A Caring System

By: Choong Tet Sieu
Asian Week, July 28, 2000

Let's start by demolishing a myth: That an aging nation is a rich nation, and Japan is the prime example. The fact is societies turn gray when there are more people reaching old age than there are children being born. And that is what is going on across much of Asia, from the Philippines to India — countries can be poor and gray.

It's a process that is happening very quickly too — largely because of positive changes. Families get smaller as standards of living improve. Clean water, better nutrition and medical treatment mean people live longer. For example, a Thai man who was 60 in 1995 was likely to have another 18 years ahead of him. Asia is already home to 52% of the world's citizens over 60. By 2020, the United Nations estimates, that percentage will rise to 57%. Indeed, the proportion of people over 65 in Thailand and Sri Lanka is projected to be higher than the current ratio in the U.S. The group that is growing fastest, though, is the over-80s (see chart page 38). Asia will account for almost half of them in two decades. Within five decades, the 60-pluses will make up 30% of China's population. Even in the high-fertility Philippines, one in five people will be over 60. That streak of gray runs wide.

This presents special health-care challenges. Basic early-childhood programs such as immunization are still needed so we can fight off infectious bugs. But as populations age, more resources will be needed for the last third of life. Inevitably, emphasis will shift to degenerative conditions (heart disease, for instance) as well as treatment for age-related problems such as hip fractures and cataracts. Seniors who are hospitalized tend to require longer stays, which will mean even bigger medical bills. 

Who will care for the old and sick? Governments? Families? And where is all the money going to come from? Especially when there will be more payouts to retirees than tax revenues from working people. Are there special arrangements for elderly women? After all, women tend to live longer than men, and many may have little savings of their own, having spent their lives caring for others. 

Such questions loom large for many Asian governments. In Hong Kong, public health spending has swollen over the past decade from 8.9% of the budget to the current 14.6% (about $3.9 billion). According to some projections, 40% of people in the SAR will be over 60 by 2020, which makes it the leader in Asia's silver stakes. Given rising public expectations and that kind of demographic, a government-funded study warned that the existing health system (based on publicly subsidized hospitals) would be unsustainable in less than 20 years. 

Japan is already at that critical juncture. Its health insurance system — made up of separate schemes for the self-employed, small firms and corporations — is close to bankruptcy, and the medical bill is growing by some $9.36 billion annually. Prolonged recession has made the corporate program, once the most viable of the three health-care components, increasingly shaky. Companies are balking at rising contributions (as much as 40% of premiums must go to the government for elderly benefits). Last year, Sanrio, which markets Hello Kitty goods, refused to pay more than half its share, saying the system was unfair to firms with many young employees.

Tokyo expects to save several billion dollars a year through a new nursing-care insurance that will allow bedridden seniors to be placed in private-care homes. But that will only be a stopgap, says Suzuki Reiko, a social-service specialist. "If the current situation continues, the [health insurance] system will collapse in 10 to 20 years." Launched in April, the nursing scheme is already mired in controversy over a complex application process and lack of trained personnel and care facilities. Nervous officials have now delayed collecting the $28 monthly premiums levied on the elderly until the autumn. "We have to make a change," a senior health official admits. The ministry is considering options such as reducing coverage, raising premiums and introducing a separate health system for the elderly. All will pose political headaches. "There has been a great deal of debate, but we are still very far from consensus," the official says.

Japan's pension system is in worse straits. Many young people are refusing to contribute for fear that they will receive nothing back in their old age. The government recently raised the retirement age to 65 to ease the fiscal pressure on social security, but health officials admit that the system faces bankruptcy unless there is a 20% cut in pension payments or an equivalent increase in payroll deductions. 

Retirement may become irrelevant as more people are able to lead longer and healthier lives. But that's not really likely. So even relatively young countries like Malaysia cannot avoid raising the pensionable age for long, says Siti Hawa Ali, a specialist on elderly policy in the country. This will allow seniors not only to remain in the workforce, she says, but to continue to be active consumers and taxpayers — which the economy needs.

China faces a much more acute problem. Not only has its one-child policy hastened the gray tide, the large and creaking state sector can no longer meet its welfare obligations. Benefits under the old iron-ricebowl system ranged from housing to medical care. But nominal pension deductions, which were often used to hide red ink, have long vanished. Now a third of state enterprises fail to make pension payments. Retirees sometimes wait for years to be reimbursed for medical expenses. If a funded social security system isn't in place soon, some studies estimate that by 2030 workers would have to pay as much as 38% of their salary for pensions — clearly, an untenable situation. 

Health care is a scarcer commodity in the Chinese countryside, where 70% of the elderly live. Facilities are poor and hardly anyone is protected by any form of social security. Much the same applies to India's seniors, who are also mostly rural folk working in the informal economy. The peasants' insurance remains their children. But for how much longer? In villages from Thailand to the Philippines, young people are heading to the cities — or abroad — in search of better jobs, leaving their elders behind. Even in cities "many families are unable to care for their elders due to migration, lack of space or financial and other constraints," says Malaysia's Siti Hawa. As a result, traditional systems of helping the aged are coming apart.

So are traditional values. So far, the policy in many Asian countries has been to keep safety nets modest and rely on the traditional extended family. But respect and a sense of duty toward the elderly are being eroded in many communities. According to some Hong Kong academics, such changes in social mores and a lack of options for the less well-off are driving some seniors in rural China, the SAR and Singapore to suicide. Dr. Kalyan Bagchi, a robust 80-year-old who heads the Society of Gerontological Research in India, says most of his contemporaries face a "fragile" existence. "In towns as well as villages, they are feeling socially isolated," he observes, with growing numbers suffering depression and dementia. "Our attitude towards the aged has to be revolutionized," he says. "Neglect is evident in all strata of Indian society."

Maneka Gandhi, India's minister for social justice, is trying to change that. Funds are a "crippling problem," she says. The current $2 monthly social-security stipend to citizens over 60 makes a huge dent in India's national budget, she says, "but without anyone really being helped." On the government's agenda instead: a pension program intended to cover an estimated 268 million people in the informal sector, which includes farmers, shopkeepers and taxi drivers. If approved, "it will be one of most ambitious savings schemes anywhere," Gandhi says.

Singapore's health-care system, evolved over the past 20 years or so, is perhaps the most effective in the region. It rests on three pillars: a tax-based component intended for the poor or those too old to have joined the central provident fund, an optional insurance plan covering catastrophic illnesses such as cancer, and a compulsory savings scheme for hospital treatment. Even so, more families like Lim Chee Keong's are finding that the system does not meet the needs of the elderly infirm for longer-term nursing. The 34-year-old professional had enormous difficulties getting long-stay beds when his parents were recovering from serious illnesses. He engaged a part-time nurse, and turned freelance so that he could have flexibility to look after them at home.

In affluent communities like Singapore and Hong Kong, many middle-class families are employing foreign helpers to take on those responsibilities. But this cheap labor may not be available 10 years from now, observes Dr. Yap Keng Bee of the department of geriatric medicine in Singapore's Alexandra Hospital. In small, dual-career families, caring for frail parents at home often means one spouse giving up work — the wife. Lower-income groups don't have that choice. Hence the ElderCare Fund in Singapore. Set up in April with initial capital of $114 million, the program aims to help those who can't afford nursing homes. 

Some activists object to old-age homes as being contrary to Asian culture. Dr. Kwok Ka-ki of the SAR's Action Group on Medical Policy calls for incentives such as allowances to encourage home care. But some seniors prefer to live apart because of lifestyle conflicts with their families. As it is, more and more people are choosing to shift into old-age homes, observes Dr. Shubha Soneja, an Indian geriatric psychologist. "They don't want to take nonsense from their children any more." Among the middle and upper-middle classes, such a trend is inevitable, adds M.M. Sabharwal, 79, founder of the charity Helpage India. Beside providing company, modern homes offer seniors access to special amenities, for instance medical equipment, they would otherwise not have.

India is training a group of geriatric paramedics to cater to rising and evolving needs. But New Delhi is clearly relying on non-government organizations to extend such initiatives. Helpage, for example, has pioneered an eye-care service for rural communities. A fleet of vans with trained personnel tour the countryside, where they identify old folks with cataracts and bring them to an eye hospital for free surgery (60,000 operations last year). Another NGO, the Agewell Foundation, is charged with attending to seniors' grievances under an initiative called Aadhar, or support. Among Agewell's programs: a helpline run by grassroots volunteers, an employment exchange for old folks and a "family life" service that runs errands for seniors.

For Asia, the demographic changes that occurred gradually over 100 years in the West have been compressed into a few decades. The dramatic projections have sometimes fostered a kind of "moral panic" over the costs of providing care for the elderly, says David Phillips, director of the Asia-Pacific Institute of Aging Studies in Hong Kong. Proposed reforms in the SAR, for example, are partly postulated on rising costs. 

"But health care for an aging community is not automatically expensive," Phillips argues. A community-based system that relies on a good network of primary-care physicians (general practitioners) may cost less than a hospital-based service. GPs would screen patients and refer to specialists only those who need hospital treatment. Indeed, a gradual shift from a reliance on long-stay wards toward convalescence centers and community care is likely to bring savings, says Dr. Lo Wing-lok of the Hong Kong Medical Council.

In Shanghai, China's fastest-aging city, seniors are helping one another in an experimental program called the Time Bank. And it operates like one, except that the currency is time spent caring for other old folks. The hours put in by volunteers, usually able-bodied retirees or laid-off workers, are logged for exchange at a later date. The idea, of course, is to "save" for the future, when today's helpers will need a hand too. According to Sun Changmin, of the city's Institute of Population and Development Studies, the concept could be a "breakthrough," not least because it doesn't rely on family members or expensive nursing homes.

In Manila, another unusual scheme trains seniors to be barangay or neighborhood health workers. Run by COSE, the Coalition of Services of the Elderly, members choose two representatives from the barangay chapter. They are taught to monitor blood pressure, measure the blood glucose of diabetics, look out for signs of impending heart problems and decide when to alert a physician. Antonia Maravillas, a 68-year-old seamstress, is one of these volunteer gerontologists. They are the direct links between their barangay chapters and COSE's assigned doctors, who provide services such as electrocardiograms and medicines, and to the elite St. Luke's Hospital, which offers discounted treatment through an outreach program.

So although they live in a shanty colony, Maravillas and 84 other seniors in her group now enjoy one of the best health services in the Philippines. While cheap, the service is no handout. "This allows the people to retain their dignity," says a COSE campaigner. Investing in good habits aside, such community-based schemes could be the building blocks of an excellent health care system — especially where funds are tight. 

With reports by Yulanda Chung Hong Kong, Paul Mooney, Beijing, Raissa Robles/Manila, Ritu Sarin/New Delhi and Jonathan Watts Tokyo