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When frontline workers exercise their discretion: evidence from care-needs certification for long-term care in Japan

2016 Conference Presentation

Workforce Japan

6 September 2016

When frontline workers exercise their discretion: evidence from care-needs certification for long-term care in Japan

Reiko Arami, Massachusetts Institute of Technology, United States


Objective: Japan has become the most rapidly aging country in Asia. As the decentralization of welfare policies in Japan continues, frontline welfare workers play an increasingly important role in shaping the policy outcomes of the welfare state, including the realm of long-term care policy.

The purpose of this paper is to examine when and how Care-Needs Certification investigators for Japan’s long-term care insurance (LTCI) programs exercise their discretion, with particular attention to how their decisions might be made by considering the local officials that manage them as well as their clients. As part of implementing this program, the government has delegated part of the process of determining eligibility to non-state actors.

The investigators’ motivations and their behaviors are considered to be different from those of traditional street-level bureaucrats. In this sense, the investigators for Care-Needs Certification in Japan are ‘new’ frontline workers. So far few studies since Smith and Lipsky (1993) have explored how new frontline workers are disciplined by the local officials and clients of LTCI and when investigators exercise their discretion. There are also very few studies on the policy implementation process of long-term care insurance systems and welfare benefits that require considering the ‘needs’ of both the person who receives care and those who take care of the elderly. The existing literature generally considers the Care-Needs Certification system of Japan to be ‘centralized’ and no variations of Care-Needs Certification are supposed, leaving the possibility of variations unexamined.

Data and methods: I use data from an original survey that was distributed in the summer of 2012 to investigators in the Fukui Prefecture, which is a rural area of Japan. The survey response rate was 60.0% (N=562). I also interviewed in-depth twenty investigators who answered the survey. Using both qualitative and quantitative data, I explore when and how frontline workers exercise their discretion in view of organizational management.

Results: The results show that the level of mutual trust between LTCI investigators and the local officials who supervise them has an significant influence on exercising their discretion and the relationship between the investigators and the clients. Previous research suggests that supervisors work hard to eliminate worker discretion, but my analysis suggests that investigators, who are a new kind of frontline workers, come to their own conclusions based on their beliefs on how other actors, such as local officials and clients, tend to act.

Policy implications: The more that government tries to make adjustments to manage investigators more uniformly, the less successful the government is, and the less investigators are able to grasp clients’ real needs.

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Morgan, J.K., and A.L.Campbell. 2011. The Delegated Welfare State: Medicare, Markets and the Governance of Social Policy, Oxford University Press.

Riccucci, Norma M. 2005. How Management Matters: Street-Level Bureaucrats and Welfare Reform. Washington DC: Georgetown University Press.

Smith, S. Rathgeb and Michael Lipsky. 1993. Nonprofits For Hire: The Welfare State in the Age of Contracting. Harvard University Press.