Challenges and Lessons to Scaling up Policy …Challenges and Lessons to Scaling up Policy Innovation The process of institutionalization in long-term care policy in Japan Subtheme:

Challenges and Lessons to Scaling up Policy InnovationThe process of inst i tut ional izat ion in long-term care pol icy in Japan

Subtheme: Managerial Innovation -Improving Governments and Governance

EROPA 2015 @Shanghai2015/10/20

Kyoko OHTA, Ph.D.Project Researcher

Policy Alternatives Research Institute, University of [email protected]

Table of Contents1. Challenges for Japanese local governance

Background: Japan’s aging society

National Long-term Care Insurance and elderly care policy

2. Scaling up of policy innovation Policy making in Japanese local governance

Scaling up

Special Zones: institutionalization of niche innovation?

3. “Toyama model” of multi-generation day care

4. Lessons learned

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Challenges and Lessons to Scaling up Policy Innovation

1. Challenges for Japanese local governance• Background: Japan’s aging society

• National Long-term Care Insurance and elderly care pol icy

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Background: Japan’s aging society

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Population aging rate: 25.1%（65 or older, 2013）

“2025 crisis” (baby-boomers become 75 or older)

Aging in rural area (e.g. depopulation)→ Aging in urban areaGrowth rate of population of 65 or older, 2010→2025: Shimane 8%, Akita 10% (rural areas); Saitama 35%, Chiba 34%, Kanagawa 34% (suburbs of Tokyo)

Depopulation impact→ Local municipalities could become extinct??


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Change of Demographic Breakdown

65 and older

15 ～ 64

Under 15


National Long-term Care Insurance and elderly care policy 1950s～： family care and residualized care with welfare placement

(“Sochi” system)= state subsidy ＋ decision of placement by municipalities

Elderly care/welfare became agenda in 1970s～: Failure of free medical care policy for elderly leaded bed blocking in hospital

National Long-term Care Insurance Act 1997, implementation from 2000; 40 and older are insured and municipalities (cities, 1st tier gov) as insurer

Post-Long-term Care Insurance legislation: Implemented in 2000, amended in every 3-5 years

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Financial structure of National Long-term Care Insurance

Type I insured Type II insured

厚生労働省ホームページ（http://www.mhlw.go.jp/seisakunitsuite/bunya/hukushi_kaigo/kaigo_koureisha/gaiyo/dl/hoken.pdf）より一部改変

Tax

Insurance

Municipalities (Insurer)

Municipalities Prefectures State government

Financial stability fund


After 2000

Age-related policies coordinated in local community, preparing for “2025 crisis”

Community integrated care (Insurance-based synthesis of medicine, nursing and care policies) and “small-size multi-functional care facility” are strongly encouraged in National Long-term Care Insurance program

Proximity of housing policy, community living e.g. special residence with life support for elderly, organized by Ministry of Health (MHLW) and Ministry of Land/Infra/Trans (MLIT)

However… Financial pressure (National Health Insurance, pension, payment fee for

home medical care…)

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National Long-term Care Insurance and elderly care policy


Care team

Image of Community General Support Center / Community Integrated Care

Person insured

Team approach

Social workers, care workers

Care manager etc.

Public health nurse etc.

Family doctor

Care manager

Integrated and continuous support of care management

General advice and support

Preventing abuse, advocacy

Various local bodies (town hall, health center,

child care bureau, volunteer center, adult

guardianship bureau etc.

Cross-sector support

Family doctor

Prevention

Community General Support Centre’s Management Council

Establish per “community” Establish per

municipality

Support, networking and evaluation

Securing neutrality, support for human

resources

Source: MHLW website, edited by author

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介護費用と保険料の推移

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出典：厚生労働省ホームページ（http://www.mhlw.go.jp/topics/kaigo/zaisei/sikumi.html）より

Increasing fees and insurance premiums for elderly care

Total expenses

Insurance premium per person over 65


2. Scaling up of policy innovation• Pol icy making in Japanese loca l governance

• Sca l ing up

• Specia l Zones: inst i tut ional izat ion of n iche innovat ion?

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Delegation and the division of policy making in bureaucracy Central bureaucracy as “the biggest think-tank in Japan”

Functional division of labor in bureaucracy: division (each Ministry) and coordination (Cabinet Office)

Policy making processin central government in Japan

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Policy making in Japanese local governance

出典：秋吉他2010, p48 に加筆修正

Policy issues Ministries

Public policy B’ E’

A B C D E Cabinet

DietDeliberation and

Legislation

Enforcement

Implementation Planning, implementation, project

Ministries

Local authorities

Decision in Cabinet

Analysis, Examinationand policy making


Policy making in Japanese local governance In line with Care Insurance, Local Government Decentralization Reform（implemented in 2000） ─ Another background for the local government as a insurer of long-term care insurance

Inter-governmental relations in Japan: distinguished as a different actor, each has its own purpose and preferences. A kind of interest group politics, but still many “rules of the game”.

National plan as a “institution”: In this perspective, inter-gov relations is not a pure game, but many parts of its result are already decided as a kind of “national plan”. It is often difficult for local government to draft its policies freely from the beginning. Also the regulations conducted by different Ministries (and conflict among them) prevent them from making innovative policies.

Policy making competency of local government: we can find a certain progress since Local Government Decentralization Reform in 2000, with regard to delegation of authority, but not of financial resources.

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Policy making in Japanese local governance There’s a correlation between the progress of decentralization and that of policy making competency, so the development of the latter is essential for the quality of the decentralization.

Challenges The cities (except capital city Tokyo) across Japan shared the same issues of

aging, shrinking population and financial deficit. How they become sustainable, and how to manage transition to the sustainability in urban habitation, economic activity, resilient infrastructure and feasible administration?

Especially, how we can understand the innovation and the transformation from “solid” and “stable” institutional frames towards something more flexible that guarantees the economic sustainability of the city?

And what is the potential of the citizens, or the local governance, for the transition?

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Scaling up Sustainable transition based on “city” Theory: Transition management and transition governance（Grin et al. 2010）

Basic ideas: Three-tier structure, stages of transition (take-off, acceleration, stabilization), transition arena

“Strategic niche” perspective

Scaling up

Experiment and learning

Transition = how to sustain or scale-up niche innovation

Sustainability ≠ inertia nor routine

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Transition phases

Sustainable

society?

health care

energywaste

waterconstruction

mobility finance

predevelopment

take-off

acceleration

stabilisation

Based on Rotmans et al, 2001Based on Rotmans et al. 2001, edited by Loorbach’s presentation in 2013/7/12


Scaling up 移行の三層構造（Multi-level perspective）

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Scale up

Landscape*

（macro-level）

Regimes

（meso-level）

Niches

（micro-level）

* By J.Rotmans, R.Kemp, F.Geels, D.Loorbach, et al., edited by S. Murakami


Scaling up Bottom-up and scale-up effects from niche level to the strong and stable regime level (Geels 2011, pp27-8)1. Articulation of expectations or visions

2. Building of social networks and the environment of more actors

3. Leaning and articulation processes on various dimensions

However… Regime acts as a barrier which prevents niche innovation to have bigger

opportunity

Niche must have an alternative development strategy in the multi-regime interaction (Konrad et al 2008; Grin et al. 2010; Raven and Verbong 2007)

Role of micro-level actors/individuals Policy entrepreneur

Key actors sometimes link the geographical scales (Raven et al. 2012, p68)

Hybrid actors who go across multiple levels and contribute to the scaling up of niche experiment (Kivisaari et al. 2013, p190)

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Special Zones: institutionalization of niche innovation? Special Zones for Structural Reform （構造改革特区） In the Zone, the project which used to be prohibited can be carried out

because of the deregulation.

Implemented from 2003, led by Cabinet Office (not by the Ministries)

Comprehensive Special Zones （総合特区） Deregulation plus budgetary support and tax treatment

Implemented from 2011, led by Cabinet Office (not by the Ministries)

As a tool for experiment of innovative policy → lessons learned

Diffusion and institutionalization if needed

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3. “Toyama model” of multi-generation day careA case of scal ing up of local innovative policy

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Toyama city

Population

Size

Budget ¥152 bil≒ $1.3 bil

Regional core city


Background: since 1980s, niche services of “day home for elderly” (similar to the nursery) were develop by local government and NPOs across Japan.

Unique multi-generation day care facility “Takurou-sho” in Toyama

Small-size multi functional care facility

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Takurou-sho “Konoyubi-tomare” (multi-generation day care facility) in Toyama, established in 1993


Characteristics of “Toyama model” Small size. Utilize second-hand residence in the local community.

Cohabitation care. The elderly is supposed to be the main user, but adultphysically handicapped, mentally handicapped, as well as handicapped children can use. Various services are provided under the same roof, and users share the same space.

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In 1993, retired hospital nurses start small-size and homely day care service for the elderly.

Then started nursery services for infants and disabled children. The improvement of mental condition of the elderlies.

There is a possibility of various types of subsidy by central government.

However, the functionally divided regulation by central administration is the barrier to the subsidy for "everybody"

The founders approach Toyama City to develop the new grant project which cover both the elderly and the handicapped, and they managed.

There is the limitation for City's budget, so the founders encouraged prefecture government (Toyama prefecture) as well to develop the flexible grant program.

In 1997, "Toyama civil day service development project" initiated by Toyama prefecture. The grant covers "everybody".


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"Toyama model" becomes famous for its small-size multi-functional services which goes across administrative division. Lots of visitors from central and local governments.

In 2000, National LTCI starts and central government subsidy for "elderly" section.

In 2003, Toyama Prefecture and Toyama City become approved as Special Zones for Structural Reform(構造改革特区) by Cabinet Office.

In 2006, new legislation for supporting handicapped people. The "handicapped" section of Toyama model becomes institutionalized across Japan.

In 2006, amendment of LTCI Act. Toyama model is introduced in the LTCI scheme (those facilities become paid by LTCI fee) and institutionalized across Japan.


4. Lessons learned

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Outcome of Scaling up: Institutionalization of small-scale multi-functional care in the community Conjunction point: new legislation for supporting handicapped people on the one hand, and amendment of Long-term Care Insurance Act on the other, both in 2006

Shift of long-term care policy in 2006 towards autonomous community care, rather than “paternalist” insurance-based care. Introduction of small-size multi-functional care by central government.

Characteristics of scaling up of Toyama model The original idea (in Toyama) is to cover the gap between divided services.

Hybrid services and hybrid resources: the strategy to draw central subsidy whoever (elderly, handicapped or handicapped child) uses the facility.


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Key to the scaling up There must be various channels for local niche to persuade upper levels of

government (municipality, prefecture, central Ministry and Cabinet Office) to understand the necessity of deregulation

These channels are: elected politicians (member of the Diet), mayors, and personnel exchange of officials (between central and local government)

In central government, there is a typical contrast between Ministries who try to avoid deregulation and Cabinet Office (and Prime Minister) who prefers deregulation. (Conflict of regimes)

Special Zones for Structural Change is a kind of resolution between Ministries and Cabinet Office.

For Ministries (such as Ministry of Health), they can learn important lessons from the “experiment” carried out in Special Zones.

← Potential for scaling up of strategic niche.

Outcome of Scaling up: Institutionalization of small-scale multi-functional care in the community


Thank you very much!

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Kyoko OHTA, Ph.D.Project Researcher

Policy Alternatives Research Institute, University of [email protected]

Documents

Challenges and Lessons to Scaling up Policy …Challenges and Lessons to Scaling up Policy Innovation The process of institutionalization in long-term care policy in Japan Subtheme: