夾在國家政策與原住民族文化之間的原鄉居家服務

Collisions between State Policies and Indigenous Cultures: Home Care in Indigenous Communities

研究目的：原鄉長照是在原住民族部落文化與漢人國家政策的矛盾中進行，如何在「普遍平等」的原則下，納入「尊重差異」的彈性，是原鄉長照發展的關鍵。研究目的在於檢視長期照顧政策在原鄉的實施狀況，探討政策與文化如何型塑居家服務。研究方法：運用民族誌研究，以南部某縣市原鄉的居家服務方案為場域，運用訪談與參與觀察，共計訪談與觀察行政人員10名、居服社工5名、居服員26名、以及個案43名。研究期間為2013年8月至2014年7月。研究結果：原鄉長照從原民會移轉到內政部，居家服務從愛心媽媽的關懷轉變為專業管理的照顧，居服員成為領薪水的照顧者；自付額制度讓部落居民意識到居家服務變成付費購買的商品。國家帶入照顧商品化與部落傳統照顧文化之間形成居服員、案主與照顧關係的多樣性。但在國家長照的強勢文化中，部落傳統文化對照顧的詮釋往往被視為個人問題而被忽略。研究結論：長照政策需要尊重原住民文化的差異，並由原住民族集體照顧文化來提供現有長照方案，讓長照成為原住民族文化復振的解殖過程，而不是同化原住民族的殖民工具。居家服務在原鄉的服務提供模式需要有所調整。首先，照管專員在評估時需要與訂定照顧計畫應該給予更多彈性，讓居服員可以有更多自主權。第二、現有一對一的居家服務提供模式也應該要有所突破，讓居服員可以合併提供服務，以符合原住民族集體分享的文化特性。第三、外來社福組織在原鄉提供居家服務過程需要培養文化敏感度，尤其是管理者與督導要跳脫把居服員與個案所呈現的問題背後其實是文化觀的差異性所致。在組織內創造不同文化彼此對話與學習的空間是外來社福組織進入原鄉必須要學習的文化課題。

Purpose: The purpose of this study is to examine the interaction between culture and government health care policy by exploring how long-term care policy shapes home care practices in indigenous communities in Taiwan. We expect that the key to providing the best service is finding the flexibility to recognize indigenous cultures in government policies that are intended to be universal. Methods: We conducted ethnographic research (in-depth interviews and participant observation) in a home care program operated by an NGO in 8 indigenous communities in southern Taiwan. Participants included 10 administrators, 5 supervisors, 26 home care workers, and 43 clients. Results: The theme analysis showed that when the jurisdiction of long-term care policy shifted from the Council of Indigenous Affairs to the Ministry of the Interior, the definition of home care changed from care by community members to care by paid workers. When a co-payment system was implemented, clients began to see home care as a commodity, which resulted in a new understanding of home care workers, clients, and their relationship. The indigenous understanding of home care now tends to be problematized and portrayed as an individual problem, and so gets neglected. Conclusions: Long term care policy needs to recognize the different perceptions of indigenous peoples in contrast to Han people in order to make long-term care a process of de-colonization rather than a tool of assimilation. The provision of home care in indigenous communities needs modification. First, case managers should allow more autonomy for frontline workers in their care planning. Second, the one-on-one mode of care should have the possibility to adjust to a collective mode of care to suit the indigenous tradition of mutual sharing. Last, the cultural competence of NGOs working in indigenous communities needs to be fostered to encourage sensitivity to cultural differences in the understanding of managerial problems in home care.