Using private finance to reform healthcare – Taiwan Focus

Taiwan's early welfare policies were based on an informal social support system. The legal system played only a supplemental role. Since 1990, Taiwan society has seen gradual economic development and has evolved into a mature modern democracy. To establish a system of social welfare programmes for long-term care, the Taiwan government has been propagating related policies for approximately 10 years. The government has passed various acts for disadvantaged social groups including: People with Disabilities Rights Protection Act, the Senior Citizens Welfare Act, and the Nursing Staff Act. Several long-term care related policies have been proposed that are directed mainly at low-middle to low-income families or solitary senior citizens. They are: Enhance Elderly Services and Care Act, 1998-2007, 3-Year Program of Elderly Long-Term Care, 1998, New Era Health Care Program, 2001-2005, Pioneer Project of Construction of Long-Term Care Project, 2000-2003 and Provide Nursing Service and Its Industry Development Plan, 2002-2007.

From the end of 2007, the Taiwanese government started to promote what it called the 10-Year Long-Term Care Programme plan, and extended the scope of the application of services to the elderly with middle class income (50-year-olds with disabilities, 55-year-old aboriginals, and 65 year-old men and women). These programmes focus mainly on providing home nursing services, home healthcare, physical therapy at home and in the community, the purchase and lease of assistive device services, home accessible environmental improvements, nourishing meals for the elderly, respite care services, transportation services, and long-term care facility services. With long-term health care insurance being insufficient, the Taiwan government needs to establish a long-term care service network and enact a Long-Term Care Services Act in order to encourage development in those resource insufficient areas and integrate the National Health Insurance into the long-term care programmes.

The problems

Care services are provided by related government departments and non-profit organisations, but their poor efficiency and service quality have often been criticised. Below are the main issues encountered:

1. Administrative confusion

The social services system is afflicted with interference and with conflicting competitive-cooperative relationships, which need immediate attention. Responsibility for the following acts and laws resides in different administrative departments and agencies (see table one).

2. Insufficient resources for long-term care

Except for fully equipped long-term care services developed in government owned facilities, home-based care and community-based care cases have a severe resources problem. For example in 2010, 27,800 people used home-based care. This is 5,783 more individuals than in 2009 or a 26% increase over the previous year. Up until May 2011, only 69 community-based day care facilities had been established. This included 12 Dementia Day Care Centres (Ministry of the Interior, 2011). This amount is far below the 10-year policy schedule goal, namely one long-term care facility for each county/city/district.

Not only are there limited resources, but there is also an uneven distribution in remote mountainous areas and on the various islands. The goal to have these facilities established and operational by 2011 was missed.

3. Uneven quality in the private sector

Even though the number of private facilities is sufficient, the quality is not uniform and varies so considerably that it arouses mistrust and suspicion. It is indeed impossible to predict the kind of care that will be received from one facility to another.

The situation will only deteriorate with the aging wartime baby boomers. More facilities will be needed with more than basic service items. How to create people-oriented services that are diversified, life-fulfilling and dignified is the true challenge for these facilities.

4. Lack of manpower

Long-term care is a labour intensive service and with the increasing demand for services more trained nursing staff needs to be involved. There were 18,991 nurses in 2009. It is estimated that there will be between 48,569 and 64,300 in 2015, with 29,578 to 45,309 under a training programme.

However, with salaries below average, a relatively low social status and competition from lower-paid foreign labourers, it is difficult to keep a stable employment number and rate in the nursing industry. If this problem remains, long-term care policies will eventually become moot and there will be much more reliance on foreign nursing staff.

5. Problems with local government

There are several important differences among counties/cities in the implementation and operation of 10-year long-term care programmes. These differences are key to identifying the underlying reasons for the failure in both their implementation and operation and must be understood so that past errors are not repeated.

Using private finance

In view of Taiwan's rapidly aging society, there is a growing demand in the senior services industry. Social welfare resources and mainstream industry attitudes towards this expanding industry are lagging far behind and restricting needed development.

In order to comply with global privatisation, the Taiwanese authorities have aggressively introduced public resources to the process.

In addition to expanding social welfare on a vastly accelerated scale, the Ministry of the Interior, as dictated by the Executive Yuan, will actively assist all county/city regional administrations, through Private Financing Initiatives (PFI), employing a Value for Money analysis, in the development of state-owned Senior Citizens' Welfare Facilities.

The authorities have completed a Private Finance Initiative principle for future organisers to follow as public-private partnerships continue to receive attention. A PFI project for long-term care has recently been initiated in Pingtung county and Kinmen.