This is a CTP of initiative: Volunteer Labour Bank/Network (Japan)
This CTP concerns the introduction the Long-Term Care Insurance Law, which was passed in 1997, but becoming operational 2000-2001. The LTCI Law was one of a set of new laws in Japan, representing and contributing to a shift in government policies concerning community organisations and who should assume responsibility for care of the aged. The two main laws are the Non-Profit Organisation (NPO) Law (1998) and the Long-Term Care Insurance (LTCI) Law. The NPO Law is addressed as another CTP.
The LTCI is a scheme for mandatory universal insurance of those aged 40+ to provide care in old age. It was modelled on a 1995 German scheme, but incorporates important differences to fit the Japanese context. Payment into the scheme is obligatory for those aged 40+. Beneficiaries (at age 65+) with qualifying care needs are assessed and allocated to one of seven categories of care with services ranging from basic assistance with household tasks for those living at home to 24-hour care in institutions for those who are bedridden and without family support. Beneficiaries co-fund with 10% of care costs. The scheme meets the other 90%. This contribution is funded through insurance premiums and general tax revenues. Local government authorities and agencies administer the scheme on the basis of local conditions.
The LTCI has further shifted the balance of care of aged persons from the family (female family members in particular) and onto society as a whole. At the time of its introduction the scheme was “the biggest and most radical program of public mandatory long-term care insurance in the world.” Its objective was to allow the elderly to stay as long as possible in their own chosen environment in the community. NPOs (especially TimeBanks) act as providers, often in support of official agencies that implement the LTCI scheme. This provides a stream of activity/work and a stream of money for TimeBanks and their members. Commercial organisations also provide care under the scheme.
The LTCI scheme reimburses 90% of the cost of specific services. If provided by a commercial company care and service are likely to be limited to the specific service. TimeBanking organisations can compete and fill gaps by meeting the emotional and companionship needs of the elderly, which commercial providers are less likely to provide for. Those who have provided service within a TimeBank will also be able to use their time credits to pay for care. The LTCI scheme therefore widens the range of care providers and provides a framework within which TimeBanks can fill gaps by offering a quality of service that would not necessarily be available under the insurance arrangement alone.
Together, the NPO and LTCI Laws provided the legal and institutional framework for a major social change in how care for the elderly is arranged. Nevertheless, implementation and actual social change has been achieved bottom-up through activities organised within this new governance framework by newly-legitimated and empowered community organisations.
TimeBanks have been important actors both in pushing for this legislation and new organising elderly care through TimeBanking mechanisms. The two laws together allowed for creating a new relationship between the public and private sectors. They have led also to innovations in TimeBanking and the co-development of new variants/models of TimeBanking, some of which involve money payments and many of which involve men as well as women as carers. These involve a creative hybridisation of traditional values and modern needs.
The scope of socially acceptable lifestyles for both men and women in Japan had previously been very restricted, especially concerning responsibilities for providing care to the aged. Prior to 1989 (the Gold Plan) and even into the 1990s, women were expected to give up any personal ambitions for activity outside the home (work, education, sport, recreation) if aged parents required care. This included quitting paid jobs. Women were expected to conform by assuming a full-time role as carer or face being stigmatised in their neighbourhoods. Equally, the coming of frailty in old age was feared as it brought the threat of dependency without the opportunity to engage in reciprocity.
Before the 1990s, both the Japanese government and the community accepted that the family had main responsibility for aged care. Only the small few without close relatives were deemed to be deserving of state assistance in old age. Families unable to cope with looking after their aged relatives frequently resorted to placing them in hospitals rather than nursing homes, for both cost and social reasons. No social disgrace was attached to hospitalisation, whereas placement in a nursing home was seen as a failure to live up to social ideals. But this compromised hospitals, which were becoming de facto places of long-term care rather than medical facilities for the sick needing treatment. In the early 1990s, the Japanese hospital system had the longest patient stays of any system in the industrialised and post-industrialised world.
The change brought about has been the shift from selective application of care benefits for a poverty-stricken minority to universal application for all older Japanese needing care. This has involved overcoming the stigma and dishonour formerly associated with asking for help outside the family. There has been a shift in how Japanese people view the respective responsibilities of families and communities toward the aged. The LTCI scheme establishes the right to obtain services and the fact that benefits can be seen as coming from one’s own past contributions means that recipients can feel entitled to them within a cycle of reciprocity.
"Gender roles have been as rigid in Japan as age roles have been. Both have been undergoing some transformation over the last decades as a number of Japanese manage to step outside them. Population aging has been partially responsible for this shift. Policy makers see raising levels of both female and elderly participation in the workforce as a way to compensate for decline in younger workers.".
Volunteering has provided a space for experimentation with switching gender roles. TimeBanks have been part of this questioning and changing. Since the 1990s (i.e. the second and third wave of TimeBanking in Japan) they have become spaces where older men (as well as women) are encouraged to become carers. “That this has been espoused by two high profile male retirees who themselves have defied gender constraints by moving into volunteering has helped to make it more socially acceptable.”
The LTCI scheme was designed to eradicate customs, such as pressure on women to leave work to care for older relatives. But the LTCI scheme alone was not able to provide a solution to the need for new models of care in Japan. TimeBanking “has [helped] fill the gaps the LTCI scheme doesn’t cover”.
“What is new (about the change) is that an older generation of Japanese is at its forefront”.
The new legislation has benefitted TimeBanks through giving greater legitimacy to NPO activity. It has enabled them to further refine the citizen-style mutual volunteering model that they pioneered and to work out how to co-produce care services for the aged. The possibilities of care work under the LTCI scheme has helped attract recruits aged in their 50s and 60s to Japanese TimeBanks and into training and certification as ‘carers’. In the first 6 years of the scheme, around 500,000 people had gained official carer qualifications.
In turn, TimeBanks have become major providers of training courses, certification and delivery of care under the scheme. It has been established that the greatest take-up of the LTCI scheme is for the lowest levels of care (i.e. household help with simple tasks), which incentivised volunteers are well able to provide after base-level qualification.
Some Japanese TimeBanking organisations have gone on to become leading researchers and sources of information for policymakers and businesses about the needs and wants of the aged. These activities provide a finance stream for the concerned TimeBanks and their members.
The expansion and diversification of Japanese TimeBanking and the emergence of more innovative networks has contributed to the relative and absolute decline of the VLN, whose ‘purist’ model is less useful and attractive to prospective members in the changing context than the more innovative variants.
The LTCI scheme was drafted with NPO involvement. Two groups heavily involved were WABAS (Women’s Association for a Better Ageing Society) and TCC (the Ten Thousand Citizens’ Committee). The TCC connected with the New Democratic Party of Japan. It lobbied to stop the LTCI Bill being shelved by conservative members of the parliament and worked with the New Democratic Party, which proved important for securing passage of the LTCI Bill.
The LTCI scheme is closely related to the NPO laws. The NPO reforms legitimated non-governmental and community organisations, making it easier to establish and operate civil society organisations and, by reducing governmental oversight and regulation, enabling these to have a high degree of autonomy and to be responsive and innovative.
Japanese Laws that regulated non-governmental associations up to 1998 were based on the Civil Code of 1896 and post WWII amendments. These required groups seeking legal status to apply to the ‘competent authorities’. This was a high cost, slow process, requiring significant capital assets. Legal establishment required wealth, but tax rules also put the wealth of individuals and their families at risk through membership of ‘private’ associations. Yet, without legal status, those representing social organisations lacked the social status essential in Japan to secure critical links with business and government. The post-war amendments also prohibited public funding of private groups. One reason that housewife-based mutual help groups for aged care needed to charge for their services in the 1980s and 1990s is attributed to their inability to gain public funding because they could not incorporate.
Other laws passed around the same time have also facilitated greater flexibility in Japanese society, expanding the range of choices open to individuals across the life course. These include laws to promote greater gender equality and to provide access to leave from employment to care for children and the elderly. These laws were designed to enable greater workforce participation by women and to enable progress to higher positions. The care leave laws legitimate to be engaged in careers while being available for family care on a needs-arising basis. Laws enabling men and women to take time off to care for family members challenge the previous gender stereotypes that formerly recognised only females in these roles. The Elderly Employment Stabilization Law, which obliges employers to raise or abolish mandatory retirement age, is another relevant piece of legislation, since it challenges received notions about older people being required to leave post and recognises that the active elderly can still contribute to society.
These laws can be seen partly as responses to changes in society, but they also provided impetus for further change. The context is one of a nation undergoing rapid demographic, social and economic change and experiencing growing alarm over the possible economic and social repercussions of rapid population ageing. Government sought new ways to curb public spending, including by reducing the burgeoning cost of aged care by drawing on volunteers. The retiree population offered a source of such helpers. The (package of) legislation that includes the LTCI, the NPO and the gender laws (among others) is designed for a society in which non-profit civil society organisations are assuming an increasingly higher profile and encouraging older Japanese people to join them.
Objections to the related LTCI scheme were voiced initially on the basis that older people might not want strangers caring for them. In practice, it has since been found that while some do reject offers of domiciliary care from non-kin carers, many others actually prefer non-kin carers.
The issues of who would provide care services to the elderly, if/how these would be remunerated and how to assure care quality were initially contentious. Feminist lobbyists – albeit supporting the scheme – did not want to legitimate and entrench the idea of women as carers, so were opposed to paying allowances to family members providing care.
Concerns were alleviated by introducing voucher systems and by introducing training for non-kin carers. Agencies administering the scheme at the local level supply vouchers to those needing care and these are used to ‘pay’ for care provided largely (though not exclusively) by trained and certified members of NPO organisations, such as TimeBank members. Insurance premiums pass partly to carers and partly to the network organisations. They are used also to cover the expenses of those providing care; e.g. transport costs. This created opportunities for the emergence of a second and third wave of TimeBanks, including some that remunerate their members with money alongside time credits.
The challenges of demographic change (falling birth rates and an ageing society) were anticipated by Mizushima long before they became a prominent societal or governmental concern. Her response was to develop TimeBanking as a mechanism through which members could donate care and support to those in institutionalised settings (formal residential care homes) and could also build time credits for mutual (i.e. within group) support, whereby active TimeBankers (mostly women) would care for frail TimeBankers in their own homes as they aged. This was the first ‘wave’ of TimeBanking in Japan. This model paved the way for at least two further waves of TimeBanking, based on variants of this model. The second wave of TimeBanking (represented most notably by the JCSA) emerged in the 1980s. Third-wave’ ‘variants’, such as SWF, TJN and NALC were facilitated by the NPO and LTCI laws. Each of these TimeBanking networks was able to offer a variant on the purist TimeBanking model of VLB/VLN. In the context of an overall expanding and diversifying Japanese TimeBanking scene, these developments overtook the VLB/VLN, which has declined relatively and absolutely as these other networks have expanded and (some, at least) have institutionalised.
Two aspects of the challenges of demographic change were recognised by government in the 1980s. One concerned the decline in the working age population, which necessitated bringing new entrants into the workforce, including women. The other concerned the increasing share of older people. The two were related, since in traditional Japanese society women were expected to care for the frail elderly. The first response of government to this challenge was to introduce the Gold Plan in 1989. This was a decade-long plan to ease the burden of elder care on women. Targets were set under the Gold Plan to increase the numbers of carers, introduce qualification and certification schemes for professional carers, and provide day-care facilities for the elderly. This first ‘solution’ of a public scheme with professional carers proved able only to deliver care to a small number of those most in need and was too costly to generalise. The LTCI scheme that replaced it took a completely different approach; i.e. universal coverage drawing on the middle-aged and active elderly (both men and women) as ‘volunteer’ carers.
TimeBanking in Japan has been studied from both within and outside the concerned organisations and from within and outside Japan. The major external study is the PhD thesis of Jill Miller, which takes the perspective of learning how Japan has used TimeBanking to address its social, demographic and economic challenges and how changes in external governance arrangements have facilitated and legitimated (incentivised) volunteering. This has expanded and opened the body of learning from Japanese experience, which hitherto was largely known about only in Japan.
The role of the NPO and LTCI reforms have been studied and lessons learned, especially about the roles played by the key leaders of the concerned organisations in co-creating the reforms and about the strengths and weaknesses of different variants of the basic TimeBanking model in respect to meeting different needs and suiting different contexts. It has helped that the leading advocates and practitioners had high status and strong/close connections with the establishment (i.e. leading roles in earlier careers in industry/business and/or government and law making, strong connections with the media, etc.) and that they have been demonstrably willing to engage actively themselves in the activities they advocate (e.g. by training and working as carers themselves), which has made them respected role models in the social changes they are pioneering.
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