| Summary: | 碩士 === 國立臺灣大學 === 健康政策與管理研究所 === 103 === Background: In major developed countries sustainability crisis has haunted their publicly-funded health systems in the past few decades, including Taiwan''s National Health Insurance (NHI). National-wide surveys had showed that although Taiwanese citizens support the system on the whole, they hold conflicting judgments among the system''s core value, such as the problems of inclusion criteria of the insured, rationale of priority setting, and accountability of performance. Society must meet consensus on how to solve these problems so that limited resources could be legitimately distributed, obligations between community members could be clarified, and public system could been sustainable. Civic republicanism traditions, liberalism since Rawls''s account, and public health ethics thoughts all indicate that citizens'' sense of the common is the key factor to solve these problems. However, in Taiwan, where the institutions are imported from the West and lack these thought origins, whether citizens have such sense lacks empirical data to support.
Objectives: To (1) explore citizens’ reasoning and recognition of the value foundation of the NHI and (2) depict citizens’ sense of the common and explore its relation with sustainability of the NHI.
Methods: Using Taiwan''s National Health Insurance as a policy case, the research adopted descriptive ethics approach and typical case sampling to select average-like cases. In order to enhance the diversity of social position of participants, quota sampling by age, gender, education and work status were adopted. Researcher conducted semi-structured face-to-face in-depth interview with participants. The interview outline included five a prior themes: (1) interviewee''s attitude toward the NHI, (2) legitimacy of compulsory inclusion of the insured, (3) inclusion criteria of the insured, (4) conditions that interviewee would be willing to withhold her/his welfare to maintain the system''s sustainability, and (5) interviewee''s experiences in any forms of public participation. As the interview progress new themes emerged. Thematic framework analysis was used to analyze the transcription. By the end of the research, 17 participants were interviewed in two stages of recruitment, 5 in the pilot stage started from April 2014 to May 2014 and 12 in the second stage started from November 2014 to January 2015.
Results: Despite great difference exists between participants'' understanding of the NHI system, most of them recognize the system''s core values. According to the recognition of different levels of mutual assistance, the reasons behind them, and the connection between other members of the community, two types of sense of the common could be distinguished. Those with a strong sense of the common recognize a set of core values that uphold the NHI system. Those with a weak sense of common could support the system for their long-term interests via cooperation. These two senses are both the contextual factor for a sustainable healthcare system. The former can actively support the system’s sustainability, while the latter is a necessary condition for maintaining the system’s normal function. These findings suggest that the Rawlsian assumption of social cooperation could be agreed by most of the participants and applied in a limited community. The diversity of the reasons and the vague boundaries of community imply that the moral community where the NHI is grounded might need further construction.
Conclusion: Through the case of Taiwan''s NHI the research has depicted the possible appearance of the sense of the common, explored the reasons behind it, and provided empirical data to support theories of solidarity and political thoughts. Public system should be founded not on the equilibrium of interest calculation and political power, nor the appeal of abstract universal ethics principles, but the basis of community member’s sense of the common. The NHI policy planners and reformers should adopt measures actively to improve citizens'' sense of the common and ensure sufficient debates to meet social consensus so that a sustainable NHI system could be possible.
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