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Published on August 20, 2007

It was a breezy afternoon in Ayutthaya. An entourage of elderly couples accompanied their 80-something relative to see Jaroonluck Kongtaveesakullert, the resident physiotherapist at Bangsai Hospihouse, where the octogenarian is staying and where one of the other couples, Thai-Americans in their sixties, has recently bought a house.

For the present, it was perhaps an uncommon sight; an early hint of a community of ageing people, banded together for their common good, helping one another.

It is the stark and sometimes scary reality of the future.

Faced with a seismic shift of 14 million baby boomers into the country's dependent elderly population by 2025, Thai society and its economy risk being ripped apart. It's little consolation that Thailand is far from being alone with the monumental question: How will we take care of them?

A study by Worawet Suwanrada, an economics lecturer at Chulalongkorn University, shows that, as of this year, every six Thai adults are working to support one elderly person. In 18 years time, the ratio will be reduced to just three adults working for every old person.

The once-large structure of Thai families is gradually giving way to a single-family structure. As people have fewer children and migrate into the cities, the familial safety net, long taken for granted, is growing smaller.

Pakorn Pantu, director of the Bureau of Social Welfare Services at the Ministry of Social Development and Human Security, refers to the "violent" impact of the spiralling number of aged and dependent on Thai society, but says problems may be avoided if the public and private sectors work together - with the government providing clear and sustainable policies and regulations, while the private sector meets the very fundamental human need for support and care in old age.

But so far progress has been lopsided, Pakorn admits.

Siriphan Sasat, a lecturer in nursing old people at Chulalongkorn, says there are about 133 nursing homes registered with the Medical Registration Division of the Ministry of Public Health - all of them private.

With uncertain and unclear policies and laws relating to care for the aged, the private sector - usually hospitals - is left to cope. But it does so at a price.

The middle- to high-income population, like the families at the private nursing home in Ayutthaya, can afford a minimum of Bt18,000 to Bt20,000 a month for nursing home services. But what happens to those without the financial means?

"There is a system-wide imbalance. People are getting old before they get rich," Siriphan says, paraphrasing the research findings of Worawet. Both are members of a subcommittee for the elderly under the Office of the Prime Minister and report directly to Deputy Prime Minister Paiboon Wattanasiritham.

With the gap between Thailand's rich and poor widening, the problem is creating growing social and official alarm.

Disparate government policies have long encouraged the elderly to stay with their families and communities for as long as possible. Responsibility for their interests has been delegated to local government, with the central government doing little more than monitoring standards.

The advantages are two-fold: cost-cutting - the state's residential homes are spared from over-overcrowding - and the community's social fabric is maintained.

"But what you get is old people flocking in under the Bt30 [health] scheme instead, taking up beds and resources, when in fact they do not necessarily need to stay," says social worker Umaporn Phongjit.

The number of elderly people in nursing homes will soon catch up with those being cared for at home.

According to the Chulalongkorn study, the number of old people in nursing homes will grow exponentially from 5,780 in 1995 to 101,192 in 2015. Those staying at home will grow from 71,277 to 111,843 over the same period.

In countries like Japan and Singapore, financial incentives are used to mitigate the burden on citizens of caring for the aged. The Japanese government puts up half of the cost of geriatric care from tax revenues, while old people pay the rest from pensions, provident or other funds and savings.

The Singapore government takes a similar approach to Japan - with plenty of financial schemes offering security in old age, such as the ElderShield insurance scheme offered through two private insurers. Singapore also wants its elders to remain within their communities. Family and community support is the "lowest-cost option" for an ageing society, Singaporean minister Lim Boon Heng told The Straits Times last month.

But there are calls in the city-state for a 2,000 Singapore dollars (Bt45,000) tax rebate for caregivers. Whether the rebate is granted or not, activities related to care for the aged are closely monitored and regulated by the Health Ministry - a stark contrast to the situation in Thailand.

Services for the elderly here are directly and comprehensively accountable to neither the Public Health Ministry nor the Social Development and Human Security Ministry. And there is no central body to oversee and coordinate, Umaporn says.

There is a total lack of over-arching laws and regulations that clearly define care for the elderly and the scope of work involved. This particularly affects nursing homes, which have elements of both social and medical services, and the consequence is a lack of development of the system and its ancillary industries.

For now, to open a nursing home, one has to obtain permission from the Medical Registration Division of the Department of Health Service Support. Although there are a handful of laws dealing with establishing and regulating of medical service providers, none of them directly address nursing homes.

Chalermchat Vanapruks, founder of Senior Healthcare, says that medically speaking, the level of care needed by elderly people is dictated by a set of categories dividing them into those who can take care of themselves both within and outside the house, those who must remain within the house and those who are bed-ridden.

Due to the intensive nature of long-term care - as opposed to acute care in hospital nursing - nursing homes often have difficulty recruiting capable staff. Chalermchat, who teaches geriatric medicine at Phramongkutklao Hospital's medical school, says the shortage of specialised nurses and doctors specialising in geriatric medicine is a major drawback. It is a worldwide problem, and countries such as Canada and the UK are recruiting nurses and assistants abroad.

To combat the shortage, one of Thailand's first nursing homes, Kluaynamthai Geriatric Hospital 2, trains its own caregivers. In a one-year course certified by the Education Ministry, students complete 2,200 hours of study in both theory and practice. So far, the course has been popular. Some students have been offered jobs in Canada.

But giving care is just one function, albeit a very important one, in a web of services.

"It is a matter of synergy," says Srikarin Chanate, Kluaynamthai Geriatric Hospital 2's chief executive. Hospitals with long-established track records stand a good chance of dominating the market. Doctors at Kluaynamthai, for instance, work with nutritionists, nurses, physiotherapists, psychologists and other specialists to devise the best programmes for patients.

Elsewhere, real estate developers have been looking to break into the industry. Already a developer in Lop Buri is talking with Boonchai Issarapisit, chairman and chief executive of Ayutthaya's Bangsai Hospihouse, about converting part of a housing development into a nursing home complex.

But not all think that nursing homes for the elderly are a gold mine. According to Siriphan, they are not the most profitable of healthcare businesses. While hospitals want a quick turnover of patients, nursing homes specialise in long-term care. Turnover is low - as it should be - Chalermchat says, because nursing homes are in the business of prolonging life.

Bangkok's Vibhavadi Hospital only last year closed its nursing home business to make room for expansion of its chronic kidney disease and haemodialysis centre. A patient can spend anything from Bt15,200 to Bt22,800 a month for dialysis.

But it is not just about the bottom line.

"It is all about making the old folks happy," says Srikarin, whose hospital's nursing home unit has been operating for 26 years. "It is about building trust and meeting the physical, psychological and spiritual needs of the elderly."

In an atmosphere of crisis it is easy to be overwhelmed by talk of policies, laws and capital. But one must never forget the patients themselves, despite their swelling numbers.

Ki Nan Tsui

The Nation