Care facilities for the elderly are found throughout our cities. The demands of city living and our busy working lives mean that many people do not have the space, time or capacity to care for the elderly members of their family. As a result, special facilities are required to provide for the needs of our elderly.

For care workers like Ms. Umehara in Tokyo, daily work involves simple support tasks like feeding, washing and dressing. At the same time, the effort she makes to go for a stroll in the park or a simple one-on-one conversation, helps to brighten the day for many of the residents.

Some elderly people who have enjoyed a higher income, or perhaps did not have children, are able to retain a sophisticated lifestyle by moving into high-rise care facilities like Elegano Kobe. With 5-star service, social events, rooftop bar, salon, medical team and a hospice, this upscale facility has everything needed to live the wisdom years in style.

While longer life expectancy is a tremendous human achievement, it is also a challenge for the health systems of many countries. As a result of ageing and declining fertility rates, the shrinking national workforce faces difficulties in supporting such a large number of retirees.

This situation has serious financial and economic implications for hyper-aged societies like Japan in terms of state pension provision and increased health costs. For instance, health care spending in Japan rose, in real terms, by 2.5% between 2000 and 2005, and this trend will continue as the population ages.

Source: OECD, 2005 []

Who will care for our elderly in today’s ageing world?

Ideally, the elderly can remain healthy and active, and some studies suggest disability decreasing amongst the elderly. However, there will always be a need for care. Moreover, there are fears that current ageing trends will generate a demand that outpaces the supply of formal care. Societies like Japan are therefore called upon to find innovative ways to provide care and ensure the well-being of their citizens.

There are generally three types of care for older citizens:

Informal care: family support systems (elderly living with families)

Spouses, parents and children, and especially mothers, wives, daughters and daughters-in-law, have traditionally been the primary providers of family-based care, certainly in Japan. In addition to allowing elderly to retain relationships with their families, informal care can be provided even by families of limited means and also appears ideal in terms of placing little or no burden on governments.

However, it will be difficult for family carers to maintain such a large share of care giving responsibilities. First, with an increasing number of women working outside the home, it will be difficult for them to continue to shoulder such a large burden of care.

Second, studies have shown that informal care is often physically, financially and mentally arduous for caregivers and sometimes harmful, so it is questionable as to whether it is even desirable for informal care to continue as it has in the past, without offering different kinds of support.

Third, with the increased number of elderly people worldwide, informal caring is less able to keep up. Furthermore, as high birth rates are replaced by very low birth rates, each generation has fewer children to support and take care of them as they age. While extended families are still a prominent feature of many societies, a long-term trend toward nuclear families continues.

In Japan, as few as 21% of elderly now live with their extended family. Meanwhile, a growing number of elderly live alone. According to a 2005 survey by the Japanese Ministry of Health, Labour and Welfare, the number of elderly living alone has grown five-fold in the last 30 years and now constitute 22% of all elderly households. In addition, an International Comparative Study on Senior’s Living and Perspectives highlighted the lower frequency of contacts between elderly and their grown-up children in Japan compared to other countries based on the results of a survey undertaken in 2005. For instance, only 17% of elderly Japanese only see their children “almost everyday”, while in France the number is 23%, and in the USA this is as high as 41%.

Source: International Comparative Study on Senior’s Living and Perspectives, March 2007.

The desirable level of relationship with children and grandchildren has also been changing, with Japanese respondents less likely to declare “living with them” and more likely to report “having meals and conversations with them from time to time.”

Domiciliary and community care

Domiciliary and community care encompass a broad array of services such as personal care (e.g. bathing and grooming), household chores (e.g. meal preparation and cleaning), life management (e.g. shopping, medication management, and transportation), assistive devices (e.g. canes and walkers), more advanced technologies (e.g. emergency alert systems and computerized medication reminders), and home modifications (e.g. ramps and hand rails). This mix of services is designed to minimize, restore, or compensate for the loss of independent physical or mental functioning.

The use of home-delivered services is expected to grow sharply in the next few years as a result of technological advances. Domiciliary care has been described as the most efficacious alternative in today’s demographic transition as well as the best policy to ensure the well-being and continuous involvement of elderly within their community.

Long-term provision of care (e.g. nursing homes)

Long-term care includes activities undertaken for persons that are not fully capable of self-care on a long-term basis in specialized facilities. While traditionally seen as an extension of the hospital setting, the environment of nursing homes in many countries has been progressively more resident-centered, catering for the emotional needs of the residents in addition to their medical needs.

Depending of the level of needs of the individual, different types of facilities are available ranging from retirement communities to nursing homes. Of course, such facilities tend to be very expensive, a cost borne by families or the elderly themselves in some cases, by governments in other cases.

Population ageing is a serious economic challenge for many countries

Countries with extensive social provisions and benefits have been struggling to ensure the sustainability of their programmes.

According to the Japanese government, total medical expenses for elderly people accounted for over 43% of all medical expenses. Between 2006 and 2007, average expenses for patients aged 69 or younger increased by 1.5%, while those for patients aged 70 and above increased by 2%.

The significant growth in social security costs in Japan has led to changes in the nation’s pension system. Major reforms include decreased benefits, higher worker contributions and an ongoing rise in the pensionable age for full benefits to 65, from 60 for men and 58 for women.

It is necessary for policy-makers to explore the effect of ageing on the overall health system. Alternative interventions to increase community involvement and support and decrease disability among older people are possible solutions in that regard. But essentially, providing benefits that encourage elderly care in families and the community appear a sound investment, helping to reduce demand for expensive long-term care facilities.

More details can be found at:

Lessons for long-term care policy around the world

The following table provides examples of long term care policies found in different parts of the world. How do these compare with the situation in Japan or in your home country?

Republic of Korea
High income and ageing rapidly, low burden of communicable diseases
The Republic of Korea has a high level of expenditure on health services (per capita). There is a very low level of under-5 mortality and high life expectancy. There is a moderate proportion of elderly (7.1%), but the population is ageing very rapidly, and by the year 2025 16.9% of its population will be age 65 and over. The Republic of Korea is consequently concerned with the rise of chronic disease and disability.

The Republic of Korea has a strong health system and a significant social service sector, both of which participate in the provision of long term care services. These services include a broad package of home health, personal care and homemaking services. It has particularly emphasized family education and training. These trends might be understood in light of its relatively high proportion of elderly, the decline in family size, along with a higher proportion of women in the labour force and the availability of resources due to its relatively high- income level. Institutional long term care is very limited in the Republic of Korea, but there is an interest in developing more institutions in order to reduce acute hospital usage by individuals in need of long term care.

Costa Rica
Moderate income level, but high health expenditure (per capita), and a strong health system
Under-5 mortality is low in Costa Rica. The proportion of elderly is low, but the proportion of those age 65 and over will double during the next 25 years. For this reason, Costa Rica is mostly concerned with the rise of chronic disease and disability, rather than with the burden of communicable diseases.

Costa Rica’s choice, at a relatively low income level, to spend a considerable amount of money on health care is quite unique, and it appears to have contributed to the very low communicable disease burden. In this way, it is avoiding the emergence of a double disease burden as it ages.

Costa Rica has focused on developing home health provision emphasizing family education and training. A broader package of long-term care services including personal care and homemaking have not been introduced. Institutional long term care is almost non-existent. These patterns can be understood in light of their low proportion of elderly and low proportion of women in the labour force.

South Africa
Relatively high income level, high burden of communicable disease (especially related to the HIV/AIDS crisis), low life expectancy, attempting to introduce some forms of community long-term care
South Africa is a country that has been devastated by the HIV/AIDS pandemic. Although the country has a fairly high level of economic resources and although it spends a relatively high percentage of GDP per capita on health care, the effects of HIV/AIDS and other communicable diseases has driven down South Africa’s life expectancy to the lowest level of any of the countries included in the study.

Largely in response to the disabling effects of HIV/AIDS on the general population and the destruction of the traditional family unit, the Government of South Africa has begun to develop some forms of community care for individuals suffering from the disease. The community care programme, as proposed, will take a comprehensive approach to the needs of all ages in the family and builds heavily on the participation of volunteers from the community. Alternative models, some integrated into primary health care and some independent, are being experimented with.

Low income, high burden of communicable disease, low proportion of elderly
Indonesia represents a country with a low proportion of elderly and low economic resources, which is highly concerned with the burden of communicable diseases as reflected in a high under-5 mortality rate. At the same time, it is ageing rapidly, as the proportion of those 65 and over will nearly double in the next 25 years. It thus confronts a rapid increase in the burden of chronic disease and disability.

The Indonesian situation raises the primary issue of where to begin to support the development of long term care services in the face of a low level of health infrastructure and a high communicable disease burden. Long term care services in Indonesia, to the extent that they are available, are largely based on volunteers. This raises the question of how to strengthen volunteer roles and of the limits of expectations from voluntary activity.

Source: WHO 2002 Lessons for long-term care policy.

Relevant Documents and Links:

WHO – Lessons for Long-Term Care policy

Global Review of Projecting Health Expenditures for Older Persons in Developing Countries

Ministry of Health, Labour and Welfare website on Long-Term Care insurance in Japan

Information on the new public health insurance plan in Japan (Japanese)