………………..….……………………………………..40 Chapter Four- Result………………………………………………………………..….47 4.1 Governance Structure………………………………………….……………………..49 4.2 Service Delivery…………………………………………….………………………..57 4.3 Finance Scheme………………………………………………………………………70 4.4 Sustainability Scheme……………………………..……………………………...…..74 4.5 Discussion……………………………..……………………………...……………...82 Chapter Five- Conclusion…………………………………………………………………89 5.1 Research Limitation……………………………..……………………………...…..91 5.2 Future Research……………………………..……………………………...……….92 Reference……………………………………………………………………………..…93 Appendix…………………………..………………………………………………………99. i. DOI:10.6814/NCCU201901221.

(4) A Table of Contents – Detailed Edition. Chapter One- Introduction…………………………………………………………………..1 1.1 Research Background……………………………………………………..…………1 1.2 Research Motivation……………………………………………………...……………2 1.3 Research Questions…………………………………………….………………………9 Chapter Two- Theory and Literature Review……………………………..………………11 2.1 History of The Welfare State Theory and Practice……………………………………11 2.1.1 Long-term Care and Welfare State………………………….………………..13 2.1.2 Comparative Institutional Analysis…………………………………….…..16 2.2 Past and Present of Long-term Care Policies…………………………………………22 2.2.1 Aspect of Japan……………………………………………..………………..22 2.2.2 Aspect of Taiwan……………………………………………...……………..31 Chapter Three- Methodology…………………………………………………..…………..39 3.1 Document Analysis………………..…...……………………………………………..39 3.2 In-Depth Interview………………………..…………………………………………..40 3.2.1 Research Steps and Targets…………………………………………………..41 3.2.2 Interview Outline……………………………………………………………43 3.2.3 Ethic…………………………...……………………………………………..45 3.2.4 Analytical Method……………………………….…………………………..46 Chapter Four- Result…………………………………………………………………..….47 4.1 Governance Structure………………………………………….……………………..49 4.1.1 Industrialization……………………………..……………………………...53 4.1.2 Integration……………………………..……………………………...…….56 4.2 Service Delivery…………………………………………….………………………..57 ii. DOI:10.6814/NCCU201901221.

(5) 4.2.1 Decentralization……………………………..……………………………....63 4.2.2 Human Resources……………………………..……………………………..64 4.2.3 Allocation of Resources……...…………………..………………..…………66 4.2.4 Administrative Process Efficiency………………………………..…………68 4.3 Finance Scheme………………………………………………………………………70 4.3.1 Insurance Policy/ Tax Policy……………………………..…………………72 4.4 Sustainability Scheme……………………………..……………………………...…..74 4.4.1 Securing of Financial Resources……………………………..………...……75 4.4.2 Retrenchment……………………………..……………………………...….76 4.4.3 Prevention……………………………..……………………………...……..76 4.4.4 Political Support……………………………..……………………………...77 4.4.5 Private-public Partnership……………………………..……………………78 4.5 Discussion……………………………..……………………………...…………….82 4.5.1 Policy Suggestions……………………………..……………………….…83 Chapter Five- Conclusion…………………………………………………………………89 5.1 Research Limitation……………………………..……………………………...…..91 5.2 Future Research……………………………..……………………………...……….92 Reference……………………………………………………………………………..…93 Appendix…………………………..………………………………………………………99. iii. DOI:10.6814/NCCU201901221.

(6) A Table of Contents – Graphs. 1.. Taiwan’s Dependency Ratio Overtime…………..............................................................3. 2.. Japan’s Dependency Ratio Overtime......................................................................4. 3.. Japan and Taiwan’s Dependency Ratio Overtime..................................................5. 4.. The Total Budget Expectation in Taiwan............................................................................6. 5.. World Population Aged 65 And Above..................................................................8. 6.. Theoretical Framework.................................................................................................20. 7.. Population Pyramid of Japan................................................................................24. 8.. The Problems of Welfare and Medical Systems for The Elderly in Japan.........................27. 9.. The Differences Before and After The Long-term Care Insurance System in Japan........29. 10. Trends and the Future Prospects of Long-term Care Benefits and Premiums in Japan......31 11. Total Loan Long-term Care Insurance and the Total Number of Borrowers in Japan........32 12. Population Pyramid of Taiwan..........................................................................................34 13. The Target Population Change of Long-term Care Plans in Taiwan..................................37 14. In-depth Interview Steps...................................................................................................42 15. Institutional Aspect input....................................................................................48 16. Long-term Care Governance Structure in Taiwan.............................................................51 17. Long-term Care Governance Structure in Japan...............................................................52 18. Long-term Care Service Delivery in Japan.......................................................................59 19. Long-term care Service Delivery in Taiwan......................................................................61 20. Numbers of the three tiers of service delivery in Taiwan...................................................62 21. The Finance Scheme of Long-term Care Insurance in Japan.............................................71 22. The PFI Procurement Process...........................................................................................80. iv. DOI:10.6814/NCCU201901221.

(7) A Table of Contents – Tables. 1.. Chronicle of long-term care policies in Japan..................................................................25. 2.. Chronicle of long-term care policies in Taiwan.................................................................35. 3.. Targets of The Interviews in Taiwan.................................................................................43. 4.. Targets of The Interviews in Japan..................................................................................43. 5.. Interview Outline- Taiwan................................................................................................44. 6.. Interview Outline- Japan...................................................................................................45. 7.. The Overall Comparison of Japan and Taiwan..................................................................85. v. DOI:10.6814/NCCU201901221.

(8) A Table of Contents – Appendix. 1. The Total Budget Expectation in Taiwan.............................................................................99 2. The Four Divisions of Long-term Care and Their Job Descriptions...................................100 3. the Community-based Integrated Care System Model (Japan) .........................................102 4. the Comprehensive Community Care System (Taiwan) ...................................................103 5. Strategies of Enriching Local Resources (LTC 2.0) ..........................................................104 6. Long-term Care Service Development Fund in Taiwan.....................................................106 7. The proposal of “Long-term care integrated service in the aboriginal region” .................107 8. Long-term Care Subsidized Areas in Taiwan.....................................................................110 9. Subsidies for Long-term care 2.0.......................................................................................111 10. Interview Outline of Chinese Version.............................................................................113 11. Interview Outline of Japanese Version.............................................................................114 12. Interview Transcript..........................................................................................................115. vi. DOI:10.6814/NCCU201901221.

(9) Chapter One- Introduction. 1.1 Research background There is little doubt that many developed nations around the world are increasingly forced to deal with the reality of population decline or at the very least an aging population or low birth rates. Such is the case of several East Asian nations such as Japan and Taiwan. Because of this, serious thought needs to be allocated towards how to adjust public policy and economic policy in order to be able to adequately tackle these problems.. According to Ministry of the Interior, R.O.C. (Taiwan), the percentage of people over 65 years old in Taiwan increased to over 14% in March 2018, making Taiwan a so-called aged society. Hence, the establishment of sound policies to assure the well-being of senior citizens has become an important issue. Moreover, the growth of the aged population and structural changes in families and employment have increased demand for the caregivers. As a result, long-term care has not only gradually transformed from a private risk to a public one, but has also been defined as a “New Social Risk” (Morel, 2006).. According to the Central Intelligence Agency, 27.28% of Japan’s population was over 65 years old in 2016, a situation that many view as a reflection of Taiwan’s future. In addition, long-term care insurance was established in Japan almost 20 years ago, earlier than in Taiwan.. Japan learned from Germany’s experience in 1989 and started its ten-year plan for long-term care insurance in the year 2000 (Campell & Ikegami, 2003; Campell, Ikegami, & Kwon, 2009); recognizing that it was likely to follow in Japan’s footsteps, the Executive Yuan started Taiwan’s ten-year long-term care plan in 2007 and subsequently initiated the ten-year longterm care 2.0 in 2016. In their efforts to carry out more robust and sound long-term care policies, 1. DOI:10.6814/NCCU201901221.

(10) both countries are working hard to identify better ways to address current issues. Focusing on the issue of long-term care financial sustainability, in this study, we aimed to support the development of solutions in this regard.. 1.2 Research motivation There are three main reasons why I chose long-term care financial sustainability comparisons between the countries Japan and Taiwan. The reasons include the similar characteristics of the two countries, relationship between financial problems and long-term care, and the fact that everyone gets old one day.. The first thing to be discussed is the reasons why this research had chosen Japan to compare with Taiwan. Japan and Taiwan has many similar and common characteristics specifically when it comes to the issue of aging population. Japan’s situation toward aging popularity is said to be the future of Taiwan in terms of the high dependency ratio overtime and the similarity of the tendency. From graph 1, the old age population dependency ratio increases unsurprisingly overtime due to the expanding aging population; however, in the sense of the low fertility problem in Taiwan, the young age population dependency ratio has gone the opposite way compare to the old age population one. Though the low fertility offsets some of the dependency ratio, the overall dependency ratio of Taiwan is still gradually increasing which it is predicted to increase even more steeply in the future 40 years.. 2. DOI:10.6814/NCCU201901221.

(11) Graph 1. Taiwan’s Dependency Ratio Overtime Dependency Ratio. Young age population dependency ratio. old age population dependency ratio 100 90 80. PERCENTAGE. 70 60 50 40 30 20 10 0 1960. 1970. 1980. 1990. 2000. 2010. 2020. 2030. 2040. 2050. 2060. YEAR. Source. Ministry of The Interior (1960-2010), National Development Council (2015-2060). Likewise, for Japan in graph 2, we can clearly see that the old age population dependency is increasing gradually but the young age population dependency is decreasing overtime. Just like Taiwan, the overall dependency rate is climbing dramatically in the past years and even more for the future prediction.. 3. DOI:10.6814/NCCU201901221.

(12) Graph2. Japan’s Dependency Ratio Overtime Dependency ratio. Young age population dependency ratio. Old age population dependency ratio 120. 100. PERCENTAGE. 80. 60. 40. 20. 0 1960. 1970. 1980. 1990. 2000. 2010. 2020. 2030. 2040. 2050. 2060. YEAR (PREDICTED AFTER AND INCLUDING 2015). Source: National Institute of Population and Social Security Research (1960-2060). Therefore, I put both Japan and Taiwan together in graph 3. From the graph, we can tell that Taiwan’s dependency ratio was decreasing at first but then started to increase approximately after the year 2010. However, that of Japan has already been growing since 1990s. We learned that Taiwan’s overall dependency ratio is slowly catching up with Japan’s, and as predicted, meet at the same point in the end. As a result, having such a similar tendency, I hope to understand the upcoming future problems and moreover the resolving possible approaches to suggest the government, the policy makers, and the analysts to implement sound policies in terms of having a more solid future long-term care plans.. 4. DOI:10.6814/NCCU201901221.

(13) Graph 3. Japan and Taiwan’s Dependency Ratio Overtime Japan. Taiwan. 120. 100. PERCENTAGE. 80. 60. 40. 20. 0 1960. 1970. 1980. 1990. 2000. 2010. 2020. 2030. 2040. 2050. 2060. YEAR (PREDICTED AFTER AND INCLUDING 2015). Source. Ministry of The Interior, National Development Council, National Institute of Population and Social Security Research. The second thing I would like to discuss is the relationship between financial problems and long-term care. The idea of this sentence is intuitive in the sense that without financial support, it would be highly impossible for governments to put through sound policies and to reach the goal of providing satisfying care services for the elderly. In the case of Taiwan, according to the Ministry of Health and Welfare, the total budget expectation of long-term care in 2018 is approximately 3 billion NTD and undoubtedly it would only be increasing financially. The total budget expectation from the year 2017 to 2026 of Long-term Care 2.0 is in graph 4 (The original chart is shown in appendix 1). The budget includes a variety of long-term care services, for example, not only housing care and institutional care services but also financial support for the long-term care in remote and rural areas in order to balance the allocation of resources.. 5. DOI:10.6814/NCCU201901221.

(14) Financial supports of long-term care in Taiwan are not only from the Ministry of Health and Welfare and some other ministries, but also most of them are from the tax. According to the Ministry of Finance, the financial support of long-term care from Estate Tax is about 1.38 billion NTD, Gift Tax is approximately 2.65 billion NTD from the beginning of 2018 to the end of April. Also, the government received 144.4 billion NTD from the Tobacco Tax from June 2017 to April 2018.. Graph 4. Total Budget Expectation. Total Budget Predicted (million NTD) 736.48 651.85 601.64 531.26 459.02. 493.88. 409.5 361.34 314.45. 162.26. 2017. 2018. 2019. 2020. 2021. 2022. 2023. 2024. 2025. 2026. Source: Ministry of Health and Welfare (Long-term Care 2.0, 2016: 168). Though the taxes mentioned above seem to be enough for the budget, according to an article “Long-term Care 2.0 Has Started. Where Does the Financial Resources Come From?” (H. Lin, 2016) in the magazine “遠見”, the professor of the Department of Public Finance and Tax Administration in National Taipei University of Business, Yaw-Huei Hwang, mentioned how unstable the tax policy is as a financial resource when it comes to financial sustainability of long-term care. Also, it was said to be impossible to be able to afford the future aging issues 6. DOI:10.6814/NCCU201901221.

(15) that have been increasing gradually. For instance, the issue of financial needs for future Dementia patients. Hence, it seems that we shouldn’t take the current financial support for granted.. Furthermore, according to the article “Japan's Elderly Boomers Squeezed to Pay More As Care Facilities Struggle” by Brasor and Tsubuku in Japan Times in 2015, Japan has suffered from the shortage of nursing care facilities for the elderly since the central and local governments were cutting down subsidies to nursing care facilities in a sense of financial problems. From this news, we learned how important financial support could be. In the other word, without money, it is impossible for long-term care plans to be successfully conducted by governments. Therefore, in my opinion, financial sustainability could be the first important task when it comes to long-term care.. The third reason why I was motivated to do this research is the sense that everyone will get old one day. Namely, getting old is inevitable for everyone and most of us will have to rely on long-term care someday. According to OECD, Japan has facing the level of “super-aging” that no country has ever experienced yet sooner or later other countries such as countries in Europe and Asia will also have to confront the same issues that Japan is facing now.. From the aspect worldwide, according to the Department of Economic and Social Affairs of United Nations, the number of the elderly around the world is rising as a whole. Graph 5 is the world population overtime that were aged 65 and above. From the tendency line, we can clearly see the intense growth of the aged population group in within 60 years.. 7. DOI:10.6814/NCCU201901221.

(16) Graph 5. World Population Aged 65 And Above 7. population (10 thousands). 6 5 4 3 2 1 0 1955. 1965. 1975. 1985. 1995. 2005. 2015. Source: United Nations, Department of Economic and Social Affairs, Population Division (2017). World Population Prospects: The 2017 Revision, DVD Edition.. The unavoidable increase in the share of elderlies due to the decline in fertility and improvement in living standard that characterized the demographic transition. Furthermore, it is occurring throughout the whole world but not just Japan and Taiwan, which is showed in graph 1 and 2. In this respect, as the average of the whole population keeps on rising, governments should implement policies to address the needs, including for those elderly cares related to housing, employment, health care, and even social protection.. As a person with both nationalities of Taiwan and Japan, I experienced the different outcomes of elderly cares from both of my grandparents in both countries. Also as a person who will become an elderly one day in the future, I would want to know the differences under the systems of long-term care policies in Japan and Taiwan in order that both countries can learn from each other and fulfill the goal of financial sustainability.. 8. DOI:10.6814/NCCU201901221.

(17) 1.3 Research Questions This research will be comparing and contrasting the main features of long-term care policies in Japan and Taiwan on the basis of welfare state theory. Particularly, it’ll be focused on the sustainability of the long-term care financial affairs for both countries. The research will focus on the research questions:. 1. What are the differences between Taiwan and Japan’s policies toward long-term care finance? 2. What elements in long-term care policies determine the effect of financial sustainability? Why? 3. After comparing Taiwan and Japan, how could Taiwan learn from the experiences and practices of long-term care policy in both countries?. 9. DOI:10.6814/NCCU201901221.

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(19) Chapter Two- Theory and Literature Review. 2.1 History of the Welfare State Theory and Practice To understand welfare state, the research must start with a discussion and explanation of the ambiguities in the concept and the idea of welfare state, which is to consider from how welfare state has evolved to how the past inspires current circumstances is essential. Also, in this respect, it would be more clear for the possible gap in the literature. Hence, it is possible to both think more critically about the contents and outcomes of the welfare state and to formulate expectations about their relationship. (Gough, 2000). The idea of welfare state has been developed since the late 20th century, so compare to other theories, it might not be as old; in fact, people are still trying to define it. In the other word, due to the variety of understandings to this theory, people tend to explain and furthermore apply it differently. In this sense, Titmuss (1968: 124) views welfare states as an “indefinable abstraction”, which is known to be an abstract idea that is hard to define.. The phrase “Welfare State” was first used to describe Labor Britain after the year 1945; later, the concept of economic change with regard to welfare state was defined in British. Welfare state entails direct and immediate social consequences, including the “abolition of poverty” and the “conquest of unemployment” (Briggs, 1961). According to Skocpol (1995: 4), the word “welfare state” appeared early from the industrializing Western world. She also mentioned that the beginning approach in regard to welfare state was from between the era 1880s and World War I. It includes not only the public pensions for the elderly but also the partly contributory and publicly funded social insurance measures.. 11. DOI:10.6814/NCCU201901221.

(20) Even more clearly, Hicks (1999) divided the history of welfare state into five different stages, including “origins”, which started in the 1880s; “consolidation”, which started from 1920; “social democratic dominance”, which continued from 1930s to 1950s; “democratic neocorporativism” that started from 1960s to 1980s, which Esping-Andersen called it the “golden age” (1996) due to such as secure growth, full employment, moderate welfare needs and so on. However, beginning from 1970s, the economic performance started to decline and led to a stagnation of the welfare state expansion; therefore, the idea of “perceived” retrenchment appeared, which is said to be the current status of welfare state. Also, this current stage is referred as the “silver age” of labor market restructuring, demographic transition and economic globalization by Taylor-Gooby (2002). The measures of retrenchment are also widely used by the governments nowadays due to the necessities of reducing costs of policies. In this sense, retrenchment could be related to financial sustainability and would further be discussed in the research.. When it comes to welfare state, people think of Germany and the measures of Bismarck due to their early development of social welfare institutions, which is also known for its pension system from the mid-19th century. After their integral development of welfare state, the concept then soon been extended to not only other European countries, mostly western part of Europe but also countries such as America and Australia. Flora and Heidenheimer (1981) noted that in the year 1878, the concept of welfare state first developed in Germany and known as “Wohlfahrstaat” in German. Furthermore, in 1941 the term had publicly been used by the British. Trying to sustain morale and discipline during the war, the word “Welfare” had been more involved with the concept of social benefits, which the governments in Britain tried to launch in the country once the war is over. Later, the concept has passed on to the Asian countries such as Japan and Taiwan to name a few.. 12. DOI:10.6814/NCCU201901221.

(21) 2.1.1 Long-term Care and Welfare State Before going through the literature review, there are some terms that should be clarified to be able to apply the concept. According to OECD (2017), there has been a dramatic soar in the older population in all European countries, however, not only Europe but the whole world is facing the same aging issue. Therefore, we need long-term care to make sure not only the living quality but the safety for the elderly who might not be capable of depending on themselves and yearning for something to rely on. According to the U.S. Department of Health & Human Services, the definition of the term “Long-term care” is1:. a variety of services designed to keep a person healthy or meet a personal care need during a short or long period, and these services help old people live as independently and safely as possible when they are unable to perform well on their daily activities.. Also, according to X. Zhuang (2009), long-term care can be divided into three main categories, including home care, community care, and institutional care. Firstly, home care means care recipients receive their long-term cares in their own houses. Also, it includes the “housing service” that has been promoting these years in Japan and Taiwan. Secondly, X. Zhuang also noted that the concept of community care is from the theory of welfare state, which means care recipients receive their long-term cares in their own communities. Both Japan and Taiwan are now conducting the scheme of service delivery regarding community care, and it would be further discussed. Finally, the institutional care means care recipients receive their long-term cares in the institutions. Hence, often times it is rather far compare to the community care.. 1. The information is retrieved from https://www.nia.nih.gov/health/what-long-term-care 13. DOI:10.6814/NCCU201901221.

(22) By carrying out a sound policy of long-term care, we need some theories to support the idea in order for us to come up with right suggestions for the governments, policy makers, and analysts. Hence, the research will be using the theory of welfare state. Welfare state is a system and a theory that has been used worldwide. Moreover, there are some terms and concepts that are associated with “Welfare State theory” that should be acknowledged first. Modern welfare states include countries such as Germany, France, Belgium and many other Nordic countries. Also, as mentioned in last section (2.1), the idea of welfare state has also spread to the Asian countries including Japan and Taiwan.. When It comes to welfare state theory, it is also essential to know the central recurring concept in this literature, which is the idea of “Welfare regime typology” by Esping-Andersen. He is a Danish sociologist who is famous for the devotion in welfare state. He is also the most influential person that first came up with the idea of welfare regimes. He defined and categorized welfare state into three different regimes in his book “The Three Worlds of Welfare Capitalism” (1990). Esping-Andersen is said to be the most frequently cited author in the realm of welfare state. And there is no paper on the topic that can overlook his dominating position in driving the current discourse. (John Velit-Wilson, 2000). Therefore, though there are lots of researchers and sociologists who stated about their concepts toward the typology of welfare capitalism after Esping-Andersen, this research decided to apply his concepts and ideas with regard to the three regimes of the welfare state.. According to Esping-Andersen (1990), the three typology of regimes includes Liberal, conservative, and social democratic. Liberal regime is for when there is a problem in the structures of family or market, for example, when a person is unable to satisfy his/her life through the family or market, the system of welfare state will support the person with a substitutional and temporary plan, and at often times the targets are low-income individuals. 14. DOI:10.6814/NCCU201901221.

(23) However, this kind of system would lead to the existence of the hierarchy between the majority and the low-income recipients in the society. A representative country of liberal welfare state is the United State.. The idea of the conservative regime is to have a corporate system that keeps the traditional hierarchies, meaning the state would design different kinds of welfare schemes toward different levels of people, which is also called stratification. Also, the state tends to encourage families to assist dynamics. In the sense, the assistance of a state would only intervene when a family is unable to support its own members. A representative country of conservative welfare state is Germany.. The social democratic regime promotes a sense of equal benefits and services for the people of the state without regarding a person’s income level or status. A representative country of social democratic welfare state is Sweden.. When it comes to the three welfare state regimes, it is very important to have the concept of Decommodiciation, which comes from the word commodity. When a worker is commodified, they have to devote in the market in order to survive; namely, they will have to work to live or to support their families. Vice versa, decommodification means that people don’t have to sell their labor to be able to survive in a society. Therefore, oftentimes we use this term to measure the three welfare regimes. In this sense, social democratic regime is the highest level of decommodification, which the country would make workers independent of the labor market for them to not be forced to work in order to survive. To be more precise, the high levels of decommodification requires universalist policies, which the social rights granted on the basis of a person’s citizenship instead of the person’s performance. For instance, one has the right to receive a good long-term care is not because on can afford to pay, rather, it is because one is a 15. DOI:10.6814/NCCU201901221.

(24) citizen. Liberal regime however is the lowest level of decommodification. Namely, the state does not have universalist policies. In fact, the state would make people as dependent as possible in order for them to rely on the market and have incentives to dedicate in it. Finally, Conservatives are classified as the middle level of decommodification.. According to Esping-Andersen (1996, 1997), Japan and Taiwan are classified as a ‘hybrid case’; namely, it is a special case that falls between conservative and liberal welfare regimes. Moreover, when it comes to welfare state system, it seems that Japan is considered to be a good role model to Asian countries. According to Goodman and Peng (1996). A good example of this thesis is the case of the Japanese social welfare system, particularly since the mid 1970s, where there has been a decisive divergence away from any Western pattern.” (p. 193). In the other word, Japan not only has more experiences but also is more mature than Taiwan when regarding welfare system specifically but not exclusively long-term care. Thus, there would be no other countries more suitable than Japan to compare with Taiwan. More specifically, for these two countries to learn from each other.. The sense of welfare state is usually related to the elderly care. According to the book “Hikaku fukushi kokkaron: Yuragi to orutanatibu” edited by Okazawa, N. and Miyamoto, T. (1997), when it comes to conducting the research of comparing welfare state countries, it is usually about explaining the reasons behind the development of the welfare state by understanding the industrialization and economic growth or even socio-economic issues such as ageing population.. 16. DOI:10.6814/NCCU201901221.

(25) By comparing Japan and Taiwan that share the same welfare state regime, hybrid case, we would understand more about the socioeconomic issues of ageing population; more importantly, this thesis would finally propose some suggestions of the issue, financial sustainability, regarding long-term care.. 2.1.2 Comparative Institutional Analysis For this research, the instrument of comparative institutional analysis will be mainly utilized and therefore applied. This is also combined with the theory of welfare state. Also, specifically the ideations surrounding what constitutes as a “hybrid case” will be the core foundation for this research with regard to the comparative nature of the long-term care policies in Taiwan and Japan from the aspect of financial sustainability. Moreover, by using the instrument which oftentimes referred to as a document analysis and with the perspective of the economic development and the demographic structures, this research will explore the differences between Taiwan and Japan’s long-term care policies to propose some suggestions to Taiwanese government or other policymakers and analysts about the policy settings.. The comparative institutional analysis is used to show and analyze how institutions influence different outcomes. More precisely, institutions affect transaction costs (Coase, 1960; North, 1990), which include the search cost, procedural and monitoring costs, even the cost of preparing project design documents. More importantly, a good institutional structure lowers the transaction costs. Thus, by implementing a robust policy in terms of financial affairs, comparative institutional analysis is a decent choice of approach.. Comparative institutional analysis combines a number of approaches from a broad range of disciplines including that of economics and political science to sociology and even public administration (Ostrom, 2005). Therefore, this study toward policies approaches and 17. DOI:10.6814/NCCU201901221.

(26) applications will not only be a single integrated framework regarding the stabilization of the current systems comparatively. Rather, this research is also about and addresses issues surrounding the generating and the changing of policies, which include long-term care and the problems in which Taiwan and Japan face with an aging and declining population in the context of a micro and macroeconomic lens. Though compared to other comparative methods, comparative institutional analysis is relatively new, it is a one-of-a-kind research perspective. In addition, it should be regarded as a theoretical framework, which has been recognized and utilized as a highly effective and useful tool for analysis by academics, policymakers, and other analysts concerned with political economic issues such as and related to the ones covered in this research. Furthermore, it is a unique and somewhat holistic lens through which to analyze and to apply comparatively between Japan and Taiwan. Especially, for long-term care policies from the new aspect of financial affairs because of the broad range of generalized fields that it can be applied to such as finance or stakeholder building for example.. There are two important points to verify or address for comparative institutional analysis that this research applies from a theoretical perspective generally speaking. First and foremost, to establish a sound policy in order to efficiently make good use of recourses and improve source allocations, remains a key element of policymakers within political economic institutions. Because of this or perhaps in spite of this, it is important to meanwhile acknowledge that it is difficult or nearly impossible to 100 percent be able to balance the gains and losses of political economic leaders, individuals who are using the institutional frameworks or mechanisms in which they need to obtain resources from, and the resources of the state at a quantitative level. In other words, the limitations of quantitative analysis at such a large and comparative level is quite daunting and would require too many variables with too many actors on too many levels with too much complexity to truly be able to meaningfully make any conclusions regarding the efficacy of long-term care policies without either becoming lost in 18. DOI:10.6814/NCCU201901221.

(27) the details or losing the big picture altogether.. Instead, we could only hold bounded rationalities to choose and to induce the closest solutions. In other words, using institutional analysis and theoretical approach to generate abstract generalities so as to be able to apply theoretical applications to other cases in future research is just as important if not more important than mere number crunching. Furthermore, it is a better approach to extend regime analysis into some developing countries like Taiwan. To conclude the highlighting of this epistemological point, comparative policy analysis requires a more abstract approach to be handled effectively.. Secondly, policies’ interrelatedness is another key or critically important factor when it comes to comparative institutional analysis. When an effective policy has been conducted or pursued in the past, analysts or policy makers expect a similar policy under similar circumstances to also be effective. Also, other policies to adapt to the original successful policy for the purpose of smooth and coherent policy applications so as to avoid inconsistencies, double policy applications or waste, and other wrinkles in the policy process that oftentimes tends to accentuate large and oftentimes ineffective or slow to act bureaucratic institutions in general. By applying the sense of interrelatedness, it becomes more helpful for the improvement of the economic policy research (M. Aoki, A. Greif & P. Milgrom, 2001). In this sense, the four aspects are selected: governance structure, service delivery, finance scheme, and sustainability scheme. In order to apply to the comparative institutional analysis, the framework of the Institutional trait is made in this thesis. (graph 6). 19. DOI:10.6814/NCCU201901221.

(28) Graph 6. Theoretical Framework. Institutional Aspects. Sustainability Scheme. Finance Scheme. Service Delivery. Governance Structure. Tax. Social Insurance Source: This research. These are the four institutional aspects. To be more precise, the four aspects including finance scheme, sustainability scheme, service delivery and governance structure are the 4 elements to compare with between Taiwan and Japan.. When it comes to finance scheme, from the book Ageing and Pension Reform Around the World: Evidence from Eleven Counties by G. Bonoli and T. Shinkawa (2005), it indicates that social insurance countries are facing the largest sustainability problems. In other words, social insurance pension schemes are controlled by government, and the bulk of the intergenerational transfer is performed on a pay-as-you-go (PAYG) basis, which makes the countries very sensitive to demographic change. For example, aged societies such as Japan is facing the issue of severe demographic change. In this sense, places with only a few citizens would be more difficult to carry out long-term care plans due to the lack of budget.. 20. DOI:10.6814/NCCU201901221.

(29) On the aspect of long-term care that rely on tax policies, such as Taiwan, as mentioned above in section 1.2, though taxation now in Taiwan seems to have met the budget, it is rather controversial in a sense that oftentimes it is said to be neither a long-term scheme nor steady reform when it comes to financial sustainability. Hence, speaking of financial sustainability, it is worth digging deeper into the finance scheme in both countries.. Sustainability seems to be the main focus when it comes to financial affairs. Therefore, sustainability scheme is indeed one of the aspects in the institutional trait. For instance, the idea of social investment is said to be a decent way of saving the financial deficit of long-term care. Letting private corporations and companies to invest in and to participate in the long-term care institutions not only solved the problems of insufficient funds but also attracted the human capital by industry investments. Furthermore, this innovates both the services and the technologies. In this respect, a better long-term care system would be built (J. Su, 2018). It would be further discussed in the Result of this research.. According to the research called Frameworks of Integrated Care for the Elderly: A Systematic Review by M. MacAdam (2008), she announced that in Europe and other developed countries, integrated care is seen as a key to improve financial sustainability. Integrated care is also known as integrated health and according to the definition from WHO (Technical Brief No.1, 2008), the meaning of the integrated service delivery is “the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.” And the brief definition is “the focus of which is providing the ‘right care’ in the ‘right place’.” In this sense, service delivery will be one of the essential aspects to compare with and to dig more into when discussing about financial sustainability of the welfare state in a country.. 21. DOI:10.6814/NCCU201901221.

(30) Last but not least, governance structure is intuitively very essential when comparing or even understanding the functions and policies of two countries in terms that every country has its own system of operation. To be more specific, the system includes the setting of policies, procedures, values, and more importantly the long-term plans of a society. By examining the governance structure of Japan and Taiwan, it would be more clear for us to seek insight into the plans and the strategies of the government.. 2.2 Past and Present of Long-term Care Policies By improving the long-term care system and policies, histories and current status of longterm care are also an important element to be acknowledged in the literature review. Therefore, in this section, both histories and current conditions of not only the aspect of Japan, but that of Taiwan will be discussed.. 2.2.1 Aspect of Japan According to the population pyramids of Japan in graph 7, we know that there is a huge difference between the three periods of time, including the year 1970, 2015, and even the predicted 2060. From the pyramids, we know the age-sex distribution of Japan. Gender is shown on the left and right sides, age on the y-axis, and the percentage of the population on the x-axis. In 1970s, they have an expanding shape, meaning it is still in the process of developing and younger generation holds the most part of the population. In this sense, the dependency ratio of young age population was higher than old age one at that era2. Then, about 2015, it came to the shape of stationary and even contracting, which the dependency ratio of old age population has surpassed the young. Moreover, people aged 65 and above fell into the cohort of top two groups. Also, from the developing of the three graphs, we can clearly see that the. 2. Please refer to graph 2 for detailed content. 22. DOI:10.6814/NCCU201901221.

(31) elderly groups are gradually increasing. In the other word, we can tell that birth rate is decreasing but the proportion of old generation is increasing rapidly. As predicted, a large part of the pyramid will be the old generation.. 23. DOI:10.6814/NCCU201901221.

(32) Graph 7. Population Pyramid of Japan. Source: National Institute of Population and Social Security Research. 24. DOI:10.6814/NCCU201901221.

(33) As a matter of fact, Japan was one of the earliest countries that had to face the problem of aging population and had to first carry out long-term care policies. From table 1, the chronicle of long-term care policies in Japan are showed, which we could see the development of the policies overtime. From the table, there are five main eras of the long-term care policies in Japan started from 1960s to 2000s.. Table 1. Chronicle of long-term care policies in Japan 1963. Enactment of the Act on Social Welfare Services for the Elderly. 1973. Free healthcare for the elderly. 1982. Enactment of the Health and Medical Services Act for the Aged. 1989. Establishment of the Gold Plan. 1994. Establishment of the New Gold Plan. 1997. Enactment of the Long-term Care Insurance Act. 2000. Enforcement of the Long-term Care Insurance System Source: This Research. In fact, the year 1973 is also called “fukushigennenn” (福祉元年), which means the main welfare revolutions started from this year such as the amelioration of the pension and the free healthcare policy for the elderly. Hence, though the increase rate of the social security expenditure was once 17.2% in average between the year 1966 and 1972, it rallies up to about 32.8% from 1973 to 1975 (T. Shinkawa, 1997: 156). Additionally, in the era of 1990s, Japan’s long-term care was different from other countries. In other words, their long-term care policies were unique since they were provided by hospitals. That is to say, people aged 65 and over that were hospitalized then increased from 2% in 1970 to 4% in 1990. Due to the unexpected high dependence toward hospitals by the elderly, the number of old people, who were hospitalized increased dramatically, especially for the small and medium sized hospitals. After all, the costs of hospital care were covered by insurance. Later, Health Facilities of Elders were established, 25. DOI:10.6814/NCCU201901221.

(34) which is a kind of facility for the elderly that are in need of long-term cares. This kind of facilities were established in 1986.. Before the year 1989, which is the year that Japan had carry out the “Gold Plan”. The gold plan is the ten-year strategy that government conducted to promote health care and welfare for the elderly. After five years, the “New Gold Plan” in 1994 was carried out to revise and had made improvements fiscally. For example, it increased the number of home-helpers for the elderly; also, it improved in the short-stay facilities, which the elderly could be able to stay and rest for a period of time and be specially cared; moreover, they also added the amount of athome services such as doctors and nurses’ visit. Because of the New Gold Plan, the goal of the number of full-time home-helpers increasing from 38,945 to approximately 170,000, and the number of short-stay centers increasing from 1,615 to about 17,000 (Kousei Tokei Kyokai, 1996) were successfully reached (MHLW, 2001). Another new measure of long-term care that was then carried out in the year 2000 is called “Gold Plan 21”, which the main goal was to vitalize the image of the elderly. Namely, to not only support their independent living but also develop supportive local communities and establish more trust-worthy long-term care services. The plan had continued for 4 to 5 years.. 26. DOI:10.6814/NCCU201901221.

(35) Graph 8. The Problems of Welfare and Medical Systems for The Elderly in Japan. Welfare System for The Elderly. Medical System for The Elderly. • Services provided: • Intensive Care Home for the Elderly, etc. • Home-help service, Day service, etc.. • Services provided: • Health center for the elderly, Sanatorium medical facility, general hospital, etc. • Home-visit nursing, day care, etc.. • Problems: • Users could not choose services : Municipal governments decided services and service providers. • Psychological resistance : Means test was required when applying services. • Services tended to be unvarying without competition: Services were basically provided by municipalities or organizations entrusted. • Service fee could be heavy burden for the middle/upper income group: The principle of ability to pay according to income of the person/Supporter under Duty.. • Problems: • Long-term hospitalization to be cared in hospitals (“social hospitalization”) increased: hospitalization fee is less expensive than welfare services for middle/upper income group, as well as basic maintenance of the welfare service was insufficient. →Medical cost increased: Hospitalization fee was more expensive comparing with Intensive Care Home for the Elderly and Health center for the elderly. →Facilitation of hospital was not sufficient enough for long-term care with staff and living environment: Hospitals are expected to provide “cure” (e.g. Limited room area for care, dining hall or bathrooms. Source: Health and Welfare Bureau for the Elderly, Ministry of Health, Labour and Welfare, 2017. Above all, the year 2000 was also the year that the government in Japan introduced their “Long-term Care Insurance” policy instead of tax-based system. In fact, the long-term care insurance policy was registered in 1997 due to the failure of the welfare system and the medical system for the elderly before the long-term care insurance system (graph 8)3. For example, for. 3. the information was retrieved from http://aging-asia.info/sites/default/files/conference/s204.pdf 27. DOI:10.6814/NCCU201901221.

(36) welfare system, care recipients cannot choose their services. In the other word, municipal governments used to decide the services and the service providers. On top of that, the service fee could still be heavy for those middle or upper income groups. As for the medical system, they used to provide house center for the elderly and the home-visit nursing and day care; however, there were problems such as high medical cost. Even the hospitalization fee could be cheaper than the welfare services. As a result, long-term care insurance policy was carried out in Japan. There are some concepts for the policy. For instance, the system is meant to support the independence of the elderly instead of just simply provide personal cares; also, an individual is supposed to have their own choice of the services he/she received. Namely, it not merely a support for independence but it is user oriented. Apart from those, the relationship between benefits and burdens is also clarified (MHLW, 2017). Therefore, the policy was not only widely accepted by the insurers but also a great leap forward for the whole long-term care histories in Japan.. 28. DOI:10.6814/NCCU201901221.

(37) Graph 9. The Differences Before and After The Long-term Care Insurance System in Japan. Before. After. 1. Municipal governments decided services, after users’application.. 1. Users themselves can choose services and service providers. 2. By making use plans of care service (Care Plan), integrated medical and welfare services can be utilized.. 2. Separated applications were required for each service of medical and welfare systems. 3. Services are provided by various associations such as private companies and NPOs, etc.. 3. Services were provided mainly by municipal governments and other public organizations (e.g. Council of Social Welfare). 4. Regardless of income, co-payment is set as 10% (20% for persons with income above certain level, after August 2015).. 4. Co-payment was heavy burden for the middle/upper income group, which kept them from applying to services.. Source: Health and Welfare Bureau for the Elderly, Ministry of Health, Labour and Welfare, 2017.. In summary, from graph 9, we can see that there are mainly four differences before and after the long-term care insurance in Japan. Firstly, whether or not an individual can choose their own services and service providers. Secondly, care recipients have to separately apply for each service of medical and welfare system, however, by making use plans of care service, integrated medical and welfare services can be utilized after the long-term care insurance system were addressed . Thirdly, the services were usually provided by minicipal governments and other public organizations such as Council of Social Welfare; but then many associations and private companies such as NPOs are nowadays also participating in providing long-term care services. Finally, The co-payment was a heavy burden for the middle and upper income 29. DOI:10.6814/NCCU201901221.

(38) groups due to the principle of ability to pay according to income of the person under duty. After the insurance system, regardless of the income, the co-payment is set as 10%, and 20% for those that have incomes above a certain level in the year 2015.4. When it comes to financial sustainability, according to the Taiwan Medical Journal, Learning From Japan, Upgrade Taiwan and Start Again- The Second Report On The Longterm Care System in Japan(借鏡日本提升台灣再出發-第二次日本長期照護制度考察報告) (Z. Li, 2016, Vol.59, No.4), though Japan’s long-term care insurance plan has already started for many years, the financial problems are still unsolved due to the increasing of the demand. The total insurance payment is kept on increasing; namely, the insurance payment for the elderly will have to increase in the future as well. According to Ministry of Health, Labor and Welfare (2016), the premium of long-term care insurance is increasing overtime and it will be in the future too. Every three years is set as a term, and the municipal governements formulate the policy every term. That is to say, the amount of national average insurance premium per month increases every three years. As showed in graph 10, the trends and the future prospects of long-term care benefits and premiums could be clearly seen.. 4. the information was retrieved from http://aging-asia.info/sites/default/files/conference/s204.pdf 30. DOI:10.6814/NCCU201901221.

(39) Graph 10. Trends and the Future Prospects of Long-term Care Benefits and Premiums in Japan. ource: Health and Welfare Bureau for the Elderly, Ministry of Health, Labour and Welfare (2016). In addition, from graph 11, it shows the total long-term care insurance loan and the total number of borrowers in Japan from the year 2015 to 2017. The amount of numbers for both the loans and the borrowers are gradually increasing in three years. Therefore, financial sustainability with regard to long-term care is not only our issue but also Japan’s.. 31. DOI:10.6814/NCCU201901221.

(40) Graph 11. Total Loan Long-term Care Insurance and the Total Number of Borrowers in Japan. Million. Source: Ministry of Health, Labor and Welfare (2015-2017). 2.2.2 Aspect of Taiwan After understanding the history, the current situation, even the development of Japan, this section will be the turn of Taiwan’s. Comparing to Japan’s population pyramids (graph 7), from graph 12, there is a slice different in the year 1970, the cohort of 0-14 years old in Taiwan held a larger part of the whole pyramid and the working–age population is obviously less than that of Japan’s; namely, though they both had the expanding shape, Japan was more developed than Taiwan in that period of time. Then as the time passes, from the pyramid graph, it is clearly shown that, Taiwan is gradually following the ageing steps of Japan’s. Likewise, in 2015, they 32. DOI:10.6814/NCCU201901221.

(41) both have come to the shape of stationary and even contracting. Moreover, in the predicted 2060, they will be almost the same shape.. 33. DOI:10.6814/NCCU201901221.

(42) Graph 12. Population Pyramid of Taiwan. Sources: 1. Ministry of the Interior, “Demographic Fact Book R.O.C. 2. National Development Council, “Population Projections for R.O.C. (Taiwan): 2018~2065”. 34. DOI:10.6814/NCCU201901221.

(43) Different from Japan, in table 2, it shows the chronicle of long-term care policies in Taiwan and we can know that it didn’t start as early. According to the research The Development and Challenge of Taiwan’s Long-term Care Industry (C. Xue, 2016, p.5-7), The start of the long-term care policies can be traced back to the year 1997. Noticing the issue of becoming an aging society, the new founded committee from Executive Yuan, Social Welfare Promotion Committee, had started the first long-term care plans in Taiwan. Hosting by Liu Chao-shiuan, they soon came up with the policy to enhance the elderly care the next year. Then in the year 2000, Ministry of the Interior established the Pilot Program for the development of long-term care. They not only had researchers to distribute the demand survey but also conducted the experimental plan, which was held in Taipei and Chiayi.. Table 2. Chronicle of long-term care policies in Taiwan 1998. 1. Enhancement of elderly service plan 2. Long-term care three-year plan. 2000. Establishment of the Pilot Program for the Development of LongTerm Care. 2002. Care services and industrial development programs. 2007. Long-term Care Plan 1.0. 2015. Establishment of Long-term Care Service Network and Long-term Care Service Plan. 2016. Long-term Care Plan 2.0 Source: This research. After a few years of improving the service delivery, resource development, financial system, decree system, and the information system of the long-term care, learning from the experience of Japan’s “Ten-year Golden Plan”, Executive Yuan established the long-term care plan 1.0. There are 8 different services for the content of the plan, including home care service, community and home rehabilitation service, purchase and rental of assistive devices, home. 35. DOI:10.6814/NCCU201901221.

(44) services of improving access-free facilities, nutrition and health advice services for the elderly, respite care, transportation service, long-term care institution service. The care recipients included people aged over 65 years or more, aboriginal people whose residence address are in mountain indigenous district or township that are aged 55 years or more, disabled people that are aged 50 years or more, also old people that are IADL (Instrumental Activities of Daily Living Scale) disabled and live on their own.. The year 2008 is considered as a threshold to the long-term care system and the financial affairs due to the financial crisis and the non-stop rapid increase of the elderly; in other words, the percentage of the people that were 65 years old or more was already around 10%, which seemed to also be as ticklish as the financial problems. As a result, the main goal for the longterm care is to have a more stabilized and robust policy since 2008.. However, Long-term Care Plan 1.0 didn’t go as successful as expected. Instead, because of its lack of resources, flexibility of the services, stability, lavishly using of the foreign caregivers, also the miscellaneous application approaches for citizens, the government then updated it to the long-term care plan 2.0 and established in the year 2016.. For long-term care plan 2.0, the government not only improved the budget but also the variety of target service groups and the content. From graph 13, we can see that the target groups have increased another 4 types of target populations including people with Dementia (aged 50 and over), plain-land indigenous people with functional limitations that are aged 55 and over, people with disability that are aged 49 and under, and the older people with frailty that are aged 65 and over.. 36. DOI:10.6814/NCCU201901221.

(45) Graph 13. The Target Population Change of Long-term Care Plans in Taiwan. Source: Ministry of Health and Welfare (2017). However, according to the article “Long-term Care 2.0 Is Officially One the Road. Is It Better?” from The Reporter by the director of Taiwan Association for Promotion Public Health also a medical reporter, H. Liu (2017), though the new long-term care plan 2.0 emphasized their improvement of the policy, there are still three important points to focus on in the longrun; there are the labor shortage of professionals for long-term care services, unstable financial resources and the uneven allocation of the resources.. Speaking of the labor shortage in long-term care services, even though there are over 100,000 caregivers with professional license for care services in Taiwan, somehow not many of them are really contributing to the long-term care service institutions. More precisely, there are actually only about 20,000 people that dedicate to it (Liu Hui-min, 2017).. 37. DOI:10.6814/NCCU201901221.

(46) Secondly, As the article mentioned, there is an unstable problem of the taxation policy that the government chose to improve our foundation toward long-term care. After Tsai Ing-wen was elected to be the president of Taiwan, which can be called the Democratic Progressive Party (DPP) era, they began the taxation for the long-term care finance. The taxation includes from the earliest House and Land Transactions Income Tax and Business Tax to the latest Gift tax and Tobacco Tax. As I mentioned in 1.2 Research Motivation, whether the scheme of taxation is sustainable or not, it is still known to be with reservation.. Finally, the problem of the unequal distribution of the resources especially between urban and rural areas. There is an important point in the content of the long-term care plan 2.0, which is the construct of the Long-term Care ABC for Communities. That is to say, according to Ministry of Health and Welfare, the long-term care service tiers will be parted into three: Tier A is community integrated service center, tier B is combined service center and tier C is to set long-term care stations around the blocks. The goal of the policy creates a 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. Lu, 2017); however, there are areas with different density of populations. Hence, it is still under evaluation that the resource distribution and the quality of services be robust in every area or district in Taiwan.. 38. DOI:10.6814/NCCU201901221.

(47) Chapter Three- Methodology. This thesis will be adopting 3 methods. The first is “comparative institutional analysis”, which is a relatively new but a useful one when it comes to comparing two institutions and policies in different states. Since the theory was mentioned in 2.1.2 Comparative Institutional Analysis, this chapter would focus more on the next two methods.. It is very essential when the goal is to understand policies and the reasons behind more thoroughly in order to learn from the lessons from the past, also be able to read between the lines in the transcript from the interview data. Therefore, the second method would be document analysis.. Finally, the “in-depth interviews” will be utilized in this research. This method is also used in many qualitative researches; moreover, it allows the interviewer to deeply explore the respondent’s perspectives on a subject on the basis of a semi-structured interview approach. After the discussion with the respondents, the analytical method of “content analysis” would be used as the main analyzing tool. With these methods successfully applied altogether, it would result in rich background information that can form further and deeper questions relevant to long-term care financial sustainability.. 3.1 Document Analysis Document analysis is a highly reliable resource when utilizing comparative institutional analysis and In-depth interview. It is about discussing the background, reasons for changes, choice-making, and problems encountered. By reading the pertinent documents, theses, journals, and data, this research would be discussing both Japan and Taiwan’s long-term care. 39. DOI:10.6814/NCCU201901221.