Taiwan

This is a long article, and I kept looking for places to cut, but it was so interesting I just left it whole. We never really realize how good we have it until we realize how awful it is other places. I left the translation.

Judy


Low-level Publicity of Long-term Care

長期照顧低度公共化
2005-11-02 / Taiwan News / Edited by Tina Lee/Translated by Susanne Ganz


The heart of the problem is that the state, by making needs invisible and a matter of personal affairs for a long time, has legalized the extremely supplementary and low-level development of long-term care services, shifting the pressure to provide care to individuals, families and the market.

The state defines low-income households very strictly, using the broadest definition of family responsibility, automatically presumed income and other methods to exclude people in need of long-term care services. It is estimated that Taiwan should have 2 to 5 percent low-income households, while it has only 0.7 percent.

Then again, the state uses an ethic of filial piety to exclude the households of disabled people within a family. The care services system step-by-step releases resources based on a categorization and classification of the recipients (veterans, low-income households, the physically and mentally handicapped, the elderly, single mothers, indigenous people, employers of foreign workers and employers of domestic workers) but only creates comparison and competition among social disadvantaged groups, as well as opposition from the weak against the state.

On the grounds that “national resources are limited” current care services even stipulate that services must be mutually exclusive, which makes it impossible for them to serve the needs of care recipients.

In a care services system that lacks public involvement and is not widely available, care recipients and their families enter the system begging the state for grace. They are not able to demand the state’s involvement in their “capacity as citizens” and to rationalize the state’s role as an administrator. More so, they get lost in the false superficial confrontation between domestic workers and foreign workers over employment opportunities and the clash of interests between employers and foreign workers.

核心問題在於，國家長期透過隱形化與私化需求，合法化長期照顧服務的極度殘補與低度發展，將照顧壓力交托在個人、家庭與市場身上。國家將低收入戶嚴格界定，以最寬廣的家庭責任、自動預設收入等方式來排除需要的人民，預估應有2-5％的低收入戶，在台灣只有0.7％。再用孝道倫理排除有家人的失能者家庭。照顧服務體系以不同身份別（榮民、低收入戶、身心障礙者、老人、單親婦女、原住民、雇用外勞與本勞）的階層化方式，逐步釋放資源，但造成弱勢族群之間的比較與競爭，削弱與國家抗爭的社會力量。現有的照顧服務更以「國家資源有限」為名，規定服務之間必須互斥，導致服務無法依照受照顧者的需求為依歸。缺乏公共化與普及化的服務體系，受照顧者與其家庭都是以乞求國家恩典的姿態進入體系，無法以「公民身份」要求國家的介入，合理化國家做為管理者的角色，更迷失在本勞與外勞競爭工作機會、雇主與外勞權益衝突的虛假表面衝突之中。

Sun Man-wei:

Recently there was a piece of news related to kindergartens. Due to negligence at a kindergarten in Taichung County a child suffocated on the kindergarten bus. This incident actually not only highlights negligence by the kindergarten teacher or bus driver, it also highlights the entire state’s negligence of its responsibility for early childhood care.

The state has handed the responsibility for early childhood care to commercial market players. As a result of the commercialization of early childhood education, we can find a lot of kindergartens with a beautiful outer appearance that even advertise bilingual or all-English language classes. Parents spend NT$30,000-40,000 a month to send their kids to such kindergartens, but will later on discover, nonetheless, that the school has not provided an education with corresponding quality and content.

孫嫚薇：最近有一則與幼稚園比較相關的新聞，台中縣某一所幼稚園的疏忽，使一位在該幼稚園的小孩在娃娃車裡被活活悶死了。其實這個事件呈顯出來不只是一個幼稚園老師或娃娃車司機的疏忽，也呈顯出整個國家對幼托照顧責任的疏忽。國家把幼拖照顧的責任都交給了市場業者，幼托教育市場化的結果，我們可以看到很多幼稚園的外觀都好漂亮，還標榜雙語或全美語教學，家長花了三、四萬塊送小孩去上這樣的幼稚園，但後來卻發現它並沒有提供相對品質與內涵的教育。
From the perspective of a kindergarten operator, the highest costs in early childhood education are personnel costs. Therefore if I am a kindergarten operator without a conscience, the first thing I will do is to reduce personnel costs. For instance, if I hire a teacher from China with a degree in early childhood education I will need to pay a salary of just NT$10,000. Moreover, the teacher will live in the kindergarten round-the-clock, won’t be able to come and go freely, but you need to provide free food and accommodation.

In comparison, if you hire a (Taiwanese) teacher with a university degree in early childhood education you might have to spend more than NT$20,000 on the salary. Together with payments into the Labor Insurance Fund and the new pension system you will probably have to spend NT$30,000-40,000, which means you can of course save a lot of costs if you hire a Chinese teacher. Aside from providing housework services, foreign caregivers also take care of the kids, which compresses our space for establishing a daycare profession and the public provision of early childhood care.

從業者的角度來看，從事幼教最大的成本是人事經費，因此如果我今天是一個沒有良心的業者，第一個要做的就是要緊縮人事成本，譬如引進大陸幼教科系的老師，一個月只需要一萬塊的薪水，還可以24小時住在園所裡，不能自由進出、包吃包住。相較之下，請一個大學幼教老師，可能要花兩萬多，加上勞保和新的退休金制度加起來可能要花三、四萬，請一個大陸的老師當然節省很多成本。外籍監護工除了提供家事服務，還兼帶孩子，這也壓縮了我們建立保母專業與幼托公共化的空間。

The establishment of public early childhood education and care should incorporate the voices of three groups of people: Parents, teachers, as well as kindergarten and daycare center operators. Presently all policy comes from the government and scholars, while those who are actually working in the first line do not have a voice. Furthermore we hope that relevant non-profit groups and community organizations can get involved in the field of early childhood care.

幼托公共化的建立應該包括來自三方面的聲音：家長、老師與業者。現在所有的政策都來自於政府與學者，沒有實際上在第一線的工作的人的聲音。另外我們也希望相關的非營利團體或社區組織能夠參與幼托照顧這塊領域。

Moderator Hsia Hsiao-chuan: We would like to thank kindergarten principal Ms. Sun for presenting her views. Now we would like to ask Ms. Hu Yi-ting, secretary general of the Taipei Association for Mentally Retarded Persons, to talk about the care problems of physically and mentally disabled people.

主持人夏曉鵑：謝謝孫嫚薇園長。接下來我們請台北市智障者家長協會總幹事胡宜庭小姐來談談身心障礙失能者的照顧問題。

Hu Yi-ting: Thank you Mr. Moderator. Actually I was quite astonished when the forum organizers invited me to speak, because organizations for the physically or mentally disabled are very seldom invited. The problem of long-term care for the physically and mentally disabled is also rarely noticed.

胡宜庭：謝謝主持人，其實主辦單位在邀請我的時候，剛開始我蠻驚訝的，因為身心障礙團體很少被邀請，身心障礙者長期照顧的問題也很少被看見。

People with physical or mental handicaps are disabled people. In the government’s eyes, however, they aren’t, because the state is not willing to assume responsibility for genuine care. I remember how a representative from the Council of Labor Affairs, raising his hands, once pleaded with me at a conference: “I beg you, we are only an agency that helps you look for people.” The CLA believes it is an “agency that looks for people,” and the health and social affairs agencies hide behind its back without saying anything. We don’t know where the tomorrow of Taiwan’s long-term care will be.

身心障礙者是失能者，可是在政府的眼裡卻不是，因為國家不願意去負擔真正的照顧責任。我記得在有一次的會議裡，來自勞委會的代表就曾經兩手一攤跟我說說：「拜託，我只不過是幫你們找人的單位。」勞委會認為自己是「找人的單位」，衛生單位、社政單位也躲在幕後不出來說話，我們不知道台灣的長期照顧的明天在哪裡？

Left without any other choice, many parents are forced to hire foreign workers. Let’s take elderly care institutions as example, which the government does not subsidize at all. As far as I know, the cheapest elderly care institutions in Taipei City cost at least NT$25,000 a month. If an elderly person also needs to wear diapers and requires special nutrition, namely tube feeding, the family needs to pay extra for these things. If unfortunately this old person needs to live in a nursing home, then sorry, costs will start at NT$40,000. These are only the care costs, which do not yet include other consumables. The cost of care is very high, causing a very big burden for families with a member in need of long-term care.

釵h家長在不得已的狀況之下，必須請外勞。以老人安養機構為例，政府是完全不補助的。然而就我的理解，台北市的老人安養機構最便宜起價是兩萬五千塊，如果這個老人要包尿布、要吃特別營養的食品——就是灌食，家屬還要自己另外出錢；如果不幸地這個老人家必須去住護理之家，不好意思，四萬塊起跳，這是照顧費，同樣不包含其他耗材。照顧的成本非常高，對家裡有一個必須長期照顧的家人造成很大的負擔。

The government dumps the entire care burden on the family, because it only needs to pull out the so-called “mutual obligation to maintain one another” of Article 1114 of the Civil Code, to put all members of the family under a spell. Even brothers and sisters and family members living in the same household are usually listed as having a “joint obligation to maintain one another.”

When you need to submit an application to the government for care services, the whole family is probed. We once came across the case of a woman who had turned 60, her husband was deceased, and her son was a drug addict who had been in and out of prison countless times. Her only daughter was retarded, but the women still could not get an allowance under the low-income household rule, because the government found out that her 80-year-old father-in-law in Taichung owns property. This means that her father-in-law had to assume responsibility for her under the so-called “mutual obligation to maintain each other.”

政府把所有的照顧責任全部推給家庭，因為它只要搬出民法1114條所謂的「互相扶養義務」搬出來，全家人都被放上緊箍咒，連兄弟姊妹、共同居住之家人，通通都被列為有「共同扶養義務」，當你需要向政府申請照顧服務時，這些人都會找出來。我們曾經碰到的一個例子，有位老阿嬤本身已經六十歲了，先生過世，兒子是一個進出監獄無數次毒蟲，唯一的孫女還有發展遲緩的問題，可是她依然申請不到低收入戶補助，因為政府查到她住在台中八十歲的公公名下有財產，意思是要她的公公負起所謂「互相扶養義務人」的責任。

The government is also not willing to sincerely face the problem of lacking fiscal resources for the establishment of a care system. Why isn’t there a single government official courageous enough to loudly say that we need to raise taxes? Our tax rate is very low in the first place. If you only pay NT$10 in taxes per every NT$100 that you make, what are you then expecting to get from the entire public services? Even some people working in social welfare are not honest themselves. I once heard a social worker say “I knew early on that I wouldn’t participate in the national health insurance scheme, because I never get ill.” In such attitudes we can see the selfishness of mankind. Without sufficient fiscal resources, many mechanisms of the care system are difficult to establish.

政府也不願意誠實面對建立照顧體系財源短缺的問題，為什麼沒有一個政府官員敢勇敢的出來喊加稅？我們的稅率本來就很低，如果你賺錢一百塊，你只拿出十塊錢繳稅，你期待整個公共服務給你什麼？甚至一些從事社會福利工作的人員自己也不誠實，我就曾經聽過一為社會工作者說：「早知道我就不要參加健保，因為我都不生病。」從這裡可以看到人性的自私。如果缺乏財源，很多照顧體系的制度是難以建立的。

Moderator: We would like to ask Professor Tseng Ai-lan to discuss long-term care from the perspective of the problems of a long-term care system for the elderly.

主持人：接下來請曹愛蘭老師談談老人長期照顧體系的問題角度來談長期照顧的問題。

Tseng Ai-lan: I will first cite the example of Taipei County. Taipei County’s Department of Social Affairs trained more than 2,600 local people in care services between 2003 and 2005. Up to today just 300 of those who have completed their training as care services personnel are actually doing home-care services. And among these 300 home caregivers, only 78 are working fulltime.

However in Taipei County alone a total of more than 20,000 disabled persons need someone to take care of their daily living needs. I beg to ask what are these elderly people supposed to do? They virtually have only three options. The first option is like (Hu) Yi-ting just said, to pay more than NT$20,000 a month and go to an elderly care center. The quality of these elderly care centers leaves much to be desired.

Once one of my students told me after visiting several elderly care centers: “Teacher, I don’t want to live beyond age 50.” Because the average elderly care center has seven to eight beds per room. These elderly people have only their beds as living space, they live very miserable lives virtually devoid of dignity.

The second option is that a family member quits work to stay at home and take up family care work that is most likely unpaid, round-the-clock, and without any vacation. These are the options that we currently have. If I ask the CLA to act as broker, ask it to help me find a person who is willing to do 24-hour home care, the success rate is virtually nil, even if I am ready to pay NT$60,000 a month, because the pressure from such work is too high. As a result, we have just a single option left: We have no other choice but hire a foreign worker.

曹愛蘭：我先以台北縣做例子，台北縣社會局從民國92年到94年一共訓練了兩千六百多位本國照顧服務員，到目前為止，這些受完訓練的照顧服務員有去從事居家服務工作的有三百多位，而這三百多位當中將居家照顧工作當作全職工作的只有78位。然而台北縣一共有兩萬多位失能者需要有人照顧他們的生活起居，請問這些老人要怎麼辦？他們幾乎只有三個選擇，第一個選擇就是像剛才怡婷講的，繳兩萬多塊以上的費用送到老人安養中心。這些安養中心的品質堪虞。曾經我的一個學生去看過一些安養中心之後回來告訴我：「老師，我不要活過五十歲。」因為一般的安養中心裡，一個房間可能就放了七、八張床，這些老人的生活空間就是那一張床，他們過的是非常悲慘、毫無尊嚴的生活。第二種選擇就是家人辭掉工作，回家去負擔一個可能是無酬、二十四小時、沒有任何假期家庭照顧工作。這是我們目前的選擇。如果我請勞委會幫忙媒合，請它幫忙找一個願意做二十四小時居家照顧工作的人－－即使我願意出一個月六萬塊－－成左瑣鰷v也幾乎是零，因為居家照顧工作的壓力太大，所以剩下唯一的選擇：只有請外勞。

The biggest structural problem at the back of this policy is that the state has not established diverse service types in the communities that would allow all kinds of families with disabled persons of different needs to obtain services. Consequently, it can’t help but allow most families to hire foreign workers.

The government should design various different types of care services work for domestic workers. Japan, for example, does not use foreign workers to care for its elderly. They have a lot of daycare centers in their communities where disabled elderly people can be sent during the day. At such centers the elderly have a lot of company and can participate in some really good activities. There are also family daycare centers for the elderly, where the caregiver functions as a daycare mother.

If I care for an elderly person of my own family and at the same time care for several other elderly persons, I can fulfill my care responsibility and also earn a salary. For the elderly this means that they don’t need to face day in and out a foreign worker with whom they cannot communicate, they have their own elderly companions and can do some light handiwork or sing songs, which enriches their lives mentally.

In Japan, there is also have a lot of care housing, not like in Taiwan where many elderly people end up confined to their apartments in five-story apartment blocks without a elevators, never getting out of the house because they can’t walk anymore. The Ministry of the Interior and the Department of Health should work together to create many different types of services for people with different degrees of disability.

The state should intervene to regulate the quality of such services and also monitor and subsidize them so that such services can be universally established in every community. In that event, many families won’t need to depend on foreign workers and disabled persons would also be able live their lives in dignity.

整個政策背後最大的一個結構性問題是，國家並沒有在社區裡面建立多元的服務型態，讓各種家裡有不同需求的失能者家庭得到服務，所以它只好讓大部分的家庭去請外勞。政府應該要設計各種不一樣型態的照顧服務工作給本國的勞工，我舉個例子，譬如日本就不用外勞來照顧他們的老人，他們社區裡有非常多的日間托老中心，白天把失能老人送到中心，讓他們有很多同伴，可以從事一些很好的活動；他們也有家庭托老中心，照顧工作者就像保母一樣，我照顧我自己的老人，也同時照顧其他幾位老人，既可以盡到照顧責任，又可以賺到一些薪水。對老人家來說，也不需要每天面對一個彼此語言不通的外勞，他們有其他老人做伴，也可以做一點小手工或唱唱歌，在精神生活上比較更豐富一些；他們有很多的照顧住宅，不像台灣很多老人只要不能走路了，就得被關在五樓的樓梯公寓裡，永遠也下不來。內政部跟衛生署應該要整合起來，針對失能的不同程度，去創造很多不同型態的服務，國家應該要介入規範這些服務的服務品質，並且進行監督與補助，讓這樣的服務在每一個社區裡頭普遍設立，這樣的話，很多家庭就不需要依賴外勞，也能讓失能者生活得有尊嚴。
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