Taiwan Today

The first thing that occupies the mind of 62-year-old Tsai Mei-hwa (蔡美華) each morning is what kind of meals she will put together for her mother on that day. While cooking for an 85-year-old hypertension sufferer is difficult in its own right, Tsai’s mother is also quite a picky eater. “I used to just bring her takeout food, but it contained too much salt and caused her feet to swell badly,” Tsai says. “Now I insist on giving her only home-cooked food, even though it takes a lot more time. Often, she tells me that she doesn’t want onions or bitter squash in her food, or no more rice and things like that. Then I have to figure out something else to feed her.”

Tsai says she usually spends the morning preparing dishes to be placed in two meal boxes—one for lunch and the other for dinner—then takes them to her mother around noon. Tsai stays with her mother throughout the afternoon, doing laundry and cleaning the apartment, before returning home in the evening. The devoted daughter has barely missed a day of the routine for years, even when she had a surgery earlier this year. “The doctor told me not to move and rest as much as possible to help the wound heal,” Tsai recalls. “But if I don’t do this for her, who will?”

An Aging Society

Tsai’s mother is just one of the nearly 400,000 seniors in Taiwan who require long-term assistance in their daily life. As of the end of July this year, Taiwan had about 2.5 million people aged 65 or older, with such seniors accounting for 10.77 percent of the population. The extent of the country’s aging is not as great as that in Japan, the United States and some countries in Europe, but, with the world’s lowest birth rate, Taiwan is quickly catching up. It took Japan about 25 years, the United States 73 years, Sweden 85 years and France about 115 years to double their populations of those 65 or older from 7 percent to 14 percent, the respective thresholds set by the United Nations for aging and aged societies. In Taiwan, that same transition is expected to take only 24 years, as the Council for Economic Planning and Development projects that the country’s elderly population will go from 7 percent in 1993 to 14 percent in 2017.

An aging population means new demands on social welfare services. “Most baby boomers … are expected to turn 65 or older by 2017. At that point, the demand for long-term care services will increase rapidly and dramatically,” says Teng Sue-wen (鄧素文), director-general of the Department of Health’s (DOH) Bureau of Nursing and Health Services Development. “To address these needs, [the country] has to plan ahead for a long-range support scheme,” she says, which is why the government launched the 10-year long-term care program in 2008. According to the DOH, that project represents Taiwan’s first large-scale extended care initiative for elderly people with disabilities, although previous projects partially subsidized the establishment of long-term care management centers in a handful of areas.

The goals of the scheme are to assess the needs of seniors who require long-term care and set up a network to make services available to them throughout the country, Teng says. “Since the plan came into effect, the government has established long-term care management centers in all of Taiwan’s cities and counties,” she says.

“When applicants contact their local facility, a care manager will go to their residence to perform an assessment and decide which of the care options available to them are the most suitable,” Teng explains. The centers then contract care providers—mostly nursing homes and nongovernmental organizations (NGO)—to offer a variety of services. These include community-based and institutional care, medical and non-medical home care, respite care and meal, rehabilitation and transportation services.

According to DOH regulations, applicants receive and pay for such services based on their degree of incapacitation and income level. In the case of non-medical home care, the most commonly requested service, those identified as having a slight disability are eligible to receive subsidies from the central government for up to 25 hours of services per month. Seniors who are more seriously incapacitated—those who experience difficulty eating, dressing and using the bathroom, for example—are entitled to receive subsidies from 50 to a maximum of 90 hours, depending on the number of activities they cannot perform. The government pays up to 90 percent of the cost of such services for low-income recipients and 70 percent for those in higher income categories. Most services cost around NT$200 (US$6.50) per hour, meaning low-income earners pay just NT$20 (US$0.65) per hour. Recipients must pay the full amount for services rendered in excess of their hourly limit.

The development of the long-term care service network for seniors began to deliver results in the second half of 2009, when the DOH saw a significant growth in applications, Teng says. “Only 3 percent of [disabled seniors] requested the services in 2008, but the figure surged sixfold in three years to roughly 20 percent by the end of August this year,” she says, adding that the recent percentage translates to nearly 900,000 recipients. “It shows that more and more people became aware of the resources and learned to access them,” she points out.

The success of the 10-year project is a major factor behind the government’s drive to push for the creation of a national long-term care insurance system in the near future, Teng says. Similar to Taiwan’s National Health Insurance (NHI) scheme, the preliminary sketch of the long-term care insurance plan would require all citizens to participate by paying premiums. Seniors who require care would receive insurance benefits in the form of services instead of cash payments.

Frank T. Y. Wang (王增勇), an associate professor in the Graduate Institute of Social Work at National Chengchi University in Taipei, acknowledges that the 10-year long-term care program has succeeded in establishing the rules of the game and making state-backed services more widely available. “But its largest problem is unstable financial support,” Wang says. Although seniors with disabilities need continual and reliable care services, he says, the amount of funding the project receives changes annually as its budget is approved on a year-to-year basis. “That’s why a long-term care insurance system is important. Each of us would contribute to the insurance system, just as we all share the risk of becoming disabled when we’re older. That way, we’d secure a stable source of funding for the country’s long-term care services,” he says.

Teng believes, however, that more groundwork needs to be done before the government rushes to kick off such an insurance program. “The priority for now is strengthening the service network to make sure there are sufficient services on offer,” she says. One government measure to promote the development of long-term care services and enhance the quality of care they provide is the drafting of the Long-term Care Service Act. Designed to regulate the provision and certification of care professionals and the management of care institutions, a draft of the act was approved by the Cabinet in March this year and is currently awaiting approval in the legislature.

Monitoring Alliance

Along with his teaching duties, NCCU’s Wang is also the chairman of the Taiwan Association of Family Caregivers (TAFC). In 2010, the TAFC worked with the Awakening Foundation, an NGO devoted to promoting gender equality, to found a strategic alliance called Long-term Care Watch (LCW) that is dedicated to monitoring government policy related to long-term care.

For the nearly 30 NGOs that are LCW members today, the version of the act proposed by Cabinet is a clear disappointment. The watchdog body organized a protest of the draft act in May this year, criticizing its lack of vision and failure to address several important issues. “The policy excludes the 190,000 families that hire foreign caregivers from the long-term care network,” Wang says. “Having foreign caregivers seems to be considered some kind of luxury. For that reason, these families are not eligible to use [most] public long-term care services. We keep asking the government how it can deny these people access to public services, considering they’re all taxpayers. On top of that, they’re obviously the group that needs services most urgently because they’re already getting 24/7 care provided [at home],” he adds.

At the same time, Wang says, not allowing families who employ foreign caregivers to receive public long-term care benefits also has the effect of depriving foreign employees of rights and protections enjoyed by other workers, including limitations on forced overtime, scheduled breaks and days off. “Without regular breaks, caregivers can easily become physically and emotionally exhausted,” Wang says, pointing to the 2003 tragedy in which an Indonesian caregiver killed her paralyzed employer, famous writer Liu Hsia (劉俠). “What do people do if they are exploited or abused? They abuse a person who’s more vulnerable. In this case, the vulnerable people are those being cared for.”

The DOH’s Teng argues that families with foreign caregivers are still qualified to apply for two of the care options provided by the 10-year project: medical home care and rehabilitation services. With a limited budget, she says the government had to prioritize the needs of some groups over others when determining how to allocate other services, but adds that service availability will be expanded as finances allow.

The LCW, however, continues advocating the establishment of a more comprehensive and integrated long-term care mechanism to prevent abuse of foreign caregivers. “Eventually we hope that foreign employees can be included in the government’s service network and their hiring can be shifted from private homes to the [government’s] contracting nursing institutions,” Wang says, adding that the LCW’s goal would be for all families that need services to apply to their local long-term care management center, from which they could receive care provided by both domestic and foreign caregivers.

In addition to the foreign labor issue, the LCW expresses concerns over the welfare of caregivers within a family. The monitoring organization points to a 2009 TAFC study indicating that 65 percent of all family caregivers show signs of depression. On average, family caregivers spend 13 hours per day looking after an incapacitated relative, with such care typically lasting for nine years. According to the TAFC, an indication of the seriousness of the problem can be seen in more than 80 news reports filed in 2009 concerning family caregivers who killed bedridden family members and then committed suicide. Wang believes a lack of quality respite care resources in Taiwan—temporary care services families can turn to—is to blame. “The government does offer up to 21 days of respite services per year, allowing family members to put seniors in nursing homes for a while,” Wang says. “But it still hasn’t addressed such issues as whether the elderly person will be comfortable enough to go to the nursing homes and whether there are nearby care institutions available. We hope to see a wider range of respite care options listed and even stipulated in the Long-term Care Service Act.”

According to a 2009 DOH survey, 68.7 percent of Taiwan’s senior citizens are looked after by family members. Another survey conducted by the Ministry of the Interior in 2006 showed that nearly 80 percent of all family caregivers for the incapacitated are women. “In Taiwan’s families, single, low-income women are often assigned to shoulder the task of caring for aging parents,” Wang says. “Since they don’t know how long they have to look after [an elderly family member], it becomes very hard for them to go back to the workplace again. As a result, they can lack a retirement pension or any kind of insurance, which means they are even more prone to poverty in old age.” If such family caregivers remain unemployed, the only economic security they might find when they get older could be the benefits provided by the National Pension System (NPS), which was launched in 2008. Under that scheme, insurants are entitled to receive a monthly pension of at least NT$3,000 (US$100) after the age of 65, depending on how many years of premiums they have paid.

Although there are a number of issues confronting long-term care for seniors, the traditional values of most Taiwanese also ensure that many elderly citizens enjoy a relatively good quality of life. As in the case of Tsai Mei-hwa spending much of her day caring for her mother, Wang says it is an asset for Taiwan that families are still willing to look after their aging relatives, unlike the situation found in many other countries.

Wang believes Taiwan should support such strong family bonds as a way to develop more alternatives for long-term care. For example, government-contracted care providers could “hire” a family member to care for their own incapacitated relatives, paying them as they would a contract caregiver. In that way, Wang says family caregivers could enjoy the rights and benefits of regular employees, while the elderly would receive care from the people who best understand their needs and to whom they feel closest. “After all, the key to [quality] long-term care services is relationships,” he says.

Write to Audrey Wang at audrey@mail.gio.gov.tw