The Institutional Factors Affecting the Growth of Korean Migrant Care Market and Sustainability in Long-Term Care Quality

: Due to an increase in the ageing population, the migrant care market now includes new home-based long-term care (LTC) under the national long-term care insurance. This study underlines a perspective of the Korean migrant care market in terms of long-term care quality in South Korea. Thus, the study explored the institutional factors that restrict and promote the migrant care workers (MCWs). Two migrant workers groups were analysed: migrant care workers in home-based long-term care versus nursing hospitals. Designed as an in-depth policy-oriented content analysis, this study used three types of data including interviews with eight participants (MCWs, the nursing hospital manager, and the LTC home manager), organisational documents (employment eligibility criteria), and institutional texts (law, administration rules, etc.). Our results indicate that the factors hindering employment of MCWs in home-based LTC were visa status, qualiﬁcation requirements (the National Qualiﬁed License), wage regulation policies, and social security obligations. A promoting factor was jobs that hired on an on-call basis. In conclusion, our ﬁndings suggest that the growth of the migration care market and sustainability in LTC quality depend on the policy directions of the Korean long-term care insurance.


Introduction
Over the past few decades, the problem of global care workers in poor countries has raised various issues. With a rapidly growing elderly population, developed countries are struggling to resolve the shortage of care workforce in LTC sectors [1,2]. The core of these issues is the lack of care workers, cost efficiency, and sustainability. Most developed countries are responding to these problems through a variety of policies. One solution to this problem is to accept MCWs.
According to scholars, migrant labourers move from country to country based on personal preference. However, labour migration is actually affected by each country's specific social policies [3,4]. More recently, researchers have focused on labour migration (particularly of MCWs) and how institutional mechanisms vary across countries [1,3,[5][6][7][8].
While plans to replace workers with MCWs in the LTC sector are more limited in Nordic countries such as Finland, Denmark, and Norway, southern European countries and the United Kingdom have relatively fewer restrictions [2] (p. 44).
A similar trend can be observed in East Asian countries. For instance, Singapore, Hongkong, Taiwan, and Japan have shown a positive response to the hiring of MCWs [4,9], while this issue is still debated in South Korea [10]. Compared to other Asian countries, Korea and Japan have placed more restrictions on the hiring of MCWs [11] but Japan has increased the use of MCWs in recent years. In Japan, a serious shortage of care workers has led to a change in laws by way of an amendment to the Immigration Control and Refugee Recognition Act in 2018 [12] (p. 246). However, the Korean government has been far more passive compared to other Asian countries [11,13,14]. For example, the Korean government only just implemented an employment permit system in 2004; further, they deregulated migration policies targeting overseas Koreans in the early 2000s and passed the Multicultural Family Support Act for immigrant spouses in 2008. However, there are not any laws that directly target MCWs [10].
Research on the Korean migration and care system has lagged behind other Asian studies. Since the launch of Korea's long-term care insurance in 2008, problems of oversupply have resulted in a strong competition among for-profit providers, which is one of the leading causes of lower LTC quality and poor working conditions for the LTC workforce [15][16][17][18][19]. Due to the mismatch of worker supply and demand, MCWs (or Korean-Chinese MCWs) have been heavily recruited to fill the niche [14]. Korean-Chinese MCWs generally have fewer qualifications than Korean native workers [10,16,17]. Despite Korean-Chinese migrants among all Korea's immigrants are most highly regarded [18] given their similar physical appearance to Koreans and their communication skills with the elderly and their families, the debate on the sufficiency of MCWs' geriatric knowledge and communication skills is ongoing [3,10]. The focus of this study is on Korean-Chinese MCWs who have recently joined the LTC workforce [3,20]. Specifically, this study addressed long-term care quality to ensure sustainability in South Korea.
In general, South Korea has two formal migrant eldercare markets: nursing hospitals and LTC sectors [20]. The two groups have their commonalities and differences. Although the two groups have both performed the similar job of caring for the elderly, they exhibited differences in the care system. The first is the historical background. The nursing hospitals in the migrant care market were first established in the 2000s when the immigration policy for Chinese compatriots was improved. In contrast, home-based LTC started when the long-term care insurance system was launched in 2008. Secondly, are institutional factors. In particular, a comparative study is needed because the differences between the two groups across the three institutional systems (migration, care, and employment) lead to promotion and hindrance of the foreign workforce. Home-based LTC is in-home, but nursing hospitals are inpatient facilities. Home-based LTC directly hires its manpower, whereas nursing hospitals outsource their care workers.
However, some studies have explored the intersectional migration and care regime of Asian countries and compared Korea to other East Asian countries [4,[9][10][11]. Only a few studies have investigated care and migration regimes in South Korea [3]. Previous studies have either treated these two eldercare sectors as the same, or they have neglected the newly formed migrant LTC market [20,21].
In a broader sense, elderly citizens benefitting from National LTC are receiving homebased LTC services from qualified Korean care workers, while seniors who live in nursing hospitals are receiving care services from Korean-Chinese MCWs. Unlike home-based LTC, nursing hospitals can generally hire through outsourcing agencies or companies. While Korean-Chinese MCWs are consistently ranked as the largest group of care workers that is continuously increasing [18], we know little about why MCWs are actively flowing into nursing hospitals and not home-based LTC due to a lack of official statistics [22].
In this context, the study aimed to examine the institutional factors that hinder and promote MCWs working in home-based LTC by comparing them to other MCWs in nursing hospitals in South Korea. To that end, we pose the following research questions:

1.
Are there differences in the occupational entry barriers for the two care markets (nursing hospitals vs. home-based LTC)? 2.
If the institutional features differ, what are the specific combinations of migration, care, and employment systems that hinder or promote the employment of MCWs in the homecare provided under long-term care insurance?

The First Inter-Institutional Associations between Migration and Employment System
The MCW for elderly care can be examined from the following three combinations of inter-institutional associations ( Figure 1). As noted, MCW is influenced by three-angled institutional features (Figure 1) such as their legal status (i.e., migration policy), job skills (i.e., care system), and workplace conditions (i.e., employment system) ( Table 1).
1. Are there differences in the occupational entry barriers for the two care markets (nursing hospitals vs. home-based LTC)? 2. If the institutional features differ, what are the specific combinations of migration, care, and employment systems that hinder or promote the employment of MCWs in the homecare provided under long-term care insurance?

The First Inter-Institutional Associations between Migration and Employment System
The MCW for elderly care can be examined from the following three combinations of inter-institutional associations ( Figure 1). As noted, MCW is influenced by three-angled institutional features (Figure 1) such as their legal status (i.e., migration policy), job skills (i.e., care system), and workplace conditions (i.e., employment system) ( Table 1). The first framework is a combination of 'immigration policy' (i.e., visa status) and recruitment using the employment permit system as the interaction between migration and the employment system. First, the immigration policy [23][24][25] impacts MCWs who intend to enter Korea, as they must hold some form of visa [26]. As noted, Korean-Chinese MCWs are the largest group of migrants in Korea [18]; further, the immigration policies related to Koreans overseas has continued to develop [3]. Work eligibility for the LTC sector and nursing hospitals only requires one of five visas: Work and Visit (H2), Overseas Korean Visa (F4), Permanent Residence Visa (F5), Resident Visa (F2), and Marriage Immigration Visa (F6) [27] (p. 7) Second, the recruitment of H2 work and visit visas (for ethnic Koreans) is carried out via Korea's immigration-related employment permit system, which displays the permitted Korean Industry Standard Classification industry codes [28]. While LTC workers belong to the 'social welfare services (87)' industrial code, nursing hospitals fall under 'private nursing and similar services (96993)'.
Meanwhile, the employment permit system provides low-cost workers to companies that struggle to remain competitive [13] (p. 20). The home-based LTC directly employs MCWs, while nursing hospitals employ for-profit brokering agencies to source their care workers. MCWs in nursing hospitals are treated as self-employed workers, which corresponds to the private nursing and similar service (96993) industrial code; these workers must autonomously search for employment or be recruited by government employment centres. Further, MCWs seldom utilise 'Worknet', which is a government employment platform in South Korea [25] because for-profit agencies operate other job platforms [29] that offer employment to MCWs.  The first framework is a combination of 'immigration policy' (i.e., visa status) and recruitment using the employment permit system as the interaction between migration and the employment system. First, the immigration policy [23][24][25] impacts MCWs who intend to enter Korea, as they must hold some form of visa [26]. As noted, Korean-Chinese MCWs are the largest group of migrants in Korea [18]; further, the immigration policies related to Koreans overseas has continued to develop [3]. Work eligibility for the LTC sector and nursing hospitals only requires one of five visas: Work and Visit (H2), Overseas Korean Visa (F4), Permanent Residence Visa (F5), Resident Visa (F2), and Marriage Immigration Visa (F6) [27] (p. 7).
Second, the recruitment of H2 work and visit visas (for ethnic Koreans) is carried out via Korea's immigration-related employment permit system, which displays the permitted Korean Industry Standard Classification industry codes [28]. While LTC workers belong to the 'social welfare services (87)' industrial code, nursing hospitals fall under 'private nursing and similar services (96993)'.
Meanwhile, the employment permit system provides low-cost workers to companies that struggle to remain competitive [13] (p. 20). The home-based LTC directly employs MCWs, while nursing hospitals employ for-profit brokering agencies to source their care workers. MCWs in nursing hospitals are treated as self-employed workers, which corresponds to the private nursing and similar service (96993) industrial code; these workers must autonomously search for employment or be recruited by government employment centres. Further, MCWs seldom utilise 'Worknet', which is a government employment platform in South Korea [25] because for-profit agencies operate other job platforms [29] that offer employment to MCWs.

The Second Inter-Institutional Associations Migration and Care System
The second framework of combination involves the migration and the care system, which consists of 'qualifications' and 'visas' related to foreigner requirements. The labour market that one can enter depends on the training processes one has undergone. Two possible avenues for certification exist for workers to qualify as MCWs: an LTC license or a private certificate [30] (p. 195). Table 1 indicates that those with an LTC license are referred to as LTC workers (Yoyangbohosa), whereas those with the private certificate are referred to as private nursing workers (Ganbyungin).
Although LTC home-based organisations and nursing hospitals are formal institutions for the elderly population with vulnerable health conditions, both these institutions have adopted different laws and policies. For instance, the LTC sector is covered by the long-term care insurance and the employment of care workers is compulsory [31]. In contrast, nursing hospitals are covered by the NHI (National Health Insurance). Employment of nursing care workers is not mandatory, even though these hospitals require professional medical personnel such as physicians and nurses to deliver medical services [21] (p. 220).
Under the LTC Workers Qualification System, Yoyangbohosa can denote either Korean citizens or 'foreigners'. A 'foreigner' is a person who has not violated Korea's Immigration Act [23] in terms of their residency status or duration of stay [27] (p. 7). Table 1 shows provisions for foreigners who are eligible for an LTC license.
Next, Ganbyungin are assistive personnel who perform care-related tasks in nursing hospitals that are trained and certified by for-profit companies [32] or the Private Qualification Association [33], but they are not licensed unlike doctors and nurses [34]. Doctor and nurses are subsidised by the NHI but not the Ganbyungin workers. Further, migrants are trained to provide basic nursing tasks without any visa requirements by a for-profit agency and then obtain a private certification [14].

The Third Inter-Institutional Associations Care and Employment System
The third framework of combination involves the interaction between care and the employment system, which comprises regulation of 'labour cost' and 'legal labour protection' [35]. Broadly speaking, employment quality relates to a set of labour market and social policies.
In the case of LTC settings, the Korean government regulates the labour cost expenditure ratio to improve the wages of LTC workers through 'The administrative rule of the Long-Term Care Insurance' [36] and enforces social insurance to protect LTC work-  [37][38][39][40]. The long-term care insurance's reimbursement policy indicates that the longterm care insurance is legally required to meet a minimum wage ratio or higher in its total budget for LTC workers' labour costs [2] (p. 116). Annually, the Ministry of Health and Welfare presents its proportion of labour costs for LTC workers through Article 11-2 [36], which denotes the proportion of labour costs as part of the total budget. Therefore, it was decided that labour costs should comprise 86.5 per cent of home-based LTC revenues [36]. Additionally, LTC workers and enforced social insurance are protected under the Long-Term Care Insurance Act [41]. An LTC worker can benefit from social insurance [37][38][39][40], while their labour rights are guaranteed by the Labour Standard Act [35,42].
Ganbyungin workers at nursing hospitals have subordinate, disguised employment relationships. This is because Ganbyungin are treated as self-employed workers, which corresponds to the 'private nursing (96993)' industrial code in Table 1. They are also recruited through for-profit employment agencies, which can potentially foster illegal employment [3,30]. As they are not covered by social insurance and they are not guaranteed labour rights.

Data Collection
The study collected data in the following three ways:

1.
Three authors interviewed MCWs, a manager as MCW, and employers working at the home-based LTC and nursing hospitals using semi-structured interview guidelines which were extracted from the theories and institutions.

2.
On-site collection of documents (i.e., work contracts, salary statements, and the documents required for entry etc.) were collected. Since organisation documents were not made publicly available, the authors used them only for analysis.
The data collection was carried out from January to September 2020 even though interviews were suspended from February to May 2020 due to the COVID-19 pandemic. For document collection, we collected the documents from three organisations (organisation(O)# 2, 3, and 4) who participated in the interviews. Three authors and another reviewer with expertise in the domain of LTC system, migration issues, and employment systems discussed the appropriate documents and institutional texts to be collected on-site and online. The documents were selected after consensus was reached between the researchers.
The interviews enabled us to confirm the information collected from the institutional texts. Based on this, we constructed interview guidelines which were extracted from the theories and institutions. Regarding the interviews, three authors conducted interviews with participants using relevant institutional text as guidelines with questions such as 'What are the institutional requirements for MCWs to care for the elderly in South Korea?' and 'Is there any difference between the system and real working as LTC workers?'. One-to-one interviews were conducted until the data were saturated, which took nearly one-and-ahalf hours each. The interviews were recorded with participant consent, and field notes were taken.

Setting and Participants
The participants were selected through purposive and criterion-based institutional sampling. The basis for institutional sampling originates in the institutional framework in Section 2. To recruit study participants, three authors directly contacted nursing hospitals and home-based LTC organisations located in the metropolitan area of South Korea where many MCWs work. Despite the numerous organisations contacted, only four agreed to participate and only three of them provided on-site documents. A paired interview was conducted at each organisation except for one (O# 4). The fourth organisation (O# 4 in Table 2) only participated an employer because a MCW did not agree to participate. Table 2 Sustainability 2022, 14, 3366 6 of 14 indicates two MCWs and one manager as MCW in a nursing hospital and two MCWs and three Korean employers at home-based LTC organisations. The ages of the MCWs ranged from the 50s-60s in both the home-based LTC and nursing hospital. We did not sample at a specific age because we performed institutional sampling (home vs. nursing hospital) in the sampling. However, the average number of Korean caregivers working in Korea are in their late 50s, the highest among OECD countries [2]. Of the four MCWs, two were females and two were males. Three out of four MCWs graduated from high school at least, while the education background of the last MCW was unknown. The three Korean employers were younger and more educated than the MCWs. The visa status of MCWs varied from H2 to F6. The LTC certificate was held by one MCW manager (#3) at a nursing hospital and two MCWs working at a home-based LTC. The period of experience of MCWs was about one year, whereas MCWs at home-based LTC had 5 years' experience.

Analysis
The researchers analysed the qualitative data to investigate the institutional context regarding home-based LTC and nursing hospitals [43,44] for migration, care, and employment. We first analysed institutional texts before coding the interview content found therein. Thus, this study draws from various data sources and carries out a content analysis of adopted laws and policies to formalise these sectors as well as field documents and qualitative data (i.e., interview scripts) of the matched interviewee to explore the institutional factors with the migration, care and employment systems for MCWs [43].
Qualitative content analysis techniques are classified as either conventional, directed, or cumulative [45] (p. 1277). Specifically, this study used a 'directed' content analysis methodology because a directed content analysis starts with a theory or relevant previous research as initial codes. Prior to data analysis, the theory specifies the coding categories in advance, and coding is generated from the results of the related theories [45] (p. 1286). In the directed content analysis method, preset categories are used as analysis categories for initial coding in subsequent analysis [45] (p. 1282-1283), and data are allocated to categories generated from theory or previous studies [46] (p. 266-267). The interview contents were transcribed and coded according to the analysis category.

Rigor and Ethical Considerations
Qualitative data were collected from the interviewees who agreed to participate in this study. All interviewees' information was anonymised with an encrypted password, and the confidentiality of all interviewees were strictly protected. To prevent bias in document selection and data analysis, the researchers and a reviewer extensively discussed and reviewed the differences before finalising the analysis. This study complied with ethical procedures and standards by obtaining approval from Hallym University's Institutional Review Board (on 23 December 2019, IRB Number: HIRB-2019-099) while upholding the tenets of the Declaration of Helsinki [47].

Results
Our results indicate that a combination of migration, employment, and care system influences the employment of MCWs in home-based LTC and nursing hospitals (Table 3). This study considered three perspectives: 1. the migration system via visa policies such as the Immigration Act and the Enforcement Decree of the Immigration Act; 2. the care system, specifically qualification and training programs through the Welfare of Older Persons Act as well as the costs of labour regulations such as the Act on Long-Term Care Insurance for Older Persons; 3. the employment system, specifically recruitment through the employment permit system and the quality of employment as regulated by the Act on the Employment of Foreign Workers, Employment Insurance Act, Enforcement Decree of the Industrial Accident Compensation Insurance Act, and Act on the Guarantee of Employees' Retirement Benefits.

Home-Based LTC Are Reluctant H2-Visa Holders for Recruitment under Employment Permit System
The nation's migration and employment systems operate under the Immigration Act and Act on the Employment of Foreign Workers. In terms of legal recruitment, although more workers in home-based LTC were considered eligible for H2 or higher visas (Table 2), the result revealed that Home-based LTC are often reluctant to hire the H2 visa. Specifically, most of the MCWs working in home-based LTC only had an F4 visa or higher.
There are two reasons for this. The first involves the employment permit system for H2 visas; the LTC employers surveyed during our study did not want the administrative burden that comes from employing H2 visa holders even though home-based LTC operate in a sector permitted by the employment permit system. If the manpower needs are not met despite the efforts to recruit Koreans, an application for the employment of foreign workers may be filed at the 'Korea Workers' Compensation & Welfare Service' [48], after which a work permit must be submitted. The required documents are the 'foreign worker The second reason is that the F4 visa is similar to the H2 visa with a three-year stay period; however, the F4 visa has no limit on the number of renewals. Thus, there are no inconveniences when it comes to leaving and re-entering the country. These LTC employers typically prefer employees with F4, F5, and F6 visas. In contrast, nursing hospitals typically hire those with H2 visas or higher. Immigrants can apply for the LTC examination with an H2 visa, but it is difficult to get a job after obtaining an LTC license. The following interviewees provided experience of their employment: 'I entered the country with a tourist visa of B2 for the first three months. I started this job after obtaining an H2 visa.' (MCW at nursing hospital #1). 'We must first prepare administrative documents since "only F4 visa can be employed". The H2 visa holders of employment permit system are not hired in public LTC settings, but it is possible to hire personal care and similar services (96993). [...] We have to register here (at the Ministry of Health and Welfare). We must report our workforce to the government, so we cannot hire people with this visa (H2)' (Employer of LTC home care #4).
In the LTC sector and nursing hospital, the employment permit system was applied to different categories of industry code. The LTC manager recognised that LTC were public services (87) and not private nursing services (96993). The LTC employers were responsible for man-power management and they had to hire MCWs who could stay for a long time. There is a clause in the H2 visa which requires immigrants to return to their home country once every three years, and that they are only allowed to stay for as long as four years and 10 months [49]. These visa requirements can negatively affect the quality of elder care services due to the lack of care continuity when a foreigner with an H2 visa is hired, as indicated by the following interviewee comments: 'People with an H2 visa must return to their home country once every 3 years [ . . . ] An F4 visa is possible for LTC workers, but not a H2 visa' (MCW at LTC home #7).

The Second Combination Care and Migration System Differences in Initial Training and Visa Requirements
The results differed between home-based LTC and nursing hospitals in terms of their qualifications and visa requirements. When matching MCWs for employment, one employer noted that a service user's family believed that professional licensing was necessary: 'There are many Korean-Chinese care workers who have a lot of experience as professional, and obtaining Licence of LTC workers is not easy for Koreans because they have to pass the exam' (MCW #7).
'Even foreigners are considered smart and professional if they have this' (Employer of LTC home care #8).
Alternatively, MCWs at nursing hospitals are qualified by for-profit companies [32] or the Korea Private Qualification Association [33]. While MCWs at nursing hospitals may have similar job functions to LTC workers, the training provided to them is insufficient, as discussed by the following interviewees: 'It came through the XX Profit Agency. I only learned suction for three days before I started working here' (MCW at nursing hospital #1).

The Third Combination Employment and Care System
The third combination is comprised of public expenditure (regulation of labour costs) and the quality of employment for MCWs (non-standard employment, wages, vacation time, and social insurance among others). There was a significant difference between home-based LTC and nursing hospital workers in terms of the element mentioned above.

Regulation for Labour Cost and Public Long-Term Care Insurance Expenditure
First, home-based LTC are legally required to meet a minimum ratio of labour costs under the Act on Long-Term Care Insurance for Older Persons [2] (p. 116). As detailed in the following interview with LTC employer #8, home-based LTC must ensure that labour costs account for a certain rate of their total budget, such that the hourly wage exceeds the minimum wage. If the LTC centre does not comply with this, it may receive a penalty from the government: 'If a wage of KRW 10,850 is paid under the Labour Standards Act of 2020, it will not meet the 86.5% requirement mentioned in the Administrative Rule of the Long-Term Care Insurance Act. Thus, we matched the 86.5% requirement by providing additional benefits in lieu, such as allowances and holiday bonuses' (Employer of LTC home care #8).
'The government says it's a "minimum wage or higher", but it's the minimum wage' (MCW#5).
As anticipated, nursing hospitals did not directly hire Ganbyungin. Such workers were usually sourced from a Private Qualification Association. However, wage disparities exist between MCWs and Korean workers in nursing hospitals; MCWs have recognised that their wages are not proportional to their efforts because they are not Korean workers: 'This is not problem for a hospital, but for a Private Qualification Association. The association gives more than 10,000 KRW to Koreans and less than 10,000 KRW to Chinese immigrants. Although it is harder, I still do it' (Manager of nursing hospital #3).

Vacation and Work-Life Balance
Nursing hospitals appear to provide fewer vacation days and produce higher rates of exhaustion, unlike home-based LTC. One manager interviewed stated that she wanted to provide quality care for the elderly by recharging MCWs with vacation days. However, one manager said that the MCWs were reluctant to take time off since their wages are then paid to those who come to work on their behalf. Meanwhile, the working environment of home-based LTC is not conducive to rest. This phenomenon disrupts the work-life balance of MCWs, which eventually deteriorates the quality of service for the elderly: 'Anyway, LTC workers can take a break depending on the situation' (Employer of LTC home care #6).

Guaranteed Social Insurance
MCWs in the long-term care insurance system have social insurance and various benefits, which are mostly similar to domestic workers, including severance pay and unemployment benefits. Workers in long-term care insurance-including temporary workers who work more than 60 h per month-contribute to a public pension as well as health, employment, and accident compensation insurance [2] (p. 117).
Specifically, the interviews were inconsistent between managers and MCWs at homebased LTC regarding employment insurance, industrial accident insurance, and severance pay. The managers indicated that unemployment benefits are misused, while the MCWs noted that although these benefits were legally designed to provide social insurance and severance pay at long-term care insurance.
'The salary and benefits of Koreans and MCWs are the same, [including] national pension and health insurance, as well as employment insurance, industrial accident compensation insurance, and severance pay' (Employer of LTC home care #8).
Unlike home-based LTC, nursing hospitals only provide a few social insurance benefits, and no protections from wage inequity in this sector: 'What needs to change is social insurance or better training, which are necessary to prepare the conditions for good workforce employment. I've been doing this job for more than five years and I even have an LTC license. If I move to an LTC setting, I can be covered by four types of social insurance benefits. However, I'm not sure if they are hiring MCWs there' (Manager of nursing hospital #3).

On-Call Work and 'Unstable' Labour
This study also revealed that on-call work for home-based LTC have promoted the inflow of MCWs into the LTC sectors. Although LTC workers are afforded some form of labour protection as mentioned earlier, they still lack long-term job security and a proper income. It is difficult for in-home LTC workers to maintain long-term job continuity due to the influence of several factors that could result in a cessation of work, such as a hospital stay due to worsening symptoms, or patient death. Therefore, zero-contract labour or on-call work does not guarantee a living wage because they often have to account for a potential loss of income: 'An elderly died who taking care for a month. Another elderly died after 40 days of care. In another case, I had to quit my job because the elderly had surgery and needed to stay in the hospital. Regardless of my will, my work is unstable' (MCW at LTC home #7).
'MCWs are called to working conditions avoided by Koreans. For example, the elderly with dementia or hallucinations, poor traffic . . . ' (Employer of LTC home care #8).

Discussion
Our findings revealed multiple factors both hindering and promoting MCWs working in long-term care insurance based on three inter-institutional associations between migration, care, and employment in South Korea. First of all, the hindering factors of MCWs are as follows: strict visa requirements, qualification requirements, wage regulation policies, and social security obligations.
First, in terms of the first combination (employment permit system and visa requirement), although home-based LTC were thought to be eligible for H2 visas, the results that they were ineligible for the H2 visa. Unexpectedly, the study found that the employment permit system has not been adopted in the LTC sector and that most MCWs working in home-based LTC have an F4 visa or higher, which indicates that practical entry barriers still exist. In addition MCWs made sense of job qualifications and working conditions based on their co-workers' occupational knowledge as opposed to laws or administrative rules. Such occupational knowledge was constituted outside the institutional system. It was interpreted as the decoupling phenomenon of the institution and in the MCW's real world.
On the other hand, the reason why LTC homes only recruit MCWs who are F4 holders or better is that the employers would prefer not to shoulder the administrative burden of frequently replacing care workers. A foreigner's visa is a pre-requisite to work in elder care and subsequently a regulatory condition for MCWs to be hired in the LTC sector. Thus, this study suggests that the administrative burden of the employment permit system needs to be reduced to facilitate the influx of MCWs in the LTC sector.
Second, considering the second combination of migration and care system (visa requirement and qualifications), this study has demonstrated that the intersection of labour migration and the LTC schema are related in their efforts to maintain qualified, regulated eldercare workers in home-based LTC. Nevertheless, MCWs without proper training can still easily enter the nursing hospital sector.
A difference may exist in the quality of care for the elderly depending on whether the LTC workers are licensed. While private nursing workers (Ganbyungin) at nursing hospitals and LTC workers may have similar occupations, the quality of training for Ganbyungin is lacking. To compensate, it is necessary to strengthen the qualifications for private nursing workers (2). Given the current shortage of MCWs in Korea, we recommend that clear labour regulations be created regarding the hiring and management of MCWs, especially in terms of their training in nursing hospitals. In gerontology, it is very important for the care worker to communicate effectively with the elderly and to have emotional empathy. Since elderly Korean folk tend to prefer Koreans over MCWs, the Korean government should take into consideration that Korean care workers have greater advantages in communication with the elderly over the MCWs.
Third, regarding the third combination of care and employment systems, because the LTC system for the elderly receives financial support for labour costs from the long-term care insurance, which also provides social insurance, it tends to be filled with more local workers compared to MCWs. A nursing hospital can be seen to have less favorable working environments compared to a home-based LTC. Accordingly, physical and mental breaks for LTC workers must be provided through designated leaves. According to Kaye et al. [50], the personal care and health-related workforce witnessed lower wages higher turnover. In the field of elderly care, the working conditions of care workers correlates strongly with the quality of service. [51].
This study contributes to the existing research on factors influencing the inflow of MCWs. Similar to the previous study [3], this study also revealed factors hindering the home-based LTC inflow of MCWs due to the visa requirements, LTC license exam, and employment system. According to a previous study [7], strict institutional regulations of care, migration, and employment have been proven to hinder the growth of the Live-in Migrant Care Market even with the restructuring of the Dutch LTC system in recent years. The findings of our study will aid the Korean government in implementing a policy for limiting MCWs in the LTC market [7], which will improve the quality of jobs and help secure job continuity for the Korean care workers.
Next, a promoting factor was jobs that worked on an on-call-work and zero hours contracts. Recently, various employment types with unstable job characteristics have emerged [52]. On-call work is a representative job for non-standard employment. Similar to a previous study [53], the study showed the precariousness when it comes to parttime workers, non-regular workers, or a specific work condition in living with a patient's family who hires the care worker, etc. In particular, this type of employment has been demonstrated to negatively impact the quality of employment in home-based LTC. It may be considered as a suitable workforce under various conditions. For example, foreign workers can be employed for tasks or conditions that Korean workers avoid (when one-hour services are needed several times a day, three meals, and taking medicine). However, the influx of foreign workers into jobs that Koreans avoid is not desirable because it causes labor discrimination problems.
In addition, the introduction of this study raised the issues that MCWs are flowing into eldercare areas with low job quality in terms of cost efficiency. The core of these issues is LTC quality (care workforce's expertise), cost effective (from an elderly perspective), and sustainability. The Korean government should recognise challenges of LTC quality and cost effectiveness. The perspective of person-centred care refers to good care from the perspective of consumers (for the elderly). This is related to the elderly's preference for Korean workers in various coping skills necessary for caring for the elderly and communication with the elderly. In response, if the Korean government wants to promote the LTC field to domestic workers, it can be strengthened with policies aimed at transforming the on-call nature of the work and improving the quality of LTC. These policies will act as a hindering factor for MCWs and draw in more Korean employees. It could make the quality of service more sustainable, although it would be costly to hire local care workers.
On the contrary, if precarious jobs such as on-call job with zero-hours contract are neglected, the influx of MCWs is likely to become more active. Overall, the growth of MCWs depends on the direction of policies impacting the Korean long-term care system.
Although this study contributes expansion and understanding of institutional factors for MCW to be able to work in LTC settings of South Korea, it does have several limitations. First, this study could not interview a large number of MCWs and managers due to the COVID-19 situation. Second, there were laws and documents that were not covered by the institutional sampling in this study. Third, this study did not deal with LTC facilities (nursing home) and day health care centres for elderly under the long-term care insurance, but only for home-based LTC. Finally, this study is a qualitative study that has limited generalisation. Future studies utilising better quantitative and qualitative data from a larger sample are needed.

Conclusions
This study explored the institutional factors hindering and promoting the inflow of migrant care workers in LTC sectors using interview, on-site collection of documents, and online institutional texts. This study augments the current research on MCWs in the Korean LTC market in comparison with nursing hospitals. Due to the weak regulations of the Korean government, MCWs can enter more easily into a nursing hospital which can influence low care quality for the elderly and low wages for the workers. Although the long-term care insurance is legally required to meet a minimum wage ratio or higher, MCWs hold the minimum wage level in the LTC market. This means that they do not receive adequate wages compared to the labor intensity. Their wages are lower than those of the OECD counties [2] (p. 102). Korean government should intervene deeply in these wages of the LTC care market. The reason is that improving service quality and securing expertise can ultimately be cost-effective.
We believe that our study filled the gaps in the existing literature because it presents a preliminary look at the influx of MCWs in an LTC setting within the South Korean context which is one of the rapidly aging countries.  Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patient(s) to publish this paper.
Data Availability Statement: The data are available upon reasonable request.