Ageing Int (2009) 33:28–49 DOI 10.1007/s12126-009-9028-5
Health and Health Care System for Older Persons Jiraporn Kespichayawattana & Sutthichai Jitapunkul
Published online: 17 March 2009 # Springer Science + Business Media, LLC 2009
Abstract Thailand has now reached a new demographic turning point with the advent of an ageing society. Improvements in the health care system and technology advancement over recent decades mean that Thais can now enjoy better health in old age than previously. Life expectancy at birth for the Thai population has been increasing steadily, and there has been an improvement among older persons in all aspects of health behaviors. Even though the majority of Thai elderly are sufficiently healthy to take care of themselves, there are an increasing number of elderly people who have difficulty with essential daily activities, leading to problems with disability and dependency. Non communicable diseases such as hypertension, diabetes mellitus, dyslipidemia, osteoarthritis, cardio-cerebrovascular diseases and tumor are some of the major health problems confronting older Thais. Due a higher incidence of illness and chronic conditions as compared to young people, the elderly typically require different types of care and health services. As Thailand becomes an ageing society, health services and proper care systems specifically for the elderly group need to be prepared and well established. Given the far greater likelihood of chronic conditions and disabilities among older persons compared to the rest of population, pressures on long-term care facilities and services will increase enormously. The issue of ageing should be given a high priority in both local and national government agendas. All sectors should be involved in adjusting care systems and programs to accommodate the rapid growth of older persons and the relative balance of age groups within the population. It will be crucial for the health sectors to provide services oriented towards geriatric and long-term care issues. Keywords Health . Health indicators . Health care system . Older persons . Thailand J. Kespichayawattana (*) Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand e-mail:
[email protected] S. Jitapunkul Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand e-mail:
[email protected]
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Introduction Population Ageing in Thailand: Demographic Changes, Issues and Trends Population ageing is an inevitable result of the demographic transition associated with declining birth and death rates. This trend holds true in Thailand where the demographic changes are determined by the past trends in fertility, mortality, and migration. As it is occurring in much of other developing countries in Asia, population ageing in Thailand is taking place at a far faster pace than has happened in developed countries in the West. The increasing share of older persons in the Thai population is due to the fact that the growth rate of the older-aged population in Thailand exceeds that of the overall population. Not only the overall share of the ageing population is increasing, but also the older population itself is ageing as evidenced by an increase in the percent of older persons who are aged 80 years and over (the oldest-old). The percent increase of the oldest-old is greater than that of the overall aged population. From the year 2000 to 2050, the total older adult population is projected to increase by 227% while the oldest-old population (age 80 and over) will increase by 686%. In 2000, nearly 10% of Thai elderly were the oldest-old, however, that percentage will increase to23.6 in 2050. This group will clearly demonstrate the physiological changes of ageing as well as the state of dependency resulting from the occurrence of functional disability and chronic diseases. The oldest-old undoubtedly requires more care and health services. Since the consequences of ageing are different for the oldest-old and the young old elderly, it is crucial to take into account the individual needs and concerns of the aging population in order to inform policies, programs, and improvements in the health care system.
Ageing Population: Health Indicators Life Expectancy As a result of medical and health advancements, and the improvement in the delivery of health care services, the elderly population has increased in number and is living longer than before. Life expectancy at birth for the Thai population has been also increasing. With the current population of 63.1 million (January, 2008), Thailand has seven million older adults, with life expectancy at birth of males and females of 69.5 and 76.3 years respectively (Mahidol Gazzette 2008). According to survey of Population Change, 2005–2006, done the by National Statistical Office (NSO 2008), considering the life expectancy of older Thais at age 60, the average number of years the elderly can be expected to live are 19.3 and 21.6 years, for males and females, respectively. Male and female elderly of urban residence are likely to live longer than those non-municipal residents. For regional comparison, both male and female elderly in the Bangkok area live longer than those in other regions. This may be due to better economic status and health service access of the municipal and Bangkok elderly residents (Table 1). Measures of overall life expectancy reflect mortality but do not take into account that some years may be in poor health or in a state of disability. Differences between
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Table 1 Life expectancy at age 60, by region and sex, 2005–2006 Regions
Male
Female
Whole Kingdom
19.3
21.7
Municipal
20.3
24.0
Non-municipal
19.1
20.9
Bangkok
22.2
26.2
Central (exclude Bangkok)
18.5
24.1
Northern
19.7
19.2
North-Eastern
18.6
20.5
Southern
21.8
24.1
Source: Survey of Population Change, 2005–2006, National Statistical Office 2008
active and overall life expectancy indicate the number of years that an older adult can be expected to live in poor health or with a disability. Figure 1 shows estimates of active life expectancy at age 60 using different definitions and data sources. All indicate that at age 60 women can expect to live longer active lives than men but can also expect to experience longer periods of poor health or disability when they may not be able to function without some personal assistance. At the same time, for both men and women, a large majority of their older years will be in reasonable health and not require hands-on long term care (Knodel and Chayovan 2008).
25.0 21.3 expected years of life
20.0
19.9
18.9
18.2 16.4
18.1 Men Women
15.0
10.0 5.7 3.9
5.0
1.6
2.6
1.8
2.6
0.0 years without disability
years with disability
years of self years care care needed
Long-term disability life expectancy1996-97
Self care life expectacy 1996-97
years in reasonable health
years in poor health or disabled
Healthy life expectancy 2002
Fig. 1 Estimates of active life expectancy at age 60 by gender for Thailand. Source: (Jitapunkul 2003; Rakchanyaban 2004 as reported in Kanchanachita et al. 2007)
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Mortality The age-specific mortality rates of the Thai population have been declining for more than four decades (Fig. 2). After the age of 10, age-specific mortality rates increase with age, with the highest rate increase in the age group of 70 years and older. The pattern of cause of death among the elderly Thai population is similar to the cause of mortality found in developed countries (Jitapunkul et al. 2003). Cancer, cardiovascular diseases particularly heart failure and cerebrovascular diseases are common causes of death in both male and female older Thais (Fig. 3). This is supported by the most recent data from 2006, in which mortality rates of the elderly people were 403 per 100,000 for all types of cancer, 175 per 100,000 for heart disease, and 111 per 100,000 for cerebrovascular disease. Morbidity The elderly are more susceptible to illness because of the deterioration of their health. Among those who have illness, 93% have sought treatment and 7% do nothing (Jitapunkul et al. 1999). Older persons who had self-limiting symptoms or diseases such as a common cold, headache, or myalgia tend to do nothing while older persons with chronic conditions such as peptic ulcers, hypertension, asthma, or diabetes mellitus seek medical services. Nearly 40% of older persons with illness report using over-the-counter drugs. The pattern of chronic disease among older Thais is similar to that of developed countries (Jitapunkul et al. 1993; Thailand Health Research Institute, National Health Foundation 1996). Around 50% of older persons have chronic diseases (National Statistical Office 2007). Common chronic diseases are hypertension, diabetes mellitus, dyslipidemia, osteoarthritis, coronary heart diseases, cerebrovascular diseases, chronic airway obstructive diseases, and tumors. Except coronary heart disease and chronic airway obstructive disease, older women have higher prevalence rates of chronic disease than their male counterparts (Jitapunkul et al. 1998b). Nutritional Status In 2005 the National Statistical Office conducted a survey of health behaviours in the Thais, including exercise and food consumption (Fig. 4). The study indicated Fig. 2 Age-specific mortality rate (per 1,000 populations) of Thai population in 1960, 1970, 1980, 1990, and 2000. Source: Division of Health Statistics, Ministry of Public Health, 1965, 1975, 1986, 1996, 2001
80
60 1960 40
20
0
1980 2000
Mortality Rate / Per 100,000 elderly persons
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Ageing Int (2009) 33:28–49
500 400 300 200 100 0 2002
2003
2004
2005
2006
Years Cancer
Heart dis.
Cerobrovascular dis.
Fig. 3 Mortality rate of the elderly by causes of death (the first three causes) 2002–2006. Source: Policy and Strategic Division, Ministry of Public Health
that more than 90% of the elderly do consume vegetables and fruits as well as meat and other proteins. However, nearly 80% also eat high-fat food. Among elderly of all ages, males consume more food than females, while the latter consume more snacks, vegetables and fruits. 59.6% of older Thais have vegetables and fruits on daily basis. From this 2005 survey (Fig. 5), it also found that over 80% of the elderly eat three meals per day, and about 15.6% had two meals (of which 0.7% skipped the evening meal). Regarding hand washing behaviours, 60.3% of respondents washed their hands before every meal, while 36.8% of respondents had occasionally washed their hands before eating, and 2.8% never at all. Exercises As Thais age, their stated purpose of exercise is to improve health, slow down deterioration of the body’s organs, joy and pleasure, and to slow down the ageing process. Suitable exercises for elderly include brisk walking, jogging, and bicycle ergometry.
Fast food Food Supplement Snacks soft drink / sweeten drink high fat food Ready to eat meal Meat & Poultry fruits & vegetables 0
4.1 16.7
17.1 59.1 77.2 79.9 95.3 98.9
20
40
60
80
100
%
Fig. 4 Kinds of food consumed by the elderly in 2005. Source: The Survey of Health Behaviors among Thai Population 2005
Ageing Int (2009) 33:28–49
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Skip breakfast
4.9%
Skip lunch
10.0%
Skip dinner
0.7%
More than 3 meal / day 1.40% 1 meal / day 0.40%
2 meal / day 15.60%
3 meal /day
82.60%
Fig. 5 Numbers of meal taken in a day by elderly, 2005. Source: The Survey of Health Behaviors among Thai Population 2005
The practice of exercise has been increasing among elderly people. The rate of exercise has increased from 9.2% in 2002 to 16.3% in 2003 and reached 21.3% in 2004. There are a greater number of male rather than female elderly exercising regularly (Fig. 6). Reasons for their practicing exercises are gaining strength 75.0%, having health problem 19.6%, and reducing tension 2.6%. Health Risk Behaviors There has been a decline in regular or daily smoking among the Thai elderly. The percentage of smokers in the population fell from 21.1% in 2001 to 16.6% in 2006 (Fig. 7). The decline occurred in both male and female elderly. Those who are 25
22.1 21.3
20
17.7
Percent
20.5 16.3
15
15.1
11.1
10 5
9.2 7.6
0 2002
2003 Total
2004 Male
Sex
Female
Fig. 6 Percentage of the elderly who exercise 2002–2004. Source: The Survey of Participate in Sport, Exercise Activities of Thai Population 2002, NSO
Percent
34
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50 40 30 20 10 0
40.9
35.2
34.3
17.7
16.9
3
2.8
27.5 21.1 14.1 4.3
2001
2.9
2003
Total
2004
Male
2005
Year
Female
Fig. 7 Percentage of the elderly who are smoker (smoke everyday) 2001–2005. Source: The Survey of Health and Welfare 2003 and 2006 / and The Surveyof Health Rist Behaviors of Thai Population 2001, 2004
smokers, average between 1 and 10 cigarettes per day. About half (50.0%) of active elderly smokers began smoking between ages 15 and 19 years, and 25.2% between ages of 20 and 24 years. Likewise, the trend of drinking alcohol declined though not substantially. Elderly drinkers were reduced from 20.2% in 2001 to 18.1% in 2006 (Fig. 8). The number of male drinkers decreased compared to a slight increase among females. Moreover, 7.6% occasionally drink and 4.0% drink everyday. Health Status and Health Problems According to three rounds of the Survey of Older Persons in Thailand, there has been a steady improvement in self-assessed health for both males and females as well as for young old and oldest-old. The results also indicate that women are less likely to report their health as good or very good than are men and that older are considerably less likely than younger elderly persons to report health as good or very good. Gender differences in self-assessment of health are contradictory with respect to life expectancy and active life expectancy. Older men are more prone to fatal accidents and diseases while women are more prone to non-life-threatening illnesses (Knodel and Chayovan 2008; Fig. 9). From the most recent national survey in 2007 regarding health problems and illness among Thai elderly, it showed that almost one fourth judge themselves to be in poor or very poor health. This increases substantially with age with less than one 40
37
31.2
35
18
19.3
18.1
6.9
6.1
5.9
33.2
Percent
30 20
20
10 5.7
0 2001
2003
Total
2004
Male
2006
Year
Female
Fig. 8 Percentage of the elderly who drink alcohol 2001–2005. Source: The Survey of Health and Welfare 2003 and 2006 / and The Survey of health risk behaviors of Thai Population 2001, 2004
Ageing Int (2009) 33:28–49
35
60
53 53 50
40
46 47
53
43 40
38
55
43
42
34 35
34 29
30
20
10
0 All elderly
Men
Women 1994
2002
Age 60-69
Age 70+
2007
Fig. 9 Percentage of population age 60 and older reporting good or very good health, Thailand 1994, 2002 and 2007. Source: 1994, 2002, and 2007 Surveys of Older Persons in Thailand as presented in Knodel and Chayovan 2008
Table 2 Health problems, by age, gender and area of residence, Thailand 2007 Total
Age
Gender
Type of area
60–69
70–79
80+
Men
Women
Urban
Rural
24.2
18.4
29.9
41.4
20.1
27.5
21.4
25.4
Sees clearly without glasses
53.7
60.7
46.8
33.6
56.1
51.7
46.8
56.4
Sees clearly with glasses
25.4
26.3
25.1
20.7
28.0
23.3
38.9
20.0
Does not see clearly
20.5
12.9
27.5
44.2
15.5
24.6
14.0
23.1
0.4
0.1
0.6
1.4
0.3
0.4
0.3
0.4
84.4
91.7
79.1
57.1
85.6
83.4
86.8
83.4
1.2
1.1
1.3
1.5
1.4
1.0
1.1
1.2
14.1
7.2
19.3
39.7
12.6
15.3
11.8
15.0
Percentage in poor or very poor health Vision (% distribution)
Blind Hearing (% distribution) Hears clearly without aid Hears clearly with hearing aid Does not hear clearly Deaf
0.3
0.1
0.4
1.8
0.4
0.3
0.3
0.4
% having problems with incontinence
17.0
12.3
21.2
32.3
13.6
19.8
14.6
18.0
% who were ill sometime during the past 5 years
63.5
59.5
67.0
76.1
60.5
65.8
62.0
64.1
Source: 2007 Survey of Older Persons in Thailand as presented in Knodel and Chayovan 2008
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Ageing Int (2009) 33:28–49
fifth of persons age 60–69 reporting poor or very poor health, compared to over 40% of those 80 and older. Women and rural elderly are more likely to say their health is poor or very poor than men or urban elderly (Table 2). Problems with vision are relatively common among older persons. Although few indicate that they cannot see at all, one fifth indicate they do not see clearly (and presumably either have no eyeglasses or eyeglasses cannot correct their vision). Hearing problems are somewhat less common. Very few elderly cannot hear at all, but 14% indicate they do not hear clearly (and apparently lack a hearing aid to correct the problem). Both vision and hearing problems increase substantially with age and are more common among older women than men and more prevalent in rural and urban areas. This is particularly the case for vision problems, and in terms of the urban-rural contrast likely reflects more untreated cataracts among the rural elderly. Problems with incontinence, either with respect to urination or defecation, are reported by 17% of older persons. A study done by Jitapunkul et al. (1998b) confirmed that Thai older women have a higher prevalent rate of incontinence compared to Thai older men. Incontinence problems increase with age, are higher for women than for men, and are somewhat more prevalent in rural and urban areas (Knodel and Chayovan 2008). Functional Limitations and Disability Declining health and increased frailty associated with ageing lead to difficulty with physical movement and an increased need of assistance. The basic functional activities (i.e. eating, dressing, and bathing and using the toilet) are the activities of daily living that were used to assess the level of dependency. Almost of persons aged 60 and over have no problem in doing these three activities by themselves (this sentence makes no sense). Moderately higher percentages of the elderly report having difficulties squatting, climbing two or three stairs, and counting change when using money. Considerably higher proportions of older persons are unable to undertake activities which require a higher level of physical exertion such as lifting 5 kg or walking 200+ m. Using transportation such as buses or boats also posed difficulty for a substantial share of older Thais. Overall, more than a third report at least one functional limitation (Table 3). The percentages of the elderly who have difficulty doing these activities independently vary considerably by age. Substantially higher percentages of persons age 70 and over have difficulty doing these activities without help from others. Women are more likely than men to report difficulties in doing each of these activities on their own. The most critical functional limitations such as are eating, dressing, bathing, and tolieting lead to the need for a caregiver to assist on a daily basis. However, less than 4% of older persons report limitations with respect to any of these most basic activities. This percentage increases with age and is by far the highest for those aged 80 and over (Knodel and Chayovan 2008). Women are more likely than men and elderly urban residents are more likely than their rural counterparts to report at least one of these basic limitations (Figs. 10 and 11) The percentage of elderly with disabilities increased from 5.8% in 2001 to 9.3% in 2002, and 15.3% in 2007. Female elderly with disabilities outnumber their male
Ageing Int (2009) 33:28–49
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Table 3 Percent who can not do selected activities without personal assistance or without aids, by age, gender and area of residence, Thailand 2007 Age Total
60–69
Eating
2.3
Dressing
3.0
Bathing/using toilet
3.4
Gender
Type of area
70+
Men
Women
Urban
Rural
1.0
4.0
2.1
2.4
3.4
1.8
1.4
5.3
2.6
3.3
4.1
2.6
1.6
5.9
2.8
3.9
4.8
2.8
Squatting
12.4
6.5
20.8
8.4
15.6
15.8
11.0
Lifting 5 kilos
27.0
14.8
44.2
18.0
34.2
30.0
25.7
Walking 200–300 meters
16.8
7.5
30.1
12.1
20.6
17.9
16.4
Climbing 2 or 3 stairs
13.6
6.0
24.4
9.9
16.6
15.2
13.0
Using transportation
25.8
12.2
45.2
17.6
32.4
25.3
26.0
Counting change
10.7
3.9
20.5
7.9
13.1
10.2
11.0
Any of the above
36.1
21.2
57.3
25.4
44.6
37.0
35.7
Source: 2007 Survey of Elderly in Thailand as presented in Knodel and Chayovan 2008
counterparts. Since life expectancy is higher in female elderly, the elderly widow can experience loneliness due to a deceased spouse and in addition may suffer from disabilities, hence living with difficulties that might be more serious in the absence of a caregiver. The three most common disabilities found in elderly are blurred vision, deafness, and paralysis. Among them, blurred vision is more common in females, while deafness and paralysis occur more in males. Major Health Problems The three most common major health problems in the Thai elderly are diseases of the musculoskeletal system and connective tissue, diseases of respiratory system, and cardiovascular disease (Fig. 12). Despite the fact that annual medical checkups are important for the early detection and treatment of health problems, the 2007 survey indicated that only 52.3% of all elderly people had undergone a medical check-up during the past year, and of that percentage, the majority were females.
Health Care System of Thailand Background and Development The WHO defines a Health system as all activities purposed to promote, restore or maintain health (WHO 2000), a health system can be further classified as either formal or informal. Generally, government is the main responsible actor of the formal health system. The informal, which constitutes a larger part of the heath
38
a
Ageing Int (2009) 33:28–49
16.0
14.8 14.0
no one assists someone assists
12.0
percent
10.0 8.0
5.4
6.0 4.0
4.2
4.0
3.7
3.2
3.1
1.8 2.0 0.0
total
60-69
Total
b
70-79
80+
Age
men
women
urban
Gender
rural
Area
45.0 39.4
40.0
no one assists someone assists
35.0
percent
30.0 25.0 20.0 16.1 15.0
14.1
13.6
11.8
11.1 9.0
10.0 5.0 5.0 0.0 total Total
60-69
70-79 Age
80+
men
women
Gender
urban
rural
Area
Fig. 10 Percentage of population age 60 with functional problems and whether someone provides assistance. A Cannot do at least one basic activity of daily living by self. B Cannot do at least one basic activity of daily living by self and has major mobility problem. Source: 2007 Surveys of Older Persons in Thailand as presented in Knodel and Chayovan 2008. Note: Basic activities of daily living considered are eat, dress, bathe, or use toilte; a major mobility problem is defined as not being able to both walk 200-300 meters and climb 2-3 steps
Ageing Int (2009) 33:28–49
39
20
Percent
15
10
5
0 2001
2002
Total
Year
2007
Male
Female
Fig. 11 Percentage of elderly with disability 2001, 2002 and 2007. Source: The Survey of Health and Welfare 2001, (National Statistical Organization) The Survey of Disability 2002, 2007 (National Statistical Organization
system usually includes activities provided by individuals, families, and the community. Many elements of the formal and informal health systems are collaborative such as health care activities, health financing, and health care resources. The Ministry of Public Health (MoPH) is the main health care provider of Thailand and plays an essential role in health system performance and reform. Health Care Reform: Policies and Strategy Since the MoPH was established in 1922, health care reform has led to expansion of the public hospital system to every province and every district in the country. Originally, the health care system paid more attention to curative care in hospital settings rather than other dimensions of care. But in 1973, a second health system reform began. The structure of the MoPH was reorganized, which provided an opportunity for the expansion of medical services at the district level, but also focused on strengthening the role of public health activities especially the promotion 30
28. 3 22. 8
percent
25 20
19
15
14. 3
22. 6
23. 7 22. 1
22. 3 21. 3 17. 5
13. 9
21. 4 19. 4 17. 3
15. 4
10 5 0 2003
2004 Respiratory
2005 Musculoskeletal
2006
2007
Year
Cardiovascular
Fig. 12 Percentage of three majors health problems in elderly group 2003 - 2007. Source: The Survey of Health and Welfare 2003-2007
40
Ageing Int (2009) 33:28–49
of “primary health care”. During this period of time, the community health centers were developed at the sub-district levels (Tambon and village), which aimed to act as the primary contact between people and the public health care system. The mission of the public health system included assuring a quality of all health services, food and education, adequate supplies of safe water, and basic sanitation. Health care financing was supply-oriented during the first and second generations of health system reform and most of the Thai population depended on their own resources to pay for healthcare. Before 1990, health care security was available only for government officers and state employees. The Social Security Act was enforced in 1990 to cover businesses with 20 or more employees. Three years later, it also extended the coverage to businesses with ten or more employees. A third generation of health system reform, which was concerned with demand, was implemented on April 1st, 2001. The reform concentrated on a health care finance system that could make “money follow the patient” as well as initiated universal healthcare coverage (known as “thirty baht scheme”). Initially, people were required to pay 30 baht (less than one US. dollar) for the treatment. However, since 2006, the government has stopped collecting the 30 baht fee, which has made healthcare coverage in Thailand truly universal health coverage. Under this universal health care scheme more than 90% of the Thai elderly are covered (The National Statistical Office 2008); however, only 74% of the general population are covered (Wibulpolprasert 2007). Since this latest reform, Thailand has seen the development of comprehensive community care which focuses more on preventive health care. In addition to universal coverage, there are two other financing systems for health care in Thailand. These include social security, which covers employees in the private sector and those who are not covered by any public insurance (social security covers11.4% of the population). Employees, employers, and the government are the three major contributors to the social security fund. The social security fund is under the management of the Social Security Office. The Social Security Fund provides six types of benefits for insured persons in the contingencies of non work-related as follows: sickness or injuries benefits, maternity benefits, invalidity benefits, death benefits, child allowance benefits and old-age pension benefits. A second coverage plan is the Civil Servant Medical Benefit Scheme (CSMBS) and state enterprise benefit (CSMBS covers 8.9% of the population) are fully paid by the government (taxation) and state enterprises. The Ministry of Finance is responsible for the CSMBS and the state enterprises are responsible for medical bills of their employees. Since the government is the major provider of services and monetary support for the universal health coverage systems, sustainability of the system is a concern. A mixed model of direct contribution from employees/employers, tax revenue, and public provision may be the most suitable health financing system. While this latest development will inevitably put pressure on the national budget, it is invaluable for ageing population. Health Care Delivery System The Ministry of Public Health (MoPH) is the main health care provider in Thailand, and provides 62% of total hospitals and beds. Other state organizations such as
Ageing Int (2009) 33:28–49
41
university and state enterprises also provide health care particularly at the secondary and tertiary health care levels. At present, the private sector provides around 25% of total hospitals and beds. The MoPH and the Bangkok Metropolitan Administration (BMA) are the primary providers for almost all of the public health services, particularly health promotion and disease prevention activities. The health care system in Thailand can be categorized in to three levels; primary health services, secondary health services, and tertiary health services. The primary health services for communities in provincial areas are provided through networks of “community health centers” under the responsibility of the MoPH, while “public health centers” provide care in areas of Metropolitan Bangkok and are run by the Bangkok Metropolitan Administration (BMA). The community health centers of the MoPH are usually located in rural areas of other provinces and are mainly staffed by community health officers. Although health promotion and prevention are the intended functions of these centers, they spend most of their resources, particularly human resources, in providing basic curative care. Community hospitals, which are often the first contact for those living in rural areas, also provide primary health services. Secondary health services are provided by medical and health personnel with various degrees of specialization. General and specialized facilities include community hospitals, general, or regional hospitals. A community hospital can be located in a district or sub-district with ten to 120 inpatient beds, covering a population of 10,000 or more. Medical and health personnel in community hospitals put more emphasis on curative care, compared to those at primary care facilities. Tertiary level health services are provided by medical and health personnel, a number of whom are medical specialists. Tertiary care facilities include general hospitals, regional hospitals, university hospitals, and large private hospitals (generally with over 100 beds and medical specialists). A general hospital in this category is equipped with 200 to 500 beds, while a regional hospital has over 500 beds and medical specialists in all fields. Therefore, the secondary- and tertiary level hospitals take up a large share of public health budget. Resources, such as physicians and other health personnel are concentrated in Bangkok and other urban areas, which leads to a poor distribution of resources across the country. Private Hospitals are run as a business with both full-tine and part-time staff, and clients are required to pay for services. Private hospitals and clinics are under the control of the Medical Registration Division of the Ministry of Public Health, in accordance with the Medical Facilities Act, 1998. In the private sector, there is no formal referral system and typically clinics or private hospitals refer patients to the second or the third referral centers of the public sector. Figure 13 shows the formal health care system, numbers of facilities, and referral network among these health care organizations. National Policy and Plan for Older Persons: Strategies and Implementations A free medical care program for destitute elderly was initiated in 1989 and extended to cover all elderly in 1992. Under this program, all government hospitals and health centers provide free medical services to persons aged 60 and over who registered for an ‘elderly card’. It operates on a referral system from lower level to higher level health facilities. Free care for older persons continued after the universal health coverage was introduced in 2001.
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Public sector Other provinces Health centre/ community health centre (primary care level) 9762 health centers Community hospital (1 st referral level) 730 community hospitals General hospital (2 nd referral level) 70 general hospitals Regional hospital / University hospital / specialize hospital (3 rd referral level) 78 hospitals
Bangkok Public health centre (primary care level) 68 health centers University hospital / BMA hospital / Specialize hospital 45 hospitals Clinics 16800 clinics Private hospitals 344 hospitals
Private sector
Fig. 13 Health care system of Thailand. Source: Jitapunkul, Kespichayawattana, Chayowan, and Yodpet, 2008
In addition, Thailand has taken steps to ensure its older population can access health care services that will meet their needs According to the 2003 Act on Older Persons, older adults have the right to access convenient and rapid medical and health care services. In April 2005, the MoPH issued a Ministerial Notification that medical and public health services be conveniently and rapidly accessible to older persons. Therefore, hospitals under the supervision of the MoPH throughout the country are required to accelerate their adoption of these measures. A “Green Channel or Fast Lane” for Older Persons was created in order to facilitate older adult’s quick access to medical services in the outpatient section of hospitals. The MoPH has reported that 90% of public hospitals throughout the country have already set up this green channel for the elderly. Geriatric clinics have been developed in hospitals, although the quality and efficiency of these services are not yet evaluated. Human Resources and Training The distribution of health resources in Thailand has been improving during the last few decades. However, health professional distribution in rural areas, particularly doctors, dentists, and pharmacists is significantly less than in urban areas (Table 4). In order to address the medical care needs of the elderly, it is essential to provide specialized health services carried out by staff who specialize in geriatric medicine. These health care providers need to have undergone training and education specifically related to health in the elderly. There are a limited number of doctors and nurses with training in geriatric medicine. In recognition of the increasing
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Table 4 Distribution of health resources (Resource to population ratio) Type/region
Nationwide
Bed
1: 462
Health centers
1: 4895
Doctors
1: 3295
Dentist
1: 13991
Pharmacist
1: 8511
Nurse (all categories)
1:556
Nurse (professional
1:739
Nurse (technical)
1:2240
Health center staff
1:1762
Sources: Report on Health Resources, Bureau of Policy and Strategy, MoPH 2002
demand for quality elderly care, the Ministry of Public Health established the Institute of Geriatric Medicine in 1992. The Institute serves to develop and transfer new knowledge, technologies, and guidelines regarding care for older persons as well as develop new effective models of health care for ageing population. Care Services and Resources for Older Persons Acute Care The elderly often suffer from several medical conditions at the same time. Since the MoPH has established elderly clinics in hospitals, there is the ability for some of these clinics to cater particularly to the elderly. Specialist wards providing care to the elderly are still rare, since the state-run hospitals mainly emphasize acute care or short-term services for their patients. However, the chronic illnesses typical among the elderly require long term care. Specialist hospitals for the elderly operated by the private sector tend to charge high fees, which puts them out of the reach of most elderly people. Long-Term Care Most of the elderly in Thailand who need long-term care (LTC) receive informal care provided by their families and relatives. According to Thai traditions, caring for the elderly is the responsibility of children and grandchildren, and should take place in the family. The informal care provided by family is recognized as the main means of care by the National Committee on Ageing of Thailand (1986). Although the first National Long-term Plan (1982–2001) mainly emphasized the informal care of the family, the provisions to support the family were not practically implemented. During that time, state organizations paid little attention to developing home/ community services to assist the older persons and their caregivers. In 2001 the second National Plan for Older Persons (2001–2019) was implemented (National Commission on the Elderly 2002). It includes strategies on LTC provisions
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which cover a wide range of activities including the promotion and support of informal care within the family, the provision of health and social services in both home/community and institution, and the development of shelter/accommodation services and environmental adaptation. Nursing Home During the past decade, there has been a growing demand for rehabilitative and nursing homes for older persons convalescing or suffering from frailty or chronic illness. The state has not yet become involved in this area. These older persons are often those who have been discharged from hospitals in order to avoid overcrowding and to mitigate the high cost of care. This burden on the family for taking care of chronically ill elderly has led to the institutionalization of frail elderly people for rehabilitation and nursing care, especially in Bangkok and urban areas. As there has been no registration or state record of nursing homes in Thailand, it is difficult to know the exact number providing care for older persons. However, based upon the advertisements seen in newspapers and on the internet, long term care represents one of the fastest growing elder care services. Their expenses, without medication and special treatment, ranged from 18,000–33,900 baht per month (Department of Social Welfare 2001a). Most nursing homes also provide short to medium-term admission for rehabilitation. Most of these rehabilitative and nursing homes are organized by the private sectors and aim to serve the families of middle to high economic status. The available data on nursing home and residential home shows that less than 4,000 older persons are in institutionalized for long-term care (Jitapunkul 2000). Hence, most of the elderly who need long-term care receive informal care in the communities. While it is certain that the number of those needing care services will increase, the important policy issue is how to support an informal care system in order to keep the number of older persons who need to be placed in institutions as low as possible. Systems need to be in place so that families and relatives can provide adequate care to elderly people. The non-profit and for-profit private sectors have been the major contributors for nursing home services during the past decade (Jitapunkul 2000), mainly private hospitals and religion-linked non-government organizations. Since there is no specific ministerial regulation for nursing homes, the nursing home can be registered under the ministerial regulation of an acute hospital, and private hospitals with facilities to treat acute illnesses can immediately convert beds to a long-stay care service. Quality accreditation of nursing home services is crucial, and the Department of Health under the MoPH is working with setting the standards and regulations for these formal long care services for the elderly. Paid Caregiver The demand for long-term care for the elderly with disabilities or chronic illnesses is increasing at the same time that taking care of elderly people within the family is becoming more difficult due to the limit number of children in families as well as the changing pattern of adults working outside, and often far away from the family home. Changes in the provision of long-term care for the elderly have been occurring predominantly in urban areas. Families are beginning to hire formal
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caregivers to assist their elderly parents with daily activities or caregiving when family members themselves are unable to do so. Elder care centers which provide care assistance services for the elderly at home have become popular businesses since they can respond to the needs of individuals/ families in metropolitan areas. Family members sometimes do not have time or are not prepared to take care of the elderly. Information sources for hiring elder care workers who have been trained to provide services include newspapers, the internet, business cards or one-on-one information exchange. In Bangkok, for example, almost of eldercare training schools or centers are owned or managed by medical or nursing professionals. The schools provide training and also support job placement, providing linkages between workers, elders and families. Although it estimated that there are more than 500 such centers nationally, only a limited number are registered and licensed. There are also no regulations or assurances of the training standards. Both the licensing and training standards are issues deserving public attention. Home and Community Services In recent years, with the increasing awareness of the needs of older persons in community settings, post-hospital discharge services provided by public hospitals have become broader in their scope of care. In addition, the main policy direction of the Second National Long-term Plan for Older Persons emphasized home and community-based services to enable older persons to continue living in their own homes or in the community. Community and home-based services for older and disabled persons are important services to develop. In tertiary care hospital settings, special services provide the ambulatory care or home visit for discharged patients. However, most home-visit services are only provided to elderly patients for a limited time period, and cannot be regarded as true home health services. During the 1990s, the MoPH launched a “Home Health Care” policy stating that a hospital should have an outreach team, including a physician, nurse, social worker and physiotherapist, to visit patients in their homes. However, the ‘Home Health Care’ service did not develop as anticipated. The only existing services in some areas are community curative care for people with chronic diseases and this does not include rehabilitation. Moreover, data from the assessment survey of the Government’s health services for older persons showed that less than one-third of older persons have ever been visited by a health care worker in their homes (Kamnuansilpa et al. 2000). In 2005, the Ministry of Public Health launched a pilot project call “The home health care: HHC” in 26 local hospitals. The HHC project focuses on providing health services to older persons in their own communities. The project is designed to improve elderly physical and mental health and social conditions; services include risk prevention, health promotion, treatment or rehabilitation. The project has been expanded to central and provincial hospitals in all provinces, while 65 percent of the community hospitals also provide home health care services. Nevertheless, palliative care for dependent and frail older persons and community rehabilitation are less well-developed and respite care does not existed. The model of community services that integrate health care and social services is a new and promising trend. This model started in Bangkok metropolitan areas and is
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called “the Bangkok 7 Model.” The model was adopted by the Department of Health, Bangkok Metropolitan Administration (BMA) and implemented by the BMA public health centers. The MoPH is also now implementing a project “Community-Based Integrated Services of Health Care and Social Welfare for Thai Older Persons” in four settings (Chiangrai, Nonthaburi, KonKaen, and Surathani provinces) in all regions of Thailand. This four-year project (2007–2010) is designed to develop a model of elderly care in the community by using inter-sectional cooperation between two main ministries and collaboration among local authorities, volunteers, and the elderly themselves.
Emerging Challenges for the Health Care System Given the exponential increases in the elderly population in Thailand, the government must confront the emerging challenges that face and will continue to face health care systems. Some of the key trends and issues surrounding the health care system include: – – – –
– –
– –
–
Significant increases in the number of older adults in Thailand means that the country has a shorter-than-ideal period of time to develop appropriate programs and resources for this group. As a result of medical and health advancement, Thais tend to live longer than before. Female elderly, and elderly who live in municipal or urban areas are likely to live longer but also experience longer periods of poor health or disability. Patterns of health problems in the Thai elderly population do not differ from those in developed countries. Non-communicable diseases such as hypertension, diabetes mellitus, dyslipidemia, osteoarthritis, cardio-cerebrovascular diseases and tumor are major health problems for Thai older persons. These health problems may also lead to long-term disabilities. Health promotion activities and behaviors among Thai elderly (e.g., nutritional awareness, exercise) have improved. There was also a decline in smoking and alcohol consumption in the elderly during the past 5 years. An increasing number of older Thais report their health as good or very good. However, women and rural elderly are more likely to say their health is poor or very poor than men or urban elderly. Vision and hearing problems increase substantially with age and are also more common among older women than men, and more prevalent in rural areas. The higher aged group and elderly women are more likely to report difficulties with activities of daily living. A majority of older persons who have difficulties with activities of daily living receive assistance with these tasks. The Ministry of Public Health (MoPH) is the main health care provider in Thailand, and is overseeing health system performance and reform. The major formal health coverage system for Thais is the “Universal coverage scheme” which will inevitably put pressure on the national budget. Governmental agencies are the main health care providers particularly at the primary health care level. However, the current health delivery system does not
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–
– –
47
match the needs of the ageing society especially at the primary and long-term care levels. There has been growing demand for long-term care and nursing homes services for frail elderly, and the governmental institutes have not yet established these services. Private, for-profit organizations contribute mostly to institution-based health care including geriatric hospitals and nursing homes in mostly urban areas. Almost all of the elderly who need long-term care mainly receive informal care in the communities. The number of those needing formal care services will increase. Thailand is now developing several innovative long-term care programs. It is critical to have effective home and community-based care to support the informal care system, assure that families and relatives can provide adequate care to older persons, and to keep the number of older persons who need to be placed in institutional care as low as possible.
Conclusions Thailand has reached a demographic turning point with the advent of an ageing society. Improvements in the health care system and technology advancement over recent decades mean that Thai enjoy better health in old age than they used to. Life expectancy at birth for the Thai population has been increasing steadily. During most of the elderly age span, the large majority of Thai elderly are sufficiently healthy to take care of themselves. The illness profile of an ageing society differs from that of a younger age group. In an ageing society, illness rates for infectious diseases and malnutrition are relatively low, while rates for chronic conditions and diseases attributable to deterioration of bodily organs are high. Due to more illnesses and more chronic conditions than young people, the elderly typically require different types of care and health services. As Thailand becomes an ageing society, health services and proper care systems specifically for the elderly group need to be well-established. Given the far greater likelihood of chronic conditions and disabilities among older persons compared to the rest of population, pressures on long-term care facilities and services will increase enormously. The issue of ageing should be given high priority in government agendas at all levels from local to national. All sectors should be involved in adjusting care systems and programs to accommodate the rapid growth of older persons. Health sectors must provide services oriented toward geriatric and long-term care issues. It is certain that the demand for long-term care will increase rapidly because the number of elderly people with disabilities or chronic illnesses will increase. Thais believe that looking after elderly parents is a way of repaying the debt owed to them, and is consistent with religious precepts (Kespichayawattana 1999). However, although the tradition is still honored, practically, caring for elderly in a family is becoming increasingly difficult especially when caring for those who are truly frail, demented, or disabled. Families can provide the most love and concern, but they often lack the necessary knowledge, skills and experiences. In these circumstances, it is inevitable that some older people who are unable to help themselves, will be cared for in settings other than the family residence or will have some at-home services delivered. The care services might be provided by the community or by other
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appropriate institutions/agencies. Home and community-based programs to provide personal assistance or home care to elderly by non-family members and local health personnel might be developed to help fulfill needs of elderly for whom family based care is impractical or insufficient. According to the demographic changes as well as the review of existing services and trends of care for the elderly, it is clear that Thailand is facing a number of challenges. The challenges involve preparing Thai people to improve their health, decreasing morbidity and disabilities, and improving care systems to support people in making the transition to an ageing society. Health and health care systems for Thai older persons need to be considered and seriously attended to by the public, government agencies, and all other stakeholders.
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Jiraporn Kespichayawattana is an Associate Professor at Faculty of Nursing, Chulalongkorn University, Bangkok, Thailand 10330. Her areas of specialty are elderly health, health promotion, and health care system for Thai older persons.
Sutthichai Jitapunkul is a Professor at Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand 10330.
