If ever there was a time when a country should come to appreciate the value of having a functional (semi) universal national healthcare service, it would be during a pandemic.
Despite there being glaring and unacceptable gaps in Taiwan’s health insurance and healthcare systems, which often have detrimental effects on unemployed people and those with severe illnesses who cannot afford necessary treatment, even with a government discount, most Taiwanese are the beneficiaries of a high-quality and relatively cheap service that has worked tirelessly to ensure that COVID-19 has not spread unchecked around the country.
Much of Taiwan’s success in tackling the pandemic owes itself to government measures to prevent the virus’ spread, such as quarantine, mask mandates, effective tracing of cases, and a public attitude of willingness to follow temporary restrictions.
That success has also come alongside some less appealing facets of life in Taiwan, notably the government’s arcane and illogical customs regulations regarding the rights of foreign spouses, and a clear but taboo undercurrent of racism towards migrant workers, seen as a disposable necessity who, apparently, are preferably neither seen nor heard.
Despite this, most Taiwanese are grateful for their healthcare system and for the tireless work of doctors and nurses in tending to a population that is very health conscious, even outside of a pandemic. On a Monday morning visit to Taipei Veterans General Hospital recently, I remarked to an administrator that it seemed as busy as a shopping mall on a weekend.
“Is this normal?” Yes, came the answer.
There is of course the famous joke about a group of old men who meet at the hospital every week. One time, the group is missing a member. “Where is Chen?” one of the gents asks. “He cannot make it today,” comes the answer. “He is sick.”
Taiwanese love their healthcare system and use it to the fullest extent, as is and should be their right given that they have paid health insurance from their wages.
What this means is that all the workers involved in delivering clinical and particularly hospital care in Taiwan — from doctors to orderlies, nurses, and administrators — are usually very busy. Overtime is the norm, not the exception.
During the pandemic, and especially in carrying out the vaccination program, healthcare workloads have increased significantly.
A person’s remuneration for work should match their input. If a person is working more hours, they should receive greater remuneration to match that. It is one of those universal truths that I think everyone agrees with in principle, yet most of those who pay wages and salaries often find a series of complex and apologetic reasons for why they cannot apply it in practice.
Consider the case of a nurse I recently spoke to. This is an intelligent, hardworking individual. She joined nursing college after high school and did very well in her seven years of training, passing with good grades. She applied to work at National Taiwan University Hospital (NTUH), the nation’s largest and most prestigious healthcare institution. The competition was tight but she gained employment as a nurse, having proven her ability.
She earns about NT$42,000 per month, just above the median national wage. She clocks in and she clocks out on a standard 40-hour week. Her managers demand that she works overtime, off the clock, for which she is not paid. After two years of this exploitation and labor theft, for there is no other way to describe it, she quit for a sales job.
The Ministry of Health might bemoan a shortage of healthcare workers, but it knows the main reasons, and number one on the list is poor wages and long hours.
Here was a motivated, talented young woman who had undergone difficult and lengthy professional training, right at the start of what should have been a long and successful career as a nurse, essentially forced out because NTUH demanded — and worse, expected — free labor.
Furthermore, to move to a higher salary band, nurses have to pass a rigorous exam. The higher salary band? An additional NT$2,000 per month. It is an insult.
NTUH is an extremely profitable and wealthy institution. It seems to think it is “an honor” to be a member of its staff, but honor does not pay the rent and bills, put food on the table, provide for an aged relative or cover childcare. Honor cannot be cashed in at the local supermarket like a government voucher. Honor does not give you back all the extra hours you spent working when you could have been resting or doing things that give your life meaning and vitality. Honor is not a vaccine against physical and mental burnout.
NTUH is not alone in this, but one would expect higher standards and respect for its workforce from the nation’s leading hospital, if only to set a benchmark for other hospitals to follow.
Businesses often moan about the inflexibility of Taiwan’s heavily centralized labor laws, but they have only become necessary because, in the absence of them, businesses have proven that they ruthlessly exploit their workers, stealing their productivity and time while telling them they should be grateful they have work at all.
However, there is another universal truth that all businesses know, but do not want workers to think about: Without workers, the owners would not be able to grow their businesses and generate the profits that they do and are then so loathe to share. If a business cannot afford to provide a salary that allows an employee to work a 32-hour week and still cover all of their most essential expenses — rent, food, and bills — then that business cannot afford to hire that employee.
The recent John Deere strike in the US is instructive of this. The company claimed it could not afford the modest demands of the workers: that all workers enjoy the same package of benefits. It was willing to fight the strike at an immense cost to the business to maintain this claim. The company is realizing that without the workers, there is no John Deere.
Post pandemic, many fast-food restaurants in the US cannot find staff, having laid many off during the shutdown. Suddenly, the US$15 an hour federal minimum wage the industry spent millions lobbying the US Congress to prevent coming into force is being offered on hastily made “Jobs Available” signs stuck in restaurant windows.
They could have afforded it all along. They just chose to maximize their profits while forcing Washington to subsidize their low wages through social security spending to fill the gap between their wages and the cost of living.
In Taiwan, as in the US and many other countries, productivity has steadily increased over the past 20 years and wages have remained stagnant. On a chart, the gap between the two lines represents income and wealth stolen from the workforce. Unpaid wages and payments employees have been cheated out of dwarf any kind of welfare or entitlements fraud by an order of magnitude.
In 2017, an Economic Policy Institute study found that minimum wage violations — being paid an effective hourly rate below the binding minimum wage — in the 10 most populous US states covering about 2.4 million workers represented US$8 billion annually. That is an average of US$3,300 per year for year-round workers, or nearly a quarter of their earned wages.
The study said that this form of wage theft affects 17 percent of low-wage workers in all demographic categories being cheated out of pay.
The quality of a healthcare system rests on a number of factors, but aside from the cost of medical materials and instruments, building maintenance and cleaning, and so on, how much the staff are paid can directly affect the quality of staff recruited and the quality of care provided.
I think of it like flying on a plane. I want the pilots and flight attendants to receive a very good wage because I want them to be selected for their proven skills, which deserve that wage, because my life is in their hands.
“Key workers” who manage our household waste should be paid very well, otherwise towns and cities quickly become unlivable clusters of disease. A well-qualified nurse in Taipei who meets the hiring standards of a top-quality hospital should be on a starting wage of at least NT$60,000 per month. To those who argue that leading academics in the best universities earn little more than that, I would say they should earn a lot more. Let’s have that discussion too.
Companies, governments and hospitals that seek to make “efficiency” savings from the salaries of their workers do not deserve those workers. They should first make savings by eliminating cultures of corruption that add hidden operational costs that are passed on to customers.
A respectful salary could easily be provided to every nurse and doctor in every hospital if the senior management cut out the bribes their purchasing directors take to accept products at prices well over their competitive market value. Hospitals, and by extension the government and taxpayers, are getting ripped off to pad the profits of the private sector.
If we really respect nurses and doctors, educators and sanitary workers, and we want to retain the quality of those workforces, we need to pay them what they are worth or we can and should expect them to leave professions that undervalue them.
Do not thank workers, pay them appropriately for the skills and the high-quality output they provide.
Ben Goren is an essayist, businessman and long-term resident of Taiwan.
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