Culture,institution and diverse approaches to care and care work in East Asia

Abstract

Spanish

French

This article describes two broad approaches to care and care work within a spectrum of approaches that are evident in East Asia: one that accepts care as a core public policy agenda, and tries to leverage it as a potential engine to activate the incipient care economy; and the other, that sees care as strictly private family responsibility, and hence opts to partially underwrite the familial care with a mix of tax and policy incentives through the private market – including creating channels for families to outsource care to foreign migrant care workers. The author uses elder care policies to illustrate ways in which socio-cultural ideas and institutional history shape national policies, and how these policies in turn shape ways in which care is delivered, and care work organized within the family and in the market.

Keywords

Ageing care care work culture East Asia elder care family gender institution long-term care social policy

Introduction

Despite their shared familialistic approach to welfare, significant differences exist among East Asian countries when it comes to organizing and providing care. This is because government care policies are shaped by broader socio-cultural and institutional factors, and those policies shape the way care is provided and marketized. This article describes two broad approaches within a spectrum of approaches to care and care work that are increasingly evident in East Asia: one that accepts care as a core public policy agenda, and tries to leverage it as a potential engine to activate the incipient care economy; and the other that sees care as strictly a private family responsibility, and partially underwrites this responsibility with a mix of tax and policy incentives through the private market – including creating channels for families to outsource care to foreign migrant care workers. I use elder care policies to illustrate the way in which socio-cultural ideas and institutional history shape national care policies, and how these policies in turn shape the ways in which care is delivered, and care work organized within the family and in the market.

Elder care is an important and useful lens to analyse care and care work in East Asia. First, unlike in many Western countries where family policies are largely focused on children and child care, in East Asia the cultural emphasis on filial piety puts elder care squarely at the centre of family policy. It is therefore impossible to ignore elder care in any discussion of East Asian family policies. Second, elder care is now one of the most important public policy priorities for East Asian countries because of their rapid and significant population ageing. An analysis of elder care policies in East Asia is therefore both timely and relevant.

I compare four East Asian countries – Japan, South Korea (hereon ‘Korea’), Hong Kong, and Singapore¹ – to illustrate how distinct approaches to elder care may lead to different forms of elder care markets. Elder care policies in Japan and Korea can be characterized as a regulated institutional approach. These countries have introduced compulsory universal long-term care insurance that provides publicly funded and publicly and/or privately delivered elder care services to their older citizens. The regulated elder care market in these two countries (though the extent of regulation differs between the two countries) has served to suppress the demand for and the use of foreign care workers.

In contrast, the Hong Kong and Singapore governments follow what may be called a liberal private market approach to elder care. Both have firmly maintained elder care as a private family responsibility. Instead of providing social care, tax incentives and policy measures have been made to help families purchase care in the market, especially to hire foreign domestic workers, most of whom undertake significant amounts of care for children and/or the elderly (again, there are also some differences between the two).

The first section of this article provides a background to East Asian family policies. The second section describes the two contrasting approaches to care among the four East Asian countries. The third section explains how the two approaches have evolved and how they in turn have shaped elder care markets and care work. Finally, the last section discusses the implications of this for the global sociology of care and care work.

Changing family contexts in East Asia

Japan, Korea, Hong Kong and Singapore share similar familistic cultural traditions grounded on the practice of filial piety. Accordingly, parents are expected to raise and educate their children, and in return, children are obliged to be obedient and to look after their parents in old age. The strict gender role division that exists in these countries means that, normally, sons look after the economic welfare of their ageing parents, while daughters and daughters-in-law provide elder care. As a result of this familistic orientation elder care has been traditionally considered almost entirely a family responsibility. The four countries have been low welfare spenders, particularly with regard to public social spending on families and care. For example, until 1990, with the exception of Japan, they all had public social spending well below 10% of GDP, as compared to the OECD average of 17% (OECD, n.d.). There have, however, been some increases in social spending in recent years, particularly in Japan (Table 1).

Table 1.

Public social spending as percentage of GDP, 2000–2015.

Country	Health		Education		Social security and welfare		TOTAL social spending
Country	2000	2015	2000	2015	2000	2015	1990^a	2000	2015
Japan	6.1	7.6	3.7	2.8	10.2	16.0	11.1	20.0	26.4
S. Korea^b	2.0	3.9	3.1	3.2	3.0	5.6	2.7	8.1	12.7
Hong Kong	2.4	2.9	3.9	3.3	2.1	2.7	2.5	8.4	8.9
Singapore	0.9	1.8	3.9	3.0	0.6	1.6	1.4	4.7	6.4 (2014)

Source: Asian Development Bank (2017).

1990 figures for Japan and S. Korea are from the OECD social spending database (OECD, n.d.); Hong Kong from the Hong Kong Council of Social Service (2017); and Singapore from the Asian Development Bank (1999). Both of these exclude education spending.

Korea data on health care spending adjusted using OECD data.

These familial ideas and practices are, however, undergoing a rapid transformation in East Asia as a result of structural and cultural changes. All four countries have been experiencing rapid demographic ageing, largely due to very low fertility. For example, in 1990 only about 12% of the Japanese population was over the age of 65, today the figure is about 27%, and by 2035, this population is projected to reach close to 32%. The proportions of people over the age of 65 in the other three countries were well below 10% in 1990, but they have more than doubled since then, and by 2035 they will make up more than a quarter of the total population. In all four countries, more than a third of population will be over the age of 65 by 2060 (Table 2). Elder care therefore is a serious public policy concern for these countries, and will continue to be over the next several decades. More than half of all adult women in these countries now work outside the home. This, combined with the decline in co-residence of elderly parents with adult children since the 1980s, has put pressure on many families to manage and provide child care and elder care.

Table 2.

Demographic profiles of the East Asian countries.

Countries	% population aged 65 +	Total fertility rate	Old age dependency ratio	Women’s employment rate	% social expenditure to GDP
Year	2015	2015	2015	2015	2015
Japan	26.3	1.4	47.2	66.7	26.4
South Korea	13.1	1.2	19.6	57.9	12.7^a
Hong Kong^b	15.1	1.2	15.0 (2014)	55.0	8.9
Singapore	11.7	1.3	16.2	60.4	6.4 (2014)
OECD average	17.6	1.7 (2013)	27.3	63.0	21.1

Sources: Asian Development Bank (2016, 2017); OECD (2017a); the Department of Statistics Singapore; and the Food and Health Bureau Hong Kong.

South Korean data are based on the OECD family database (OECD, 2017b), whereas the % social spending data for the other three countries are based on the ADB database (Asian Development Bank, 2017).

Hong Kong Census and Statistics Department (2016).

These structural and behavioural changes pose serious challenges to traditional family values, such as intergenerational family interdependency, strict gender role segregation and familial welfare and care. Today, family values and relations have become more diverse, ambiguous and contradictory. The widespread ideals of love-based democratic marriages, individualism, the nuclear family and greater gender equality all compete with traditional values like patriarchy, filial piety and gender discrimination (Canda, 2013; Jones, 2005; Martin, 1990; Nagase, 2011; Yi, 2013). These tensions have led East Asian families to increasingly ‘subcontract out filial piety’ (Lan, 2002) whereby families can fulfil part or most of their filial obligations by employing domestic and/or care workers. The governments too have begun to respond to these socio-cultural changes by reforming family policies, resulting in an increased public policy focus on the family, and a greater externalization of care.

Two approaches to elder care in East Asia

The liberal private market approach

The basic state philosophy of elder care in Singapore and Hong Kong is that family should take care of their elderly members as affirmed by the tradition of filial piety, and failing that, the community should support the family in caregiving. In both cases the states limit their roles to encouraging and regulating the family and the community to provide elder care through such measures as the Maintenance of Parents Act (MPA)² and ‘Many Helping Hands’ policy in the case of Singapore, or through community care/ageing-in-place policies in Hong Kong.

Both governments have introduced cash allowances, tax relief and other material incentives aimed at subsidising private home-based elder care, and at supporting elderly parent–adult child co-residence. While the two places differ in terms of the extent of state emphasis on familism, undergirding their heavy reliance on the family and individualistic solutions for care is the free market principle for care provision, including little or no direct state intervention in service provision, pervasive bidding and contract systems – of grants to NGOs to provide community care – and an extensive use of financial and tax incentives for the family to address their care needs. In Hong Kong, a Social Security Allowance Scheme provides both universal and means-tested welfare support for the elderly. Those between the ages of 65 and 69 can receive a universal Normal Old Age Allowance (HK$625 – approximately US$80 – per month), while those aged 70 and over receive Higher Old Age Allowance (HK$705 – US$96 – per month), if in need of more intensive care. Elderly people with disability are also eligible to receive Normal Disability Allowance (HK$1260 – US$162) or Higher Disability Allowance (HK$ 2520 – US$324), depending on their disability level. A means-tested Old Age Living Allowance is made available for very low-income elderly residents (Hong Kong Social Welfare Department, n.d.).

These allowances however amounts to barely subsistence level (Chan and Phillips, 2002). For families willing to live with one or more elderly relatives the ‘Elderly in the Family Priority Scheme’ reduces the waiting period for public housing. Similarly, older people who are willing to live with another elderly person can also get public housing priority through the ‘Priority Housing Scheme for Two Applicants’, all designed to encourage elderly parent–adult child co-residence or other forms of elderly co-residence (Chan and Phillips, 2002).

The community care programme in Hong Kong is modelled after the UK’s community care programme. In theory the idea was to provide a continuum of care for older people and their families within the community, and thus reduce the use of hospital and/or residential care. In practice, however, community care policies have been ineffectual – largely due to a combination of the lack of resources, lack of system integration and coordination, and perverse incentives created by the public health care system – resulting in the over-use of hospital and/or residential health care services (Chan and Phillips, 2002; Chui, 2011). Hong Kong has a publicly funded health care system that does not include long-term care for the elderly (Chi, 2001). Instead, long-term care is administered through social services, on a means-tested basis, and mostly delivered through community-based NGOs. Some attempts were made to re-engineer home help services in 1999; however, low transfer payments and chronic under-funding problems have resulted in minimal community care services (La Grange and Yung, 2002). This in turn has reinforced the use of residential care – in the form of social hospitalization – as a care of last resort. The institutionalization rate of elderly people in Hong Kong is nearly 7%, significantly higher than other Asia Pacific countries – such as Japan (3.0%), Singapore (2.3%), Taiwan (2.0%), Canada (4.2%) and the US (3.9%) – and yet waiting lists for residential care remain high (Chui, 2011). To address this problem, the government launched a Community-Care Service Voucher for the Elderly in 2013, a four-year pilot project to help disabled elderly people on the waiting list for residential care to access required care in the community. Those families that could afford private residential services put their frail elderly family members into private nursing homes and other residential care services. Alternatively, middle-class Hong Kong families are increasingly turning to foreign domestic helpers to provide elder care within the home.

In contrast to Hong Kong, where the lack of public support for community care has led families to resort to social hospitalization, or to rely largely on the private market for elder care, Singapore’s approach is straightforwardly individualistic and private market oriented. Singaporean family policy assumes that individuals are personally responsible for their old age; if necessary, their family is expected to support them too (Rozario and Hong, 2011; Yap, 2009). Strict means-tests are applied to ensure that older adults and their children bear most, if not all, of the cost of long-term care (Teo et al., 2006). Singapore’s Central Provident Fund (CPF), a form of enforced individual savings account, was introduced in 1955 by the British colonial government, largely for the benefit of British expatriates. The predominant view of the colonial government at the time was that the state should not provide direct financial support for citizens, other than minimal public assistance, as public assistance would undermine work incentive. Instead, the state should focus on ensuring low inflation and full employment (Ghesquière, 2007; Khan, 2001; Ramesh, 2000; Vasoo and Lee, 2006). The Singaporean government maintained the CPF plan after independence. Some argue that the plan was more a form of regulation and control than social protection (Zhang, 2003).

In response to the changing socio-cultural context and diversification of family values, the Singapore government introduced the Maintenance of Parents Act (MPA), in 1995, to reinforce children’s economic and care obligations to ageing parents. The re-culturation of Confucian ethics as a part of a public policy effort – to address population ageing – is evident from the public debates and official reports related to MPA (Rozario and Hong, 2011). The Elder Shield Programme, an opt-out CPF account for long-term care for citizens aged 40 or over, was added onto the regular CPF in 2002. Account holders must register with a privately managed long-term care disability programme to finance long-term care services in later life (CAI, 2006). The original programme provides a cash pay-out of SG$300 for 60 months, to supplement the cost of formal services for older people who require assistance with at least three of six activities of daily living (ADL), including bathing, grooming, toileting, feeding, mobility and transfers (Agency for Integrated Care, 2011). Because of its opt-out option, the enrolment rate is low. To further promote intergenerational family support the government also provides SG$11,000 tax relief for adult children living with their dependent parents with ADL needs. Those not co-resident with elderly parents receive SG$4500 (Inland Revenue Authority of Singapore, 2011). The National Council of Social Service funds non-profit organizations to provide community-based support, such as preventive care, neighbourhood links and day activity centres, however most of these programmes are only available for very low-income families (Chui, 2011; Mehta and Vasoo, 2000; Teo et al., 2006).

As an extension of private market solutions to family care, both the Hong Kong and Singaporean governments encourage the family to employ foreign domestic workers by providing tax concessions and incentives. The Singaporean government has loosened employment restrictions, and created a special immigration channel, so that families can hire foreign domestic workers. This loosening includes a reduced monthly levy on families employing foreign domestic workers, from SG$265 to SG$170 if there is a frail elderly member (Reisman, 2009). Similarly, the Hong Kong government has reduced levies on family employers who hire foreign domestic workers. Currently approximately 240,000 and 330,000 registered foreign domestic workers are working in Singapore and Hong Kong, respectively, providing live-in domestic and care services, in private homes. In Singapore, most of the foreign domestic workers provide care for the elderly. In Hong Kong, more foreign domestic workers are now providing care for the elderly than children, a change from previous decades, when most of the foreign domestic workers in these places were caring for children. A recent survey found that almost half of older adults aged 75 years and over were being cared for by a foreign domestic worker (Huang et al., 2012).

The regulated institutional approach

In contrast to Hong Kong and Singapore, the Japanese and Korean governments have adopted more regulated institutional approaches to elder care. Japan has had a formal public elder care system (the Gold Plan) since 1989, providing elder care, on a means-tested basis, through local governments (Peng, 2002a). However, as population ageing accelerated, the government was forced to develop a more comprehensive system for elder care. Inspired by Germany’s Long-Term Care Insurance (LTCI), the Japanese government replaced the Gold Plan with its own LTCI in 2000 (Campbell and Ikegami, 2000; Peng, 2012).

The LTCI is a universal mandatory social insurance that covers long-term care of people over the age of 65 and those between the ages of 40 and 64 with age-related disabilities such as Alzheimer’s. The LTCI premium is levied on all citizens and residents over the age of 40. This insurance covers a wide range of domiciliary, community-based and institutional care services. The Japanese LTCI is financed by general tax (50%), insurance premiums (30%) and co-payments (up to 20%),³ and provides only services, and no cash allowances. It operates on a quasi-market system, as all the care providers (public and private, for- and not-for-profit) must be registered and certified by the government; care workers also must be certified by accredited professional bodies, and all the fees are set by the state. In short, Japan’s response to increasing elder care needs has been to socialize care through the LTCI.⁴

Like Japan, the Korean government also adopted a regulated institutional approach to elder care, albeit with less strict regulation than Japan. Korea began preparing for LTCI in 2006, largely in anticipation of rapid population ageing (at the time of LTCI implementation in 2008, the proportion of population over 65 was barely 10%, but it was anticipated that this proportion would increase to nearly 30% by 2035) and in response to Japan’s LTCI (Peng, 2012). The Korean LTCI is modelled on the Japanese LTCI scheme. Like Japan, Korea’s LTCI is a universal social insurance, financed through compulsory insurance premiums (60–65%) levied on citizens and residents over the age of 40, tax subsidies (20%) and co-payment fees (20% for institutional care; 15% home-based care) (Park, 2015).

The programme covers the long-term care needs of people over the age of 65 and the age-related care needs for those under age of 65. Individual care needs are determined by standard assessment procedures, and the amount of care provided by LTCI is set based on the level of disability. Like Japan, Korea’s LTCI provides mainly services. In remote areas where services are not readily available, cash allowances are made available for the family (Rhee et al., 2015). Although both Japanese and Korean LTCIs are publicly funded and mixed public/privately delivered systems, Korea’s LTCI is more reliant on the private sector for service delivery compared to Japan. Korea had much less public and institutional infrastructure for elder care when LTCI was introduced. The Korean population was still relatively young when LTCI was introduced, and hitherto most elder care was provided by the family. Concerns about public cost containment for long-term care and the pressure to expand long-term care services within a very short period of time also led the government to open the LTCI service delivery system to private sector care providers. This resulted in a significant relaxation of regulation for service providers. Much of LTCI in Korea, as a result, is provided by private for-profit care providers (Chon, 2014).

Explaining the two approaches to elder care and how they relate to elder care markets and work

The origins of the two approaches to elder care

The two different approaches to elder care in East Asia can be explained by the differences in socio-cultural and institutional development. Japan and Korea have a long history of developmental state-led economic development. Throughout the last century the two states took what some have argued is an explicitly ‘interventionist’ role in managing their national economies and industrialization processes (Johnson, 1995; Woo-Cumings, 1999). Partly motivated by the fear of being colonized if they did nothing, and by the goal of national survival, these countries embarked on concerted nation building projects in the 20th century. Governments in these countries actively invested in human capital and social and infrastructural development, as part of their economic development and industrialization strategies. Japan avoided being colonized by the Western colonial powers in the 19th century largely by executing a political reformation in 1868, and by galvanizing its people in a nation building project that focused on rapid industrialization and the strengthening of military power. Korea came under Japanese colonial rule from 1910 to 1945. However, as Kim (2009) points out, it managed to avoid the kind of ‘extractive colonial institution’ experienced by many Southeast Asian countries that were colonized by Britain and other Western colonial powers – ironically – because it had a relatively small labour force, and few pre-existing institutions that colonizers could exploit. As a result, the Japanese colonial government had to invest in social and economic infrastructure in its effort to industrialize Korea.

After the Second World War, the Japanese government continued its economic and industrial development strategies, while in Korea, political leaders undertook land reform⁵ and built on the institutional structure and social organization that was put in place during the colonial era. Korea’s postwar economic development and industrialization took off during the authoritarian regime of Park Chun-hee (1961–1980), who was educated in Japan during the colonial era. The Park Chun-hee regime implemented a similar state-led export-oriented industrialization strategy to Japan. It involved, on the one hand, centralizing economic planning under the presidential control, consolidating state–business linkages and investing in strategic industries, and on the other, also investing in economic and social infrastructures that would facilitate economic development, including child care.

In both Japan and Korea, economic development policies focused on mobilizing human capital. But whereas male industrial workers were incorporated into the core labour market, dominated by corporate enterprises, women were relegated to the peripheral labour market. To facilitate working-class women’s and single mothers’ employment, public child care systems were developed after the Second World War. Postwar Japan saw a rapid expansion of public and private kindergartens and public child care facilities across the country, the former offering early childhood education for the growing middle-class families, and the latter, for children of single working mothers and other poor families (Peng, 2002b; Shimoebisu, 1994). In Korea, child care institutions developed rapidly after the Korean War to accommodate orphans and children from poor families. Child care centres continued to grow throughout the postwar era in both countries, as the governments’ industrialization policies drew more working-class women into the labour market. It should be pointed out, however, that the child care system was much more developed in Japan than in Korea.

The establishment of public child care systems in the two countries was important for the subsequent implementations of other social care programmes, such as LTCI. The public child care systems not only established an institutional framework for social care, but also normalized the idea and practices of socializing care, and established a clear state role and mandate in providing care. Hence, when elder care became a public policy issue in the 1980s in Japan, it was not difficult for the government to introduce the Gold Plan, and public support was strong. The Gold Plan in turn led to the implementation of LTCI in 2000. Similarly, it was not difficult for the Korean government to introduce LTCI in 2008 as a proactive policy measure, to address the anticipated rise in demand for elder care. The idea of social care as a solution for elder care was loudly supported by the public in both countries. Public opinion surveys in both places show high and sustained support for LTCI, at over 80%. It is not accidental that LTCI was seen as a way to address real and anticipated demands for elder care in both countries. Rather, it was an extension of the two countries’ institutional path-dependent policy trajectory reinforced by widespread public support and expectations for such a solution.

In contrast to Japan and Korea, Hong Kong and Singapore’s socio-cultural and institutional history is noticeably different. The two city-states had over 150 years of British colonial rule before they gained their independence, and Hong Kong’s status vis-a-vis China remains ambivalent. The economic base of the two city-states, as free ports and international trade entrepôts, meant a history of significant international trade and labour migration. Their economic development strategy differed markedly from those of Japan and Korea. The idea of economic and industrial development as a part of nation building was non-existent in both city-states under colonial rule; rather the idea of free markets and international trade dominated colonial and subsequent post-independence governments’ policy and institutional thinking. In addition to establishing multiethnic and multicultural, and racially and class divided social structures, British colonial governments also reinforced a culture of servitude using mui tsai – an old Chinese practice of having ‘domestic bonded servants, often children, always female’ – to undertake domestic work (Leow, 2012: 1736). Even though the use of mui tsai was outlawed in the early 1930s, expatriates and wealthy Chinese families in these countries continued the practice of hiring paid domestics. This practice of employing domestic workers/helpers to undertake household and care services resurfaced amongst the middle-class families in the 1970s, as the two economies grew and women began to enter the labour market.

The two city-states’ historical practice of employing foreign labour to address labour shortages, and the availability of foreign labour in immediate neighbouring Southeast Asian countries have made the practice of outsourcing domestic and care work a reasonable option. The source country for paid domestic workers shifted from China to the Philippines in the 1970s, as the Philippines’ economy worsened. In short, the different socio-cultural and institutional paths taken by Japan and Korea, on the one hand, and Hong Kong and Singapore, on the other, have shaped nationally specific ideas about, and practices of, elder care, and these national specificities and attitudes towards elder care, in turn, have influenced the national policies towards elder care. Again, it is important to note the internal variation between Hong Kong and Singapore. Whereas the public health care system in Hong Kong allows a high level of institutional care for the elderly through social hospitalization, the lack of public health care in Singapore precludes social hospitalization while the government firmly upholds familism as the solution to elder care.

Two types of elder care market and care work

Japan and Korea’s regulated institutional elder care systems formalize elder care work, whereas the work of domestic workers in private homes in Hong Kong and Singapore tends to be less formalized. In the former countries, elder care work is clearly defined and structured within the LTCI system, and at the workplace, and is bounded by the Standard Employment Act. This gives workers basic labour protection, even if the wages of care workers may be lower than other work and many care workers are working on a part-time or contractual basis. As stated earlier, in addition to the socio-cultural and institutional practices that discourage the use of care workers within private homes, strict regulations surrounding the elder care system in Japan make the use of a private market for elder care unnecessary in the first place, and in the second, extremely difficult because the supply of native-born care workers is very low, and immigration policies have, until very recently, excluded domestic or care work as an occupational category for temporary work visa. The 2014 immigration policy reform, however, allows the intake of ‘domestic workers’ under the temporary work class, but only in special economic regions, such as Tokyo and Kansai. The market for private foreign domestic workers in Japan is, however, miniscule, while the EPA (Economic Partnership Agreement) programmes have been less than satisfactory largely because of high entry barriers placed on foreign nurses and care workers. Most EPA nurses and care workers are employed as nursing and care worker trainees until they pass the Japanese national occupational licensing examination (in Japanese) in the respective fields, and their continued employment is contingent on them passing the examination within four years. The pass rates have been very low.⁶ Yet, because of the formalization of elder care work in Japan, foreign nurses and care workers are accorded standard employment legislation and are paid equal wages to their Japanese counterparts. As well, since foreign care workers – and almost all Japanese elder care workers – are employed by public or private care institutions or by community-based NGOs rather than private homes, human rights abuse concerns are rare and legal enforcement of employment standards is more effective compared to Hong Kong and Singapore where such issues arise more frequently.

In Korea, government regulations on care work are less strict and there is more room for informality. As the co-payment for LTCI services is high, many low- and middle-income older people are unable to access elder care through LTCI, or are forced to limit their use of LTCI services. Private for-profit LTC institutions thus often employ low-wage nursing aides (gambyoin) to provide supplementary elder care outside the LTCI system. The dual care market that results from many private for-profit care providers, looser institutional and employment regulations, and the cash option – though limited to a small proportion of the elderly – within LTCI, has meant that formal LTCI provides standard elder care services according to the LTCI system, while in the secondary care market, private services – often provided by female migrant co-ethnic Korean Chinese (Joseonjok) – can be purchased at a lower price. To facilitate this, the Korean government revised its immigration policies by expanding the employment categories for the H-2 visa holders (mainly low-skilled Joseonjok) to include domestic and personal care services. In sum, in Korea the combination of a less regulated elder care market, the strong presence of private for-profit providers, the cash option within the LTCI and the availability of co-ethnic foreign migrant workers within the country has thus encouraged the formation of a dual market system for elder care where foreign (co-ethnic) migrant care workers are increasingly channelled into the informal secondary market.

Unlike Japan and Korea, much of the care work done by foreign domestic workers in Hong Kong and Singapore is informal. In neither places does the Standard Employment Act apply to foreign domestic workers, nor is there much in the way of state protection in the case of human rights violation or abuse: foreign domestic workers are required to live with employers; their employment conditions and descriptions are wide ranging and vague at best; no maximum working hours nor minimum wage regulations are applied to their work; and while employment agencies are subject to agency/placement fee regulations in both countries, significant loopholes exist for these agencies to dodge the regulations.⁷ Moreover, because of the private nature of employment, enforcement of what few regulations there are is very poor. Yet the lack of regulations and the market informality make entry to the care market in these countries easy for foreign care workers. The foreign domestic and care market in these two places is further fuelled and complicated by not only the sending country state’s active involvement in the promotion of labour out-migration, but also the growing private intermediary recruitment and employment agencies on both the sending and receiving sides, often in collusion with bureaucracy, in recruiting, training and certifying migrant domestic workers to dispatch abroad (Killias, 2009; Lindquist, 2010).

These experiences reveal reciprocated relationships between national approaches to elder care, national elder care policies and forms of care market and care work. They illustrate that national policies towards elder care are powerfully shaped by the countries’ historical and institutional experiences, and national policies in turn shape the ways in which care markets operate and how care work is organized. Although these dynamics may appear path-dependent and institutional, we cannot ignore politics in reinforcing or challenging the directions of elder care policies or the ways in which the care market might take shape. For example, in Japan and Korea, political actors have begun to build on the existing accepted norms and ideas about social care to further expand and reshape it into a new economic development strategy. Political leaders in the two countries have been actively leveraging social care expansion (in both child care and elder care) to promote the care economy. In Japan, social care expansion is framed not simply as a tool to address growing care needs and to encourage higher fertility (by reducing work–family tensions for working mothers), but also as a crucial part of Prime Minister Abe’s ‘Womanomics’ policy, an active and efficient use of women’s human capital, the aim of which is to stimulate and increase the country’s economic growth (Mizuno, 2016). Similarly, the state’s social investment in social care in Korea is widely promoted as a positive social and economic policy that will create a virtuous economic cycle by supporting maternal employment and creating jobs (Peng, 2012).

Conclusion

Family and care policies in East Asia have undergone quite significant changes over the last several decades. Faced with rapid social, economic and demographic transformations East Asian families and societies are revising traditional practices of filial piety by outsourcing elder care to non-family care providers. The changes in elder care practices reflect, in part, changes in social and cultural underpinnings of these societies, and in part, government policies on care and migration. This article focused on elder care, an important family obligation and practice for familistic society, and examined two evidently contrasting approaches to outsourcing elder care in East Asia today. Whereas Japan and Korea have adopted what may be called a regulated institutional approach to elder care, Hong Kong and Singapore have employed a more liberal private market approach. The comparison of the two approaches to elder care reveals several things. It shows that despite their shared Confucian cultural heritage, and their similar social and demographic contexts, approaches to care and care policies can still vary considerably. This is partly explained by the differences in their socio-cultural histories and institutional contexts.

Having outlined these two broadly different approaches to elder care, it is important to point out that there are noticeable internal variations within the two. For example, LTCI in Japan is more regulated than in Korea, partly due to the more established institutional structure that had been in existence at the time of policy reform in Japan, and partly because of the Korean government’s decision to open LTCI to private for-profit care providers. Similarly, because of its emphasis on the family to care, and its preference for liberal private market solutions for elder care in the case of family failure, Singapore is much stricter in enforcing family’s (adult children’s) care obligations and the use of market solutions for care. These variations within the two different approaches remind us that what we are seeing is more a spectrum than discreet fixed models or typologies to elder care. The variations in approaches to care among the four East Asian countries discussed in this article thus underscore a significant diversity among countries that have been widely thought to share very similar welfare state cultures. Through country-specific discussions of policy changes, we see that these variations arise from their different socio-cultural, political and institutional contexts. In the light of ongoing socio-cultural and demographic changes faced by these countries, we can anticipate continuous readjustment of family and care policies as these nations face progressive demographic changes, and as families face increased distanciation and economic imperatives for both men and women to work.

Third, in all cases elder care is becoming increasingly marketized, even if the forms of elder care market might be different in the two cases discussed here. The process of marketization of elder care may involve the privatization of elder care services through care allowances, tax credits and/or other forms of financial support, leaving the individual or family members to source care from the market, as is the case in Singapore. But even in the more regulated elder care market in Korea, the presence of for-profit service providers and the cash option within LTCI has encouraged the development of a dual care market, whereby formal elder care services are provided by certified and native-born Korean care workers through LTCI, while informal elder care services are offered by non-certified co-ethnic migrant care workers, at a cheaper price outside the LTCI system.

East Asian governments are faced with increasing pressure to marketize elder care. As the case of Korean LTCI illustrates, the government’s political imperatives to expand elder care is sharply offset by concerns about controlling welfare spending, and marketization has proven to be an expedient and cheaper solution. Even in Japan, where market regulation of social care is probably the strictest among the four East Asian countries compared here, there has been significant pressure and a gradual loosening of the state’s regulatory control over social care since the 2000s, as more private sector service providers have entered the care market.

Finally, across East Asia, as elsewhere, there is a shared belief among policymakers and economists that the market is the most efficient and economical way of delivering elder care, as market competition is inevitably leading to lower prices.

Footnotes

Funding

This research has been funded by Social Sciences and Humanities Research Council of Canada (SSHRC) Partnership Grant, ‘Gender, Migration and the Work of Care’ (File No: 895-2012-1021; Ito Peng, PI).

Notes

Author biography

Ito Peng is a Professor of Sociology and Public Policy, and Canada Research Chair in Global Social Policy at the University of Toronto. She has written extensively on family, gender and social policies, and the social and political economy of care, in East Asia. Her new book (2017), co-edited with Sonya Michel, is called Gender, Migration and the Work of Care: A Multi-Scalar Approach to the Pacific Rim.

References

Agency for Integrated Care, Singapore (2011) Inaugural yearbook. Available at: www.aic.sg/sites/aicassets/AssetGallery/About%20Us/2010%20Yearbook.pdf (accessed 25 July 2017).

Asian Development Bank (1999) Key indicators of developing Asian and Pacific countries 1999. Available at: www.adb.org/publications/key-indicators-developing-asian-and-pacific-countries-1999 (accessed 25 July 2017).

Asian Development Bank (2016) Basic statistics 2016. Available at: www.adb.org/publications/basic-statistics-2016 (accessed 25 July 2017).

Asian Development Bank (2017) Key indicators for Asia and the Pacific 2017. Available at: www.adb.org/publications/key-indicators-asia-and-pacific-2017 (accessed 12 January 2018).

CAI Singapore (2006) Committee on Ageing Issues: Report on the ageing population, MCYS 22–01A-01. Available at: http://unpan1.un.org/intradoc/groups/public/documents/APCITY/UNPAN024041.pdf (accessed 26 July 2017).

Campbell

Ikegami

(2000) Long-term care insurance comes to Japan. Health Affairs 19(3): 26–39.

Canda

(2013) Filial piety and care for the elders: A contested Confucian virtue re-examined. Journal of Ethnic and Cultural Diversity in Social Work 22: 213–234.

Chan

ACM

Phillips

(2002) Policies on ageing and long-term care in Hong Kong. In: Phillips

Chan

ACM

(eds) Ageing and Long-term Care: National Policies in the Asia Pacific. Singapore: Institute of Southeast Asian Studies, pp. 23–67.

Chi

(2001) Long-term care policy for elders in Hong Kong. Journal of Aging and Social Policy 13(2/3): 137–153.

10.

Chon

(2014) The expansion of the Korean welfare state and its results: Focusing on long-term care insurance for the elderly. Social Policy and Administration 48(6): 703–720.

11.

Chui

EW-T

(2011) Long-term care policy in Hong Kong: Challenges and future directions. Home Health Care Services Quarterly 30: 119–132.

12.

Ghesquière

(2007) Singapore’s Success: Engineering Economic Growth. Singapore: Thomson Learning.

13.

Göransson

(2009) The Binding Tie: Chinese Intergenerational Relations in Modern Singapore. Honolulu: University of Hawaii Press.

14.

Hong Kong Census and Statistics Department (2016) Women and men in Hong Kong: Key statistics 2016 edition. Available at: www.censtatd.gov.hk/hkstat/sub/sp180.jsp?productCode=B1130303 (accessed 25 July 2017).

15.

Hong Kong Council of Social Service (2017) Public expenditures on social welfare services as percentage of Gross Domestic Product. Available at: www.socialindicators.org.hk/en/indicators/low_income/18.1 (accessed 25 July 2017).

16.

Hong Kong Social Welfare Department (n.d.) Social Security Allowance (SSA) Scheme. Available at: www.swd.gov.hk/en/index/site_pubsvc/page_socsecu/sub_ssallowance/ (accessed 12 January 2018).

17.

Huang

Yeoh

Toyota

(2012) Caring for the elderly: The embodied labour of migrant care workers in Singapore. Global Networks 12(2): 195–215.

18.

Inland Revenue Authority of Singapore (2011) Singles taking care of parents enjoy other reliefs. Available at: www.iras.gov.sg/irashome/News-and-Events/Newsroom/Forum-Replies/2011/Singles-taking-care-of-parents-enjoy-other-reliefs/ (accessed 25 July 2017).

19.

Johnson

(1995) Japan: Who Governs? The Rise of the Developmental State. New York and London: W.W. Norton.

20.

Jones

(2005) The ‘flight from marriage’ in South-East and East Asia. Journal of Comparative Family Studies 36(1): 93–111.

21.

Khan

(2001) Social policy in Singapore: A Confucian model? Citeseer. Korea Net. Available at: http://siteresources.worldbank.org/WBI/Resources/wbi37165.pdf (accessed 25 July 2017).

22.

Killias

(2009) Politics of bondage in recruitment, training and placement of Indonesian migrant domestic workers. Sociologus 59(2): 145–172.

23.

Kim

(2009) Rethinking colonialism and the origins of developmental state in East Asia. Journal of Contemporary Asia 39(3): 382–399.

24.

La Grange

Yung

(2002) Poverty and single elders in Hong Kong. Ageing and Society 22(2): 233–257.

25.

Lan

P-C

(2002) Subcontracting filial piety: Elder care in ethnic Chinese immigrant families in California. Journal of Family Issues 23(7): 812–835.

26.

Leow

(2012) Do you own non-Chinese mui tsai? Re-examining race and female servitude in Malaya and Hong Kong, 1919–1939. Modern Asian Studies 46(6): 1736–1763.

27.

Lindquist

(2010) Labour recruitment, circuits of capital and gendered mobility: Conceptualizing the Indonesian migration industry. Pacific Affairs 83(1): 115–132.

28.

Martin

(1990) Changing intergenerational family relations in East Asia. The Annals of the American Academy of Political and Social Science 510(1): 102–114.

29.

Mehta

Vasoo

(2000) Community programmes and services for long-term care of the elderly in Singapore: Challenges for policy-makers. Asian Journal of Political Science 8(1): 125–140.

30.

Mizuno

(2016) Abenomics is Womanomics. Discuss Japan: Japan Foreign Policy Forum, 5 June 2016. Available at: www.japanpolicyforum.jp/archives/economy/pt20160605163823.html (accessed 25 July 2017).

31.

Nagase

(2011) Women and family in contemporary Japan. Journal of Family Theory and Review 3(2): 159–162.

32.

OECD (n.d.) Social expenditure database. Available at: www.oecd.org/els/soc/expenditure.htm (accessed 25 July 2017).

33.

OECD (2017a) Pension at a glance 2015 in the OECD Social expenditure database (SOCX). Available at: www.oecd.org/social/expenditure.htm (accessed 25 July 2017).

34.

OECD (2017b) OECD family database. Available at: www.oecd.org/els/family/database.htm (accessed 25 July 2017).

35.

Park

(2015) Equity of access under Korean national long-term care insurance: Implications for long-term care reform. International Journal of Equity Health 14(82): 1–10.

36.

Peng

(2002a) Social care in crisis: Gender, demography and welfare state restructuring in Japan. Social Politics 9(3): 411–443.

37.

Peng

(2002b) Japan: The interaction of gender and demography in a low-birth rate and aging society. In: Mahon

Michel

(eds) Child Care at the Crossroads: Gender, Entitlements, and Welfare State Restructuring. New York: Routledge, pp. 31–56.

38.

Peng

(2012) Social and political economy of care in Japan and South Korea. International Journal of Sociology and Social Policy 32(11/12): 636–649.

39.

Peng

(2016) Testing the limits of welfare state change: Immigration policy reforms in Japan. Social Policy and Administration 50(2): 278–296.

40.

Ramesh

(2000) The politics of social security in Singapore. The Pacific Review 13(2): 243–256.

41.

Reisman

(2009) Social Policy in an Ageing Society: Age and Health in Singapore. Cheltenham: Edward Elgar.

42.

Rhee

Done

Anderson

(2015) Considering long-term care insurance for middle-income countries: Comparing South Korea with Japan and Germany. Health Policy 119: 1319–1329.

43.

Rozario

Hong

(2011) Doing it ‘right’ by your parents in Singapore: A political economy examination of the Maintenance of Parents Act of 1995. Critical Social Policy 31(4): 607–627.

44.

Shimoebisu

(1994) Kazokuseisaku no Rekishiteki tenkai [The historical development of family policy]. In: Shakai Hosho Kenkyujo (ed.) Gendai Kazoku no Shakai Hosho [The Modern Family and Social Security]. Tokyo: University of Tokyo Press.

45.

Singapore-MOM (2013) MOM: Employment agency fees are already capped. Available at: www.mom.gov.sg/newsroom/press-replies/2013/mom-employment-agency-fees-are-already-capped (accessed 26 July 2017).

46.

Teo

Mehta

Thang

L-L

Chan

(2006) Ageing in Singapore: Service Needs and the State. Abingdon: Routledge.

47.

Vasoo

Lee

(2006) Achieving social development and care through the Central Provident Fund and housing in Singapore. In: Tan

Vasoo

(eds) Challenge of Social Care in Asia. Singapore: Marshall Cavendish Academic, pp. 164–182.

48.

Woo-Cumings

(ed.) (1999) The Developmental State. Ithaca, NY: Cornell University Press.

49.

Yap

(2009) Ultra-low fertility in Singapore: Some observations. In: Straughan

Chan

Jones

(eds) Ultra-low Fertility in Pacific Asia: Trends, Causes and Policy Dilemmas. Abingdon: Routledge, pp. 160–180.

50.

C-C

(2013) Changing East Asian families: Values and behaviors. International Sociology 28(3): 253–256.

51.

Zhang

(2003) Pacific Asia: The Politics of Development. London: Routledge.