Skip to main content
Log in

Solidarity with Whom? The Boundary Problem and the Ethical Origins of Solidarity of the Health System in Taiwan

  • Original Article
  • Published:
Health Care Analysis Aims and scope Submit manuscript

Abstract

Publicly-funded health systems, including those national health services and social or National Health Insurances, are institutionalized solidarity in health. In Europe, solidarity originated from the legacies of labor movements, the Judeo-Christian traditions, and nationalist sentiments in the re-construction Era after the WWII. In middle-to-high income East Asian countries, such as Japan, Taiwan, Korea, the health systems were built on different grounds and do not have such ethical origins of solidarity. As health systems in Europe and East Asia are both facing sustainability crises due to aging population, stagnant economy, changing boundaries, and advancing medical technologies, how those systems with the European solidaristic ethical traditions can be revived and how those without the European traditions could survive become a matter of theoretical interests and an urgent policy problem to be addressed. Drawing on contemporary theories of solidarity, this essay analyzes the boundary problem and its impact on the sustainability of the health system in Taiwan. It then considers two plausible origins of solidarity in Taiwan. One is the re-emerged civic nationalism, and the other is an ethos of common life. It is argued that after years of implementation, the National Health Insurance in Taiwan might have shaped the social values and people’s habits and formed an ethos of common life. Such ethos could be an ethical origin of solidarity in non-western societies and help the health systems endure the prolonged sustainability crises.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

Notes

  1. Here, for the simplicity of discussion, we specifically refer to those Chinese who consider themselves as the decedents of the Republic of China (ROC), not the People’s Republic of China (PRC).

  2. Note that this is a hypothetical scenario constructed by the author, not a quotation from an interview. The sentiment may be similar to the exclusionary or even xenophobic sentiments in European countries as well as the individualist perception of responsibility for health in the United States. Despite the different norms and cultures between these places, what in common through the lens of solidarity is the lack of mutual recognition between “us” and “them” in such scenario. We remain neutral to what scope of recognition is ethically justifiable at this moment of argument. The scope could be as wide as the entire population of human species or as narrow as a blood lineage, depending on the contexts. The scenario is used to illustrate the solidaristic rationale.

  3. We use the term “enemies” here purposefully. It is actually an issue at the very core of conflicts in Taiwanese society that some groups of population are often considered as the nation’s enemies. Note that the “nation” and its “enemies” could be defined in various ways. To name a few: Taiwanese had defined those with Chinese identity as enemies. Chinese had defined those with Taiwanese identity as enemies. Chinese had defined those with ROC identity as enemies. ROC believers had defined those with Taiwanese identity as enemies. There are more combinations. This phenomena derives from Taiwan’s experiences in being under multiple colonialism [60]. We are not suggesting that these de facto definitions are justifiable, but rather, we are suggesting that even though they are dynamic and subject to change under the international relationship and the attitudes of geopolitical stakeholders, such as Beijing and Washington D.C., they should be taken into account seriously by those who care about the future of the NHI.

  4. Which is highly probable due to the structural challenges mentioned before. According to an official actuarial estimation, the NHI fund will be in deficit by the end of 2021 if the covered services package and the rate of premium are held unchanged [41].

  5. At least in an abstract manner through the social contract, people agree to participate in the common life; particularly, in a democratic polity, ideally people have been entitled to the opportunity to voice, to vote, and even to leave the community.

  6. Yeh has reported preliminary qualitative findings [62], which to our knowledge is the closest available one. Other few studies have covered health sector solidarity in Taiwan, but may not serve as directly evidence [22, 32, 65]. Further researches are needed to better investigate this phenomenon and monitor the current status of health sector solidarity in Taiwan.

References

  1. Beauchamp, D. E. (1985). Community: The neglected tradition of public health. Hastings Center Report,15(6), 28–36.

    PubMed  CAS  Google Scholar 

  2. Beauchamp, D. E. (1996). Health care reform and the battle for the body politic. Philadelphia: Temple University Press.

    Google Scholar 

  3. Béland, D., & Lecours, A. (2008). Nationalism and social policy: The politics of territorial solidarity. New York: Oxford University Press.

    Google Scholar 

  4. Bradby, H., Humphris, R., Newall, D., & Phillimore, J. (2015). Public health aspects of migrant health: A review of the evidence on health status for refugees and asylum seekers in the European Region (Vol. 44, Health Evidence Network synthesis report). Copenhagen: WHO Regional Office for Europe.

  5. Brodie, J. (2002). Citizenship and solidarity: Reflections on the Canadian way. Citizenship Studies,6(4), 377–394.

    Google Scholar 

  6. Broxton, A. (2017). Why should the people wait any longer? How Labour built the NHS. British Politics and Policy. https://blogs.lse.ac.uk/politicsandpolicy/why-should-the-people-wait-any-longer-how-labour-built-the-nhs/.

  7. Bump, J. B. (2015). The long road to universal health coverage: Historical analysis of early decisions in Germany, the United Kingdom, and the United States. Health Systems & Reform,1(1), 28–38. https://doi.org/10.4161/23288604.2014.991211.

    Article  Google Scholar 

  8. Chen, F.-Y., & Yen, W.-T. (2017). Who supports the sunflower movement? An examination of nationalist sentiments. Journal of Asian and African Studies,52(8), 1193–1212. https://doi.org/10.1177/0021909616645372.

    Article  Google Scholar 

  9. Cheng, T.-M. (2015). Reflections on the 20th anniversary Of Taiwan’s single-payer National Health Insurance system. Health Affairs,34(3), 502–510.

    PubMed  Google Scholar 

  10. Chuan, K., & Lin, K. (2018). Taiwan scraps nuclear-free deadline in wake of referendum. Focus Taiwan.

  11. Cox, R. (2004). The path-dependency of an idea: Why Scandinavian welfare states remain distinct. Social Policy & Administration,38(2), 204–219.

    Google Scholar 

  12. Daniels, N. (2008). Just health: Meeting health needs fairly. Cambridge: Cambridge University Press.

    Google Scholar 

  13. Dawson, A., & Jennings, B. (2012). The place of solidarity in public health ethics. Public Health Reviews,34, 65–79.

    Google Scholar 

  14. Dawson, A., & Verweij, M. (2012). Solidarity: A moral concept in need of clarification. Public Health Ethics,5(1), 1–5.

    Google Scholar 

  15. Esping-Andersen, G. (1990). The three Worlds of welfare capitalism. Princeton, NJ: Princeton University Press.

    Google Scholar 

  16. Falkenbach, M., & Greer, S. L. (2018). Political parties matter: The impact of the populist radical right on health. European Journal of Public Health,28(Suppl_3), 15–18. https://doi.org/10.1093/eurpub/cky157.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Fu, L.-Y. (1993). The social insurance system in Taiwan: A social control explanation [台灣社會保險制度的社會控制本質]. Taiwan: A Radical Quarterly in Social Studies,15, 39–64. https://doi.org/10.29816/tarqss.199311.0002.

    Article  Google Scholar 

  18. Hamilton, C., & Joske, A. (2018). Silent invasion: China’s influence in Australia. Melbourne: Hardie Grant Books.

    Google Scholar 

  19. Heath, I. (2018). Back to the future: Aspects of the NHS that should never change—An essay by Iona Heath. BMJ,362, k3187. https://doi.org/10.1136/bmj.k3187.

    Article  Google Scholar 

  20. Ho, M. (2015). Occupy Congress in Taiwan: Political opportunity, threat, and the sunflower movement. Journal of East Asian Studies,15(1), 69–97.

    Google Scholar 

  21. Houtepen, R., & ter Meulen, R. (2000). New types of solidarity in the European welfare state. Health Care Analysis,8(4), 329–340.

    PubMed  CAS  Google Scholar 

  22. Huang, I.-T. (2003). On public’s opinion of NHI with social solidarity, Unpublished Master Thesis [以社會連帶意識態度探討民眾對全民健康保險制度意向]. Taichung College of Health and Management, Taichung, Taiwan.

  23. Jennings, B. (2007). Public health and civic republicanism: Towards an alternative framework for public health ethics. In A. Dawson & M. Verweij (Eds.), Ethics, prevention, and public health (pp. 30–58). New York, NY: Oxford University Press.

    Google Scholar 

  24. Jennings, B. (2016). Right relation and right recognition in public health ethics: Thinking through the republic of health. Public Health Ethics,9(2), 168–177. https://doi.org/10.1093/phe/phv032.

    Article  PubMed  Google Scholar 

  25. Krishnamurthy, M. (2013). Political solidarity, justice and public health. Public Health Ethics,6(2), 129–141. https://doi.org/10.1093/phe/pht017.

    Article  Google Scholar 

  26. Ku, Y. (1997). Welfare capitalism in Taiwan: State, economy and social policy. London: Palgrave Macmillan.

    Google Scholar 

  27. Ku, Y. (2001). Equality and solidarity: A critical thinking on welfare development in Taiwan [平等與凝聚:台灣社會福利發展的思考]. Social Policy & Social Work,5(1), 145–169. https://doi.org/10.6785/spsw.200106.0145.

    Article  Google Scholar 

  28. Kymlicka, W. (2007). Multicultural odysseys: Navigating the new international politics of diversity. Cambridge: Cambridge Univ Press.

    Google Scholar 

  29. Law, A., & Mooney, G. (2012). Devolution in a ‘Stateless Nation’: Nation-building and social policy in Scotland. Social Policy & Administration,46(2), 161–177.

    Google Scholar 

  30. Lin, K.-M. (2001). Democratization and public participation: The formation of National Health Insurance Policy [民主化與社會成家的公共參與:全民健保的政策形成]. In H.-H. M. Hsiao & K.-M. Lin (Eds.), Social welfare movement in Taiwan [台灣的社會福利運動]. Taiepi: Chuliu.

    Google Scholar 

  31. Lin, K.-M. (2003). Path dependence and the institutional formation of Taiwan’s National Health Insurance Plan [到國家主義之路:路徑依賴與全民健保組織體制的形成]. [Research Article]. Taiwanese Sociology,5, 1–71.

    Google Scholar 

  32. Lin, C.-Y., & Lee, Y.-C. (2014). Solidarity in Taiwan (PO-119) [連帶思想在台灣]. In 2014 Annual Taiwan Public Health Association joint meeting and conference: Health policy and management (Section 2) (p. 200). Tainan: National Cheng Kung University.

  33. Lu, J.-F. R., & Chiang, T.-L. (2011). Evolution of Taiwan’s health care system. Health Economics, Policy and Law,6(1), 85–107. https://doi.org/10.1017/S1744133109990351.

    Article  Google Scholar 

  34. Lue, J.-D. (2010). Taiwanese welfare state and modernity [台灣福利國家與現代性]. In J. Hwang, H.-L. Wang, & C.-H. Huang (Eds.), At the edge of empires: An investigation of modernity in Taiwan [帝國邊緣:台灣現代性的考察] (pp. 445–476). New Taipei City: Socio Publishing.

    Google Scholar 

  35. Lue, J.-D. (2014). Globalisation, democratisation and the institutional transformation of Taiwan’s welfare regime. Social Policy and Society,13(2), 275–284. https://doi.org/10.1017/S147474641300064X.

    Article  Google Scholar 

  36. Mann, J. M., Gostin, L., Gruskin, S., Brennan, T., Lazzarini, Z., & Fineberg, H. V. (1994). Health and human rights. Health and Human Rights,1(1), 6–23.

    PubMed  Google Scholar 

  37. McEwen, N. (2002). State welfare nationalism: The territorial impact of welfare state development in Scotland. Regional & Federal Studies,12(1), 66–90.

    Google Scholar 

  38. Michailakis, D., & Schirmer, W. (2010). Agents of their health? How the Swedish welfare state introduces expectations of individual responsibility. Sociology of Health & Illness,32(6), 930–947. https://doi.org/10.1111/j.1467-9566.2010.01262.x.

    Article  Google Scholar 

  39. Miller, D. (1995). On nationality. Oxford: Oxford Clarendon Press.

    Google Scholar 

  40. NHIA. (2018). 2018–2019 National Health Insurance annual report [2018-2019全民健康保險年報]. Taipei: National Health Insurance Administration, Ministry of Health and Welfare.

    Google Scholar 

  41. NHIA. (2018). 2017 National Health Insurance financial evaluation report [106年度全民健康保險財務評估報告]. Taipei: National Health Insurance Administration, Ministry of Health and Welfare.

    Google Scholar 

  42. Prainsack, B., & Buyx, A. (2017). Solidarity in biomedicine and beyond. Cambridge: Cambridge University Press.

    Google Scholar 

  43. Rowen, I. (2015). Inside Taiwan’s sunflower movement: Twenty-four days in a student-occupied parliament, and the future of the region. The Journal of Asian Studies,74(01), 5–21.

    Google Scholar 

  44. Ruist, J. (2015). The fiscal cost of refugee immigration: The example of Sweden. Population and Development Review,41(4), 567–581. https://doi.org/10.1111/j.1728-4457.2015.00085.x.

    Article  Google Scholar 

  45. Saltman, R. B. (2004). Social health insurance in perspective: The challenge of sustaining stability. In R. B. Saltman, R. Busse, & J. Figueras (Eds.), Social health insurance systems in Western Europe (pp. 3–20). New York: Open University Press.

    Google Scholar 

  46. Saltman, R. B. (2015). Health sector solidarity: A core European value but with broadly varying content. Israel Journal of Health Policy Research,4, 5.

    PubMed  PubMed Central  Google Scholar 

  47. Saltman, R. B., & Cahn, Z. (2013). Restructuring health systems for an era of prolonged austerity: An essay by Richard B Saltman and Zachary Cahn. BMJ,346, f3972.

    PubMed  Google Scholar 

  48. Saltman, R. B., Busse, R., & Figueras, J. (2004). Social health insurance systems in western Europe. New York: McGraw-Hill International.

    Google Scholar 

  49. Sangiovanni, A. (2015). Solidarity as joint action. Journal of Applied Philosophy,32(4), 340–359.

    Google Scholar 

  50. Singh, P. (2015). How solidarity works for welfare: Subnationalism and social development in India. New York: Cambridge University Press.

    Google Scholar 

  51. Solow, R. M. (1993). An almost practical step toward sustainability. Resources Policy,19(3), 162–172.

    Google Scholar 

  52. Tamir, Y. (1993). Liberal nationalism. New Jersey, NJ: Princeton University Press.

    Google Scholar 

  53. ter Meulen, R. (2017). Solidarity and justice in health and social care. Cambridge and New York: Cambridge University Press.

    Google Scholar 

  54. Thomson, M. (2017). The NHS and the public: A historical perspective. The King’s Fund Blog. https://www.kingsfund.org.uk/blog/2017/10/nhs-and-public-historical-perspective.

  55. Turner, B. S. (2009). TH Marshall, social rights and English national identity: Thinking citizenship series. Citizenship Studies,13(1), 65–73.

    Google Scholar 

  56. Wang, F. L. (2017). The China order: Centralia, World Empire, and the nature of Chinese power. New York: State University of New York Press.

    Google Scholar 

  57. West-Oram, P. G. (2018). From self-interest to solidarity: One path towards delivering refugee health. Bioethics,32(6), 343–352.

    PubMed  Google Scholar 

  58. Wong, J. (2004). Healthy democracies: Welfare politics in Taiwan and south Korea. Ithaca, NY: Cornell University Press.

    Google Scholar 

  59. Wu, R. (1994). The imagined community of fate: The declaration of formosan self-salvation and the post-war Taiwanese Civic Nationalism [命運共同體的想像:自救宣言與戰後的台灣公民民族主義]. In T. P. M.-M. Foundation (Ed.), The traditions and inheritance of liberalism in Taiwan. Taipei: The Peng Ming-Min Foundation.

    Google Scholar 

  60. Wu, R. (2014). Fragment of/f Empires: The peripheral formation of Taiwanese Nationalism. In S.-T. Lee & J. F. Williams (Eds.), Taiwan’s struggle: Voices of the Taiwanese (pp. 27–34). Lanham, MD: Rowman & Littlefield.

    Google Scholar 

  61. Wu, R. (2016). The Lilliputian dreams: Preliminary observations of nationalism in Okinawa, Taiwan and Hong Kong. Nations and Nationalism,22(4), 686–705. https://doi.org/10.1111/nana.12251.

    Article  Google Scholar 

  62. Yeh, M.-J. (2019). Exploring users’ perceptions and senses of solidarity in Taiwan’s National Health Insurance. Public Health Ethics,12(1), 1–14. https://doi.org/10.1093/phe/phy021.

    Article  Google Scholar 

  63. Yeh, M.-J. (2019). Discourse on the idea of sustainability: With policy implications for health and welfare reform. Medicine, Health Care and Philosophy. https://doi.org/10.1007/s11019-019-09937-z.

    Article  Google Scholar 

  64. Yeh, M.-J., & Chang, H.-H. (2015). National Health Insurance in Taiwan. Health Affairs,34(6), 1067. https://doi.org/10.1377/hlthaff.2015.0447.

    Article  PubMed  Google Scholar 

  65. Yeh, C.-Y., Yang, H.-H., Yang, Y.-H., & Huang, R.-F. (2019). The dilemma of social solidarity: How Taiwanese perceive social policy for immigration [社會團結的兩難─臺灣民眾如何看待移民福利]. Legal Aid And Society Review,3, 47–72.

    Google Scholar 

  66. Zhang, E. (2010). Community, the common good, and public healthcare—Confucianism and its relevance to contemporary China. Public Health Ethics,3(3), 259–266. https://doi.org/10.1093/phe/phq030.

    Article  Google Scholar 

Download references

Acknowledgements

A part of this essay derives from one of the author (MJY)’s PhD dissertation at Emory University, Atlanta, Georgia, USA. The authors thank Richard B. Saltman (advisor) and Jason M. Hockenberry and Deborah A. McFarland (committee members).

Funding

This study was not funded.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Ming-Jui Yeh.

Ethics declarations

Conflict of interest

The author declares no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yeh, MJ., Chen, CM. Solidarity with Whom? The Boundary Problem and the Ethical Origins of Solidarity of the Health System in Taiwan. Health Care Anal 28, 176–192 (2020). https://doi.org/10.1007/s10728-020-00397-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10728-020-00397-8

Keywords

Navigation